{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/2.2-2818.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/2.2-2818.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/2.2-2818.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/2.2-2818.html"}],"law_id":68317,"edition_id":1,"section_id":68317,"structure_id":14612,"section_number":"2.2-2818","catch_line":"Health and related insurance for state employees","history":"1970, c. 557, \u00a7 2.1-20.1; 1972, c. 803; 1973, cc. 69, 297; 1978, c. 70; 1984, c. 430; 1988, c. 634; 1989, cc. 559, 664; 1990, c. 607; 1993, c. 138; 1995, c. 353; 1996, cc. 155, 201, 905, 1046; 1997, cc. 43, 468, 521, 656; 1998, cc. 35, 56, 257, 386, 631, 709, 851, 858, 875; 1999, cc. 643, 649, 921, 941; 2000, cc. 66, 149, 465, 534, 657, 720, 888; 2001, cc. 334, 558, 663, 844; 2004, cc. 156, 279, 855; 2005, cc. 503, 572, 640, 739; 2006, c. 396; 2008, c. 420; 2009, cc. 247, 317, 813, 840; 2010, cc. 157, 357, 443; 2012, cc. 60, 201; 2013, c. 709; 2014, c. 631; 2015, cc. 38, 730; 2023, cc. 182, 183; 2025, cc. 237, 246.","full_text":"A\n\nThe Department of Human Resource Management shall establish a plan, subject to the approval of the Governor, for providing health insurance coverage, including chiropractic treatment, hospitalization, medical, surgical, and major medical coverage, for state employees and retired state employees with the Commonwealth paying the cost thereof to the extent of the coverage included in such plan. The same plan shall be offered to all part-time state employees, but the total cost shall be paid by such part-time employees. The Department of Human Resource Management shall administer this section. The plan chosen shall provide means whereby coverage for the families or dependents of state employees may be purchased. Except for part-time employees, the Commonwealth may pay all or a portion of the cost thereof, and for such portion as the Commonwealth does not pay, the employee, including a part-time employee, may purchase the coverage by paying the additional cost over the cost of coverage for an employee.\n\t\t\tSuch contribution shall be financed through appropriations provided by law.B\n\nThe plan shall:1\n\nInclude coverage for low-dose screening mammograms for determining the presence of occult breast cancer. Such coverage shall make available one screening mammogram to persons age 35 through 39, one such mammogram biennially to persons age 40 through 49, and one such mammogram annually to persons age 50 and over and may be limited to a benefit of $50 per mammogram subject to such dollar limits, deductibles, and coinsurance factors as are no less favorable than for physical illness generally.\n\t\t\t\tThe term “mammogram” shall mean an X-ray examination of the breast using equipment dedicated specifically for mammography, including but not limited to the X-ray tube, filter, compression device, screens, film, and cassettes, with an average radiation exposure of less than one rad mid-breast, two views of each breast.\n\t\t\t\tIn order to be considered a screening mammogram for which coverage shall be made available under this section:\n\t\t\t\ta. The mammogram shall be (i) ordered by a health care practitioner acting within the scope of his licensure and, in the case of an enrollee of a health maintenance organization, by the health maintenance organization provider; (ii) performed by a registered technologist; (iii) interpreted by a qualified radiologist; and (iv) performed under the direction of a person licensed to practice medicine and surgery and certified by the American Board of Radiology or an equivalent examining body. A copy of the mammogram report shall be sent or delivered to the health care practitioner who ordered it;\n\t\t\t\tb. The equipment used to perform the mammogram shall meet the standards set forth by the Virginia Department of Health in its radiation protection regulations; and\n\t\t\t\tc. The mammography film shall be retained by the radiologic facility performing the examination in accordance with the American College of Radiology guidelines or state law.2\n\nInclude coverage for postpartum services providing inpatient care and a home visit or visits that shall be in accordance with the medical criteria, outlined in the most current version of or an official update to the “Guidelines for Perinatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists or the “Standards for Obstetric-Gynecologic Services” prepared by the American College of Obstetricians and Gynecologists. Such coverage shall be provided incorporating any changes in such Guidelines or Standards within six months of the publication of such Guidelines or Standards or any official amendment thereto.3\n\nInclude an appeals process for resolution of complaints that shall provide reasonable procedures for the resolution of such complaints and shall be published and disseminated to all covered state employees. The appeals process shall be compliant with federal rules and regulations governing nonfederal, self-insured governmental health plans. The appeals process shall include a separate expedited emergency appeals procedure that shall provide resolution within time frames established by federal law. For appeals involving adverse decisions as defined in § 32.1-137.7, the Department shall contract with one or more independent review organizations to review such decisions. Independent review organizations are entities that conduct independent external review of adverse benefit determinations. The Department shall adopt regulations to assure that the independent review organization conducting the reviews has adequate standards, credentials and experience for such review. The independent review organization shall examine the final denial of claims to determine whether the decision is objective, clinically valid, and compatible with established principles of health care. The decision of the independent review organization shall (i) be in writing, (ii) contain findings of fact as to the material issues in the case and the basis for those findings, and (iii) be final and binding if consistent with law and policy.\n\t\t\t\tPrior to assigning an appeal to an independent review organization, the Department shall verify that the independent review organization conducting the review of a denial of claims has no relationship or association with (i) the covered person or the covered person’s authorized representative; (ii) the treating health care provider, or any of its employees or affiliates; (iii) the medical care facility at which the covered service would be provided, or any of its employees or affiliates; or (iv) the development or manufacture of the drug, device, procedure, or other therapy that is the subject of the final denial of a claim. The independent review organization shall not be a subsidiary of, nor owned or controlled by, a health plan, a trade association of health plans, or a professional association of health care providers. There shall be no liability on the part of and no cause of action shall arise against any officer or employee of an independent review organization for any actions taken or not taken or statements made by such officer or employee in good faith in the performance of his powers and duties.4\n\nInclude coverage for early intervention services. For purposes of this section, “early intervention services” means medically necessary speech and language therapy, occupational therapy, physical therapy and assistive technology services and devices for dependents from birth to age three who are certified by the Department of Behavioral Health and Developmental Services as eligible for services under Part H of the Individuals with Disabilities Education Act (20 U.S.C. § 1471 et seq.). Medically necessary early intervention services for the population certified by the Department of Behavioral Health and Developmental Services shall mean those services designed to help an individual attain or retain the capability to function age-appropriately within his environment, and shall include services that enhance functional ability without effecting a cure.\n\t\t\t\tFor persons previously covered under the plan, there shall be no denial of coverage due to the existence of a preexisting condition. The cost of early intervention services shall not be applied to any contractual provision limiting the total amount of coverage paid by the insurer to or on behalf of the insured during the insured’s lifetime.5\n\nInclude coverage for prescription drugs and devices approved by the United States Food and Drug Administration for use as contraceptives.6\n\nNot deny coverage for any drug approved by the United States Food and Drug Administration for use in the treatment of cancer on the basis that the drug has not been approved by the United States Food and Drug Administration for the treatment of the specific type of cancer for which the drug has been prescribed, if the drug has been recognized as safe and effective for treatment of that specific type of cancer in one of the standard reference compendia.7\n\nNot deny coverage for any drug prescribed to treat a covered indication so long as the drug has been approved by the United States Food and Drug Administration for at least one indication and the drug is recognized for treatment of the covered indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature.8\n\nInclude coverage for equipment, supplies, and outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and noninsulin-using diabetes if prescribed by a health care professional legally authorized to prescribe such items under law. To qualify for coverage under this subdivision, diabetes outpatient self-management training and education shall be provided by a certified, registered, or licensed health care professional.9\n\nInclude coverage for reconstructive breast surgery. For purposes of this section, “reconstructive breast surgery” means surgery performed on and after July 1, 1998, (i) coincident with a mastectomy performed for breast cancer or (ii) following a mastectomy performed for breast cancer to reestablish symmetry between the two breasts. For persons previously covered under the plan, there shall be no denial of coverage due to preexisting conditions.10\n\nInclude coverage for annual pap smears, including coverage, on and after July 1, 1999, for annual testing performed by any FDA-approved gynecologic cytology screening technologies.11\n\nInclude coverage providing a minimum stay in the hospital of not less than 48 hours for a patient following a radical or modified radical mastectomy and 24 hours of inpatient care following a total mastectomy or a partial mastectomy with lymph node dissection for treatment of breast cancer. Nothing in this subdivision shall be construed as requiring the provision of inpatient coverage where the attending physician in consultation with the patient determines that a shorter period of hospital stay is appropriate.12\n\nInclude coverage (i) to persons age 50 and over and (ii) to persons age 40 and over who are at high risk for prostate cancer, according to the most recent published guidelines of the American Cancer Society, for one prostate-specific antigen test in a 12-month period and digital rectal examinations.13\n\nPermit any individual covered under the plan direct access to the health care services of a participating specialist (i) authorized to provide services under the plan and (ii) selected by the covered individual. The plan shall have a procedure by which an individual who has an ongoing special condition may, after consultation with the primary care physician, receive a referral to a specialist for such condition who shall be responsible for and capable of providing and coordinating the individual’s primary and specialty care related to the initial specialty care referral. If such an individual’s care would most appropriately be coordinated by such a specialist, the plan shall refer the individual to a specialist. For the purposes of this subdivision, “special condition” means a condition or disease that is (i) life-threatening, degenerative, or disabling and (ii) requires specialized medical care over a prolonged period of time. Within the treatment period authorized by the referral, such specialist shall be permitted to treat the individual without a further referral from the individual’s primary care provider and may authorize such referrals, procedures, tests, and other medical services related to the initial referral as the individual’s primary care provider would otherwise be permitted to provide or authorize. The plan shall have a procedure by which an individual who has an ongoing special condition that requires ongoing care from a specialist may receive a standing referral to such specialist for the treatment of the special condition. If the primary care provider, in consultation with the plan and the specialist, if any, determines that such a standing referral is appropriate, the plan or issuer shall make such a referral to a specialist. Nothing contained herein shall prohibit the plan from requiring a participating specialist to provide written notification to the covered individual’s primary care physician of any visit to such specialist. Such notification may include a description of the health care services rendered at the time of the visit.14\n\nInclude provisions allowing employees to continue receiving health care services for a period of up to 90 days from the date of the primary care physician’s notice of termination from any of the plan’s provider panels. The plan shall notify any provider at least 90 days prior to the date of termination of the provider, except when the provider is terminated for cause.\n\t\t\t\tFor a period of at least 90 days from the date of the notice of a provider’s termination from any of the plan’s provider panels, except when a provider is terminated for cause, a provider shall be permitted by the plan to render health care services to any of the covered employees who (i) were in an active course of treatment from the provider prior to the notice of termination and (ii) request to continue receiving health care services from the provider.\n\t\t\t\tNotwithstanding the provisions of this subdivision, any provider shall be permitted by the plan to continue rendering health services to any covered employee who has entered the second trimester of pregnancy at the time of the provider’s termination of participation, except when a provider is terminated for cause. Such treatment shall, at the covered employee’s option, continue through the provision of postpartum care directly related to the delivery.\n\t\t\t\tNotwithstanding the provisions of this subdivision, any provider shall be permitted to continue rendering health services to any covered employee who is determined to be terminally ill (as defined under § 1861(dd)(3)(A) of the Social Security Act) at the time of a provider’s termination of participation, except when a provider is terminated for cause. Such treatment shall, at the covered employee’s option, continue for the remainder of the employee’s life for care directly related to the treatment of the terminal illness.\n\t\t\t\tA provider who continues to render health care services pursuant to this subdivision shall be reimbursed in accordance with the carrier’s agreement with such provider existing immediately before the provider’s termination of participation.15\n\nInclude coverage for patient costs incurred during participation in clinical trials for treatment studies on cancer, including ovarian cancer trials.\n\t\t\t\tThe reimbursement for patient costs incurred during participation in clinical trials for treatment studies on cancer shall be determined in the same manner as reimbursement is determined for other medical and surgical procedures. Such coverage shall have durational limits, dollar limits, deductibles, copayments, and coinsurance factors that are no less favorable than for physical illness generally.\n\t\t\t\tFor purposes of this subdivision:\n\t\t\t\t“Cooperative group” means a formal network of facilities that collaborate on research projects and have an established NIH-approved peer review program operating within the group. “Cooperative group” includes (i) the National Cancer Institute Clinical Cooperative Group and (ii) the National Cancer Institute Community Clinical Oncology Program.\n\t\t\t\t“FDA” means the Federal Food and Drug Administration.\n\t\t\t\t“Multiple project assurance contract” means a contract between an institution and the federal Department of Health and Human Services that defines the relationship of the institution to the federal Department of Health and Human Services and sets out the responsibilities of the institution and the procedures that will be used by the institution to protect human subjects.\n\t\t\t\t“NCI” means the National Cancer Institute.\n\t\t\t\t“NIH” means the National Institutes of Health.\n\t\t\t\t“Patient” means a person covered under the plan established pursuant to this section.\n\t\t\t\t“Patient cost” means the cost of a medically necessary health care service that is incurred as a result of the treatment being provided to a patient for purposes of a clinical trial. “Patient cost” does not include (i) the cost of nonhealth care services that a patient may be required to receive as a result of the treatment being provided for purposes of a clinical trial, (ii) costs associated with managing the research associated with the clinical trial, or (iii) the cost of the investigational drug or device.\n\t\t\t\tCoverage for patient costs incurred during clinical trials for treatment studies on cancer shall be provided if the treatment is being conducted in a Phase II, Phase III, or Phase IV clinical trial. Such treatment may, however, be provided on a case-by-case basis if the treatment is being provided in a Phase I clinical trial.\n\t\t\t\tThe treatment described in the previous paragraph shall be provided by a clinical trial approved by:\n\t\t\t\ta. The National Cancer Institute;\n\t\t\t\tb. An NCI cooperative group or an NCI center;\n\t\t\t\tc. The FDA in the form of an investigational new drug application;\n\t\t\t\td. The federal Department of Veterans Affairs; or\n\t\t\t\te. An institutional review board of an institution in the Commonwealth that has a multiple project assurance contract approved by the Office of Protection from Research Risks of the NCI.\n\t\t\t\tThe facility and personnel providing the treatment shall be capable of doing so by virtue of their experience, training, and expertise.\n\t\t\t\tCoverage under this subdivision shall apply only if:1\n\nThere is no clearly superior, noninvestigational treatment alternative;2\n\nThe available clinical or preclinical data provide a reasonable expectation that the treatment will be at least as effective as the noninvestigational alternative; and3\n\nThe patient and the physician or health care provider who provides services to the patient under the plan conclude that the patient’s participation in the clinical trial would be appropriate, pursuant to procedures established by the plan.16\n\nInclude coverage providing a minimum stay in the hospital of not less than 23 hours for a covered employee following a laparoscopy-assisted vaginal hysterectomy and 48 hours for a covered employee following a vaginal hysterectomy, as outlined in Milliman & Robertson’s nationally recognized guidelines. Nothing in this subdivision shall be construed as requiring the provision of the total hours referenced when the attending physician, in consultation with the covered employee, determines that a shorter hospital stay is appropriate.17\n\nInclude coverage for biologically based mental illness.\n\t\t\t\tFor purposes of this subdivision, a “biologically based mental illness” is any mental or nervous condition caused by a biological disorder of the brain that results in a clinically significant syndrome that substantially limits the person’s functioning; specifically, the following diagnoses are defined as biologically based mental illness as they apply to adults and children: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, panic disorder, obsessive-compulsive disorder, attention deficit hyperactivity disorder, autism, and drug and alcoholism addiction.\n\t\t\t\tCoverage for biologically based mental illnesses shall neither be different nor separate from coverage for any other illness, condition, or disorder for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayment and coinsurance factors.\n\t\t\t\tNothing shall preclude the undertaking of usual and customary procedures to determine the appropriateness of, and medical necessity for, treatment of biologically based mental illnesses under this option, provided that all such appropriateness and medical necessity determinations are made in the same manner as those determinations made for the treatment of any other illness, condition, or disorder covered by such policy or contract.18\n\nOffer and make available coverage for the treatment of morbid obesity through gastric bypass surgery or such other methods as may be recognized by the National Institutes of Health as effective for the long-term reversal of morbid obesity. Such coverage shall have durational limits, dollar limits, deductibles, copayments, and coinsurance factors that are no less favorable than for physical illness generally. Access to surgery for morbid obesity shall not be restricted based upon dietary or any other criteria not approved by the National Institutes of Health. For purposes of this subdivision, “morbid obesity” means (i) a weight that is at least 100 pounds over or twice the ideal weight for frame, age, height, and gender as specified in the 1983 Metropolitan Life Insurance tables, (ii) a body mass index (BMI) equal to or greater than 35 kilograms per meter squared with comorbidity or coexisting medical conditions such as hypertension, cardiopulmonary conditions, sleep apnea, or diabetes, or (iii) a BMI of 40 kilograms per meter squared without such comorbidity. As used herein, “BMI” equals weight in kilograms divided by height in meters squared.19\n\nInclude coverage for colorectal cancer screening, specifically screening with an annual fecal occult blood test, flexible sigmoidoscopy or colonoscopy, or in appropriate circumstances radiologic imaging, in accordance with the most recently published recommendations established by the American College of Gastroenterology, in consultation with the American Cancer Society, for the ages, family histories, and frequencies referenced in such recommendations. The coverage for colorectal cancer screening shall not be more restrictive than or separate from coverage provided for any other illness, condition, or disorder for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayments and coinsurance factors.20\n\nOn and after July 1, 2002, require that a prescription benefit card, health insurance benefit card, or other technology that complies with the requirements set forth in § 38.2-3407.4:2 be issued to each employee provided coverage pursuant to this section, and shall upon any changes in the required data elements set forth in subsection A of § 38.2-3407.4:2, either reissue the card or provide employees covered under the plan such corrective information as may be required to electronically process a prescription claim.21\n\nInclude coverage for infant hearing screenings and all necessary audiological examinations provided pursuant to § 32.1-64.1 using any technology approved by the United States Food and Drug Administration, and as recommended by the national Joint Committee on Infant Hearing in its most current position statement addressing early hearing detection and intervention programs. Such coverage shall include follow-up audiological examinations as recommended by a physician, a physician assistant, an advanced practice registered nurse, or an audiologist and performed by a licensed audiologist to confirm the existence or absence of hearing loss.22\n\nNotwithstanding any provision of this section to the contrary, every plan established in accordance with this section shall comply with the provisions of § 2.2-2818.2.C\n\nClaims incurred during a fiscal year but not reported during that fiscal year shall be paid from such funds as shall be appropriated by law. Appropriations, premiums, and other payments shall be deposited in the employee health insurance fund, from which payments for claims, premiums, cost containment programs, and administrative expenses shall be withdrawn from time to time. The funds of the health insurance fund shall be deemed separate and independent trust funds, shall be segregated from all other funds of the Commonwealth, and shall be invested and administered solely in the interests of the employees and their beneficiaries. Neither the General Assembly nor any public officer, employee, or agency shall use or authorize the use of such trust funds for any purpose other than as provided in law for benefits, refunds, and administrative expenses, including but not limited to legislative oversight of the health insurance fund.D\n\nFor the purposes of this section:\n\t\t\t“Peer-reviewed medical literature” means a scientific study published only after having been critically reviewed for scientific accuracy, validity, and reliability by unbiased independent experts in a journal that has been determined by the International Committee of Medical Journal Editors to have met the Uniform Requirements for Manuscripts submitted to biomedical journals. “Peer-reviewed medical literature” does not include publications or supplements to publications that are sponsored to a significant extent by a pharmaceutical manufacturing company or health carrier.\n\t\t\t“Standard reference compendia” means:1\n\nAmerican Hospital Formulary Service Drug Information;2\n\nNational Comprehensive Cancer Network’s Drugs & Biologics Compendium; or3\n\nElsevier Gold Standard’s Clinical Pharmacology.\n\t\t\t\t“State employee” means state employee as defined in § 51.1-124.3; employee as defined in § 51.1-201; the Governor, Lieutenant Governor and Attorney General; judge as defined in § 51.1-301 and judges, clerks, and deputy clerks of regional juvenile and domestic relations, county juvenile and domestic relations, and district courts of the Commonwealth; interns and residents employed by the School of Medicine and Hospital of the University of Virginia, and interns, residents, and employees of the Virginia Commonwealth University Health System Authority as provided in § 23.1-2415; and employees of the Virginia Alcoholic Beverage Control Authority as provided in § 4.1-101.05.E\n\nProvisions shall be made for retired employees to obtain coverage under the above plan, including, as an option, coverage for vision and dental care. The Commonwealth may, but shall not be obligated to, pay all or any portion of the cost thereof.F\n\nAny self-insured group health insurance plan established by the Department of Human Resource Management that utilizes a network of preferred providers shall not exclude any physician solely on the basis of a reprimand or censure from the Board of Medicine, so long as the physician otherwise meets the plan criteria established by the Department.G\n\nThe plan shall include, in each planning district, at least two health coverage options, each sponsored by unrelated entities. No later than July 1, 2006, one of the health coverage options to be available in each planning district shall be a high deductible health plan that would qualify for a health savings account pursuant to § 223 of the Internal Revenue Code of 1986, as amended.\n\t\t\tIn each planning district that does not have an available health coverage alternative, the Department shall voluntarily enter into negotiations at any time with any health coverage provider who seeks to provide coverage under the plan.\n\t\t\tThis subsection shall not apply to any state agency authorized by the Department to establish and administer its own health insurance coverage plan separate from the plan established by the Department.H\n\nAny self-insured group health insurance plan established by the Department of Human Resource Management that includes coverage for prescription drugs on an outpatient basis may apply a formulary to the prescription drug benefits provided by the plan if the formulary is developed, reviewed at least annually, and updated as necessary in consultation with and with the approval of a pharmacy and therapeutics committee, a majority of whose members are actively practicing licensed (i) pharmacists, (ii) physicians, and (iii) other health care providers.\n\t\t\tIf the plan maintains one or more drug formularies, the plan shall establish a process to allow a person to obtain, without additional cost-sharing beyond that provided for formulary prescription drugs in the plan, a specific, medically necessary nonformulary prescription drug if, after reasonable investigation and consultation with the prescriber, the formulary drug is determined to be an inappropriate therapy for the medical condition of the person. The plan shall act on such requests within one business day of receipt of the request.\n\t\t\tAny plan established in accordance with this section shall be authorized to provide for the selection of 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. 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.I\n\nAny plan established in accordance with this section requiring preauthorization prior to rendering medical treatment shall have personnel available to provide authorization at all times when such preauthorization is required.J\n\nAny plan established in accordance with this section shall provide to all covered employees written notice of any benefit reductions during the contract period at least 30 days before such reductions become effective.K\n\nNo contract between a provider and any plan established in accordance with this section shall include provisions that 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 covered employee with similar medical conditions.L\n\nThe Department of Human Resource Management shall appoint an Ombudsman to promote and protect the interests of covered employees under any state employee’s health plan.\n\t\t\tThe Ombudsman shall:1\n\nAssist covered employees in understanding their rights and the processes available to them according to their state health plan.2\n\nAnswer inquiries from covered employees by telephone and electronic mail.3\n\nProvide to covered employees information concerning the state health plans.4\n\nDevelop information on the types of health plans available, including benefits and complaint procedures and appeals.5\n\nMake available, either separately or through an existing Internet web site utilized by the Department of Human Resource Management, information as set forth in subdivision 4 and such additional information as he deems appropriate.6\n\nMaintain data on inquiries received, the types of assistance requested, any actions taken and the disposition of each such matter.7\n\nUpon request, assist covered employees in using the procedures and processes available to them from their health plan, including all appeal procedures. Such assistance may require the review of health care records of a covered employee, which shall be done only in accordance with the federal Health Insurance Portability and Accountability Act privacy rules. The confidentiality of any such medical records shall be maintained in accordance with the confidentiality and disclosure laws of the Commonwealth.8\n\nEnsure that covered employees have access to the services provided by the Ombudsman and that the covered employees receive timely responses from the Ombudsman or his representatives to the inquiries.9\n\nReport annually on his activities to the standing committees of the General Assembly having jurisdiction over insurance and over health and the Joint Commission on Health Care by December 1 of each year.M\n\nThe plan established in accordance with this section shall not refuse to accept or make reimbursement pursuant to an assignment of benefits made to a dentist or oral surgeon by a covered employee.\n\t\t\tFor purposes of this subsection, “assignment of benefits” means the transfer of dental care coverage reimbursement benefits or other rights under the plan. The assignment of benefits shall not be effective until the covered employee notifies the plan in writing of the assignment.N\n\nBeginning July 1, 2006, any plan established pursuant to this section shall provide for an identification number, which shall be assigned to the covered employee and shall not be the same as the employee’s social security number.O\n\nAny group health insurance plan established by the Department of Human Resource Management that contains a coordination of benefits provision shall provide written notification to any eligible employee as a prominent part of its enrollment materials that if such eligible employee is covered under another group accident and sickness insurance policy, group accident and sickness subscription contract, or group health care plan for health care services, that insurance policy, subscription contract, or health care plan may have primary responsibility for the covered expenses of other family members enrolled with the eligible employee. Such written notification shall describe generally the conditions upon which the other coverage would be primary for dependent children enrolled under the eligible employee’s coverage and the method by which the eligible enrollee may verify from the plan that coverage would have primary responsibility for the covered expenses of each family member.P\n\nAny plan established by the Department of Human Resource Management pursuant to this section shall provide that coverage under such plan for family members enrolled under a participating state employee’s coverage shall continue for a period of at least 30 days following the death of such state employee.Q\n\nThe plan established in accordance with this section that follows a policy of sending its payment to the covered employee or covered family member for a claim for services received from a nonparticipating physician or osteopath shall (i) include language in the member handbook that notifies the covered employee of the responsibility to apply the plan payment to the claim from such nonparticipating provider, (ii) include this language with any such payment sent to the covered employee or covered family member, and (iii) include the name and any last known address of the nonparticipating provider on the explanation of benefits statement.R\n\nThe plan established by the Department of Human Resource Management pursuant to this section shall provide that coverage under such plan for an incapacitated child enrolled under a participating state employee’s coverage shall be valid without regard to whether such child lives with the covered employee as a member of the employee’s household so long as the child is dependent upon the employee for more than half of the child’s financial support and the child is receiving residential support services.\n\t\t\tFor purposes of this subsection, “incapacitated child” means an adult child who is incapacitated due to a physical or mental health condition that existed prior to the termination of coverage due to such child attaining the limiting age under the plan for eligible children dependents.S\n\nThe Department of Human Resource Management shall report annually, by November 30 of each year, on cost and utilization information for each of the mandated benefits set forth in subsection B, including any mandated benefit made applicable, pursuant to subdivision B 22, to any plan established pursuant to this section. The report shall be in the same detail and form as required of reports submitted pursuant to § 38.2-3419.1, with such additional information as is required to determine the financial impact, including the costs and benefits, of the particular mandated benefit.","order_by":null,"text":{"0":{"id":247139,"text":"The Department of Human Resource Management shall establish a plan, subject to the approval of the Governor, for providing health insurance coverage, including chiropractic treatment, hospitalization, medical, surgical, and major medical coverage, for state employees and retired state employees with the Commonwealth paying the cost thereof to the extent of the coverage included in such plan. The same plan shall be offered to all part-time state employees, but the total cost shall be paid by such part-time employees. The Department of Human Resource Management shall administer this section. The plan chosen shall provide means whereby coverage for the families or dependents of state employees may be purchased. Except for part-time employees, the Commonwealth may pay all or a portion of the cost thereof, and for such portion as the Commonwealth does not pay, the employee, including a part-time employee, may purchase the coverage by paying the additional cost over the cost of coverage for an employee.\n\t\t\tSuch contribution shall be financed through appropriations provided by law.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":247140,"text":"The plan shall:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"B1"},"2":{"id":247141,"text":"Include coverage for low-dose screening mammograms for determining the presence of occult breast cancer. Such coverage shall make available one screening mammogram to persons age 35 through 39, one such mammogram biennially to persons age 40 through 49, and one such mammogram annually to persons age 50 and over and may be limited to a benefit of $50 per mammogram subject to such dollar limits, deductibles, and coinsurance factors as are no less favorable than for physical illness generally.\n\t\t\t\tThe term “mammogram” shall mean an X-ray examination of the breast using equipment dedicated specifically for mammography, including but not limited to the X-ray tube, filter, compression device, screens, film, and cassettes, with an average radiation exposure of less than one rad mid-breast, two views of each breast.\n\t\t\t\tIn order to be considered a screening mammogram for which coverage shall be made available under this section:\n\t\t\t\ta. The mammogram shall be (i) ordered by a health care practitioner acting within the scope of his licensure and, in the case of an enrollee of a health maintenance organization, by the health maintenance organization provider; (ii) performed by a registered technologist; (iii) interpreted by a qualified radiologist; and (iv) performed under the direction of a person licensed to practice medicine and surgery and certified by the American Board of Radiology or an equivalent examining body. A copy of the mammogram report shall be sent or delivered to the health care practitioner who ordered it;\n\t\t\t\tb. The equipment used to perform the mammogram shall meet the standards set forth by the Virginia Department of Health in its radiation protection regulations; and\n\t\t\t\tc. The mammography film shall be retained by the radiologic facility performing the examination in accordance with the American College of Radiology guidelines or state law.","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B2"},"3":{"id":247142,"text":"Include coverage for postpartum services providing inpatient care and a home visit or visits that shall be in accordance with the medical criteria, outlined in the most current version of or an official update to the “Guidelines for Perinatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists or the “Standards for Obstetric-Gynecologic Services” prepared by the American College of Obstetricians and Gynecologists. Such coverage shall be provided incorporating any changes in such Guidelines or Standards within six months of the publication of such Guidelines or Standards or any official amendment thereto.","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B1","next_prefix":"B3"},"4":{"id":247143,"text":"Include an appeals process for resolution of complaints that shall provide reasonable procedures for the resolution of such complaints and shall be published and disseminated to all covered state employees. The appeals process shall be compliant with federal rules and regulations governing nonfederal, self-insured governmental health plans. The appeals process shall include a separate expedited emergency appeals procedure that shall provide resolution within time frames established by federal law. For appeals involving adverse decisions as defined in § 32.1-137.7, the Department shall contract with one or more independent review organizations to review such decisions. Independent review organizations are entities that conduct independent external review of adverse benefit determinations. The Department shall adopt regulations to assure that the independent review organization conducting the reviews has adequate standards, credentials and experience for such review. The independent review organization shall examine the final denial of claims to determine whether the decision is objective, clinically valid, and compatible with established principles of health care. The decision of the independent review organization shall (i) be in writing, (ii) contain findings of fact as to the material issues in the case and the basis for those findings, and (iii) be final and binding if consistent with law and policy.\n\t\t\t\tPrior to assigning an appeal to an independent review organization, the Department shall verify that the independent review organization conducting the review of a denial of claims has no relationship or association with (i) the covered person or the covered person’s authorized representative; (ii) the treating health care provider, or any of its employees or affiliates; (iii) the medical care facility at which the covered service would be provided, or any of its employees or affiliates; or (iv) the development or manufacture of the drug, device, procedure, or other therapy that is the subject of the final denial of a claim. The independent review organization shall not be a subsidiary of, nor owned or controlled by, a health plan, a trade association of health plans, or a professional association of health care providers. There shall be no liability on the part of and no cause of action shall arise against any officer or employee of an independent review organization for any actions taken or not taken or statements made by such officer or employee in good faith in the performance of his powers and duties.","type":"section","prefixes":["B","3"],"prefix":"3","entire_prefix":"B3","prefix_anchor":"B3","level":2,"prior_prefix":"B2","next_prefix":"B4"},"5":{"id":247144,"text":"Include coverage for early intervention services. For purposes of this section, “early intervention services” means medically necessary speech and language therapy, occupational therapy, physical therapy and assistive technology services and devices for dependents from birth to age three who are certified by the Department of Behavioral Health and Developmental Services as eligible for services under Part H of the Individuals with Disabilities Education Act (20 U.S.C. § 1471 et seq.). Medically necessary early intervention services for the population certified by the Department of Behavioral Health and Developmental Services shall mean those services designed to help an individual attain or retain the capability to function age-appropriately within his environment, and shall include services that enhance functional ability without effecting a cure.\n\t\t\t\tFor persons previously covered under the plan, there shall be no denial of coverage due to the existence of a preexisting condition. The cost of early intervention services shall not be applied to any contractual provision limiting the total amount of coverage paid by the insurer to or on behalf of the insured during the insured’s lifetime.","type":"section","prefixes":["B","4"],"prefix":"4","entire_prefix":"B4","prefix_anchor":"B4","level":2,"prior_prefix":"B3","next_prefix":"B5"},"6":{"id":247145,"text":"Include coverage for prescription drugs and devices approved by the United States Food and Drug Administration for use as contraceptives.","type":"section","prefixes":["B","5"],"prefix":"5","entire_prefix":"B5","prefix_anchor":"B5","level":2,"prior_prefix":"B4","next_prefix":"B6"},"7":{"id":247146,"text":"Not deny coverage for any drug approved by the United States Food and Drug Administration for use in the treatment of cancer on the basis that the drug has not been approved by the United States Food and Drug Administration for the treatment of the specific type of cancer for which the drug has been prescribed, if the drug has been recognized as safe and effective for treatment of that specific type of cancer in one of the standard reference compendia.","type":"section","prefixes":["B","6"],"prefix":"6","entire_prefix":"B6","prefix_anchor":"B6","level":2,"prior_prefix":"B5","next_prefix":"B7"},"8":{"id":247147,"text":"Not deny coverage for any drug prescribed to treat a covered indication so long as the drug has been approved by the United States Food and Drug Administration for at least one indication and the drug is recognized for treatment of the covered indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature.","type":"section","prefixes":["B","7"],"prefix":"7","entire_prefix":"B7","prefix_anchor":"B7","level":2,"prior_prefix":"B6","next_prefix":"B8"},"9":{"id":247148,"text":"Include coverage for equipment, supplies, and outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and noninsulin-using diabetes if prescribed by a health care professional legally authorized to prescribe such items under law. To qualify for coverage under this subdivision, diabetes outpatient self-management training and education shall be provided by a certified, registered, or licensed health care professional.","type":"section","prefixes":["B","8"],"prefix":"8","entire_prefix":"B8","prefix_anchor":"B8","level":2,"prior_prefix":"B7","next_prefix":"B9"},"10":{"id":247149,"text":"Include coverage for reconstructive breast surgery. For purposes of this section, “reconstructive breast surgery” means surgery performed on and after July 1, 1998, (i) coincident with a mastectomy performed for breast cancer or (ii) following a mastectomy performed for breast cancer to reestablish symmetry between the two breasts. For persons previously covered under the plan, there shall be no denial of coverage due to preexisting conditions.","type":"section","prefixes":["B","9"],"prefix":"9","entire_prefix":"B9","prefix_anchor":"B9","level":2,"prior_prefix":"B8","next_prefix":"B10"},"11":{"id":247150,"text":"Include coverage for annual pap smears, including coverage, on and after July 1, 1999, for annual testing performed by any FDA-approved gynecologic cytology screening technologies.","type":"section","prefixes":["B","10"],"prefix":"10","entire_prefix":"B10","prefix_anchor":"B10","level":2,"prior_prefix":"B9","next_prefix":"B11"},"12":{"id":247151,"text":"Include coverage providing a minimum stay in the hospital of not less than 48 hours for a patient following a radical or modified radical mastectomy and 24 hours of inpatient care following a total mastectomy or a partial mastectomy with lymph node dissection for treatment of breast cancer. Nothing in this subdivision shall be construed as requiring the provision of inpatient coverage where the attending physician in consultation with the patient determines that a shorter period of hospital stay is appropriate.","type":"section","prefixes":["B","11"],"prefix":"11","entire_prefix":"B11","prefix_anchor":"B11","level":2,"prior_prefix":"B10","next_prefix":"B12"},"13":{"id":247152,"text":"Include coverage (i) to persons age 50 and over and (ii) to persons age 40 and over who are at high risk for prostate cancer, according to the most recent published guidelines of the American Cancer Society, for one prostate-specific antigen test in a 12-month period and digital rectal examinations.","type":"section","prefixes":["B","12"],"prefix":"12","entire_prefix":"B12","prefix_anchor":"B12","level":2,"prior_prefix":"B11","next_prefix":"B13"},"14":{"id":247153,"text":"Permit any individual covered under the plan direct access to the health care services of a participating specialist (i) authorized to provide services under the plan and (ii) selected by the covered individual. The plan shall have a procedure by which an individual who has an ongoing special condition may, after consultation with the primary care physician, receive a referral to a specialist for such condition who shall be responsible for and capable of providing and coordinating the individual’s primary and specialty care related to the initial specialty care referral. If such an individual’s care would most appropriately be coordinated by such a specialist, the plan shall refer the individual to a specialist. For the purposes of this subdivision, “special condition” means a condition or disease that is (i) life-threatening, degenerative, or disabling and (ii) requires specialized medical care over a prolonged period of time. Within the treatment period authorized by the referral, such specialist shall be permitted to treat the individual without a further referral from the individual’s primary care provider and may authorize such referrals, procedures, tests, and other medical services related to the initial referral as the individual’s primary care provider would otherwise be permitted to provide or authorize. The plan shall have a procedure by which an individual who has an ongoing special condition that requires ongoing care from a specialist may receive a standing referral to such specialist for the treatment of the special condition. If the primary care provider, in consultation with the plan and the specialist, if any, determines that such a standing referral is appropriate, the plan or issuer shall make such a referral to a specialist. Nothing contained herein shall prohibit the plan from requiring a participating specialist to provide written notification to the covered individual’s primary care physician of any visit to such specialist. Such notification may include a description of the health care services rendered at the time of the visit.","type":"section","prefixes":["B","13"],"prefix":"13","entire_prefix":"B13","prefix_anchor":"B13","level":2,"prior_prefix":"B12","next_prefix":"B14"},"15":{"id":247154,"text":"Include provisions allowing employees to continue receiving health care services for a period of up to 90 days from the date of the primary care physician’s notice of termination from any of the plan’s provider panels. The plan shall notify any provider at least 90 days prior to the date of termination of the provider, except when the provider is terminated for cause.\n\t\t\t\tFor a period of at least 90 days from the date of the notice of a provider’s termination from any of the plan’s provider panels, except when a provider is terminated for cause, a provider shall be permitted by the plan to render health care services to any of the covered employees who (i) were in an active course of treatment from the provider prior to the notice of termination and (ii) request to continue receiving health care services from the provider.\n\t\t\t\tNotwithstanding the provisions of this subdivision, any provider shall be permitted by the plan to continue rendering health services to any covered employee who has entered the second trimester of pregnancy at the time of the provider’s termination of participation, except when a provider is terminated for cause. Such treatment shall, at the covered employee’s option, continue through the provision of postpartum care directly related to the delivery.\n\t\t\t\tNotwithstanding the provisions of this subdivision, any provider shall be permitted to continue rendering health services to any covered employee who is determined to be terminally ill (as defined under § 1861(dd)(3)(A) of the Social Security Act) at the time of a provider’s termination of participation, except when a provider is terminated for cause. Such treatment shall, at the covered employee’s option, continue for the remainder of the employee’s life for care directly related to the treatment of the terminal illness.\n\t\t\t\tA provider who continues to render health care services pursuant to this subdivision shall be reimbursed in accordance with the carrier’s agreement with such provider existing immediately before the provider’s termination of participation.","type":"section","prefixes":["B","14"],"prefix":"14","entire_prefix":"B14","prefix_anchor":"B14","level":2,"prior_prefix":"B13","next_prefix":"B15"},"16":{"id":247155,"text":"Include coverage for patient costs incurred during participation in clinical trials for treatment studies on cancer, including ovarian cancer trials.\n\t\t\t\tThe reimbursement for patient costs incurred during participation in clinical trials for treatment studies on cancer shall be determined in the same manner as reimbursement is determined for other medical and surgical procedures. Such coverage shall have durational limits, dollar limits, deductibles, copayments, and coinsurance factors that are no less favorable than for physical illness generally.\n\t\t\t\tFor purposes of this subdivision:\n\t\t\t\t“Cooperative group” means a formal network of facilities that collaborate on research projects and have an established NIH-approved peer review program operating within the group. “Cooperative group” includes (i) the National Cancer Institute Clinical Cooperative Group and (ii) the National Cancer Institute Community Clinical Oncology Program.\n\t\t\t\t“FDA” means the Federal Food and Drug Administration.\n\t\t\t\t“Multiple project assurance contract” means a contract between an institution and the federal Department of Health and Human Services that defines the relationship of the institution to the federal Department of Health and Human Services and sets out the responsibilities of the institution and the procedures that will be used by the institution to protect human subjects.\n\t\t\t\t“NCI” means the National Cancer Institute.\n\t\t\t\t“NIH” means the National Institutes of Health.\n\t\t\t\t“Patient” means a person covered under the plan established pursuant to this section.\n\t\t\t\t“Patient cost” means the cost of a medically necessary health care service that is incurred as a result of the treatment being provided to a patient for purposes of a clinical trial. “Patient cost” does not include (i) the cost of nonhealth care services that a patient may be required to receive as a result of the treatment being provided for purposes of a clinical trial, (ii) costs associated with managing the research associated with the clinical trial, or (iii) the cost of the investigational drug or device.\n\t\t\t\tCoverage for patient costs incurred during clinical trials for treatment studies on cancer shall be provided if the treatment is being conducted in a Phase II, Phase III, or Phase IV clinical trial. Such treatment may, however, be provided on a case-by-case basis if the treatment is being provided in a Phase I clinical trial.\n\t\t\t\tThe treatment described in the previous paragraph shall be provided by a clinical trial approved by:\n\t\t\t\ta. The National Cancer Institute;\n\t\t\t\tb. An NCI cooperative group or an NCI center;\n\t\t\t\tc. The FDA in the form of an investigational new drug application;\n\t\t\t\td. The federal Department of Veterans Affairs; or\n\t\t\t\te. An institutional review board of an institution in the Commonwealth that has a multiple project assurance contract approved by the Office of Protection from Research Risks of the NCI.\n\t\t\t\tThe facility and personnel providing the treatment shall be capable of doing so by virtue of their experience, training, and expertise.\n\t\t\t\tCoverage under this subdivision shall apply only if:","type":"section","prefixes":["B","15"],"prefix":"15","entire_prefix":"B15","prefix_anchor":"B15","level":2,"prior_prefix":"B14","next_prefix":"B151"},"17":{"id":247156,"text":"There is no clearly superior, noninvestigational treatment alternative;","type":"section","prefixes":["B","15","1"],"prefix":"1","entire_prefix":"B151","prefix_anchor":"B151","level":3,"prior_prefix":"B15","next_prefix":"B152"},"18":{"id":247157,"text":"The available clinical or preclinical data provide a reasonable expectation that the treatment will be at least as effective as the noninvestigational alternative; and","type":"section","prefixes":["B","15","2"],"prefix":"2","entire_prefix":"B152","prefix_anchor":"B152","level":3,"prior_prefix":"B151","next_prefix":"B153"},"19":{"id":247158,"text":"The patient and the physician or health care provider who provides services to the patient under the plan conclude that the patient’s participation in the clinical trial would be appropriate, pursuant to procedures established by the plan.","type":"section","prefixes":["B","15","3"],"prefix":"3","entire_prefix":"B153","prefix_anchor":"B153","level":3,"prior_prefix":"B152","next_prefix":"B16"},"20":{"id":247159,"text":"Include coverage providing a minimum stay in the hospital of not less than 23 hours for a covered employee following a laparoscopy-assisted vaginal hysterectomy and 48 hours for a covered employee following a vaginal hysterectomy, as outlined in Milliman & Robertson’s nationally recognized guidelines. Nothing in this subdivision shall be construed as requiring the provision of the total hours referenced when the attending physician, in consultation with the covered employee, determines that a shorter hospital stay is appropriate.","type":"section","prefixes":["B","16"],"prefix":"16","entire_prefix":"B16","prefix_anchor":"B16","level":2,"prior_prefix":"B153","next_prefix":"B17"},"21":{"id":247160,"text":"Include coverage for biologically based mental illness.\n\t\t\t\tFor purposes of this subdivision, a “biologically based mental illness” is any mental or nervous condition caused by a biological disorder of the brain that results in a clinically significant syndrome that substantially limits the person’s functioning; specifically, the following diagnoses are defined as biologically based mental illness as they apply to adults and children: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, panic disorder, obsessive-compulsive disorder, attention deficit hyperactivity disorder, autism, and drug and alcoholism addiction.\n\t\t\t\tCoverage for biologically based mental illnesses shall neither be different nor separate from coverage for any other illness, condition, or disorder for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayment and coinsurance factors.\n\t\t\t\tNothing shall preclude the undertaking of usual and customary procedures to determine the appropriateness of, and medical necessity for, treatment of biologically based mental illnesses under this option, provided that all such appropriateness and medical necessity determinations are made in the same manner as those determinations made for the treatment of any other illness, condition, or disorder covered by such policy or contract.","type":"section","prefixes":["B","17"],"prefix":"17","entire_prefix":"B17","prefix_anchor":"B17","level":2,"prior_prefix":"B16","next_prefix":"B18"},"22":{"id":247161,"text":"Offer and make available coverage for the treatment of morbid obesity through gastric bypass surgery or such other methods as may be recognized by the National Institutes of Health as effective for the long-term reversal of morbid obesity. Such coverage shall have durational limits, dollar limits, deductibles, copayments, and coinsurance factors that are no less favorable than for physical illness generally. Access to surgery for morbid obesity shall not be restricted based upon dietary or any other criteria not approved by the National Institutes of Health. For purposes of this subdivision, “morbid obesity” means (i) a weight that is at least 100 pounds over or twice the ideal weight for frame, age, height, and gender as specified in the 1983 Metropolitan Life Insurance tables, (ii) a body mass index (BMI) equal to or greater than 35 kilograms per meter squared with comorbidity or coexisting medical conditions such as hypertension, cardiopulmonary conditions, sleep apnea, or diabetes, or (iii) a BMI of 40 kilograms per meter squared without such comorbidity. As used herein, “BMI” equals weight in kilograms divided by height in meters squared.","type":"section","prefixes":["B","18"],"prefix":"18","entire_prefix":"B18","prefix_anchor":"B18","level":2,"prior_prefix":"B17","next_prefix":"B19"},"23":{"id":247162,"text":"Include coverage for colorectal cancer screening, specifically screening with an annual fecal occult blood test, flexible sigmoidoscopy or colonoscopy, or in appropriate circumstances radiologic imaging, in accordance with the most recently published recommendations established by the American College of Gastroenterology, in consultation with the American Cancer Society, for the ages, family histories, and frequencies referenced in such recommendations. The coverage for colorectal cancer screening shall not be more restrictive than or separate from coverage provided for any other illness, condition, or disorder for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayments and coinsurance factors.","type":"section","prefixes":["B","19"],"prefix":"19","entire_prefix":"B19","prefix_anchor":"B19","level":2,"prior_prefix":"B18","next_prefix":"B20"},"24":{"id":247163,"text":"On and after July 1, 2002, require that a prescription benefit card, health insurance benefit card, or other technology that complies with the requirements set forth in § 38.2-3407.4:2 be issued to each employee provided coverage pursuant to this section, and shall upon any changes in the required data elements set forth in subsection A of § 38.2-3407.4:2, either reissue the card or provide employees covered under the plan such corrective information as may be required to electronically process a prescription claim.","type":"section","prefixes":["B","20"],"prefix":"20","entire_prefix":"B20","prefix_anchor":"B20","level":2,"prior_prefix":"B19","next_prefix":"B21"},"25":{"id":247164,"text":"Include coverage for infant hearing screenings and all necessary audiological examinations provided pursuant to § 32.1-64.1 using any technology approved by the United States Food and Drug Administration, and as recommended by the national Joint Committee on Infant Hearing in its most current position statement addressing early hearing detection and intervention programs. Such coverage shall include follow-up audiological examinations as recommended by a physician, a physician assistant, an advanced practice registered nurse, or an audiologist and performed by a licensed audiologist to confirm the existence or absence of hearing loss.","type":"section","prefixes":["B","21"],"prefix":"21","entire_prefix":"B21","prefix_anchor":"B21","level":2,"prior_prefix":"B20","next_prefix":"B22"},"26":{"id":247165,"text":"Notwithstanding any provision of this section to the contrary, every plan established in accordance with this section shall comply with the provisions of § 2.2-2818.2.","type":"section","prefixes":["B","22"],"prefix":"22","entire_prefix":"B22","prefix_anchor":"B22","level":2,"prior_prefix":"B21","next_prefix":"C"},"27":{"id":247166,"text":"Claims incurred during a fiscal year but not reported during that fiscal year shall be paid from such funds as shall be appropriated by law. Appropriations, premiums, and other payments shall be deposited in the employee health insurance fund, from which payments for claims, premiums, cost containment programs, and administrative expenses shall be withdrawn from time to time. The funds of the health insurance fund shall be deemed separate and independent trust funds, shall be segregated from all other funds of the Commonwealth, and shall be invested and administered solely in the interests of the employees and their beneficiaries. Neither the General Assembly nor any public officer, employee, or agency shall use or authorize the use of such trust funds for any purpose other than as provided in law for benefits, refunds, and administrative expenses, including but not limited to legislative oversight of the health insurance fund.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B22","next_prefix":"D"},"28":{"id":247167,"text":"For the purposes of this section:\n\t\t\t“Peer-reviewed medical literature” means a scientific study published only after having been critically reviewed for scientific accuracy, validity, and reliability by unbiased independent experts in a journal that has been determined by the International Committee of Medical Journal Editors to have met the Uniform Requirements for Manuscripts submitted to biomedical journals. “Peer-reviewed medical literature” does not include publications or supplements to publications that are sponsored to a significant extent by a pharmaceutical manufacturing company or health carrier.\n\t\t\t“Standard reference compendia” means:","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"D1"},"29":{"id":247168,"text":"American Hospital Formulary Service Drug Information;","type":"section","prefixes":["D","1"],"prefix":"1","entire_prefix":"D1","prefix_anchor":"D1","level":2,"prior_prefix":"D","next_prefix":"D2"},"30":{"id":247169,"text":"National Comprehensive Cancer Network’s Drugs & Biologics Compendium; or","type":"section","prefixes":["D","2"],"prefix":"2","entire_prefix":"D2","prefix_anchor":"D2","level":2,"prior_prefix":"D1","next_prefix":"D3"},"31":{"id":247170,"text":"Elsevier Gold Standard’s Clinical Pharmacology.\n\t\t\t\t“State employee” means state employee as defined in § 51.1-124.3; employee as defined in § 51.1-201; the Governor, Lieutenant Governor and Attorney General; judge as defined in § 51.1-301 and judges, clerks, and deputy clerks of regional juvenile and domestic relations, county juvenile and domestic relations, and district courts of the Commonwealth; interns and residents employed by the School of Medicine and Hospital of the University of Virginia, and interns, residents, and employees of the Virginia Commonwealth University Health System Authority as provided in § 23.1-2415; and employees of the Virginia Alcoholic Beverage Control Authority as provided in § 4.1-101.05.","type":"section","prefixes":["D","3"],"prefix":"3","entire_prefix":"D3","prefix_anchor":"D3","level":2,"prior_prefix":"D2","next_prefix":"E"},"32":{"id":247171,"text":"Provisions shall be made for retired employees to obtain coverage under the above plan, including, as an option, coverage for vision and dental care. The Commonwealth may, but shall not be obligated to, pay all or any portion of the cost thereof.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D3","next_prefix":"F"},"33":{"id":247172,"text":"Any self-insured group health insurance plan established by the Department of Human Resource Management that utilizes a network of preferred providers shall not exclude any physician solely on the basis of a reprimand or censure from the Board of Medicine, so long as the physician otherwise meets the plan criteria established by the Department.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"34":{"id":247173,"text":"The plan shall include, in each planning district, at least two health coverage options, each sponsored by unrelated entities. No later than July 1, 2006, one of the health coverage options to be available in each planning district shall be a high deductible health plan that would qualify for a health savings account pursuant to § 223 of the Internal Revenue Code of 1986, as amended.\n\t\t\tIn each planning district that does not have an available health coverage alternative, the Department shall voluntarily enter into negotiations at any time with any health coverage provider who seeks to provide coverage under the plan.\n\t\t\tThis subsection shall not apply to any state agency authorized by the Department to establish and administer its own health insurance coverage plan separate from the plan established by the Department.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F","next_prefix":"H"},"35":{"id":247174,"text":"Any self-insured group health insurance plan established by the Department of Human Resource Management that includes coverage for prescription drugs on an outpatient basis may apply a formulary to the prescription drug benefits provided by the plan if the formulary is developed, reviewed at least annually, and updated as necessary in consultation with and with the approval of a pharmacy and therapeutics committee, a majority of whose members are actively practicing licensed (i) pharmacists, (ii) physicians, and (iii) other health care providers.\n\t\t\tIf the plan maintains one or more drug formularies, the plan shall establish a process to allow a person to obtain, without additional cost-sharing beyond that provided for formulary prescription drugs in the plan, a specific, medically necessary nonformulary prescription drug if, after reasonable investigation and consultation with the prescriber, the formulary drug is determined to be an inappropriate therapy for the medical condition of the person. The plan shall act on such requests within one business day of receipt of the request.\n\t\t\tAny plan established in accordance with this section shall be authorized to provide for the selection of 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. 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.","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G","next_prefix":"I"},"36":{"id":247175,"text":"Any plan established in accordance with this section requiring preauthorization prior to rendering medical treatment shall have personnel available to provide authorization at all times when such preauthorization is required.","type":"section","prefixes":["I"],"prefix":"I","entire_prefix":"I","prefix_anchor":"I","level":1,"prior_prefix":"H","next_prefix":"J"},"37":{"id":247176,"text":"Any plan established in accordance with this section shall provide to all covered employees written notice of any benefit reductions during the contract period at least 30 days before such reductions become effective.","type":"section","prefixes":["J"],"prefix":"J","entire_prefix":"J","prefix_anchor":"J","level":1,"prior_prefix":"I","next_prefix":"K"},"38":{"id":247177,"text":"No contract between a provider and any plan established in accordance with this section shall include provisions that 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 covered employee with similar medical conditions.","type":"section","prefixes":["K"],"prefix":"K","entire_prefix":"K","prefix_anchor":"K","level":1,"prior_prefix":"J","next_prefix":"L"},"39":{"id":247178,"text":"The Department of Human Resource Management shall appoint an Ombudsman to promote and protect the interests of covered employees under any state employee’s health plan.\n\t\t\tThe Ombudsman shall:","type":"section","prefixes":["L"],"prefix":"L","entire_prefix":"L","prefix_anchor":"L","level":1,"prior_prefix":"K","next_prefix":"L1"},"40":{"id":247179,"text":"Assist covered employees in understanding their rights and the processes available to them according to their state health plan.","type":"section","prefixes":["L","1"],"prefix":"1","entire_prefix":"L1","prefix_anchor":"L1","level":2,"prior_prefix":"L","next_prefix":"L2"},"41":{"id":247180,"text":"Answer inquiries from covered employees by telephone and electronic mail.","type":"section","prefixes":["L","2"],"prefix":"2","entire_prefix":"L2","prefix_anchor":"L2","level":2,"prior_prefix":"L1","next_prefix":"L3"},"42":{"id":247181,"text":"Provide to covered employees information concerning the state health plans.","type":"section","prefixes":["L","3"],"prefix":"3","entire_prefix":"L3","prefix_anchor":"L3","level":2,"prior_prefix":"L2","next_prefix":"L4"},"43":{"id":247182,"text":"Develop information on the types of health plans available, including benefits and complaint procedures and appeals.","type":"section","prefixes":["L","4"],"prefix":"4","entire_prefix":"L4","prefix_anchor":"L4","level":2,"prior_prefix":"L3","next_prefix":"L5"},"44":{"id":247183,"text":"Make available, either separately or through an existing Internet web site utilized by the Department of Human Resource Management, information as set forth in subdivision 4 and such additional information as he deems appropriate.","type":"section","prefixes":["L","5"],"prefix":"5","entire_prefix":"L5","prefix_anchor":"L5","level":2,"prior_prefix":"L4","next_prefix":"L6"},"45":{"id":247184,"text":"Maintain data on inquiries received, the types of assistance requested, any actions taken and the disposition of each such matter.","type":"section","prefixes":["L","6"],"prefix":"6","entire_prefix":"L6","prefix_anchor":"L6","level":2,"prior_prefix":"L5","next_prefix":"L7"},"46":{"id":247185,"text":"Upon request, assist covered employees in using the procedures and processes available to them from their health plan, including all appeal procedures. Such assistance may require the review of health care records of a covered employee, which shall be done only in accordance with the federal Health Insurance Portability and Accountability Act privacy rules. The confidentiality of any such medical records shall be maintained in accordance with the confidentiality and disclosure laws of the Commonwealth.","type":"section","prefixes":["L","7"],"prefix":"7","entire_prefix":"L7","prefix_anchor":"L7","level":2,"prior_prefix":"L6","next_prefix":"L8"},"47":{"id":247186,"text":"Ensure that covered employees have access to the services provided by the Ombudsman and that the covered employees receive timely responses from the Ombudsman or his representatives to the inquiries.","type":"section","prefixes":["L","8"],"prefix":"8","entire_prefix":"L8","prefix_anchor":"L8","level":2,"prior_prefix":"L7","next_prefix":"L9"},"48":{"id":247187,"text":"Report annually on his activities to the standing committees of the General Assembly having jurisdiction over insurance and over health and the Joint Commission on Health Care by December 1 of each year.","type":"section","prefixes":["L","9"],"prefix":"9","entire_prefix":"L9","prefix_anchor":"L9","level":2,"prior_prefix":"L8","next_prefix":"M"},"49":{"id":247188,"text":"The plan established in accordance with this section shall not refuse to accept or make reimbursement pursuant to an assignment of benefits made to a dentist or oral surgeon by a covered employee.\n\t\t\tFor purposes of this subsection, “assignment of benefits” means the transfer of dental care coverage reimbursement benefits or other rights under the plan. The assignment of benefits shall not be effective until the covered employee notifies the plan in writing of the assignment.","type":"section","prefixes":["M"],"prefix":"M","entire_prefix":"M","prefix_anchor":"M","level":1,"prior_prefix":"L9","next_prefix":"N"},"50":{"id":247189,"text":"Beginning July 1, 2006, any plan established pursuant to this section shall provide for an identification number, which shall be assigned to the covered employee and shall not be the same as the employee’s social security number.","type":"section","prefixes":["N"],"prefix":"N","entire_prefix":"N","prefix_anchor":"N","level":1,"prior_prefix":"M","next_prefix":"O"},"51":{"id":247190,"text":"Any group health insurance plan established by the Department of Human Resource Management that contains a coordination of benefits provision shall provide written notification to any eligible employee as a prominent part of its enrollment materials that if such eligible employee is covered under another group accident and sickness insurance policy, group accident and sickness subscription contract, or group health care plan for health care services, that insurance policy, subscription contract, or health care plan may have primary responsibility for the covered expenses of other family members enrolled with the eligible employee. Such written notification shall describe generally the conditions upon which the other coverage would be primary for dependent children enrolled under the eligible employee’s coverage and the method by which the eligible enrollee may verify from the plan that coverage would have primary responsibility for the covered expenses of each family member.","type":"section","prefixes":["O"],"prefix":"O","entire_prefix":"O","prefix_anchor":"O","level":1,"prior_prefix":"N","next_prefix":"P"},"52":{"id":247191,"text":"Any plan established by the Department of Human Resource Management pursuant to this section shall provide that coverage under such plan for family members enrolled under a participating state employee’s coverage shall continue for a period of at least 30 days following the death of such state employee.","type":"section","prefixes":["P"],"prefix":"P","entire_prefix":"P","prefix_anchor":"P","level":1,"prior_prefix":"O","next_prefix":"Q"},"53":{"id":247192,"text":"The plan established in accordance with this section that follows a policy of sending its payment to the covered employee or covered family member for a claim for services received from a nonparticipating physician or osteopath shall (i) include language in the member handbook that notifies the covered employee of the responsibility to apply the plan payment to the claim from such nonparticipating provider, (ii) include this language with any such payment sent to the covered employee or covered family member, and (iii) include the name and any last known address of the nonparticipating provider on the explanation of benefits statement.","type":"section","prefixes":["Q"],"prefix":"Q","entire_prefix":"Q","prefix_anchor":"Q","level":1,"prior_prefix":"P","next_prefix":"R"},"54":{"id":247193,"text":"The plan established by the Department of Human Resource Management pursuant to this section shall provide that coverage under such plan for an incapacitated child enrolled under a participating state employee’s coverage shall be valid without regard to whether such child lives with the covered employee as a member of the employee’s household so long as the child is dependent upon the employee for more than half of the child’s financial support and the child is receiving residential support services.\n\t\t\tFor purposes of this subsection, “incapacitated child” means an adult child who is incapacitated due to a physical or mental health condition that existed prior to the termination of coverage due to such child attaining the limiting age under the plan for eligible children dependents.","type":"section","prefixes":["R"],"prefix":"R","entire_prefix":"R","prefix_anchor":"R","level":1,"prior_prefix":"Q","next_prefix":"S"},"55":{"id":247194,"text":"The Department of Human Resource Management shall report annually, by November 30 of each year, on cost and utilization information for each of the mandated benefits set forth in subsection B, including any mandated benefit made applicable, pursuant to subdivision B 22, to any plan established pursuant to this section. The report shall be in the same detail and form as required of reports submitted pursuant to § 38.2-3419.1, with such additional information as is required to determine the financial impact, including the costs and benefits, of the particular mandated benefit.","type":"section","prefixes":["S"],"prefix":"S","entire_prefix":"S","prefix_anchor":"S","level":1,"prior_prefix":"R"}},"ancestry":[{"id":14612,"edition_id":1,"name":"General Provisions","identifier":"28","label":"chapter","depth":4,"order_by":1,"parent_id":13049,"metadata":{},"date_created":"2026-06-26 03:48:55","date_modified":"2026-06-26 03:48:55","permalink":{"id":175735,"object_type":"structure","relational_id":14612,"identifier":"28","token":"2.2\/I\/E\/28","url":"\/2.2\/I\/E\/28\/","edition_id":1,"permalink":0,"preferred":1}},{"id":13049,"edition_id":1,"name":"State Officers and Employees","identifier":"E","label":"part","depth":3,"order_by":1,"parent_id":12784,"metadata":{},"date_created":"2026-06-26 03:44:11","date_modified":"2026-06-26 03:44:11","permalink":{"id":175733,"object_type":"structure","relational_id":13049,"identifier":"E","token":"2.2\/I\/E","url":"\/2.2\/I\/E\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12784,"edition_id":1,"name":"Organization of State Government","identifier":"I","label":"subtitle","depth":2,"order_by":1,"parent_id":12749,"metadata":{},"date_created":"2026-06-26 03:43:53","date_modified":"2026-06-26 03:43:53","permalink":{"id":171455,"object_type":"structure","relational_id":12784,"identifier":"I","token":"2.2\/I","url":"\/2.2\/I\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12749,"edition_id":1,"name":"Administration of Government","identifier":"2.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:51","date_modified":"2026-06-26 03:43:51","permalink":{"id":171453,"object_type":"structure","relational_id":12749,"identifier":"2.2","token":"2.2","url":"\/2.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":68109,"structure_id":14612,"section_number":"2.2-2800","catch_line":"Disability to hold state office","url":"\/2.2-2800\/","token":"2.2\/I\/E\/28\/2.2-2800","metadata":false},{"id":80552,"structure_id":14612,"section_number":"2.2-2801","catch_line":"Disability to hold state office; exceptions","url":"\/2.2-2801\/","token":"2.2\/I\/E\/28\/2.2-2801","metadata":false},{"id":75134,"structure_id":14612,"section_number":"2.2-2802","catch_line":"Exception as to public officer or employee who engages in war service or is called to active duty in the Armed Forces of the United States","url":"\/2.2-2802\/","token":"2.2\/I\/E\/28\/2.2-2802","metadata":false},{"id":83200,"structure_id":14612,"section_number":"2.2-2803","catch_line":"Exception as to public officer or employee serving in the Selective Service System of the United States","url":"\/2.2-2803\/","token":"2.2\/I\/E\/28\/2.2-2803","metadata":false},{"id":86431,"structure_id":14612,"section_number":"2.2-2804","catch_line":"Selective Service compliance","url":"\/2.2-2804\/","token":"2.2\/I\/E\/28\/2.2-2804","metadata":false},{"id":69867,"structure_id":14612,"section_number":"2.2-2805","catch_line":"Members of armed forces; reserve forces","url":"\/2.2-2805\/","token":"2.2\/I\/E\/28\/2.2-2805","metadata":false},{"id":83533,"structure_id":14612,"section_number":"2.2-2806","catch_line":"Holding other office by officers of state institutions","url":"\/2.2-2806\/","token":"2.2\/I\/E\/28\/2.2-2806","metadata":false},{"id":74638,"structure_id":14612,"section_number":"2.2-2807","catch_line":"Prohibition against holding two elected offices simultaneously; exceptions","url":"\/2.2-2807\/","token":"2.2\/I\/E\/28\/2.2-2807","metadata":false},{"id":66395,"structure_id":14612,"section_number":"2.2-2808","catch_line":"Acts under color of office; contracts in violation of chapter","url":"\/2.2-2808\/","token":"2.2\/I\/E\/28\/2.2-2808","metadata":false},{"id":75253,"structure_id":14612,"section_number":"2.2-2809","catch_line":"Bonds of certain officers required; condition","url":"\/2.2-2809\/","token":"2.2\/I\/E\/28\/2.2-2809","metadata":false},{"id":69613,"structure_id":14612,"section_number":"2.2-2810","catch_line":"Premiums on such bonds","url":"\/2.2-2810\/","token":"2.2\/I\/E\/28\/2.2-2810","metadata":false},{"id":58498,"structure_id":14612,"section_number":"2.2-2811","catch_line":"Where bonds filed","url":"\/2.2-2811\/","token":"2.2\/I\/E\/28\/2.2-2811","metadata":false},{"id":73283,"structure_id":14612,"section_number":"2.2-2812","catch_line":"Employment of personnel","url":"\/2.2-2812\/","token":"2.2\/I\/E\/28\/2.2-2812","metadata":false},{"id":79679,"structure_id":14612,"section_number":"2.2-2812.1","catch_line":"State agencies prohibited from inquiring about arrests, charges, or convictions on employment applications; exceptions","url":"\/2.2-2812.1\/","token":"2.2\/I\/E\/28\/2.2-2812.1","metadata":false},{"id":71377,"structure_id":14612,"section_number":"2.2-2813","catch_line":"Definitions; compensation and expense payments from state funds for service on collegial bodies","url":"\/2.2-2813\/","token":"2.2\/I\/E\/28\/2.2-2813","metadata":false},{"id":72502,"structure_id":14612,"section_number":"2.2-2814","catch_line":"How salaries, expenses and other allowances paid; time of payment","url":"\/2.2-2814\/","token":"2.2\/I\/E\/28\/2.2-2814","metadata":false},{"id":65734,"structure_id":14612,"section_number":"2.2-2815","catch_line":"Increase in salaries","url":"\/2.2-2815\/","token":"2.2\/I\/E\/28\/2.2-2815","metadata":false},{"id":72671,"structure_id":14612,"section_number":"2.2-2816","catch_line":"Liability of salary of officer for debt he owes Commonwealth; how enforced; when officer's right to file petition barred","url":"\/2.2-2816\/","token":"2.2\/I\/E\/28\/2.2-2816","metadata":false},{"id":73024,"structure_id":14612,"section_number":"2.2-2817","catch_line":"Defense of employees","url":"\/2.2-2817\/","token":"2.2\/I\/E\/28\/2.2-2817","metadata":false},{"id":85515,"structure_id":14612,"section_number":"2.2-2817.1","catch_line":"State agencies to establish alternative work schedules; reporting requirement","url":"\/2.2-2817.1\/","token":"2.2\/I\/E\/28\/2.2-2817.1","metadata":false},{"id":61045,"structure_id":14612,"section_number":"2.2-2817.2","catch_line":"Employees of the University of Virginia Medical Center","url":"\/2.2-2817.2\/","token":"2.2\/I\/E\/28\/2.2-2817.2","metadata":false},{"id":68317,"structure_id":14612,"section_number":"2.2-2818","catch_line":"Health and related insurance for state employees","url":"\/2.2-2818\/","token":"2.2\/I\/E\/28\/2.2-2818","metadata":false},{"id":80971,"structure_id":14612,"section_number":"2.2-2818.01","catch_line":"Employer contributions","url":"\/2.2-2818.01\/","token":"2.2\/I\/E\/28\/2.2-2818.01","metadata":false},{"id":76713,"structure_id":14612,"section_number":"2.2-2818.1","catch_line":"Supplemental health insurance coverage; state employees eligible for military health insurance coverage","url":"\/2.2-2818.1\/","token":"2.2\/I\/E\/28\/2.2-2818.1","metadata":false},{"id":64235,"structure_id":14612,"section_number":"2.2-2818.2","catch_line":"Application of mandates to the state employee health insurance plan","url":"\/2.2-2818.2\/","token":"2.2\/I\/E\/28\/2.2-2818.2","metadata":false},{"id":77915,"structure_id":14612,"section_number":"2.2-2819","catch_line":"Purchase of continued health insurance coverage by the surviving spouse and any dependents of an active or retired state employee","url":"\/2.2-2819\/","token":"2.2\/I\/E\/28\/2.2-2819","metadata":false},{"id":56145,"structure_id":14612,"section_number":"2.2-2820","catch_line":"Purchase of health insurance coverage by part-time state employees","url":"\/2.2-2820\/","token":"2.2\/I\/E\/28\/2.2-2820","metadata":false},{"id":83527,"structure_id":14612,"section_number":"2.2-2820.1","catch_line":"Repealed","url":"\/2.2-2820.1\/","token":"2.2\/I\/E\/28\/2.2-2820.1","metadata":false},{"id":76045,"structure_id":14612,"section_number":"2.2-2821","catch_line":"Workers' compensation insurance plan for state employees trust fund for payment of claims","url":"\/2.2-2821\/","token":"2.2\/I\/E\/28\/2.2-2821","metadata":false},{"id":82554,"structure_id":14612,"section_number":"2.2-2821.1","catch_line":"Leave for bone marrow or organ donation","url":"\/2.2-2821.1\/","token":"2.2\/I\/E\/28\/2.2-2821.1","metadata":false},{"id":66004,"structure_id":14612,"section_number":"2.2-2821.2","catch_line":"Leave for volunteer fire and volunteer emergency medical services","url":"\/2.2-2821.2\/","token":"2.2\/I\/E\/28\/2.2-2821.2","metadata":false},{"id":82416,"structure_id":14612,"section_number":"2.2-2821.3","catch_line":"Leave for volunteer members of Civil Air Patrol","url":"\/2.2-2821.3\/","token":"2.2\/I\/E\/28\/2.2-2821.3","metadata":false},{"id":64304,"structure_id":14612,"section_number":"2.2-2822","catch_line":"Ownership and use of patents and copyrights developed by certain public employees; Creative Commons copyrights","url":"\/2.2-2822\/","token":"2.2\/I\/E\/28\/2.2-2822","metadata":false},{"id":60037,"structure_id":14612,"section_number":"2.2-2823","catch_line":"Traveling expenses on state business; public or private transportation","url":"\/2.2-2823\/","token":"2.2\/I\/E\/28\/2.2-2823","metadata":false},{"id":86427,"structure_id":14612,"section_number":"2.2-2824","catch_line":"Monitoring travel expenses while on state business","url":"\/2.2-2824\/","token":"2.2\/I\/E\/28\/2.2-2824","metadata":false},{"id":73173,"structure_id":14612,"section_number":"2.2-2825","catch_line":"Reimbursement for certain travel expenditures; restrictions on reimbursement","url":"\/2.2-2825\/","token":"2.2\/I\/E\/28\/2.2-2825","metadata":false},{"id":86361,"structure_id":14612,"section_number":"2.2-2826","catch_line":"Travel expense accounts; review by Comptroller","url":"\/2.2-2826\/","token":"2.2\/I\/E\/28\/2.2-2826","metadata":false},{"id":66971,"structure_id":14612,"section_number":"2.2-2827","catch_line":"Restrictions on state employee access to information infrastructure","url":"\/2.2-2827\/","token":"2.2\/I\/E\/28\/2.2-2827","metadata":false},{"id":72066,"structure_id":14612,"section_number":"2.2-2828","catch_line":"Repealed","url":"\/2.2-2828\/","token":"2.2\/I\/E\/28\/2.2-2828","metadata":false},{"id":68011,"structure_id":14612,"section_number":"2.2-2829","catch_line":"Disappearance of public officer; when office presumed vacant","url":"\/2.2-2829\/","token":"2.2\/I\/E\/28\/2.2-2829","metadata":false},{"id":74132,"structure_id":14612,"section_number":"2.2-2830","catch_line":"Governor to fill vacancy in any state office where no other provision is made by law; term of appointment; benefits","url":"\/2.2-2830\/","token":"2.2\/I\/E\/28\/2.2-2830","metadata":false},{"id":76461,"structure_id":14612,"section_number":"2.2-2831","catch_line":"Payment of severance benefits; exceptions","url":"\/2.2-2831\/","token":"2.2\/I\/E\/28\/2.2-2831","metadata":false},{"id":75582,"structure_id":14612,"section_number":"2.2-2832","catch_line":"Retaliatory actions against persons providing testimony before a committee or subcommittee of the General Assembly","url":"\/2.2-2832\/","token":"2.2\/I\/E\/28\/2.2-2832","metadata":false},{"id":78628,"structure_id":14612,"section_number":"2.2-2833","catch_line":"Possession of naloxone or other opioid antagonists by state agencies","url":"\/2.2-2833\/","token":"2.2\/I\/E\/28\/2.2-2833","metadata":false}],"previous_section":{"id":61045,"structure_id":14612,"section_number":"2.2-2817.2","catch_line":"Employees of the University of Virginia Medical Center","url":"\/2.2-2817.2\/","token":"2.2\/I\/E\/28\/2.2-2817.2","metadata":false},"next_section":{"id":80971,"structure_id":14612,"section_number":"2.2-2818.01","catch_line":"Employer contributions","url":"\/2.2-2818.01\/","token":"2.2\/I\/E\/28\/2.2-2818.01","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/2.2-2818\/","history_text":"

This law was first created in 1970. The record of its establishment is cataloged in chapter 557 of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year. Unfortunately, the 1970 \u201cActs\u201d aren\u2019t available online. It has been modified 27 times. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. Those modifications are as follows: in 1972, chapter 803; in 1973, chapters 69 and 297; in 1978, chapter 70; in 1984, chapter 430; in 1988, chapter 634; in 1989, chapters 559 and 664; in 1990, chapter 607; in 1993, chapter 138; in 1995, chapter 353<\/a>; in 1996, chapters 155<\/a>, 201<\/a>, 905<\/a>, and 1046<\/a>; in 1997, chapters 43<\/a>, 468<\/a>, 521<\/a>, and 656<\/a>; in 1998, chapters 35<\/a>, 56<\/a>, 257<\/a>, 386<\/a>, 631<\/a>, 709<\/a>, 851<\/a>, 858<\/a>, and 875<\/a>; in 1999, chapters 643<\/a>, 649<\/a>, 921<\/a>, and 941<\/a>; in 2000, chapters 66<\/a>, 149<\/a>, 465<\/a>, 534<\/a>, 657<\/a>, 720<\/a>, and 888<\/a>; in 2001, chapters 334<\/a>, 558<\/a>, 663<\/a>, and 844<\/a>; in 2004, chapters 156<\/a>, 279<\/a>, and 855<\/a>; in 2005, chapters 503<\/a>, 572<\/a>, 640<\/a>, and 739<\/a>; in 2006, chapter 396<\/a>; in 2008, chapter 420<\/a>; in 2009, chapters 247<\/a>, 317<\/a>, 813<\/a>, and 840<\/a>; in 2010, chapters 157<\/a>, 357<\/a>, and 443<\/a>; in 2012, chapters 60<\/a> and 201<\/a>; in 2013, chapter 709<\/a>; in 2014, chapter 631<\/a>; in 2015, chapters 38<\/a> and 730<\/a>; in 2023, chapters 182<\/a> and 183<\/a>; in 2025, chapters 237<\/a> and 246<\/a>.<\/p>","references":[{"id":64954,"section_number":"2.2-1204","catch_line":"Health insurance program for employees of local governments, local officers, teachers, etc.; definitions","order_by":null,"url":"\/2.2-1204\/"},{"id":71900,"section_number":"2.2-2203.3","catch_line":"Employees; employment; personnel rules","order_by":null,"url":"\/2.2-2203.3\/"},{"id":61045,"section_number":"2.2-2817.2","catch_line":"Employees of the University of Virginia Medical Center","order_by":null,"url":"\/2.2-2817.2\/"},{"id":80971,"section_number":"2.2-2818.01","catch_line":"Employer contributions","order_by":null,"url":"\/2.2-2818.01\/"},{"id":76713,"section_number":"2.2-2818.1","catch_line":"Supplemental health insurance coverage; state employees eligible for military health insurance coverage","order_by":null,"url":"\/2.2-2818.1\/"},{"id":64235,"section_number":"2.2-2818.2","catch_line":"Application of mandates to the state employee health insurance plan","order_by":null,"url":"\/2.2-2818.2\/"},{"id":77915,"section_number":"2.2-2819","catch_line":"Purchase of continued health insurance coverage by the surviving spouse and any dependents of an active or retired state employee","order_by":null,"url":"\/2.2-2819\/"},{"id":56145,"section_number":"2.2-2820","catch_line":"Purchase of health insurance coverage by part-time state employees","order_by":null,"url":"\/2.2-2820\/"},{"id":82159,"section_number":"2.2-3203","catch_line":"Transitional severance benefit conferred","order_by":null,"url":"\/2.2-3203\/"},{"id":79842,"section_number":"23.1-2415","catch_line":"Employees of the Authority","order_by":null,"url":"\/23.1-2415\/"},{"id":60451,"section_number":"28.2-1001","catch_line":"Potomac River Compact","order_by":null,"url":"\/28.2-1001\/"},{"id":81770,"section_number":"38.2-3407.18","catch_line":"Requirements for orally administered cancer chemotherapy drugs","order_by":null,"url":"\/38.2-3407.18\/"},{"id":71499,"section_number":"38.2-3407.9:05","catch_line":"Step therapy protocols","order_by":null,"url":"\/38.2-3407.9_05\/"},{"id":81144,"section_number":"38.2-3418.17","catch_line":"Coverage for autism spectrum disorder","order_by":null,"url":"\/38.2-3418.17\/"},{"id":79837,"section_number":"38.2-3424.1","catch_line":"Applicability","order_by":null,"url":"\/38.2-3424.1\/"},{"id":66467,"section_number":"38.2-3445.06","catch_line":"Applicability of certain sections","order_by":null,"url":"\/38.2-3445.06\/"},{"id":83999,"section_number":"38.2-3461","catch_line":"Definitions","order_by":null,"url":"\/38.2-3461\/"},{"id":78576,"section_number":"51.1-1132","catch_line":"Health insurance coverage during disability absences","order_by":null,"url":"\/51.1-1132\/"},{"id":75331,"section_number":"51.1-1400","catch_line":"Health insurance credits for retired state employees","order_by":null,"url":"\/51.1-1400\/"},{"id":63381,"section_number":"51.1-1405","catch_line":"Participation in the state retiree health benefits program","order_by":null,"url":"\/51.1-1405\/"},{"id":61992,"section_number":"51.1-155.1","catch_line":"Exceptions from general early retirement provisions for certain state employees and constitutional officers","order_by":null,"url":"\/51.1-155.1\/"},{"id":86887,"section_number":"51.1-500","catch_line":"Definitions","order_by":null,"url":"\/51.1-500\/"},{"id":83648,"section_number":"51.1-502.1","catch_line":"Certain employees of teaching hospitals","order_by":null,"url":"\/51.1-502.1\/"},{"id":59839,"section_number":"62.1-129.1","catch_line":"Employees; employment; personnel rules; health insurance; retirement plans","order_by":null,"url":"\/62.1-129.1\/"}],"refers_to":[{"id":79842,"section_number":"23.1-2415","catch_line":"Employees of the Authority","order_by":null,"url":"\/23.1-2415\/"},{"id":72177,"section_number":"32.1-137.7","catch_line":"Definitions","order_by":null,"url":"\/32.1-137.7\/"},{"id":62100,"section_number":"32.1-64.1","catch_line":"Virginia Hearing Loss Identification and Monitoring System","order_by":null,"url":"\/32.1-64.1\/"},{"id":57129,"section_number":"38.2-3407.4:2","catch_line":"Requirements for prescription benefit cards","order_by":null,"url":"\/38.2-3407.4_2\/"},{"id":57559,"section_number":"38.2-3419.1","catch_line":"Report of costs and utilization of mandated benefits","order_by":null,"url":"\/38.2-3419.1\/"},{"id":70634,"section_number":"51.1-124.3","catch_line":"Definitions","order_by":null,"url":"\/51.1-124.3\/"},{"id":54544,"section_number":"51.1-201","catch_line":"Definitions","order_by":null,"url":"\/51.1-201\/"},{"id":68180,"section_number":"51.1-301","catch_line":"Definitions","order_by":null,"url":"\/51.1-301\/"}],"permalink":{"id":175821,"object_type":"law","relational_id":68317,"identifier":"2.2-2818","token":"2.2\/I\/E\/28\/2.2-2818","url":"\/2.2-2818\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/2.2-2818\/","token":"2.2\/I\/E\/28\/2.2-2818","dublin_core":{"Title":"Health and related insurance for state employees","Type":"Text","Format":"text\/html","Identifier":"\u00a7 2.2-2818","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> The Department of Human Resource Management shall establish a plan, subject to the approval of the Governor, for providing health insurance coverage, including chiropractic treatment, hospitalization, medical, surgical, and major medical coverage, for state employees<\/span> and retired state employees<\/span> with the Commonwealth paying the cost thereof to the extent of the coverage included in such plan. The same plan shall be offered to all part-time state employees<\/span>, but the total cost shall be paid by such part-time employees. The Department of Human Resource Management shall administer this section. The plan chosen shall provide means whereby coverage for the families or dependents of state employees<\/span> may be purchased. Except for part-time employees, the Commonwealth may pay all or a portion of the cost thereof, and for such portion as the Commonwealth does not pay, the employee, including a part-time employee, may purchase the coverage by paying the additional cost over the cost of coverage for an employee.\n\t\t\tSuch contribution shall be financed through appropriations provided by law<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> The plan shall: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Include coverage for low-dose screening mammograms<\/span> for determining the presence of occult breast cancer. Such coverage shall make available one screening mammogram<\/span> to persons age 35 through 39, one such mammogram<\/span> biennially to persons age 40 through 49, and one such mammogram<\/span> annually to persons age 50 and over and may be limited to a benefit of $50 per mammogram<\/span> subject to such dollar limits, deductibles, and coinsurance factors as are no less favorable than for physical illness generally.\n\t\t\t\tThe term “mammogram<\/span>” shall mean an X-ray examination of the breast using equipment dedicated specifically for mammography, including but not limited to the X-ray tube, filter, compression device, screens, film, and cassettes, with an average radiation exposure of less than one rad mid-breast, two views of each breast.\n\t\t\t\tIn order<\/span> to be considered a screening mammogram<\/span> for which coverage shall be made available under this section:\n\t\t\t\ta. The mammogram<\/span> shall be (i) ordered by a health care practitioner acting within the scope of his licensure and, in the case of an enrollee of a health maintenance organization, by the health maintenance organization provider; (ii) performed by a registered technologist; (iii) interpreted by a qualified radiologist; and (iv) performed under the direction of a person licensed to practice medicine and surgery and certified by the American Board of Radiology or an equivalent examining body. A copy of the mammogram<\/span> report shall be sent or delivered to the health care practitioner who ordered it;\n\t\t\t\tb. The equipment used to perform the mammogram<\/span> shall meet the standards set forth by the Virginia Department of Health in its radiation protection regulations; and\n\t\t\t\tc. The mammography film shall be retained by the radiologic facility performing the examination in accordance with the American College of Radiology guidelines or state law<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Include coverage for postpartum services providing inpatient care and a home visit or visits that shall be in accordance with the medical criteria, outlined in the most current version of or an official update to the “Guidelines for Perinatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists or the “Standards for Obstetric-Gynecologic Services” prepared by the American College of Obstetricians and Gynecologists. Such coverage shall be provided incorporating any changes in such Guidelines or Standards within six months of the publication of such Guidelines or Standards or any official amendment thereto. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Include an appeals<\/span> process for resolution of complaints that shall provide reasonable procedures for the resolution of such complaints and shall be published and disseminated to all covered state employees<\/span>. The appeals<\/span> process shall be compliant with federal rules and regulations governing nonfederal, self-insured governmental health plans. The appeals<\/span> process shall include a separate expedited emergency appeals<\/span> procedure that shall provide resolution within time frames established by federal law<\/span>. For appeals<\/span> involving adverse decisions as defined in § 32.1-137.7<\/a>, the Department shall contract<\/span> with one or more independent review organizations to review such decisions. Independent review organizations are entities that conduct independent external review of adverse benefit determinations. The Department shall adopt regulations to assure that the independent review organization conducting the reviews has adequate standards, credentials and experience for such review. The independent review organization shall examine the final denial of claims to determine whether the decision is objective, clinically valid, and compatible with established principles of health care. The decision of the independent review organization shall (i) be in writing, (ii) contain findings<\/span> of fact<\/span> as to the material<\/span> issues<\/span> in the case and the basis for those findings<\/span>, and (iii) be final and binding if consistent with law<\/span> and policy.\n\t\t\t\tPrior to assigning an appeal<\/span> to an independent review organization, the Department shall verify that the independent review organization conducting the review of a denial of claims has no relationship or association with (i) the covered person or the covered person’s authorized representative; (ii) the treating health care provider, or any of its employees or affiliates; (iii) the medical care facility at which the covered service would be provided, or any of its employees or affiliates; or (iv) the development or manufacture of the drug, device, procedure, or other therapy that is the subject of the final denial of a claim. The independent review organization shall not be a subsidiary of, nor owned or controlled by, a health plan, a trade association of health plans, or a professional association of health care providers. There shall be no liability on the part of and no cause of action<\/span> shall arise against any officer or employee of an independent review organization for any actions taken or not taken or statements made by such officer or employee in good faith in the performance of his powers and duties. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Include coverage for early intervention services<\/span>. For purposes of this section, “early intervention services<\/span>” means medically necessary speech and language therapy, occupational therapy, physical therapy and assistive technology services and devices for dependents from birth to age three who are certified by the Department of Behavioral Health and Developmental Services as eligible for services under Part H of the Individuals with Disabilities Education Act (20 U.S.C. § 1471 et seq.). Medically necessary early intervention services<\/span> for the population certified by the Department of Behavioral Health and Developmental Services shall mean those services designed to help an individual attain or retain the capability to function age-appropriately within his environment, and shall include services that enhance functional ability without effecting a cure.\n\t\t\t\tFor persons previously covered under the plan, there shall be no denial of coverage due to the existence of a preexisting condition. The cost of early intervention services<\/span> shall not be applied to any contractual provision limiting the total amount of coverage paid by the insurer to or on behalf of the insured during the insured’s lifetime. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

5.<\/span> Include coverage for prescription drugs and devices approved by the United States Food and Drug Administration for use as contraceptives. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

6.<\/span> Not deny coverage for any drug approved by the United States Food and Drug Administration for use in the treatment of cancer on the basis that the drug has not been approved by the United States Food and Drug Administration for the treatment of the specific type of cancer for which the drug has been prescribed, if the drug has been recognized as safe and effective for treatment of that specific type of cancer in one of the standard reference compendia. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

7.<\/span> Not deny coverage for any drug prescribed to treat a covered indication so long as the drug has been approved by the United States Food and Drug Administration for at least one indication and the drug is recognized for treatment of the covered indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

8.<\/span> Include coverage for equipment, supplies, and outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and noninsulin-using diabetes if prescribed by a health care professional legally authorized to prescribe such items under law<\/span>. To qualify for coverage under this subdivision, diabetes outpatient self-management training and education shall be provided by a certified, registered, or licensed health care professional. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

9.<\/span> Include coverage for reconstructive breast surgery<\/span>. For purposes of this section, “reconstructive breast surgery<\/span>” means surgery performed on and after July 1, 1998, (i) coincident with a mastectomy performed for breast cancer or (ii) following a mastectomy performed for breast cancer to reestablish symmetry between the two breasts. For persons previously covered under the plan, there shall be no denial of coverage due to preexisting conditions. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

10.<\/span> Include coverage for annual pap smears, including coverage, on and after July 1, 1999, for annual testing performed by any FDA<\/span>-approved gynecologic cytology screening technologies. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

11.<\/span> Include coverage providing a minimum stay<\/span> in the hospital of not less than 48 hours for a patient<\/span> following a radical or modified radical mastectomy and 24 hours of inpatient care following a total mastectomy or a partial mastectomy with lymph node dissection for treatment of breast cancer. Nothing in this subdivision shall be construed as requiring the provision of inpatient coverage where the attending physician in consultation with the patient<\/span> determines that a shorter period of hospital stay<\/span> is appropriate. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

12.<\/span> Include coverage (i) to persons age 50 and over and (ii) to persons age 40 and over who are at high risk for prostate cancer, according to the most recent published guidelines of the American Cancer Society, for one prostate-specific antigen test in a 12-month period and digital rectal examinations. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

13.<\/span> Permit any individual covered under the plan direct access to the health care services of a participating specialist (i) authorized to provide services under the plan and (ii) selected by the covered individual. The plan shall have a procedure by which an individual who has an ongoing special condition<\/span> may, after consultation with the primary care physician, receive a referral to a specialist for such condition who shall be responsible for and capable of providing and coordinating the individual’s primary and specialty care related to the initial specialty care referral. If such an individual’s care would most appropriately be coordinated by such a specialist, the plan shall refer the individual to a specialist. For the purposes of this subdivision, “special condition<\/span>” means a condition or disease that is (i) life-threatening, degenerative, or disabling and (ii) requires specialized medical care over a prolonged period of time. Within the treatment period authorized by the referral, such specialist shall be permitted to treat the individual without a further referral from the individual’s primary care provider and may authorize such referrals, procedures, tests, and other medical services related to the initial referral as the individual’s primary care provider would otherwise be permitted to provide or authorize. The plan shall have a procedure by which an individual who has an ongoing special condition<\/span> that requires ongoing care from a specialist may receive a standing referral to such specialist for the treatment of the special condition<\/span>. If the primary care provider, in consultation with the plan and the specialist, if any, determines that such a standing referral is appropriate, the plan or issuer shall make such a referral to a specialist. Nothing contained herein shall prohibit the plan from requiring a participating specialist to provide written notification to the covered individual’s primary care physician of any visit to such specialist. Such notification may include a description of the health care services rendered at the time of the visit. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

14.<\/span> Include provisions allowing employees to continue receiving health care services for a period of up to 90 days from the date of the primary care physician’s notice of termination from any of the plan’s provider panels<\/span>. The plan shall notify any provider at least 90 days prior to the date of termination of the provider, except when the provider is terminated for cause.\n\t\t\t\tFor a period of at least 90 days from the date of the notice of a provider’s termination from any of the plan’s provider panels<\/span>, except when a provider is terminated for cause, a provider shall be permitted by the plan to render health care services to any of the covered employees who (i) were in an active course of treatment from the provider prior to the notice of termination and (ii) request to continue receiving health care services from the provider.\n\t\t\t\tNotwithstanding the provisions of this subdivision, any provider shall be permitted by the plan to continue rendering health services to any covered employee who has entered the second trimester of pregnancy at the time of the provider’s termination of participation, except when a provider is terminated for cause. Such treatment shall, at the covered employee’s option, continue through the provision of postpartum care directly related to the delivery.\n\t\t\t\tNotwithstanding the provisions of this subdivision, any provider shall be permitted to continue rendering health services to any covered employee who is determined to be terminally ill (as defined under § 1861(dd)(3)(A) of the Social Security Act) at the time of a provider’s termination of participation, except when a provider is terminated for cause. Such treatment shall, at the covered employee’s option, continue for the remainder of the employee’s life for care directly related to the treatment of the terminal illness.\n\t\t\t\tA provider who continues to render health care services pursuant to this subdivision shall be reimbursed in accordance with the carrier’s agreement with such provider existing immediately before the provider’s termination of participation. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

15.<\/span> Include coverage for patient costs<\/span> incurred during participation in clinical trials<\/span> for treatment studies on cancer, including ovarian cancer trials<\/span>.\n\t\t\t\tThe reimbursement for patient costs<\/span> incurred during participation in clinical trials<\/span> for treatment studies on cancer shall be determined in the same manner as reimbursement is determined for other medical and surgical procedures. Such coverage shall have durational limits, dollar limits, deductibles, copayments, and coinsurance factors that are no less favorable than for physical illness generally.\n\t\t\t\tFor purposes of this subdivision:\n\t\t\t\t“Cooperative group<\/span>” means a formal network of facilities that collaborate on research projects and have an established NIH<\/span>-approved peer review program operating within the group. “Cooperative group<\/span>” includes (i) the National Cancer Institute Clinical Cooperative Group<\/span> and (ii) the National Cancer Institute Community Clinical Oncology Program.\n\t\t\t\t“FDA<\/span>” means the Federal Food and Drug Administration.\n\t\t\t\t“Multiple project assurance contract<\/span>” means a contract between an institution and the federal Department of Health and Human Services that defines the relationship of the institution to the federal Department of Health and Human Services and sets out the responsibilities of the institution and the procedures that will be used by the institution to protect human subjects.\n\t\t\t\t“NCI<\/span>” means the National Cancer Institute.\n\t\t\t\t“NIH<\/span>” means the National Institutes of Health.\n\t\t\t\t“Patient” means a person covered under the plan established pursuant to this section.\n\t\t\t\t“Patient cost<\/span>” means the cost of a medically necessary health care service that is incurred as a result of the treatment being provided to a patient for purposes of a clinical trial<\/span>. “Patient cost<\/span>” does not include (i) the cost of nonhealth care services that a patient may be required to receive as a result of the treatment being provided for purposes of a clinical trial<\/span>, (ii) costs associated with managing the research associated with the clinical trial<\/span>, or (iii) the cost of the investigational drug or device.\n\t\t\t\tCoverage for patient costs<\/span> incurred during clinical trials<\/span> for treatment studies on cancer shall be provided if the treatment is being conducted in a Phase II, Phase III, or Phase IV clinical trial<\/span>. Such treatment may, however, be provided on a case-by-case basis if the treatment is being provided in a Phase I clinical trial<\/span>.\n\t\t\t\tThe treatment described in the previous paragraph shall be provided by a clinical trial<\/span> approved by:\n\t\t\t\ta. The National Cancer Institute;\n\t\t\t\tb. An NCI<\/span> cooperative group<\/span> or an NCI<\/span> center;\n\t\t\t\tc. The FDA<\/span> in the form of an investigational new drug application;\n\t\t\t\td. The federal Department of Veterans Affairs; or\n\t\t\t\te. An institutional review board of an institution in the Commonwealth that has a multiple project assurance contract<\/span> approved by the Office of Protection from Research Risks of the NCI<\/span>.\n\t\t\t\tThe facility and personnel providing the treatment shall be capable of doing so by virtue of their experience, training, and expertise.\n\t\t\t\tCoverage under this subdivision shall apply only if: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> There is no clearly superior, noninvestigational treatment alternative; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> The available clinical or preclinical data provide a reasonable expectation that the treatment will be at least as effective as the noninvestigational alternative; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> The patient and the physician or health care provider who provides services to the patient under the plan conclude that the patient’s participation in the clinical trial<\/span> would be appropriate, pursuant to procedures established by the plan. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

16.<\/span> Include coverage providing a minimum stay<\/span> in the hospital of not less than 23 hours for a covered employee following a laparoscopy-assisted vaginal hysterectomy and 48 hours for a covered employee following a vaginal hysterectomy, as outlined in Milliman & Robertson’s nationally recognized guidelines. Nothing in this subdivision shall be construed as requiring the provision of the total hours referenced when the attending physician, in consultation with the covered employee, determines that a shorter hospital stay<\/span> is appropriate. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

17.<\/span> Include coverage for biologically based mental illness.\n\t\t\t\tFor purposes of this subdivision, a “biologically based mental illness” is any mental or nervous condition caused by a biological disorder of the brain that results in a clinically significant syndrome that substantially limits the person’s functioning; specifically, the following diagnoses are defined as biologically based mental illness as they apply to adults and children: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, panic disorder, obsessive-compulsive disorder, attention deficit hyperactivity disorder, autism, and drug and alcoholism addiction.\n\t\t\t\tCoverage for biologically based mental illnesses shall neither be different nor separate from coverage for any other illness, condition, or disorder for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayment and coinsurance factors.\n\t\t\t\tNothing shall preclude the undertaking of usual and customary procedures to determine the appropriateness of, and medical necessity for, treatment of biologically based mental illnesses under this option, provided that all such appropriateness and medical necessity determinations are made in the same manner as those determinations made for the treatment of any other illness, condition, or disorder covered by such policy or contract. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

18.<\/span> Offer and make available coverage for the treatment of morbid obesity<\/span> through gastric bypass surgery or such other methods as may be recognized by the National Institutes of Health as effective for the long-term reversal of morbid obesity<\/span>. Such coverage shall have durational limits, dollar limits, deductibles, copayments, and coinsurance factors that are no less favorable than for physical illness generally. Access to surgery for morbid obesity<\/span> shall not be restricted based upon dietary or any other criteria not approved by the National Institutes of Health. For purposes of this subdivision, “morbid obesity<\/span>” means (i) a weight that is at least 100 pounds over or twice the ideal weight for frame, age, height, and gender as specified in the 1983 Metropolitan Life Insurance tables, (ii) a body mass index (BMI<\/span>) equal to or greater than 35 kilograms per meter squared with comorbidity or coexisting medical conditions such as hypertension, cardiopulmonary conditions, sleep apnea, or diabetes, or (iii) a BMI<\/span> of 40 kilograms per meter squared without such comorbidity. As used herein, “BMI<\/span>” equals weight in kilograms divided by height in meters squared. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

19.<\/span> Include coverage for colorectal cancer screening, specifically screening with an annual fecal occult blood test, flexible sigmoidoscopy or colonoscopy, or in appropriate circumstances radiologic imaging, in accordance with the most recently published recommendations established by the American College of Gastroenterology, in consultation with the American Cancer Society, for the ages, family histories, and frequencies referenced in such recommendations. The coverage for colorectal cancer screening shall not be more restrictive than or separate from coverage provided for any other illness, condition, or disorder for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayments and coinsurance factors. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

20.<\/span> On and after July 1, 2002, require that a prescription benefit card, health insurance benefit card, or other technology that complies with the requirements set forth in § 38.2-3407.4:2<\/a> be issued to each employee provided coverage pursuant to this section, and shall upon any changes in the required data elements set forth in subsection A of § 38.2-3407.4:2<\/a>, either reissue the card or provide employees covered under the plan such corrective information as may be required to electronically process a prescription claim. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

21.<\/span> Include coverage for infant hearing<\/span> screenings and all necessary audiological examinations provided pursuant to § 32.1-64.1<\/a> using any technology approved by the United States Food and Drug Administration, and as recommended by the national Joint Committee on Infant Hearing<\/span> in its most current position statement addressing early hearing<\/span> detection and intervention programs. Such coverage shall include follow-up audiological examinations as recommended by a physician, a physician assistant, an advanced practice registered nurse, or an audiologist and performed by a licensed audiologist to confirm the existence or absence of hearing<\/span> loss. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

22.<\/span> Notwithstanding any provision of this section to the contrary, every plan established in accordance with this section shall comply with the provisions of § 2.2-2818.2<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Claims incurred during a fiscal year but not reported during that fiscal year shall be paid from such funds as shall be appropriated by law<\/span>. Appropriations, premiums, and other payments shall be deposited in the employee health insurance fund, from which payments for claims, premiums, cost containment programs, and administrative expenses shall be withdrawn from time to time. The funds of the health insurance fund shall be deemed separate and independent trust funds, shall be segregated from all other funds of the Commonwealth, and shall be invested and administered solely in the interests of the employees and their beneficiaries. Neither the General Assembly nor any public officer, employee, or agency shall use or authorize the use of such trust funds for any purpose other than as provided in law<\/span> for benefits, refunds, and administrative expenses, including but not limited to legislative oversight of the health insurance fund. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> For the purposes of this section:\n\t\t\t“Peer-reviewed medical literature<\/span>” means a scientific study published only after having been critically reviewed for scientific accuracy, validity, and reliability by unbiased independent experts in a journal that has been determined by the International Committee of Medical Journal Editors to have met the Uniform Requirements for Manuscripts submitted to biomedical journals. “Peer-reviewed medical literature<\/span>” does not include publications or supplements to publications that are sponsored to a significant extent by a pharmaceutical manufacturing company or health carrier.\n\t\t\t“Standard reference compendia” means: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> American Hospital Formulary Service Drug Information; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> National Comprehensive Cancer Network’s Drugs & Biologics Compendium; or <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Elsevier Gold Standard’s Clinical Pharmacology.\n\t\t\t\t“State employee<\/span>” means state employee<\/span> as defined in § 51.1-124.3<\/a>; employee as defined in § 51.1-201<\/a>; the Governor, Lieutenant Governor and Attorney General<\/span>; judge<\/span> as defined in § 51.1-301<\/a> and judges<\/span>, clerks, and deputy clerks of regional juvenile and domestic relations, county juvenile and domestic relations, and district courts<\/span> of the Commonwealth; interns and residents employed by the School of Medicine and Hospital of the University of Virginia, and interns, residents, and employees of the Virginia Commonwealth University Health System Authority as provided in § 23.1-2415<\/a>; and employees of the Virginia Alcoholic Beverage Control Authority as provided in § 4.1-101.05<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Provisions shall be made for retired employees to obtain coverage under the above plan, including, as an option, coverage for vision and dental care. The Commonwealth may, but shall not be obligated to, pay all or any portion of the cost thereof. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> Any self-insured group health insurance plan established by the Department of Human Resource Management that utilizes a network of preferred providers shall not exclude any physician solely on the basis of a reprimand or censure from the Board of Medicine, so long as the physician otherwise meets the plan criteria established by the Department. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> The plan shall include, in each planning district, at least two health coverage options, each sponsored by unrelated entities. No later than July 1, 2006, one of the health coverage options to be available in each planning district shall be a high deductible health plan that would qualify for a health savings account pursuant to § 223 of the Internal Revenue Code of 1986, as amended.\n\t\t\tIn each planning district that does not have an available health coverage alternative, the Department shall voluntarily enter into negotiations at any time with any health coverage provider who seeks to provide coverage under the plan.\n\t\t\tThis subsection shall not apply to any state agency<\/span> authorized by the Department to establish and administer its own health insurance coverage plan separate from the plan established by the Department. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

H.<\/span> Any self-insured group health insurance plan established by the Department of Human Resource Management that includes coverage for prescription drugs on an outpatient basis may apply a formulary to the prescription drug benefits provided by the plan if the formulary is developed, reviewed at least annually, and updated as necessary in consultation with and with the approval of a pharmacy and therapeutics committee, a majority of whose members are actively practicing licensed (i) pharmacists, (ii) physicians, and (iii) other health care providers.\n\t\t\tIf the plan maintains one or more drug formularies, the plan shall establish a process to allow a person to obtain, without additional cost-sharing beyond that provided for formulary prescription drugs in the plan, a specific, medically necessary nonformulary prescription drug if, after reasonable investigation and consultation with the prescriber, the formulary drug is determined to be an inappropriate therapy for the medical condition of the person. The plan shall act on such requests within one business day of receipt of the request.\n\t\t\tAny plan established in accordance with this section shall be authorized to provide for the selection of a single mail order pharmacy provider<\/span> as the exclusive provider of pharmacy services that are delivered to the covered person’s address by mail, common carrier, or delivery service. As used in this subsection, “mail order pharmacy provider<\/span>” 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. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

I.<\/span> Any plan established in accordance with this section requiring preauthorization prior to rendering medical treatment shall have personnel available to provide authorization at all times when such preauthorization is required. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

J.<\/span> Any plan established in accordance with this section shall provide to all covered employees written notice of any benefit reductions during the contract period at least 30 days before such reductions become effective. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

K.<\/span> No contract between a provider and any plan established in accordance with this section shall include provisions that 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 covered employee with similar medical conditions. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

L.<\/span> The Department of Human Resource Management shall appoint an Ombudsman to promote and protect the interests of covered employees under any state employee<\/span>’s health plan.\n\t\t\tThe Ombudsman shall: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Assist covered employees in understanding their rights and the processes available to them according to their state health plan. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Answer inquiries from covered employees by telephone and electronic mail. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Provide to covered employees information concerning the state health plans. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Develop information on the types of health plans available, including benefits and complaint procedures and appeals<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

5.<\/span> Make available, either separately or through an existing Internet web site utilized by the Department of Human Resource Management, information as set forth in subdivision 4 and such additional information as he deems appropriate. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

6.<\/span> Maintain data on inquiries received, the types of assistance requested, any actions taken and the disposition<\/span> of each such matter. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

7.<\/span> Upon request, assist covered employees in using the procedures and processes available to them from their health plan, including all appeal<\/span> procedures. Such assistance may require the review of health care records of a covered employee, which shall be done only in accordance with the federal Health Insurance Portability and Accountability Act privacy rules. The confidentiality of any such medical records shall be maintained in accordance with the confidentiality and disclosure laws<\/span> of the Commonwealth. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

8.<\/span> Ensure that covered employees have access to the services provided by the Ombudsman and that the covered employees receive timely responses from the Ombudsman or his representatives to the inquiries. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

9.<\/span> Report annually on his activities to the standing committees of the General Assembly having jurisdiction<\/span> over insurance and over health and the Joint Commission on Health Care by December 1 of each year. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

M.<\/span> The plan established in accordance with this section shall not refuse to accept or make reimbursement pursuant to an assignment of benefits<\/span> made to a dentist or oral surgeon by a covered employee.\n\t\t\tFor purposes of this subsection, “assignment of benefits<\/span>” means the transfer of dental care coverage reimbursement benefits or other rights under the plan. The assignment of benefits<\/span> shall not be effective until the covered employee notifies the plan in writing of the assignment. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

N.<\/span> Beginning July 1, 2006, any plan established pursuant to this section shall provide for an identification number, which shall be assigned to the covered employee and shall not be the same as the employee’s social security number. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

O.<\/span> Any group health insurance plan established by the Department of Human Resource Management that contains a coordination of benefits provision shall provide written notification to any eligible employee as a prominent part of its enrollment materials<\/span> that if such eligible employee is covered under another group accident and sickness insurance policy, group accident and sickness subscription contract, or group health care plan for health care services, that insurance policy, subscription contract, or health care plan may have primary responsibility for the covered expenses of other family members enrolled with the eligible employee. Such written notification shall describe generally the conditions upon which the other coverage would be primary for dependent children enrolled under the eligible employee’s coverage and the method by which the eligible enrollee may verify from the plan that coverage would have primary responsibility for the covered expenses of each family member. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

P.<\/span> Any plan established by the Department of Human Resource Management pursuant to this section shall provide that coverage under such plan for family members enrolled under a participating state employee<\/span>’s coverage shall continue for a period of at least 30 days following the death of such state employee<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

Q.<\/span> The plan established in accordance with this section that follows a policy of sending its payment to the covered employee or covered family member for a claim for services received from a nonparticipating physician or osteopath shall (i) include language in the member handbook that notifies the covered employee of the responsibility to apply the plan payment to the claim from such nonparticipating provider, (ii) include this language with any such payment sent to the covered employee or covered family member, and (iii) include the name and any last known address of the nonparticipating provider on the explanation of benefits statement. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

R.<\/span> The plan established by the Department of Human Resource Management pursuant to this section shall provide that coverage under such plan for an incapacitated child<\/span> enrolled under a participating state employee<\/span>’s coverage shall be valid without regard to whether such child lives with the covered employee as a member of the employee’s household so long as the child is dependent upon the employee for more than half of the child’s financial support and the child is receiving residential support services.\n\t\t\tFor purposes of this subsection, “incapacitated child<\/span>” means an adult child who is incapacitated due to a physical or mental health condition that existed prior to the termination of coverage due to such child attaining the limiting age under the plan for eligible children dependents. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

S.<\/span> The Department of Human Resource Management shall report annually, by November 30 of each year, on cost and utilization information for each of the mandated benefits set forth in subsection B, including any mandated benefit made applicable, pursuant to subdivision B 22, to any plan established pursuant to this section. The report shall be in the same detail and form as required of reports submitted pursuant to § 38.2-3419.1<\/a>, with such additional information as is required to determine the financial impact, including the costs and benefits, of the particular mandated benefit. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nHEALTH AND RELATED INSURANCE FOR STATE EMPLOYEES (\u00a7 2.2-2818)\n\nA. The Department of Human Resource Management shall establish a plan, subject\nto the approval of the Governor, for providing health insurance coverage,\nincluding chiropractic treatment, hospitalization, medical, surgical, and major\nmedical coverage, for state employees and retired state employees with the\nCommonwealth paying the cost thereof to the extent of the coverage included in\nsuch plan. The same plan shall be offered to all part-time state employees, but\nthe total cost shall be paid by such part-time employees. The Department of\nHuman Resource Management shall administer this section. The plan chosen shall\nprovide means whereby coverage for the families or dependents of state employees\nmay be purchased. Except for part-time employees, the Commonwealth may pay all\nor a portion of the cost thereof, and for such portion as the Commonwealth does\nnot pay, the employee, including a part-time employee, may purchase the coverage\nby paying the additional cost over the cost of coverage for an employee.\n\t\t\tSuch contribution shall be financed through appropriations provided by law.\n\nB. The plan shall:\n\n 1. Include coverage for low-dose screening mammograms for determining the\n presence of occult breast cancer. Such coverage shall make available one\n screening mammogram to persons age 35 through 39, one such mammogram\n biennially to persons age 40 through 49, and one such mammogram annually to\n persons age 50 and over and may be limited to a benefit of $50 per mammogram\n subject to such dollar limits, deductibles, and coinsurance factors as are no\n less favorable than for physical illness generally.\n \t\t\t\tThe term “mammogram” shall mean an X-ray examination of the\n breast using equipment dedicated specifically for mammography, including but\n not limited to the X-ray tube, filter, compression device, screens, film, and\n cassettes, with an average radiation exposure of less than one rad mid-breast,\n two views of each breast.\n \t\t\t\tIn order to be considered a screening mammogram for which coverage shall\n be made available under this section:\n \t\t\t\ta. The mammogram shall be (i) ordered by a health care practitioner acting\n within the scope of his licensure and, in the case of an enrollee of a health\n maintenance organization, by the health maintenance organization provider;\n (ii) performed by a registered technologist; (iii) interpreted by a qualified\n radiologist; and (iv) performed under the direction of a person licensed to\n practice medicine and surgery and certified by the American Board of Radiology\n or an equivalent examining body. A copy of the mammogram report shall be sent\n or delivered to the health care practitioner who ordered it;\n \t\t\t\tb. The equipment used to perform the mammogram shall meet the standards\n set forth by the Virginia Department of Health in its radiation protection\n regulations; and\n \t\t\t\tc. The mammography film shall be retained by the radiologic facility\n performing the examination in accordance with the American College of\n Radiology guidelines or state law.\n\n 2. Include coverage for postpartum services providing inpatient care and a\n home visit or visits that shall be in accordance with the medical criteria,\n outlined in the most current version of or an official update to the\n “Guidelines for Perinatal Care” prepared by the American Academy\n of Pediatrics and the American College of Obstetricians and Gynecologists or\n the “Standards for Obstetric-Gynecologic Services” prepared by the\n American College of Obstetricians and Gynecologists. Such coverage shall be\n provided incorporating any changes in such Guidelines or Standards within six\n months of the publication of such Guidelines or Standards or any official\n amendment thereto.\n\n 3. Include an appeals process for resolution of complaints that shall provide\n reasonable procedures for the resolution of such complaints and shall be\n published and disseminated to all covered state employees. The appeals process\n shall be compliant with federal rules and regulations governing nonfederal,\n self-insured governmental health plans. The appeals process shall include a\n separate expedited emergency appeals procedure that shall provide resolution\n within time frames established by federal law. For appeals involving adverse\n decisions as defined in § 32.1-137.7, the Department shall contract with\n one or more independent review organizations to review such decisions.\n Independent review organizations are entities that conduct independent\n external review of adverse benefit determinations. The Department shall adopt\n regulations to assure that the independent review organization conducting the\n reviews has adequate standards, credentials and experience for such review.\n The independent review organization shall examine the final denial of claims\n to determine whether the decision is objective, clinically valid, and\n compatible with established principles of health care. The decision of the\n independent review organization shall (i) be in writing, (ii) contain findings\n of fact as to the material issues in the case and the basis for those\n findings, and (iii) be final and binding if consistent with law and policy.\n \t\t\t\tPrior to assigning an appeal to an independent review organization, the\n Department shall verify that the independent review organization conducting\n the review of a denial of claims has no relationship or association with (i)\n the covered person or the covered person’s authorized representative;\n (ii) the treating health care provider, or any of its employees or affiliates;\n (iii) the medical care facility at which the covered service would be\n provided, or any of its employees or affiliates; or (iv) the development or\n manufacture of the drug, device, procedure, or other therapy that is the\n subject of the final denial of a claim. The independent review organization\n shall not be a subsidiary of, nor owned or controlled by, a health plan, a\n trade association of health plans, or a professional association of health\n care providers. There shall be no liability on the part of and no cause of\n action shall arise against any officer or employee of an independent review\n organization for any actions taken or not taken or statements made by such\n officer or employee in good faith in the performance of his powers and duties.\n\n 4. Include coverage for early intervention services. For purposes of this\n section, “early intervention services” means medically necessary\n speech and language therapy, occupational therapy, physical therapy and\n assistive technology services and devices for dependents from birth to age\n three who are certified by the Department of Behavioral Health and\n Developmental Services as eligible for services under Part H of the\n Individuals with Disabilities Education Act (20 U.S.C. § 1471 et seq.).\n Medically necessary early intervention services for the population certified\n by the Department of Behavioral Health and Developmental Services shall mean\n those services designed to help an individual attain or retain the capability\n to function age-appropriately within his environment, and shall include\n services that enhance functional ability without effecting a cure.\n \t\t\t\tFor persons previously covered under the plan, there shall be no denial of\n coverage due to the existence of a preexisting condition. The cost of early\n intervention services shall not be applied to any contractual provision\n limiting the total amount of coverage paid by the insurer to or on behalf of\n the insured during the insured’s lifetime.\n\n 5. Include coverage for prescription drugs and devices approved by the United\n States Food and Drug Administration for use as contraceptives.\n\n 6. Not deny coverage for any drug approved by the United States Food and Drug\n Administration for use in the treatment of cancer on the basis that the drug\n has not been approved by the United States Food and Drug Administration for\n the treatment of the specific type of cancer for which the drug has been\n prescribed, if the drug has been recognized as safe and effective for\n treatment of that specific type of cancer in one of the standard reference\n compendia.\n\n 7. Not deny coverage for any drug prescribed to treat a covered indication so\n long as the drug has been approved by the United States Food and Drug\n Administration for at least one indication and the drug is recognized for\n treatment of the covered indication in one of the standard reference compendia\n or in substantially accepted peer-reviewed medical literature.\n\n 8. Include coverage for equipment, supplies, and outpatient self-management\n training and education, including medical nutrition therapy, for the treatment\n of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes,\n and noninsulin-using diabetes if prescribed by a health care professional\n legally authorized to prescribe such items under law. To qualify for coverage\n under this subdivision, diabetes outpatient self-management training and\n education shall be provided by a certified, registered, or licensed health\n care professional.\n\n 9. Include coverage for reconstructive breast surgery. For purposes of this\n section, “reconstructive breast surgery” means surgery performed\n on and after July 1, 1998, (i) coincident with a mastectomy performed for\n breast cancer or (ii) following a mastectomy performed for breast cancer to\n reestablish symmetry between the two breasts. For persons previously covered\n under the plan, there shall be no denial of coverage due to preexisting\n conditions.\n\n 10. Include coverage for annual pap smears, including coverage, on and after\n July 1, 1999, for annual testing performed by any FDA-approved gynecologic\n cytology screening technologies.\n\n 11. Include coverage providing a minimum stay in the hospital of not less than\n 48 hours for a patient following a radical or modified radical mastectomy and\n 24 hours of inpatient care following a total mastectomy or a partial\n mastectomy with lymph node dissection for treatment of breast cancer. Nothing\n in this subdivision shall be construed as requiring the provision of inpatient\n coverage where the attending physician in consultation with the patient\n determines that a shorter period of hospital stay is appropriate.\n\n 12. Include coverage (i) to persons age 50 and over and (ii) to persons age 40\n and over who are at high risk for prostate cancer, according to the most\n recent published guidelines of the American Cancer Society, for one\n prostate-specific antigen test in a 12-month period and digital rectal\n examinations.\n\n 13. Permit any individual covered under the plan direct access to the health\n care services of a participating specialist (i) authorized to provide services\n under the plan and (ii) selected by the covered individual. The plan shall\n have a procedure by which an individual who has an ongoing special condition\n may, after consultation with the primary care physician, receive a referral to\n a specialist for such condition who shall be responsible for and capable of\n providing and coordinating the individual’s primary and specialty care\n related to the initial specialty care referral. If such an individual’s\n care would most appropriately be coordinated by such a specialist, the plan\n shall refer the individual to a specialist. For the purposes of this\n subdivision, “special condition” means a condition or disease that\n is (i) life-threatening, degenerative, or disabling and (ii) requires\n specialized medical care over a prolonged period of time. Within the treatment\n period authorized by the referral, such specialist shall be permitted to treat\n the individual without a further referral from the individual’s primary\n care provider and may authorize such referrals, procedures, tests, and other\n medical services related to the initial referral as the individual’s\n primary care provider would otherwise be permitted to provide or authorize.\n The plan shall have a procedure by which an individual who has an ongoing\n special condition that requires ongoing care from a specialist may receive a\n standing referral to such specialist for the treatment of the special\n condition. If the primary care provider, in consultation with the plan and the\n specialist, if any, determines that such a standing referral is appropriate,\n the plan or issuer shall make such a referral to a specialist. Nothing\n contained herein shall prohibit the plan from requiring a participating\n specialist to provide written notification to the covered individual’s\n primary care physician of any visit to such specialist. Such notification may\n include a description of the health care services rendered at the time of the\n visit.\n\n 14. Include provisions allowing employees to continue receiving health care\n services for a period of up to 90 days from the date of the primary care\n physician’s notice of termination from any of the plan’s provider\n panels. The plan shall notify any provider at least 90 days prior to the date\n of termination of the provider, except when the provider is terminated for\n cause.\n \t\t\t\tFor a period of at least 90 days from the date of the notice of a\n provider’s termination from any of the plan’s provider panels,\n except when a provider is terminated for cause, a provider shall be permitted\n by the plan to render health care services to any of the covered employees who\n (i) were in an active course of treatment from the provider prior to the\n notice of termination and (ii) request to continue receiving health care\n services from the provider.\n \t\t\t\tNotwithstanding the provisions of this subdivision, any provider shall be\n permitted by the plan to continue rendering health services to any covered\n employee who has entered the second trimester of pregnancy at the time of the\n provider’s termination of participation, except when a provider is\n terminated for cause. Such treatment shall, at the covered employee’s\n option, continue through the provision of postpartum care directly related to\n the delivery.\n \t\t\t\tNotwithstanding the provisions of this subdivision, any provider shall be\n permitted to continue rendering health services to any covered employee who is\n determined to be terminally ill (as defined under § 1861(dd)(3)(A) of the\n Social Security Act) at the time of a provider’s termination of\n participation, except when a provider is terminated for cause. Such treatment\n shall, at the covered employee’s option, continue for the remainder of\n the employee’s life for care directly related to the treatment of the\n terminal illness.\n \t\t\t\tA provider who continues to render health care services pursuant to this\n subdivision shall be reimbursed in accordance with the carrier’s\n agreement with such provider existing immediately before the provider’s\n termination of participation.\n\n 15. Include coverage for patient costs incurred during participation in\n clinical trials for treatment studies on cancer, including ovarian cancer\n trials.\n \t\t\t\tThe reimbursement for patient costs incurred during participation in\n clinical trials for treatment studies on cancer shall be determined in the\n same manner as reimbursement is determined for other medical and surgical\n procedures. Such coverage shall have durational limits, dollar limits,\n deductibles, copayments, and coinsurance factors that are no less favorable\n than for physical illness generally.\n \t\t\t\tFor purposes of this subdivision:\n \t\t\t\t“Cooperative group” means a formal network of facilities that\n collaborate on research projects and have an established NIH-approved peer\n review program operating within the group. “Cooperative group”\n includes (i) the National Cancer Institute Clinical Cooperative Group and (ii)\n the National Cancer Institute Community Clinical Oncology Program.\n \t\t\t\t“FDA” means the Federal Food and Drug Administration.\n \t\t\t\t“Multiple project assurance contract” means a contract between\n an institution and the federal Department of Health and Human Services that\n defines the relationship of the institution to the federal Department of\n Health and Human Services and sets out the responsibilities of the institution\n and the procedures that will be used by the institution to protect human\n subjects.\n \t\t\t\t“NCI” means the National Cancer Institute.\n \t\t\t\t“NIH” means the National Institutes of Health.\n \t\t\t\t“Patient” means a person covered under the plan established\n pursuant to this section.\n \t\t\t\t“Patient cost” means the cost of a medically necessary health\n care service that is incurred as a result of the treatment being provided to a\n patient for purposes of a clinical trial. “Patient cost” does not\n include (i) the cost of nonhealth care services that a patient may be required\n to receive as a result of the treatment being provided for purposes of a\n clinical trial, (ii) costs associated with managing the research associated\n with the clinical trial, or (iii) the cost of the investigational drug or\n device.\n \t\t\t\tCoverage for patient costs incurred during clinical trials for treatment\n studies on cancer shall be provided if the treatment is being conducted in a\n Phase II, Phase III, or Phase IV clinical trial. Such treatment may, however,\n be provided on a case-by-case basis if the treatment is being provided in a\n Phase I clinical trial.\n \t\t\t\tThe treatment described in the previous paragraph shall be provided by a\n clinical trial approved by:\n \t\t\t\ta. The National Cancer Institute;\n \t\t\t\tb. An NCI cooperative group or an NCI center;\n \t\t\t\tc. The FDA in the form of an investigational new drug application;\n \t\t\t\td. The federal Department of Veterans Affairs; or\n \t\t\t\te. An institutional review board of an institution in the Commonwealth\n that has a multiple project assurance contract approved by the Office of\n Protection from Research Risks of the NCI.\n \t\t\t\tThe facility and personnel providing the treatment shall be capable of\n doing so by virtue of their experience, training, and expertise.\n \t\t\t\tCoverage under this subdivision shall apply only if:\n\n 1. There is no clearly superior, noninvestigational treatment alternative;\n\n 2. The available clinical or preclinical data provide a reasonable\n expectation that the treatment will be at least as effective as the\n noninvestigational alternative; and\n\n 3. The patient and the physician or health care provider who provides\n services to the patient under the plan conclude that the patient’s\n participation in the clinical trial would be appropriate, pursuant to\n procedures established by the plan.\n\n 16. Include coverage providing a minimum stay in the hospital of not less than\n 23 hours for a covered employee following a laparoscopy-assisted vaginal\n hysterectomy and 48 hours for a covered employee following a vaginal\n hysterectomy, as outlined in Milliman & Robertson’s nationally\n recognized guidelines. Nothing in this subdivision shall be construed as\n requiring the provision of the total hours referenced when the attending\n physician, in consultation with the covered employee, determines that a\n shorter hospital stay is appropriate.\n\n 17. Include coverage for biologically based mental illness.\n \t\t\t\tFor purposes of this subdivision, a “biologically based mental\n illness” is any mental or nervous condition caused by a biological\n disorder of the brain that results in a clinically significant syndrome that\n substantially limits the person’s functioning; specifically, the\n following diagnoses are defined as biologically based mental illness as they\n apply to adults and children: schizophrenia, schizoaffective disorder, bipolar\n disorder, major depressive disorder, panic disorder, obsessive-compulsive\n disorder, attention deficit hyperactivity disorder, autism, and drug and\n alcoholism addiction.\n \t\t\t\tCoverage for biologically based mental illnesses shall neither be\n different nor separate from coverage for any other illness, condition, or\n disorder for purposes of determining deductibles, benefit year or lifetime\n durational limits, benefit year or lifetime dollar limits, lifetime episodes\n or treatment limits, copayment and coinsurance factors, and benefit year\n maximum for deductibles and copayment and coinsurance factors.\n \t\t\t\tNothing shall preclude the undertaking of usual and customary procedures\n to determine the appropriateness of, and medical necessity for, treatment of\n biologically based mental illnesses under this option, provided that all such\n appropriateness and medical necessity determinations are made in the same\n manner as those determinations made for the treatment of any other illness,\n condition, or disorder covered by such policy or contract.\n\n 18. Offer and make available coverage for the treatment of morbid obesity\n through gastric bypass surgery or such other methods as may be recognized by\n the National Institutes of Health as effective for the long-term reversal of\n morbid obesity. Such coverage shall have durational limits, dollar limits,\n deductibles, copayments, and coinsurance factors that are no less favorable\n than for physical illness generally. Access to surgery for morbid obesity\n shall not be restricted based upon dietary or any other criteria not approved\n by the National Institutes of Health. For purposes of this subdivision,\n “morbid obesity” means (i) a weight that is at least 100 pounds\n over or twice the ideal weight for frame, age, height, and gender as specified\n in the 1983 Metropolitan Life Insurance tables, (ii) a body mass index (BMI)\n equal to or greater than 35 kilograms per meter squared with comorbidity or\n coexisting medical conditions such as hypertension, cardiopulmonary\n conditions, sleep apnea, or diabetes, or (iii) a BMI of 40 kilograms per meter\n squared without such comorbidity. As used herein, “BMI” equals\n weight in kilograms divided by height in meters squared.\n\n 19. Include coverage for colorectal cancer screening, specifically screening\n with an annual fecal occult blood test, flexible sigmoidoscopy or colonoscopy,\n or in appropriate circumstances radiologic imaging, in accordance with the\n most recently published recommendations established by the American College of\n Gastroenterology, in consultation with the American Cancer Society, for the\n ages, family histories, and frequencies referenced in such recommendations.\n The coverage for colorectal cancer screening shall not be more restrictive\n than or separate from coverage provided for any other illness, condition, or\n disorder for purposes of determining deductibles, benefit year or lifetime\n durational limits, benefit year or lifetime dollar limits, lifetime episodes\n or treatment limits, copayment and coinsurance factors, and benefit year\n maximum for deductibles and copayments and coinsurance factors.\n\n 20. On and after July 1, 2002, require that a prescription benefit card,\n health insurance benefit card, or other technology that complies with the\n requirements set forth in § 38.2-3407.4:2 be issued to each employee\n provided coverage pursuant to this section, and shall upon any changes in the\n required data elements set forth in subsection A of § 38.2-3407.4:2,\n either reissue the card or provide employees covered under the plan such\n corrective information as may be required to electronically process a\n prescription claim.\n\n 21. Include coverage for infant hearing screenings and all necessary\n audiological examinations provided pursuant to § 32.1-64.1 using any\n technology approved by the United States Food and Drug Administration, and as\n recommended by the national Joint Committee on Infant Hearing in its most\n current position statement addressing early hearing detection and intervention\n programs. Such coverage shall include follow-up audiological examinations as\n recommended by a physician, a physician assistant, an advanced practice\n registered nurse, or an audiologist and performed by a licensed audiologist to\n confirm the existence or absence of hearing loss.\n\n 22. Notwithstanding any provision of this section to the contrary, every plan\n established in accordance with this section shall comply with the provisions\n of § 2.2-2818.2.\n\nC. Claims incurred during a fiscal year but not reported during that fiscal year\nshall be paid from such funds as shall be appropriated by law. Appropriations,\npremiums, and other payments shall be deposited in the employee health insurance\nfund, from which payments for claims, premiums, cost containment programs, and\nadministrative expenses shall be withdrawn from time to time. The funds of the\nhealth insurance fund shall be deemed separate and independent trust funds,\nshall be segregated from all other funds of the Commonwealth, and shall be\ninvested and administered solely in the interests of the employees and their\nbeneficiaries. Neither the General Assembly nor any public officer, employee, or\nagency shall use or authorize the use of such trust funds for any purpose other\nthan as provided in law for benefits, refunds, and administrative expenses,\nincluding but not limited to legislative oversight of the health insurance fund.\n\nD. For the purposes of this section:\n\t\t\t“Peer-reviewed medical literature” means a scientific study\npublished only after having been critically reviewed for scientific accuracy,\nvalidity, and reliability by unbiased independent experts in a journal that has\nbeen determined by the International Committee of Medical Journal Editors to\nhave met the Uniform Requirements for Manuscripts submitted to biomedical\njournals. “Peer-reviewed medical literature” does not include\npublications or supplements to publications that are sponsored to a significant\nextent by a pharmaceutical manufacturing company or health carrier.\n\t\t\t“Standard reference compendia” means:\n\n 1. American Hospital Formulary Service Drug Information;\n\n 2. National Comprehensive Cancer Network’s Drugs & Biologics\n Compendium; or\n\n 3. Elsevier Gold Standard’s Clinical Pharmacology.\n \t\t\t\t“State employee” means state employee as defined in §\n 51.1-124.3; employee as defined in § 51.1-201; the Governor, Lieutenant\n Governor and Attorney General; judge as defined in § 51.1-301 and judges,\n clerks, and deputy clerks of regional juvenile and domestic relations, county\n juvenile and domestic relations, and district courts of the Commonwealth;\n interns and residents employed by the School of Medicine and Hospital of the\n University of Virginia, and interns, residents, and employees of the Virginia\n Commonwealth University Health System Authority as provided in §\n 23.1-2415; and employees of the Virginia Alcoholic Beverage Control Authority\n as provided in § 4.1-101.05.\n\nE. Provisions shall be made for retired employees to obtain coverage under the\nabove plan, including, as an option, coverage for vision and dental care. The\nCommonwealth may, but shall not be obligated to, pay all or any portion of the\ncost thereof.\n\nF. Any self-insured group health insurance plan established by the Department of\nHuman Resource Management that utilizes a network of preferred providers shall\nnot exclude any physician solely on the basis of a reprimand or censure from the\nBoard of Medicine, so long as the physician otherwise meets the plan criteria\nestablished by the Department.\n\nG. The plan shall include, in each planning district, at least two health\ncoverage options, each sponsored by unrelated entities. No later than July 1,\n2006, one of the health coverage options to be available in each planning\ndistrict shall be a high deductible health plan that would qualify for a health\nsavings account pursuant to § 223 of the Internal Revenue Code of 1986, as\namended.\n\t\t\tIn each planning district that does not have an available health coverage\nalternative, the Department shall voluntarily enter into negotiations at any\ntime with any health coverage provider who seeks to provide coverage under the\nplan.\n\t\t\tThis subsection shall not apply to any state agency authorized by the\nDepartment to establish and administer its own health insurance coverage plan\nseparate from the plan established by the Department.\n\nH. Any self-insured group health insurance plan established by the Department of\nHuman Resource Management that includes coverage for prescription drugs on an\noutpatient basis may apply a formulary to the prescription drug benefits\nprovided by the plan if the formulary is developed, reviewed at least annually,\nand updated as necessary in consultation with and with the approval of a\npharmacy and therapeutics committee, a majority of whose members are actively\npracticing licensed (i) pharmacists, (ii) physicians, and (iii) other health\ncare providers.\n\t\t\tIf the plan maintains one or more drug formularies, the plan shall establish\na process to allow a person to obtain, without additional cost-sharing beyond\nthat provided for formulary prescription drugs in the plan, a specific,\nmedically necessary nonformulary prescription drug if, after reasonable\ninvestigation and consultation with the prescriber, the formulary drug is\ndetermined to be an inappropriate therapy for the medical condition of the\nperson. The plan shall act on such requests within one business day of receipt\nof the request.\n\t\t\tAny plan established in accordance with this section shall be authorized to\nprovide for the selection of a single mail order pharmacy provider as the\nexclusive provider of pharmacy services that are delivered to the covered\nperson’s address by mail, common carrier, or delivery service. As used in\nthis subsection, “mail order pharmacy provider” means a pharmacy\npermitted to conduct business in the Commonwealth whose primary business is to\ndispense a prescription drug or device under a prescriptive drug order and to\ndeliver the drug or device to a patient primarily by mail, common carrier, or\ndelivery service.\n\nI. Any plan established in accordance with this section requiring\npreauthorization prior to rendering medical treatment shall have personnel\navailable to provide authorization at all times when such preauthorization is\nrequired.\n\nJ. Any plan established in accordance with this section shall provide to all\ncovered employees written notice of any benefit reductions during the contract\nperiod at least 30 days before such reductions become effective.\n\nK. No contract between a provider and any plan established in accordance with\nthis section shall include provisions that require a health care provider or\nhealth care provider group to deny covered services that such provider or group\nknows to be medically necessary and appropriate that are provided with respect\nto a covered employee with similar medical conditions.\n\nL. The Department of Human Resource Management shall appoint an Ombudsman to\npromote and protect the interests of covered employees under any state\nemployee’s health plan.\n\t\t\tThe Ombudsman shall:\n\n 1. Assist covered employees in understanding their rights and the processes\n available to them according to their state health plan.\n\n 2. Answer inquiries from covered employees by telephone and electronic mail.\n\n 3. Provide to covered employees information concerning the state health plans.\n\n 4. Develop information on the types of health plans available, including\n benefits and complaint procedures and appeals.\n\n 5. Make available, either separately or through an existing Internet web site\n utilized by the Department of Human Resource Management, information as set\n forth in subdivision 4 and such additional information as he deems\n appropriate.\n\n 6. Maintain data on inquiries received, the types of assistance requested, any\n actions taken and the disposition of each such matter.\n\n 7. Upon request, assist covered employees in using the procedures and\n processes available to them from their health plan, including all appeal\n procedures. Such assistance may require the review of health care records of a\n covered employee, which shall be done only in accordance with the federal\n Health Insurance Portability and Accountability Act privacy rules. The\n confidentiality of any such medical records shall be maintained in accordance\n with the confidentiality and disclosure laws of the Commonwealth.\n\n 8. Ensure that covered employees have access to the services provided by the\n Ombudsman and that the covered employees receive timely responses from the\n Ombudsman or his representatives to the inquiries.\n\n 9. Report annually on his activities to the standing committees of the General\n Assembly having jurisdiction over insurance and over health and the Joint\n Commission on Health Care by December 1 of each year.\n\nM. The plan established in accordance with this section shall not refuse to\naccept or make reimbursement pursuant to an assignment of benefits made to a\ndentist or oral surgeon by a covered employee.\n\t\t\tFor purposes of this subsection, “assignment of benefits” means\nthe transfer of dental care coverage reimbursement benefits or other rights\nunder the plan. The assignment of benefits shall not be effective until the\ncovered employee notifies the plan in writing of the assignment.\n\nN. Beginning July 1, 2006, any plan established pursuant to this section shall\nprovide for an identification number, which shall be assigned to the covered\nemployee and shall not be the same as the employee’s social security\nnumber.\n\nO. Any group health insurance plan established by the Department of Human\nResource Management that contains a coordination of benefits provision shall\nprovide written notification to any eligible employee as a prominent part of its\nenrollment materials that if such eligible employee is covered under another\ngroup accident and sickness insurance policy, group accident and sickness\nsubscription contract, or group health care plan for health care services, that\ninsurance policy, subscription contract, or health care plan may have primary\nresponsibility for the covered expenses of other family members enrolled with\nthe eligible employee. Such written notification shall describe generally the\nconditions upon which the other coverage would be primary for dependent children\nenrolled under the eligible employee’s coverage and the method by which\nthe eligible enrollee may verify from the plan that coverage would have primary\nresponsibility for the covered expenses of each family member.\n\nP. Any plan established by the Department of Human Resource Management pursuant\nto this section shall provide that coverage under such plan for family members\nenrolled under a participating state employee’s coverage shall continue\nfor a period of at least 30 days following the death of such state employee.\n\nQ. The plan established in accordance with this section that follows a policy of\nsending its payment to the covered employee or covered family member for a claim\nfor services received from a nonparticipating physician or osteopath shall (i)\ninclude language in the member handbook that notifies the covered employee of\nthe responsibility to apply the plan payment to the claim from such\nnonparticipating provider, (ii) include this language with any such payment sent\nto the covered employee or covered family member, and (iii) include the name and\nany last known address of the nonparticipating provider on the explanation of\nbenefits statement.\n\nR. The plan established by the Department of Human Resource Management pursuant\nto this section shall provide that coverage under such plan for an incapacitated\nchild enrolled under a participating state employee’s coverage shall be\nvalid without regard to whether such child lives with the covered employee as a\nmember of the employee’s household so long as the child is dependent upon\nthe employee for more than half of the child’s financial support and the\nchild is receiving residential support services.\n\t\t\tFor purposes of this subsection, “incapacitated child” means an\nadult child who is incapacitated due to a physical or mental health condition\nthat existed prior to the termination of coverage due to such child attaining\nthe limiting age under the plan for eligible children dependents.\n\nS. The Department of Human Resource Management shall report annually, by\nNovember 30 of each year, on cost and utilization information for each of the\nmandated benefits set forth in subsection B, including any mandated benefit made\napplicable, pursuant to subdivision B 22, to any plan established pursuant to\nthis section. The report shall be in the same detail and form as required of\nreports submitted pursuant to § 38.2-3419.1, with such additional\ninformation as is required to determine the financial impact, including the\ncosts and benefits, of the particular mandated benefit.\n\nHISTORY: 1970, c. 557, \u00a7 2.1-20.1; 1972, c. 803; 1973, cc. 69, 297; 1978, c.\n70; 1984, c. 430; 1988, c. 634; 1989, cc. 559, 664; 1990, c. 607; 1993, c. 138;\n1995, c. 353; 1996, cc. 155, 201, 905, 1046; 1997, cc. 43, 468, 521, 656; 1998,\ncc. 35, 56, 257, 386, 631, 709, 851, 858, 875; 1999, cc. 643, 649, 921, 941;\n2000, cc. 66, 149, 465, 534, 657, 720, 888; 2001, cc. 334, 558, 663, 844; 2004,\ncc. 156, 279, 855; 2005, cc. 503, 572, 640, 739; 2006, c. 396; 2008, c. 420;\n2009, cc. 247, 317, 813, 840; 2010, cc. 157, 357, 443; 2012, cc. 60, 201; 2013,\nc. 709; 2014, c. 631; 2015, cc. 38, 730; 2023, cc. 182, 183; 2025, cc. 237, 246.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}