Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part I - Applicability and Definitions › Section 14VAC5-211-20 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this chapter
					 shall have the following meanings unless the context clearly indicates
					 otherwise:
"ACA" means the Patient Protection and Affordable Care Act
					 ( P.L.
					 111-148 ), as amended by the Health Care and
					 Education Reconciliation Act of 2010 (
					 P.L.
					 111-152 ) and any federal regulations issued
					 pursuant thereto.
"Allowable charge" means the amount from which the health
					 maintenance organization's payment to a provider for any covered item or
					 service is determined before taking into account the enrollee's cost
					 sharing.
"Basic health care services" means in-area and out-of-area
					 emergency services, inpatient hospital and physician care, outpatient medical
					 services, laboratory and radiologic services, preventive health services and
					 mental health and substance use disorder services, or all essential health
					 benefits required under § 38.2-3451 of the Code of Virginia. In the case
					 of a health maintenance organization that has contracted with this Commonwealth
					 to furnish basic health care services to recipients of medical assistance under
					 Title XIX of the Social Security Act ( 42 USC § 1396 et seq.) pursuant to
					 § 38.2-4320 of the Code of Virginia, the basic health care services to be
					 provided by the health maintenance organization to program recipients may
					 differ from the basic health care services required by this chapter to the
					 extent necessary to meet the benefit standards prescribed by the state plan for
					 medical assistance services authorized pursuant to § 32.1-325 of the Code
					 of Virginia.
"Coinsurance" means a copayment, expressed as a percentage
					 of the allowable charge for a specific health care service.
"Commission" means the State Corporation Commission.
"Copayment" means an amount an enrollee is required to pay
					 in order to receive a specific health care service.
"Cost sharing" means any coinsurance, copayment, or
					 deductible.
"Deductible" means a dollar amount an enrollee is required
					 to pay out of pocket before the health care plan pays the costs associated with
					 certain health care services.
"Dependent" means the spouse, child, or other class of
					 persons of a subscriber or eligible employee, subject to the applicable terms
					 of the policy, contract, or plan.
"Emergency services" shall have the same meaning as §
					 38.2-3438 of the Code of Virginia and means those health care services that are
					 rendered by affiliated or nonaffiliated providers after the sudden onset of a
					 medical condition that manifests itself by symptoms of sufficient severity,
					 including severe pain, that the absence of immediate medical attention could
					 reasonably be expected by a prudent layperson who possesses an average
					 knowledge of health and medicine to result in (i) serious jeopardy to the
					 mental or physical health of the individual, (ii) danger of serious impairment
					 of the individual's bodily functions, (iii) serious dysfunction of any of the
					 individual's bodily organs, or (iv) in the case of a pregnant woman, serious
					 jeopardy to the health of the fetus.
"Enrollee" means a policyholder, subscriber, participant,
					 member, or other individual covered by a health benefit plan.
"Essential health benefits" includes the following general
					 categories and items and services covered within the categories in accordance
					 with regulations issued pursuant to the ACA:
(i)  ambulatory patient services; (ii) emergency services;
					 (iii) hospitalization; (iv) laboratory services; (v) maternity and newborn
					 care; (vi) mental health and substance use disorder services; (vii) pediatric
					 services, including oral and vision care; (viii) prescription drugs; (ix)
					 preventive and wellness services and chronic disease management; and (x)
					 rehabilitative and habilitative services and devices.
"Evidence of coverage" means a certificate, individual or
					 group agreement or contract, or identification card issued in conjunction with
					 the certificate, agreement or contract, issued to a subscriber setting out the
					 coverage and other rights to which an enrollee is entitled.
"Excess insurance" or "stop loss insurance" means insurance
					 issued to a health maintenance organization by an insurer licensed in this
					 Commonwealth, on a form approved by the commission, or a risk assumption
					 transaction acceptable to the commission, providing indemnity or reimbursement
					 against the cost of health care services provided by the health maintenance
					 organization.
"Exchange certified stand-alone dental plan" means a
					 limited dental care services plan that has been approved to meet the criteria
					 for certification pursuant to the ACA.
"Grandfathered plan" means coverage provided by a health
					 carrier to (i) a small employer on March 23, 2010; (ii) an individual who was
					 enrolled on March 23, 2010, including any extension of coverage to an
					 individual who becomes a dependent of a grandfathered enrollee after March 23,
					 2010; or (iii) an employee who enrolls in the employer's grandfathered plan
					 after March 23, 2010, for as long as such plan maintains that status in
					 accordance with the ACA.
"Group contract" means a contract for health care services
					 issued by a health maintenance organization, which by its terms limits the
					 eligibility of subscribers and enrollees to a specified group.
"Group health plan" means an employee welfare benefit plan
					 as defined in § 3(1) of the Employee Retirement Income Security Act of
					 1974 (ERISA) ( 29 USC § 1002(1) ) to the extent that the plan provides
					 medical care within the meaning of § 733(a) of ERISA ( 29 USC §
					 1191b(a) ) to employees, including both current and former employees, or their
					 dependents as defined under the terms of the plan directly or through
					 insurance, reimbursement, or otherwise.
"Health benefit plan" or "health care plan" means an
					 arrangement in which a person undertakes to provide, arrange for, pay for, or
					 reimburse a part of the cost of health care services. A significant part of the
					 arrangement shall consist of arranging for or providing health care services,
					 including emergency services and services rendered by nonparticipating referral
					 providers, as distinguished from mere indemnification against the cost of the
					 services, on a prepaid basis. For purposes of this chapter, a significant part
					 shall mean at least 90% of total costs of health care services.
"Health care professional" means a physician or other
					 health care practitioner licensed, accredited, or certified to perform
					 specified health care services consistent with state law.
"Health care services" means the furnishing of services to
					 an individual for the purpose of preventing, alleviating, curing, or healing
					 human illness, injury or physical disability.
"Health insurance exchange" means a health benefit exchange
					 established or operated in the Commonwealth pursuant to § 1311(b) of the
					 ACA, including the Federally Facilitated Marketplace established pursuant to
					 § 1321 of the ACA.
"Health maintenance organization" means a person who
					 undertakes to provide or arrange for one or more health care plans. A health
					 maintenance organization is deemed to be offering one or more managed care
					 health insurance plans and is subject to Chapter 58 (§ 38.2-5800 et seq.)
					 of Title 38.2 of the Code of Virginia.
"Individual health insurance coverage" means health
					 insurance coverage offered to individuals in the individual market, but does
					 not include excepted benefits as defined in § 38.2-3431 of the Code of
					 Virginia . Individual health insurance coverage does not include short-term
					 limited duration coverage.
"Individual market" means the market for health insurance
					 coverage offered to individuals other than in connection with a group health
					 plan.
"Large employer" means, in connection with a group health
					 plan or health insurance coverage with respect to a calendar year and a plan
					 year, an employer who employed an average of at least 51 employees on business
					 days during the preceding calendar year and who employs at least one employee
					 on the first day of the plan year. Effective January 1, 2016, "large employer"
					 means, in connection with a group health plan or health insurance coverage with
					 respect to a calendar year and a plan year, an employer who employed an average
					 of at least 101 employees on business days during the preceding calendar year
					 and who employs at least one employee on the first day of the plan year.
"Large group market" means the health insurance market
					 under which individuals obtain health insurance coverage (directly or through
					 any arrangement) on behalf of themselves (and their dependents) through a group
					 health plan maintained by a large employer.
"Limited health care services" means dental care services
					 or vision care services.
"Medical necessity" or "medically necessary" means
					 appropriate and necessary health care services that are rendered for a
					 condition which, according to generally accepted principles of good medical
					 practice, requires the diagnosis or direct care and treatment of an illness,
					 injury, or pregnancy-related condition, and are not provided only as a
					 convenience.
"Net worth" or "capital and surplus" means the excess of
					 total admitted assets over the total liabilities of the health maintenance
					 organization, provided that surplus notes shall be reported and accounted for
					 in accordance with § 38.2-4300 of the Code of Virginia.
"Nonparticipating referral provider" means a provider who
					 is not a participating provider but with whom a health maintenance organization
					 has arranged, through referral by its participating providers, to provide
					 health care services to enrollees. Payment or reimbursement by a health
					 maintenance organization for health care services provided by nonparticipating
					 referral providers may exceed 5.0% of total costs of health care services, only
					 to the extent that any excess payment or reimbursement over 5.0% shall be
					 combined with the costs for services that represent mere indemnification, with
					 the combined amount subject to the combination of limitations set forth in this
					 definition and in this section's definition of health care plan.
"Out-of-area services" means the health care services that
					 the health maintenance organization may cover when its enrollees are outside
					 the geographical limits of the health maintenance organization's service
					 area.
"Out-of-pocket maximum" means the maximum dollar amount
					 that an enrollee is required to pay during a plan or policy year before the
					 health benefit plan pays 100% of the allowable charges for covered basic health
					 care services for the balance of the plan or policy year . This amount shall
					 include deductibles, coinsurance or copayments, and any other expenditure
					 required of an enrollee for any covered medical expense. This limit may or may
					 not include premiums, balance billed amounts for out-of-network services, or
					 payments for services that are not basic health care services.
"Participating provider" or "affiliated provider" means a
					 provider who has agreed to provide health care services to enrollees and to
					 hold those enrollees harmless from payment with an expectation of receiving
					 payment, other than copayments or deductibles, directly or indirectly from the
					 health maintenance organization.
"Point-of-service benefit" means a health maintenance
					 organization's delivery system or covered benefits, or the delivery system or
					 covered benefits of another carrier under contract or arrangement with the
					 health maintenance organization, that permit an enrollee to receive covered
					 items and services outside of the provider panel of the health maintenance
					 organization under the terms and conditions of the group contract holder's
					 group health benefit plan with the health maintenance organization or with
					 another carrier arranged by or under contract with the health maintenance
					 organization and that otherwise complies with § 38.2-3407.12 of the Code
					 of Virginia.
"Preexisting condition exclusion" means a limitation or
					 exclusion of benefits, including a denial of coverage, based on the fact that
					 the condition was present before the effective date of coverage, or if the
					 coverage is denied, the date of denial, whether or not any medical advice,
					 diagnosis, care, or treatment was recommended or received before the effective
					 date of coverage. "Preexisting condition exclusion" also includes a condition
					 identified as a result of a pre-enrollment questionnaire or physical
					 examination given to an individual, or review of medical records relating to
					 the pre-enrollment period.
"Premium" means all moneys paid by an employer, eligible
					 employee, or covered person as a condition of coverage from a health carrier,
					 including fees and other contributions associated with the health benefit
					 plan.
"Primary care health care professional" means a health care
					 professional who provides initial and primary care to enrollees; who
					 supervises, coordinates, and maintains continuity of patient care; and who may
					 initiate referrals for specialist care, if referrals are a requirement of the
					 enrollee's health care coverage.
"Provider" or "health care provider" means a physician,
					 hospital, or other person that is licensed or otherwise authorized to furnish
					 health care services.
"Rescission" means a cancellation or discontinuance of
					 coverage under a health care plan that has a retroactive effect. "Rescission"
					 does not include:
(i)  a cancellation or discontinuance of coverage under a
					 health care plan if the cancellation or discontinuance of coverage has only a
					 prospective effect, or the cancellation or discontinuance of coverage is
					 effective retroactively to the extent it is attributable to a failure to timely
					 pay required premiums or contributions towards the cost of coverage; or
(ii)  a cancellation or discontinuance of coverage when the
					 health care plan covers active employees and, if applicable, dependents and
					 those covered under continuation coverage provisions, if the employee pays no
					 premiums for coverage after termination of employment and the cancellation or
					 discontinuance of coverage is effective retroactively back to the date of
					 termination of employment due to a delay in administrative
					 recordkeeping.
"Service area" means a clearly defined geographic area in
					 which the health maintenance organization has directly or indirectly arranged
					 for the provision of health care services to be generally available and readily
					 accessible to enrollees.
"Small employer" means in connection with a group health
					 plan or health insurance coverage with respect to a calendar year and a plan
					 year, an employer who employed an average of at least one but not more than 50
					 employees on business days during the preceding calendar year and who employs
					 at least one employee on the first day of the plan year. Effective January 1,
					 2016, "small employer" means in connection with a group health plan or health
					 insurance coverage with respect to a calendar year and a plan year, an employer
					 who employed an average of at least one but not more than 100 employees on
					 business days during the preceding calendar year and who employs at least one
					 employee on the first day of the plan year.
"Small group market" means the health insurance market
					 under which individuals obtain health insurance coverage (directly or through
					 any arrangement) on behalf of themselves (and their dependents) through a group
					 health plan maintained by a small employer.
"Specialist" means a licensed health care provider to whom
					 an enrollee may be referred by his primary care health care professional and
					 who is certified or eligible for certification by the appropriate specialty
					 board, where applicable, to provide health care services in a specialized area
					 of health care.
"Subscriber" means a contract holder or enrollee who is
					 responsible for payment to the health maintenance organization or on whose
					 behalf the payment is made.
"Supplemental health care services" means health care
					 services that may be offered by a health maintenance organization in addition
					 to the required basic health care services.
"Surplus notes" means those instruments that meet the
					 requirements of
					 14VAC5-211-40.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
						the Code of Virginia.