Va. Code Ann. tit. 38.2, ch. 43

Va. Code Ann. tit. 38.2, ch. 43
in effect

Va. Code Ann. § 38.2-4300 Definitions

As used in this chapter: "Acceptable securities" means securities that (i) are legal investments under the laws of the Commonwealth for public sinking funds or for other public funds, (ii) are not in default as to principal or interest, (iii) have a current market value of not less than $50,000 nor more than $500,000, and (iv) are issued pursuant to a system of book-entry evidencing ownership interests of the securities with transfers of ownership effected on the records of the depository and its participants pursuant to rules and procedures established by the depository. "Basic health care services" means in and out-of-area emergency services, inpatient hospital and physician care, outpatient medical services, laboratory and radiologic services, mental health and substance use disorder benefits, and preventive health services. In the case of a health maintenance organization that has contracted with the Commonwealth to furnish basic health services to recipients of medical assistance under Title XIX of the United States Social Security Act pursuant to § 38.2-4320 , the basic health services to be provided by the health maintenance organization to program recipients may differ from the basic health services required by this section to the extent necessary to meet the benefit standards prescribed by the state plan for medical assistance services authorized pursuant to § 32.1-325 . "Copayment" means an amount an enrollee is required to pay in order to receive a specific health care service. "Deductible" means an amount an enrollee is required to pay out-of-pocket before the health care plan begins to pay the costs associated with health care services. "Emergency services" 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. Emergency services provided within the plan's service area shall include covered health care services from nonaffiliated providers only when delay in receiving care from a provider affiliated with the health maintenance organization could reasonably be expected to cause the enrollee's condition to worsen if left unattended. "Enrollee" or "member" means an individual who is enrolled in a health care plan. "Evidence of coverage" means any certificate or individual or group agreement or contract 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 the 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. "Health care plan" means any arrangement in which any person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any 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 section, a significant part shall mean at least 90 percent of total costs of health care services. "Health care services" means the furnishing of services to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability. "Health maintenance organization" means any person who undertakes to provide or arrange for one or more health care plans. "Limited health care services" means dental care services, vision care services, and such other services as may be determined by the Commission to be limited health care services. Limited health care services shall not include hospital, medical, surgical, or emergency services except as such services are provided incident to the limited health care services set forth in the preceding sentence. "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 guidance set forth in the National Association of Insurance Commissioners (NAIC) accounting practice and procedures manuals. "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 five percent of total costs of health care services, only to the extent that any such excess payment or reimbursement over five percent shall be combined with the costs for services which 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. "Participating 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. "Provider" or "health care provider" means any physician, hospital, or other person that is licensed or otherwise authorized in the Commonwealth to furnish health care services. "Subscriber" means a contract holder, an individual enrollee, or the enrollee in an enrolled family who is responsible for payment to the health maintenance organization or on whose behalf such payment is made. 1980, c. 720, § 38.1-863; 1986, cc. 76, 528, 562; 1990, c. 224; 1992, cc. 241, 481; 1993, c. 305; 1995, cc. 182 , 345 ; 2000, c. 503 ; 2003, cc. 752 , 767 ; 2004, c. 175 ; 2006, c. 448 ; 2015, c. 649 .

Va. Code Ann. § 38.2-4301 Establishment of health maintenance organizations

A. No person shall establish or operate a health maintenance organization in the Commonwealth without obtaining a license from the Commission. Any person, including a foreign corporation, may apply to the Commission for a license to establish and operate a health maintenance organization in compliance with this chapter. B. Each application for a license shall be verified by an officer or authorized representative of the applicant, shall be in a form prescribed by the Commission, and shall set forth or be accompanied by the following: 1. A copy of any basic organizational document of the applicant including, but not limited to, the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents, and all amendments to those documents; 2. A copy of the bylaws, rules and regulations, or any similar document regulating the conduct of the internal affairs of the applicant; 3. A list of the names, addresses, and official positions, and biographical information on forms acceptable to the Commission of each member of the governing body and any person with authority to manage or establish policy; and a full disclosure in the application of (i) any financial interest between such persons or any provider, organization or corporation owned or controlled by such person and the health maintenance organization and (ii) the extent and nature of the financial arrangements between such persons and the health maintenance organization; 4. A disclosure of any person owning or having the right to acquire five percent or more of the voting securities or subordinated debt of the applicant; 5. A copy of any contract made or to be made between any providers, sponsors, or organizers of the health maintenance organization, or persons listed in subdivision 3 of this subsection and the applicant; 6. A copy of the evidence of coverage form to be issued to subscribers; 7. A copy of any group contract form that is to be issued to employers, unions, trustees, or other organizations. All group contracts shall set forth the right of subscribers to convert their coverages to an individual contract issued by the health maintenance organization; 8. Financial statements showing the applicant's assets, liabilities, and sources of financial support and, if the applicant's financial affairs are audited by independent certified public accountants, a copy of the applicant's most recent certified financial statement unless the Commission directs that additional or more recent financial information is required for the proper administration of this chapter; 9. A complete description of the health maintenance organization and its method of operation, including (i) the method of marketing the plan, (ii) a statement regarding the sources of working capital as well as any other sources of funding, and (iii) a description of any insurance, reinsurance, or alternative coverage arrangements proposed, including excess insurance or stop loss insurance; 10. A description of the mechanism by which enrollees will be given an opportunity to participate in matters of policy and operation as provided in subsection B of § 38.2-4304 ; 11. A financial feasibility plan which includes, but is not limited to, (i) detailed enrollment projections, (ii) the methodology for determining premium rates to be charged during at least the first three years of operations and extending one year beyond the anticipated break-even point certified by an actuary, and (iii) a projection, along with material assumptions, of balance sheets, cash flow statements showing capital expenditures and purchase and sale of investments, income statements, and statements of anticipated covered and uncovered expenses on a quarterly basis for at least three years and extending one year beyond the anticipated break-even point; and 12. Any other information the Commission may require to make the determinations required pursuant to § 38.2-4302 . C. Notwithstanding any other provision of this title, no license shall be required of a health maintenance organization duly licensed in a state contiguous to the Commonwealth that contracts on a limited basis with health care providers in the Commonwealth for the provision of health care services to enrollees covered under a group contract neither delivered nor issued for delivery in the Commonwealth, provided that: 1. The number of Virginia residents receiving such health care services shall not exceed 500 enrollees of such health maintenance organization; and 2. The contracts with such providers shall contain a hold harmless clause that is not less favorable in any respect to any enrollee that is a Virginia resident than the "hold harmless clause" set forth in subdivision C 9 of § 38.2-5805 . 1980, c. 720, § 38.1-864; 1986, c. 562; 1998, c. 891 ; 2000, cc. 503 , 753 ; 2004, c. 175 .

Va. Code Ann. § 38.2-4302 Issuance of license; fee; minimum net worth; impairment

A. The Commission shall issue a license to a health maintenance organization after the receipt of a complete application and payment of a $500 nonrefundable application fee if the Commission is satisfied that the following conditions are met: 1. The persons responsible for the conduct of the affairs of the applicant are competent, trustworthy, and reputable; 2. The health care plan constitutes an appropriate mechanism for the health maintenance organization to provide or arrange for the provision of, as a minimum, basic health care services or limited health care services on a prepaid basis, except to the extent of reasonable requirements for copayments, deductibles, or both; 3. The health maintenance organization is financially responsible and may reasonably be expected to meet its obligations to enrollees and prospective enrollees. In making this determination, the Commission may consider: a. The financial soundness of the health care plan's arrangements for health care services and the schedule of prepaid charges used for those services; b. The adequacy of working capital; c. Any agreement with an insurer, a health services plan, a government, or any other organization for insuring the payment of the cost of health care services or the provision for automatic applicability of an alternative coverage if the health care plan is discontinued; d. Any contracts with health care providers that set forth the health care services to be performed and the providers' responsibilities for fulfilling the health maintenance organization's obligations to its enrollees; e. The deposit of acceptable securities in an amount satisfactory to the Commission, submitted in accordance with § 38.2-4310 as a guarantee that the obligations to the enrollees will be duly performed; f. The applicant's net worth which shall include minimum net worth in an amount at least equal to the sum of uncovered expenses, but not less than $600,000, up to a maximum of $4 million; uncovered expenses shall be amounts determined from the most recently ended calendar quarter pursuant to regulations promulgated by the Commission; and g. A financial statement of the health maintenance organization on the form required by § 38.2-4307 ; 4. The enrollees will be given an opportunity to participate in matters of policy and operation as required by § 38.2-4304 ; and 5. Nothing in the method of operation is contrary to the public interest, as shown in the information submitted pursuant to § 38.2-4301 or Chapter 58 (§ 38.2-5800 et seq.) or by independent investigation. Issuance of a license shall not constitute approval of the forms submitted under subdivisions B 6, 7, and 12 of § 38.2-4301 . B. A licensed health maintenance organization shall have and maintain at all times the minimum net worth described in subdivision A 3 f. 1. If the Commission finds that the minimum net worth of a domestic health maintenance organization is impaired, the Commission shall issue an order requiring the health maintenance organization to eliminate the impairment within a period not exceeding 90 days. The Commission may by order served upon the health maintenance organization prohibit the health maintenance organization from issuing any new contracts while the impairment exists. If at the expiration of the designated period the health maintenance organization has not satisfied the Commission that the impairment has been eliminated, an order for the rehabilitation or liquidation of the health maintenance organization may be entered. 2. If the Commission finds an impairment of the minimum net worth of any foreign health maintenance organization, the Commission may order the health maintenance organization to eliminate the impairment and restore the minimum net worth to the amount required by this section. The Commission may, by order served upon the health maintenance organization, prohibit the health maintenance organization from issuing any new contracts while the impairment exists. If the health maintenance organization fails to comply with the Commission's order within a period of not more than 90 days, the Commission may, in the manner set out in § 38.2-4316 , suspend or revoke the license of the health maintenance organization. 3. Prior to December 31, 1999, a health maintenance organization with less than minimum net worth which is licensed on and after June 30, 1998, may continue to operate as a licensed health maintenance organization without a finding of impairment if the licensee has net worth (i) on June 30, 1998, and up to December 31, 1998, in an amount at least equal to the sum of uncovered expenses, but not less than $300,000, up to a maximum of $2 million; (ii) on December 31, 1998, and up to June 30, 1999, in an amount at least equal to the sum of uncovered expenses, but not less than $400,000, up to a maximum of $2.5 million; and (iii) on June 30, 1999, and up to December 31, 1999, in an amount at least equal to the sum of uncovered expenses, but not less than $500,000, up to a maximum of $3 million. 1980, c. 720, § 38.1-865; 1981, c. 317; 1986, c. 562; 1992, c. 481; 1998, cc. 42 , 891 ; 2000, c. 503 ; 2003, cc. 752 , 767 ; 2004, c. 175 ; 2018, c. 706 .

Va. Code Ann. § 38.2-4303 Powers

A. The powers of a health maintenance organization shall include, but shall not be limited to, the following, provided that the activities comply with all applicable state statutes and regulations: 1. The purchase, lease, construction, renovation, operation, or maintenance of hospitals, medical or other health care facilities, and their ancillary equipment and other property reasonably required for its principal office or for other purposes necessary in the transaction of the business of the organization; 2. The making of loans to (i) health care providers under contract with it in advancement of its health care plan or (ii) any corporation under its control for the purpose of acquiring or constructing medical or other health care facilities and hospitals or in advancement of its health care plan providing health care services to enrollees; 3. The furnishing of health care services through providers that are under contract with or employed by the health maintenance organization; 4. The contracting with any person for the performance on its behalf of certain functions including, but not limited to, marketing, enrollment and administration; 5. The contracting with an insurer or with a health services plan licensed in this Commonwealth, for the provision of insurance, indemnity, or reimbursement for the cost of health care services provided by the health maintenance organization; 6. The offering, in addition to basic health care services, of: a. Additional health care services; b. Indemnity benefits covering out-of-area services; and c. Indemnity benefits, in addition to those relating to out-of-area services, provided through insurers or health services plans; 7. The offering of health care plans for limited health care services; and 8. The requirement for the enrollee to pay a deductible or copayment, or both, for any health care services offered pursuant to this chapter. B. 1. A health maintenance organization shall file notice with the Commission within 30 days after the exercise of any power granted in subdivision 1 or 2 of subsection A of this section that exceeds one percent of the admitted assets of the organization or five percent of net worth, whichever is less. A health maintenance organization shall file notice, with adequate supporting information, with the Commission prior to the exercise of any power granted in subdivision 1 or 2 of subsection A of this section that exceeds five percent of the admitted assets of the organization or 25 percent of net worth, whichever is less. Any series of transactions occurring within a 12-month period that are sufficiently similar in nature to be reasonably construed as a single transaction shall be subject to the limitations set forth in this section. The Commission shall disapprove the exercise of power if the Commission believes such exercise of power would substantially and adversely affect the financial soundness of the health maintenance organization and endanger the health maintenance organization's ability to meet its obligations. If the Commission does not disapprove the exercise of power within 30 days of the filing, it shall be deemed approved. 2. Upon application by the health maintenance organization, the Commission may exempt from the filing requirement of subdivision 1 of subsection B of this section those activities having a minimal effect. 1980, c. 720, § 38.1-866; 1986, c. 562; 1990, c. 224; 1992, c. 481; 2003, cc. 752 , 767 ; 2008, c. 214 .

Va. Code Ann. § 38.2-4304 Governing body

A. The governing body of any health maintenance organization may include providers of health care services, other individuals, or both, but in no event shall any class of health care provider be excluded from eligibility for membership on the governing body of any health maintenance organization. B. The governing body shall establish a mechanism to provide the enrollees with an opportunity to participate in matters of policy and operation through (i) the establishment of advisory panels, (ii) the use of advisory referenda on major policy decisions, or (iii) the use of other mechanisms. 1980, c. 720, § 38.1-867; 1985, c. 588; 1986, c. 562.

Va. Code Ann. § 38.2-4305 Fiduciary responsibilities

Any director, officer or partner of a health maintenance organization who receives, collects, disburses, or invests funds in connection with the activities of the organization shall be responsible for the funds in a fiduciary relationship with the subscribers and enrollees. 1980, c. 720, § 38.1-868; 1986, c. 562.

Va. Code Ann. § 38.2-4306 Evidence of coverage and charges for health care services

A. 1. Each subscriber shall be entitled to evidence of coverage under a health care plan. 2. No evidence of coverage, or amendment to it, shall be delivered or issued for delivery in this Commonwealth until a copy of the form of the evidence of coverage, or amendment to it, has been filed with and approved by the Commission, subject to the provisions of subsection C of this section. Any evidence of coverage for enrollees in the plans administered by the Department of Medical Assistance Services that provide benefits pursuant to Title XIX or Title XXI of the Social Security Act, as amended, is excluded from the provisions of this section. 3. No evidence of coverage shall contain provisions or statements which are unjust, unfair, untrue, inequitable, misleading, deceptive or misrepresentative. 4. An evidence of coverage shall contain a clear and complete statement if a contract, or a reasonably complete summary if a certificate, of: a. The health care services and any insurance or other benefits to which the enrollee is entitled under the health care plan; b. Any limitations on the services, kind of services, benefits, or kind of benefits to be provided, including any deductible or copayment feature, or both; c. Where and in what manner information is available as to how services may be obtained; d. The total amount of payment for health care services and any indemnity or service benefits that the enrollee is obligated to pay with respect to individual contracts, or an indication whether the plan is contributory or noncontributory for group certificates; e. A description of the health maintenance organization's method for resolving enrollee complaints. Any subsequent change may be evidenced in a separate document issued to the enrollee; and f. A list of providers and a description of the service area which shall be provided with the evidence of coverage, if such information is not given to the subscriber at the time of enrollment. B. Pursuant to this subsection: 1. No schedule of charges or amendment to the schedule of charges for enrollee coverage for health care services may be used in conjunction with any health care plan until a copy of the schedule, or its amendment, has been filed with the Commission. Any schedule of charges or amendment to the schedule of charges for enrollees in the plans administered by the Department of Medical Assistance Services that provide benefits pursuant to Title XIX or Title XXI of the Social Security Act, as amended, is excluded from the provisions of this subsection. 2. The charges may be established for various categories of enrollees based upon sound actuarial principles, provided that charges applying to an enrollee in a group health plan shall not be individually determined based on the status of his health. A certification on the appropriateness of the charges, based upon reasonable assumptions, may be required by the Commission to be filed along with adequate supporting information. This certification shall be prepared by a qualified actuary or other qualified professional approved by the Commission. C. The Commission shall, within a reasonable period, approve any form if the requirements of subsection A of this section are met. It shall be unlawful to issue a form until approved. If the Commission disapproves a filing, it shall notify the filer. The Commission shall specify the reasons for its disapproval in the notice. A written request for a hearing on the disapproval may be made to the Commission within 30 days after notice of the disapproval. If the Commission does not disapprove any form within 30 days of the filing of such form, it shall be deemed approved unless the filer is notified in writing that the waiting period is extended by the Commission for an additional 30 days. Filing of the form means actual receipt by the Commission. D. The Commission may require the submission of any relevant information it considers necessary in determining whether to approve or disapprove a filing made under this section. E. The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34. 1980, c. 720, § 38.1-869; 1986, c. 562; 1997, cc. 807 , 913 ; 2003, cc. 752 , 767 ; 2004, c. 185 ; 2006, c. 866 ; 2013, c. 751 ; 2014, c. 814 .

Va. Code Ann. § 38.2-4306.1 Interest on claim proceeds

A. If an action to recover the claim proceeds due under a health care plan results in a judgment against a health maintenance organization, interest on the judgment at the legal rate of interest shall be paid from the date of presentation to the health maintenance organization of proof of loss to the date judgment is entered. B. If no action is brought, interest upon the claim proceeds paid to the subscriber, claimant, or assignee entitled thereto shall be computed daily at the legal rate of interest from the date of thirty calendar days from the health maintenance organization's receipt of proof of loss to the date of claim payment. C. This section shall not apply to individual contracts issued prior to July 1, 1990, but shall apply to any renewals or reissues of group contracts occurring after that date. D. This section shall not apply to claims for which payment has been or will be made directly to health care providers pursuant to a negotiated reimbursement arrangement requiring uniform or periodic interim payments to be applied against the health maintenance organization's obligation on such claims. E. For purposes of this section, "proof of loss" means all necessary documentation reasonably required by the health maintenance organization to make a determination of benefit coverage. 1992, c. 23; 1996, c. 75 .

Va. Code Ann. § 38.2-4307 Annual statement

A. Each health maintenance organization shall file a statement with the Commission annually by March 1. The statement shall be verified by at least two principal officers and shall cover the preceding calendar year. Each health maintenance organization shall also send a copy of the statement to the State Health Commissioner. B. The statement shall be on forms prescribed by the Commission and shall include: 1. A financial statement of the organization, including its balance sheet and income statement for the preceding year; 2. Any material changes in the information submitted pursuant to subsection B of § 38.2-4301 ; 3. The number of persons enrolled during the year, the number of enrollees as of the end of the year and the number of enrollments terminated during the year; and 4. Any other information relating to the operations of the health maintenance organization required by the Commission pursuant to this chapter or Chapter 58 (§ 38.2-5800 et seq.) of this title. C. If the health maintenance organization is audited annually by an independent certified public accountant, a copy of the certified audit report shall be filed annually with the Commission by June 30. D. The Commission may extend the time prescribed for filing annual statements or other reports or exhibits of any health maintenance organization for good cause shown. However, the Commission shall not extend the time for filing annual statements beyond sixty days after the time prescribed by subsection A of this section. Any health maintenance organization which fails to file its annual statement within the time prescribed by this section shall be subject to a fine as specified in § 38.2-218 . E. The Commission may prescribe the form of the annual statement and supplemental schedules and exhibits to include additional copies in machine-readable format, and may vary the form requirements for different types of health maintenance organizations. However, as far as practicable, the form for annual statements, supplementary schedules, and exhibits shall be the same as other such forms in general use in the United States. Unless otherwise prescribed by the Commission, such annual statements shall be prepared using an annual statement convention blank developed by the National Association of Insurance Commissioners (NAIC). The annual statement, and supplementary schedules and exhibits required by this section, shall be prepared in accordance with the appropriate annual statement instructions and the accounting practices and procedures manual adopted by the NAIC, or any successor publications. F. At the request of the Commission, a health maintenance organization that is licensed under this chapter shall annually on or before March 1 of each year, file with the NAIC a copy of its annual statement convention blank, along with such additional filings as prescribed by the Commission for the preceding year. Unless otherwise prescribed by the Commission, the information filed with the NAIC shall be in the same format and scope as that required by the Commission and shall include the signed jurat page and any actuarial certification required by the Commission. Any amendments and addenda to the annual statement filed subsequently with the Commission shall also be filed with the NAIC. 1980, c. 720, § 38.1-870; 1986, c. 562; 1987, c. 520; 1998, c. 891 ; 1999, c. 482 .

Va. Code Ann. § 38.2-4307.1 Additional reports

A. In addition to the annual statement, the Commission may require a licensed health maintenance organization to file additional reports, exhibits or statements considered necessary to secure complete information concerning the condition, solvency, experience, transactions or affairs of the health maintenance organization. The Commission shall establish reasonable deadlines for filing these additional reports, exhibits, or statements and may require verification by any officers of the health maintenance organization designated by the Commission. B. The Commission may require a licensed health maintenance organization to file with the National Association of Insurance Commissioners (NAIC) a copy of its financial statement required to be filed pursuant to § 38.2-4307 , on a quarterly basis. Unless otherwise prescribed by the Commission, all such financial statements, whether filed with the Commission or the NAIC, shall be prepared in accordance with applicable provisions of the annual statement instructions and the accounting practices and procedures manual adopted by the NAIC, or any successor publications. The Commission may prescribe that additional copies of financial statements and other reports be filed in machine-readable format. C. Each annual and quarterly statement shall be accompanied by a statement of covered and uncovered expenses. The statement shall be prepared in accordance with instructions prescribed by the Commission for reporting the expenses of the health maintenance organization during the three months comprising the most recently ended calendar-year quarter. The statement of covered and uncovered expenses shall not be required for any health maintenance organization that reports a capital and surplus amount of at least $4,500,000 on its most recent annual or quarterly financial statement filed with the Commission. 1990, c. 224; 1999, c. 482 ; 2000, c. 503 ; 2006, c. 448 .

Va. Code Ann. § 38.2-4309 Investments

A health maintenance organization may invest in any Category 1 investment as defined in Chapter 14 of this title or any other investment the Commission may permit pursuant to provisions in Chapter 14 (§ 38.2-1400 et seq.) of this title. For investments made prior to July 1, 1998, by a health maintenance organization which is licensed on and after June 30, 1998, July 1, 1998 may be deemed the date of investment. 1980, c. 720, § 38.1-873; 1986, c. 562; 1998, c. 42 .

Va. Code Ann. § 38.2-4310 Protection against insolvency

Each health maintenance organization shall deposit and maintain acceptable securities with the State Treasurer in amounts prescribed by § 38.2-4310.1 . The deposit shall be held as a special fund in trust, as a guarantee that the obligations to the enrollees who are residents of this Commonwealth will be performed. The securities shall be deposited pursuant to a system of book-entry evidencing ownership interests of the securities with transfers of ownership interests effected on the records of a depository and its participants pursuant to rules and procedures established by the depository. Upon a determination of insolvency or action by the Commission pursuant to Chapter 15 (§ 38.2-1500 et seq.), the deposit shall be an asset subject to the provisions of Chapter 15 and shall be used to protect the interests of the health maintenance organization's enrollees and to assure continuation of covered services to enrollees. A health maintenance organization shall be subject to the provisions of Chapter 17 (§ 38.2-1700 et seq.). 1980, c. 720, § 38.1-874; 1986, c. 562; 1989, c. 216; 1990, c. 224; 1992, cc. 14, 20; 2000, c. 503 ; 2014, c. 814 ; 2018, c. 706 ; 2021, Sp. Sess. I, c. 158 .

Va. Code Ann. § 38.2-4310.1 Deposits

A. A health maintenance organization shall make its initial deposit prior to licensure in an amount not less than $300,000. The Commission shall review a health maintenance organization's deposit requirement at least once each year and may require an additional deposit in an amount equal to the greater of (i) the sum of all uncovered expenses for the most recent three months reported in accordance with § 38.2-4307.1 B or (ii) the value of liabilities representing uncovered health care expenses. B. The Commission may reduce or waive, and also may direct the State Treasurer to return, any or all of a deposit requirement whenever the Commission, in its discretion, is satisfied that the assets of the health maintenance organization or its contracts with insurers, health services plans, governments, or other organizations are sufficient to assure the performance of its obligations to enrollees. C. A health maintenance organization that has experienced an operating profit for the two most recent years may request that its deposit requirement be reduced. "Operating profit" shall be determined by reference to the annual statements filed by the health maintenance organization and shall mean the excess of total revenue, excluding net investment income, over total expenses. 2000, c. 503 .

Va. Code Ann. § 38.2-4312 Prohibited practices

A. No health maintenance organization or its representative may cause or knowingly permit the use of (i) advertising that is untrue or misleading, (ii) solicitation that is untrue or misleading, or (iii) any form of evidence of coverage that is deceptive. For the purposes of this chapter: 1. A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect that is or may be significant to an enrollee or person considering enrollment in a health care plan; 2. A statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if the statement or item of information may be understood by a reasonable person who has no special knowledge of health care coverage as indicating (i) a benefit or advantage if that benefit or advantage does not in fact exist or (ii) the absence of any exclusion, limitation or disadvantage of possible significance to an enrollee or person considering enrollment in a health care plan if the absence of that exclusion, limitation, or disadvantage does not in fact exist; consideration shall be given to the total context in which the statement is made or the item of information is communicated; and 3. An evidence of coverage shall be deemed to be deceptive if it causes a reasonable person who has no special knowledge of health care plans to expect benefits, services, charges, or other advantages that the evidence of coverage does not provide or that the health care plan issuing the evidence of coverage does not regularly make available for enrollees covered under the evidence of coverage; consideration shall be given to the evidence of coverage taken as a whole and to the typography, format, and language. B. The provisions of Chapter 5 (§ 38.2-500 et seq.) of this title shall apply to health maintenance organizations, health care plans, and evidences of coverage except to the extent that the Commission determines that the nature of health maintenance organizations, health care plans, and evidences of coverage render any of the provisions clearly inappropriate. C. No health maintenance organization, unless licensed as an insurer, may use in its name, contracts, or literature (i) any of the words "insurance," "casualty," "surety," "mutual," or (ii) any other words descriptive of the insurance, casualty, or surety business or deceptively similar to the name or description of any insurance or fidelity and surety insurer doing business in this Commonwealth. D. No health maintenance organization shall discriminate on the basis of race, creed, color, sex or religion in the selection of health care providers for participation in the organization. E. No health maintenance organization shall unreasonably discriminate against physicians as a class or any class of providers listed in § 38.2-4221 or pharmacists when contracting for specialty or referral practitioners or providers, provided the plan covers services which the members of such classes are licensed to render. Nothing contained in this section shall prevent a health maintenance organization from selecting, in the judgment of the health maintenance organization, the numbers of providers necessary to render the services offered by the health maintenance organization. F. No contract between a health maintenance organization and a provider shall include provisions which require a health care provider or health care provider group to deny covered services that such provider or group knows to be medically necessary and appropriate that are provided with respect to a specific enrollee or group of enrollees with similar medical conditions. 1980, c. 720, § 38.1-876; 1985, c. 588; 1986, c. 562; 1989, c. 221; 1997, c. 297 ; 1998, c. 891 ; 1999, cc. 643 , 649 .

Va. Code Ann. § 38.2-4312.1 Pharmacies; freedom of choice

A. Notwithstanding any other provision in this chapter, no health maintenance organization providing health care plans, or its pharmacy benefits manager, as defined in § 38.2-3465 , shall prohibit any person receiving pharmaceutical benefits, including specialty pharmacy benefits, thereunder from selecting, without limitation, the pharmacy of his choice to furnish such benefits. This right of selection extends to and includes any pharmacy that is not a participating provider under any such health care plan and that has previously notified the health maintenance organization or its pharmacy benefits manager on its own behalf or through an intermediary, by facsimile or otherwise, of its agreement to accept reimbursement for its services at rates applicable to pharmacies that are participating providers, including any copayment consistently imposed by the plan, as payment in full. Each health maintenance organization or its pharmacy benefits manager shall permit prompt electronic or telephonic transmittal of the reimbursement agreement by the pharmacy and ensure prompt verification to the pharmacy of the terms of reimbursement. In no event shall any person receiving a covered pharmacy benefit from a nonparticipating provider that has submitted a reimbursement agreement be responsible for amounts that may be charged by the nonparticipating provider in excess of the copayment and the health maintenance organization's reimbursement applicable to all of its participating pharmacy providers. If a pharmacy has provided notice pursuant to this subsection through an intermediary, the health maintenance organization or its intermediary may elect to respond directly to the pharmacy instead of the intermediary. Nothing in this subsection shall (i) require a health maintenance organization or its intermediary to contract with or to disclose confidential information to a pharmacy's intermediary or (ii) prohibit a health maintenance organization or its intermediary from contracting with or disclosing confidential information to a pharmacy's intermediary. B. No such health maintenance organization or its pharmacy benefits manager shall impose upon any person receiving pharmaceutical benefits furnished under any such health care plan: 1. Any copayment, fee or condition that is not equally imposed upon all individuals in the same benefit category, class or copayment level, whether or not such benefits are furnished by pharmacists who are not participating providers; 2. Any monetary penalty that would affect or influence any such person's choice of pharmacy; or 3. Any reduction in allowable reimbursement for pharmacy services related to utilization of pharmacists who are not participating providers. C. For purposes of this section, a prohibited condition or penalty shall include, without limitation: (i) denying immediate access to electronic claims filing to a pharmacy that is a nonparticipating provider and that has complied with subsection E or (ii) requiring a person receiving pharmacy benefits to make payment at point of service, except to the extent such conditions and penalties are similarly imposed on participating providers. D. The provisions of this section are not applicable to any pharmaceutical benefit covered by a health care plan when those benefits are obtained from a pharmacy wholly owned and operated by, or exclusively operated for, the health maintenance organization providing the health care plan. E. Any pharmacy that wishes to be covered by this section shall, if requested to do so in writing by a health maintenance organization or its pharmacy benefits manager, within 30 days of the pharmacy's receipt of the request, execute and deliver to the health maintenance organization or its pharmacy benefits manager, the direct service agreement or participating provider agreement that the health maintenance organization or its pharmacy benefits manager requires all of its participating providers of pharmacy benefits to execute. Any pharmacy that fails to timely execute and deliver such agreement shall not be covered by this section with respect to that health maintenance organization or its pharmacy benefits manager unless and until the pharmacy executes and delivers the agreement. No pharmacy shall be precluded from obtaining a direct service agreement or participating provider agreement for retail and specialty pharmacy if the pharmacy meets the terms and conditions of participation. Any request by a pharmacy for a direct service agreement or a participating provider agreement shall be acted upon by a health maintenance organization or its pharmacy benefits manager within 60 days of receipt of the pharmacy's request or any subsequent submission of supplemental information if requested by the health maintenance organization or its pharmacy benefits manager. F. The Commission shall have no jurisdiction to adjudicate controversies arising out of this section. G. Nothing in this section shall limit the authority of a health maintenance organization providing health care plans to select a single mail order pharmacy provider as the exclusive provider of pharmacy services that are delivered to the covered person's address by mail, common carrier, or delivery service. The provisions of this section shall not apply to such contracts. As used in this subsection, "mail order pharmacy provider" means a pharmacy permitted to conduct business in the Commonwealth whose primary business is to dispense a prescription drug or device under a prescriptive drug order and to deliver the drug or device to a patient primarily by mail, common carrier, or delivery service. 1994, c. 963 ; 1995, cc. 446 , 467 ; 2010, cc. 157 , 357 ; 2017, c. 615 ; 2021, Sp. Sess. I, c. 229 .

Va. Code Ann. § 38.2-4312.3 Patient access to emergency services

A. A health maintenance organization shall have a system to provide to its members, on a 24-hour basis: (i) access to medical care or (ii) access by telephone to a physician or licensed health care professional with appropriate medical training who can refer or direct a member for prompt medical care in cases where there is an immediate, urgent need or medical emergency. Access to a nonmedical professional who provides appropriate responses to calls from members and providers concerning after-hours care and covered benefits is not sufficient to meet the requirements of this section. B. A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable copayments, deductibles, or coinsurance, for medical screening and stabilization services rendered to meet the requirements of the Federal Emergency Medical Treatment and Active Labor Act (42 U.S.C. § 1395dd) and related to the condition for which the member presented in the hospital emergency facility if (i) the health maintenance organization or its designee or the member's primary care physician or its designee authorized, directed, or referred a member to use the hospital emergency facility; or (ii) the health maintenance organization fails to have a system for provision of 24-hour access in accordance with subsection A above. For purposes of (i) above, a primary care physician may include a physician with whom the primary care physician has made arrangements for on-call backup coverage. C. Each evidence of coverage provided by a health maintenance organization shall include a description of procedures to be followed by the member for emergency services, including: (i) the appropriate use of hospital emergency facilities; (ii) the appropriate use of any urgent care facilities with which the health maintenance organization may contract; (iii) the potential responsibility of the member for payment for nonemergency services rendered in a hospital emergency facility; and (iv) the member's covered benefits for emergency services, including an explanation of the prudent layperson standard included in the definition of emergency services in § 38.2-4300 . D. The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34. 1997, c. 139 ; 2011, c. 882 .

Va. Code Ann. § 38.2-4313 Licensing of agents

Enrollee contracts may be solicited only through life and health insurance agents as provided for in Chapter 18 of this title. Home office salaried officers whose principal duties and responsibilities do not include the negotiation or solicitation of enrollee contracts shall not be required to be licensed. 1980, c. 720, § 38.1-877; 1986, c. 562; 1999, c. 86 .

Va. Code Ann. § 38.2-4314 Powers of insurers and health services plans

A. An insurer or a health services plan licensed in this Commonwealth may, either directly or through a subsidiary or affiliate, organize and operate a health maintenance organization under the provisions of this chapter. Notwithstanding any other law that may be inconsistent with this section, any two or more licensed insurers, health services plans, or their subsidiaries or affiliates, may jointly organize and operate a health maintenance organization. B. An insurer or a health services plan may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of the failure of the health maintenance organization to meet its obligations. The enrollees of a health maintenance organization constitute a permissible group for purposes of laws applicable to insurers and health services plans. Under the contracts the insurer or health services plans may make benefit payments to health maintenance organizations for health care services rendered by providers under the health care plan. 1980, c. 720, § 38.1-878; 1986, c. 562.

Va. Code Ann. § 38.2-4315 Examinations

A. The Commission shall examine the affairs of each health maintenance organization as provided for in § 38.2-1317 at least once every five years. The Commission may examine the affairs of providers with whom any health maintenance organization has contracts, agreements, or other arrangements according to its health care plan as often as it considers necessary for the protection of the interests of the people of this Commonwealth. B. Instead of making its own examination, the Commission may accept the report of an examination of a foreign health maintenance organization certified by the insurance supervisory official, similar regulatory agency, or the state health commissioner of another state. C. The Commission shall coordinate such examinations with the State Health Commissioner to ensure an appropriate level of regulatory oversight and to avoid any undue duplication of effort or regulation. 1980, c. 720, § 38.1-879; 1986, c. 562; 1990, c. 224; 1997, c. 688 .

Va. Code Ann. § 38.2-4316 Suspension or revocation of license

A. The Commission may suspend or revoke any license issued to a health maintenance organization under this chapter if it finds that any of the following conditions exist: 1. The health maintenance organization is operating significantly at variance with its basic organizational document, its health care plan, or in a manner contrary to that described in and reasonably inferred from any other information submitted under § 38.2-4301 , unless amendments to those submissions have been filed with and approved by the Commission; 2. The health maintenance organization issues an evidence of coverage or uses a schedule of charges for health care services that do not comply with the requirements of § 38.2-4306 ; 3. The health care plan does not provide or arrange for basic health care services or limited health care services; 4. The health maintenance organization is no longer financially responsible and a reasonable expectation exists that it may be unable to meet its obligations to enrollees or prospective enrollees; 5. The health maintenance organization has failed to implement a mechanism providing the enrollees with an opportunity to participate in matters of policy and operation as provided in § 38.2-4304 ; 6. The health maintenance organization, or any person on its behalf, has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive, or unfair manner; 7. The continued operation of the health maintenance organization would be hazardous to its enrollees; or 8. The health maintenance organization has otherwise failed to substantially comply with the provisions of this chapter. B. When the license of a health maintenance organization is suspended, the health maintenance organization shall not enroll any additional enrollees during the period of the suspension except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation. C. The Commission shall not revoke or suspend the license of a health maintenance organization upon any of the grounds set out in subsection A of this section until it has given the organization ten days' notice of the proposed revocation or suspension and the grounds for it, and has given the organization an opportunity to introduce evidence and be heard. Any hearing authorized by this section may be informal. The required notice may be waived by the Commission and the health maintenance organization. D. When the license of a health maintenance organization is revoked, the organization shall proceed to wind up its affairs immediately following the effective date of the order of revocation. The health maintenance organization shall conduct no further business except as may be essential to the orderly conclusion of its affairs. It shall engage in no further advertising or solicitation. The Commission may, by written order, permit further operation of the organization that it finds to be in the best interests of enrollees for the purpose of giving them the greatest practical opportunity to obtain continuing health care coverage. 1980, c. 720, § 38.1-880; 1986, c. 562; 1992, c. 481; 1998, c. 891 .

Va. Code Ann. § 38.2-4318 License renewals

A. Each health maintenance organization licensed under this chapter shall renew its license with the Commission annually by July 1. The renewal license shall not be issued until the health maintenance organization has paid all fees and charges imposed on it and has complied with all other requirements of law. B. The Commission shall not fail or refuse to renew the license of any health maintenance organization without first giving the health maintenance organization ten days' notice of its intention not to renew the license and giving it an opportunity to be heard and to introduce evidence on its behalf. Any such hearing may be informal. The required notice may be waived by the Commission and the health maintenance organization. 1980, c. 720, § 38.1-883; 1986, c. 562; 1987, c. 519.

Va. Code Ann. § 38.2-4319 Statutory construction and relationship to other laws

A. No provisions of this title except this chapter and, insofar as they are not inconsistent with this chapter, §§ 38.2-100 , 38.2-136 , 38.2-200 , 38.2-203 , 38.2-209 through 38.2-213 , 38.2-216 , 38.2-218 through 38.2-225 , 38.2-229 , 38.2-232 , 38.2-305 , 38.2-316 , 38.2-316.1 , 38.2-316.2 , 38.2-322 , 38.2-325 , 38.2-326 , 38.2-400 , 38.2-402 through 38.2-413 , 38.2-500 through 38.2-515 , 38.2-600 through 38.2-629 , Chapter 9 (§ 38.2-900 et seq.), §§ 38.2-1016.1 through 38.2-1023 , 38.2-1057 , and 38.2-1306.1 , Article 2 (§ 38.2-1306.2 et seq.), § 38.2-1315.1 , and Articles 3.1 (§ 38.2-1316.1 et seq.), 4 (§ 38.2-1317 et seq.), 5 (§ 38.2-1322 et seq.), 5.1 (§ 38.2-1334.3 et seq.), and 5.2 (§ 38.2-1334.11 et seq.) of Chapter 13, Articles 1 (§ 38.2-1400 et seq.), 2 (§ 38.2-1412 et seq.), and 4 (§ 38.2-1446 et seq.) of Chapter 14, Chapter 15 (§ 38.2-1500 et seq.), Chapter 17 (§ 38.2-1700 et seq.), §§ 38.2-1800 through 38.2-1836 , 38.2-3401 , 38.2-3405 , 38.2-3405.1 , 38.2-3406.1 , 38.2-3407.2 through 38.2-3407.6:1 , 38.2-3407.9 through 38.2-3407.20 , 38.2-3411 , 38.2-3411.2 , 38.2-3411.3 , 38.2-3411.4 , 38.2-3412.1 , 38.2-3414.1 , 38.2-3418.1 through 38.2-3418.19 , 38.2-3418.21 , 38.2-3418.22 , 38.2-3418.23, and 38.2-3430.1 through 38.2-3454 , Articles 8 (§ 38.2-3461 et seq.) and 9 (§ 38.2-3465 et seq.) of Chapter 34, § 38.2-3500 , subdivision 13 of § 38.2-3503 , subdivision 8 of § 38.2-3504 , §§ 38.2-3514.1 , 38.2-3514.2 , 38.2-3522.1 through 38.2-3523.4 , 38.2-3525 , 38.2-3540.1 , 38.2-3540.2 , 38.2-3541.2 , 38.2-3542 , and 38.2-3543.2 , Article 5 (§ 38.2-3551 et seq.) of Chapter 35, Chapter 35.1 (§ 38.2-3556 et seq.), § 38.2-3610 , Chapter 52 (§ 38.2-5200 et seq.), Chapter 55 (§ 38.2-5500 et seq.), Chapter 58 (§ 38.2-5800 et seq.), Chapter 65 (§ 38.2-6500 et seq.), and Chapter 66 (§ 38.2-6600 et seq.) shall be applicable to any health maintenance organization granted a license under this chapter. This chapter shall not apply to an insurer or health services plan licensed and regulated in conformance with the insurance laws or Chapter 42 (§ 38.2-4200 et seq.) except with respect to the activities of its health maintenance organization. B. For plans administered by the Department of Medical Assistance Services that provide benefits pursuant to Title XIX or Title XXI of the Social Security Act, as amended, no provisions of this title except this chapter and, insofar as they are not inconsistent with this chapter, §§ 38.2-100 , 38.2-136 , 38.2-200 , 38.2-203 , 38.2-209 through 38.2-213 , 38.2-216 , 38.2-218 through 38.2-225 , 38.2-229 , 38.2-232 , 38.2-322 , 38.2-325 , 38.2-400 , 38.2-402 through 38.2-413 , 38.2-500 through 38.2-515 , and 38.2-600 through 38.2-629 , Chapter 9 (§ 38.2-900 et seq.), §§ 38.2-1016.1 through 38.2-1023 , 38.2-1057 , and 38.2-1306.1 , Article 2 (§ 38.2-1306.2 et seq.), § 38.2-1315.1 , Articles 3.1 (§ 38.2-1316.1 et seq.), 4 (§ 38.2-1317 et seq.), 5 (§ 38.2-1322 et seq.), 5.1 (§ 38.2-1334.3 et seq.), and 5.2 (§ 38.2-1334.11 et seq.) of Chapter 13, Articles 1 (§ 38.2-1400 et seq.), 2 (§ 38.2-1412 et seq.), and 4 (§ 38.2-1446 et seq.) of Chapter 14, §§ 38.2-3401 , 38.2-3405 , 38.2-3407.2 through 38.2-3407.5 , 38.2-3407.6 , 38.2-3407.6:1 , 38.2-3407.9 , 38.2-3407.9:01 , and 38.2-3407.9:02 , subsection E of § 38.2-3407.10 , §§ 38.2-3407.10:1 , 38.2-3407.11 , 38.2-3407.11:3 , 38.2-3407.13 , 38.2-3407.13:1 , 38.2-3407.14 , 38.2-3407.23, 38.2-3411.2 , 38.2-3418.1 , 38.2-3418.2 , 38.2-3418.16 , 38.2-3430.1 through 38.2-3437 , and 38.2-3500 , subdivision 13 of § 38.2-3503 , subdivision 8 of § 38.2-3504 , §§ 38.2-3514.1 , 38.2-3514.2 , 38.2-3522.1 through 38.2-3523.4 , 38.2-3525 , 38.2-3540.1 , 38.2-3540.2 , 38.2-3541.2 , 38.2-3542 , and 38.2-3543.2 , Chapter 52 (§ 38.2-5200 et seq.), Chapter 55 (§ 38.2-5500 et seq.), Chapter 58 (§ 38.2-5800 et seq.), Chapter 65 (§ 38.2-6500 et seq.), and Chapter 66 (§ 38.2-6600 et seq.) shall be applicable to any health maintenance organization granted a license under this chapter. This chapter shall not apply to an insurer or health services plan licensed and regulated in conformance with the insurance laws or Chapter 42 (§ 38.2-4200 et seq.) except with respect to the activities of its health maintenance organization. C. Solicitation of enrollees by a licensed health maintenance organization or by its representatives shall not be construed to violate any provisions of law relating to solicitation or advertising by health professionals. D. A licensed health maintenance organization shall not be deemed to be engaged in the unlawful practice of medicine. All health care providers associated with a health maintenance organization shall be subject to all provisions of law. E. Notwithstanding the definition of an eligible employee as set forth in § 38.2-3431 , a health maintenance organization providing health care plans pursuant to § 38.2-3431 shall not be required to offer coverage to or accept applications from an employee who does not reside within the health maintenance organization's service area. F. For purposes of applying this section, "insurer" when used in a section cited in subsections A and B shall be construed to mean and include "health maintenance organizations" unless the section cited clearly applies to health maintenance organizations without such construction. 1980, c. 720, § 38.1-887; 1985, c. 588; 1986, c. 562; 1989, cc. 646, 653; 1990, cc. 301, 393, 439, 531, 826; 1991, cc. 103, 369; 1992, cc. 14, 23, 800; 1993, cc. 148, 158, 306, 307; 1994, cc. 213 , 320 , 374 , 522 , 699 ; 1995, cc. 80 , 420 , 522 , 537 ; 1996, cc. 22 , 155 , 201 , 550 , 611 , 776 , 967 ; 1997, cc. 688 , 807 , 913 ; 1998, cc. 42 , 43 , 56 , 120 , 154 , 625 , 631 , 709 , 858 , 891 , 908 ; 1999, cc. 35 , 643 , 649 , 709 , 739 , 856 , 857 , 858 , 923 , 941 ; 2000, cc. 50 , 157 , 187 , 460 , 465 , 496 , 503 , 532 , 922 ; 2001, c. 663 ; 2002, c. 153 ; 2003, c. 243 ; 2004, cc. 156 , 315 , 772 ; 2006, cc. 427 , 866 ; 2007, cc. 488 , 579 ; 2009, cc. 796 , 839 ; 2010, cc. 222 , 272 , 504 , 515 , 583 , 687 , 734 ; 2011, cc. 788 , 876 , 878 , 882 ; 2012, cc. 634 , 641 ; 2013, cc. 653 , 670 , 679 , 751 ; 2014, cc. 248 , 814 ; 2015, cc. 14 , 649 , 723 ; 2016, c. 475 ; 2017, c. 643 ; 2018, c. 706 ; 2019, cc. 661 , 662 , 666 , 684 ; 2020, cc. 214 , 215 , 217 , 218 , 219 , 264 , 916 , 917 , 1094 , 1161 , 1288 ; 2020, Sp. Sess. I, cc. 44 , 53 ; 2021, Sp. Sess. I, cc. 161 , 480 ; 2023, cc. 473 , 490 ; 2024, cc. 319 , 345 , 377 ; 2025, c. 8 ; 2026, cc. 138 , 139 , 187 , 188 , 955 .

Va. Code Ann. § 38.2-4320 Authority of Commonwealth to contract with health maintenance organizations

This Commonwealth is authorized to enter into contracts with health maintenance organizations on behalf of its employees and the citizens of the Commonwealth, including contracts to furnish health care services to recipients of medical assistance under Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. 1980, c. 720, § 38.1-889; 1986, c. 562.

Va. Code Ann. § 38.2-4320.1 Explanation of benefits for health maintenance organization enrollees who are recipients of medical assistance services or covered by the Family Access to Medical Insurance Security (FAMIS) Plan

In the case of any health maintenance organization that has contracted with the Virginia Department of Medical Assistance Services to provide health care services to recipients of medical assistance services pursuant to Title XIX of the Social Security Act, as amended, or to individuals who are covered by the Family Access to Medical Insurance Security (FAMIS) Plan developed pursuant to Title XXI of the Social Security Act, as amended, the requirements for furnishing an explanation of benefits to current or former members and their respective health care providers shall be as authorized and directed in the standards prescribed in the state plan for medical assistance services pursuant to Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 and the FAMIS Plan pursuant to Chapter 13 (§ 32.1-351 et seq.) of Title 32.1. The requirements for an explanation of benefits otherwise addressed in this title shall not apply to such health maintenance organization when contracting to deliver such services to the extent that the statutory requirements differ from the standards of the Department of Medical Assistance Services. 2004, c. 185 .

Va. Code Ann. § 38.2-4321 Health maintenance organization affected by chapter

Except as otherwise provided by law, no health maintenance organization shall be operated in this Commonwealth other than in the manner set forth in this chapter. 1980, c. 720, § 38.1-890; 1986, c. 562.

Va. Code Ann. § 38.2-4322 Affiliation period

A. A health maintenance organization which offers health insurance coverage in connection with a group health plan or group health insurance coverage and which does not impose any preexisting condition exclusion allowed under § 38.2-3432.3 , with respect to any particular coverage option may impose an affiliation period for such coverage option, but only if: 1. Such period is applied uniformly without regard to any health status-related factors; and 2. Such period does not exceed two months (or three months in the case of a late enrollee). B. An affiliation period as described in subsection A shall begin on the enrollment date. C. An affiliation period under a plan shall run concurrently with any waiting period under the plan. D. Defined terms as set forth in § 38.2-3431 which are used in this chapter shall have the same meaning here that they have in Chapter 34. 1997, cc. 807 , 913 .

Va. Code Ann. § 38.2-4323 Alternative methods

A health maintenance organization may use alternative methods to an affiliation period to address adverse selection provided that they are approved by the Commission prior to their use. 1997, cc. 807 , 913 .
Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://law.lis.virginia.gov/vacode/title38.2/chapter43/Fetched: 10/16/2026

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