{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/32.1-137.2.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/32.1-137.2.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/32.1-137.2.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/32.1-137.2.html"}],"law_id":80679,"edition_id":1,"section_id":80679,"structure_id":15832,"section_number":"32.1-137.2","catch_line":"Certification of quality assurance; application; issuance; denial; renewal","history":"1998, c. 891; 2013, cc. 670, 679; 2020, cc. 1080, 1081.","full_text":"A\n\nEvery managed care health insurance plan licensee shall request a certificate of quality assurance with reference to its managed care health insurance plans simultaneously with filing an initial application to the Bureau of Insurance for licensure. If already licensed by the Bureau of Insurance, every managed care health insurance plan licensee may file an application for quality assurance certification with the Department of Health by December 1, 1998, and shall file an application for quality assurance certification with the Department of Health by December 1, 1999, in order to obtain its certificate of quality assurance by July 1, 2000.\n\t\t\tOn or before July 1, 2000, the State Health Commissioner shall certify to the Bureau of Insurance that a managed care health insurance plan licensee has been issued a certificate of quality assurance by providing the Bureau of Insurance with a copy of each certificate at the time of issuance.\n\t\t\tApplication for a certificate of quality assurance shall be made on a form prescribed by the Board and shall be accompanied by a fee based upon a percentage, not to exceed one-tenth of one percent, of the proportion of direct gross premium income on business done in this Commonwealth attributable to the operation of managed care health insurance plans in the preceding biennium, sufficient to cover reasonable costs for the administration of the quality assurance program. Such fee shall not exceed $10,000 per licensee. Whenever the account of the program shows expenses for the past biennium to be more than 10 percent greater or lesser than the funds collected, the Board shall revise the fees levied by it for certification so that the fees are sufficient, but not excessive, to cover expenses; provided that such fees shall not exceed the limits set forth in this section. Until July 1, 2014, the Department may utilize such certification funds as are needed in fulfilling its responsibilities pursuant to subsection B of § 32.1-16.\n\t\t\tAll applications, including those for renewal, shall require (i) a description of the geographic area to be served, with a map clearly delineating the boundaries of the service area or areas, (ii) a description of the complaint system required under § 32.1-137.6, (iii) a description of the procedures and programs established by the licensee to assure both availability and accessibility of adequate personnel and facilities and to assess the quality of health care services provided, and (iv) a list of the licensee’s managed care health insurance plans.B\n\nEvery managed care health insurance plan licensee certified under this article shall renew its certificate of quality assurance with the Commissioner biennially by July 1, subject to payment of the fee.C\n\nThe Commissioner shall periodically examine or review each applicant for certificate of quality assurance or for renewal thereof.\n\t\t\tNo certificate of quality assurance may be issued or renewed unless a managed care health insurance plan licensee has filed a completed application and made payment of a fee pursuant to subsection A and the Commissioner is satisfied, based upon his examination, that, to the extent appropriate for the type of managed care health insurance plan under examination, the managed care health insurance plan licensee has in place and complies with: (i) a complaint system for reasonable and adequate procedures for the timely resolution of written complaints pursuant to § 32.1-137.6; (ii) a reasonable and adequate system for assessing the satisfaction of its covered persons; (iii) a system to provide for reasonable and adequate availability of and accessibility to health care services for its covered persons; (iv) reasonable and adequate policies and procedures to encourage the appropriate provision and use of preventive services for its covered persons; (v) reasonable and adequate standards and procedures for credentialing and recredentialing the providers with whom it contracts; (vi) reasonable and adequate procedures to inform its covered persons and providers of the managed care health insurance plan licensee’s policies and procedures; (vii) reasonable and adequate systems to assess, measure, and improve the health status of covered persons, including outcome measures, (viii) reasonable and adequate policies and procedures to ensure confidentiality of medical records and patient information to permit effective and confidential patient care and quality review; (ix) reasonable, timely and adequate requirements and standards pursuant to § 32.1-137.9; and (x) such other requirements as the Board may establish by regulation consistent with this article.\n\t\t\tUpon the issuance or reissuance of a certificate, the Commissioner shall provide a copy of such certificate to the Bureau of Insurance.D\n\nUpon determining to deny a certificate, the Commissioner shall notify such applicant in writing stating the reasons for the denial of a certificate. A copy of such notification of denial shall be provided to the Bureau of Insurance. Appeals from a notification of denial shall be brought by a certificate applicant pursuant to the process set forth in § 32.1-137.5.E\n\nThe State Corporation Commission shall give notice to the Commissioner of its intention to issue an order based upon a finding of insolvency, hazardous financial condition, or impairment of net worth or surplus to policyholders or an order suspending or revoking the license of a managed care health insurance plan licensee; and the Commissioner shall notify the Bureau of Insurance when he has reasonable cause to believe that a recommendation for the suspension or revocation of a certificate of quality assurance or the denial or nonrenewal of such a certificate may be made pursuant to this article. Such notifications shall be privileged and confidential and shall not be subject to subpoena.F\n\nNo certificate of quality assurance issued pursuant to this article may be transferred or assigned without approval of the Commissioner.G\n\nWhen determining the adequacy of a managed care health insurance plan proposed provider network or the ongoing adequacy of an in-force provider network, the Commissioner shall consider whether the managed care health insurance plan proposed provider network or in-force provider network includes a sufficient number of contracted providers of emergency services and surgical or ancillary services, as those terms are defined in § 38.2-3438, at or for the managed care health insurance plan’s contracted in-network hospitals to reasonably ensure that enrollees have in-network access to covered benefits delivered at that facility.","order_by":null,"text":{"0":{"id":289154,"text":"Every managed care health insurance plan licensee shall request a certificate of quality assurance with reference to its managed care health insurance plans simultaneously with filing an initial application to the Bureau of Insurance for licensure. If already licensed by the Bureau of Insurance, every managed care health insurance plan licensee may file an application for quality assurance certification with the Department of Health by December 1, 1998, and shall file an application for quality assurance certification with the Department of Health by December 1, 1999, in order to obtain its certificate of quality assurance by July 1, 2000.\n\t\t\tOn or before July 1, 2000, the State Health Commissioner shall certify to the Bureau of Insurance that a managed care health insurance plan licensee has been issued a certificate of quality assurance by providing the Bureau of Insurance with a copy of each certificate at the time of issuance.\n\t\t\tApplication for a certificate of quality assurance shall be made on a form prescribed by the Board and shall be accompanied by a fee based upon a percentage, not to exceed one-tenth of one percent, of the proportion of direct gross premium income on business done in this Commonwealth attributable to the operation of managed care health insurance plans in the preceding biennium, sufficient to cover reasonable costs for the administration of the quality assurance program. Such fee shall not exceed $10,000 per licensee. Whenever the account of the program shows expenses for the past biennium to be more than 10 percent greater or lesser than the funds collected, the Board shall revise the fees levied by it for certification so that the fees are sufficient, but not excessive, to cover expenses; provided that such fees shall not exceed the limits set forth in this section. Until July 1, 2014, the Department may utilize such certification funds as are needed in fulfilling its responsibilities pursuant to subsection B of § 32.1-16.\n\t\t\tAll applications, including those for renewal, shall require (i) a description of the geographic area to be served, with a map clearly delineating the boundaries of the service area or areas, (ii) a description of the complaint system required under § 32.1-137.6, (iii) a description of the procedures and programs established by the licensee to assure both availability and accessibility of adequate personnel and facilities and to assess the quality of health care services provided, and (iv) a list of the licensee’s managed care health insurance plans.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":289155,"text":"Every managed care health insurance plan licensee certified under this article shall renew its certificate of quality assurance with the Commissioner biennially by July 1, subject to payment of the fee.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":289156,"text":"The Commissioner shall periodically examine or review each applicant for certificate of quality assurance or for renewal thereof.\n\t\t\tNo certificate of quality assurance may be issued or renewed unless a managed care health insurance plan licensee has filed a completed application and made payment of a fee pursuant to subsection A and the Commissioner is satisfied, based upon his examination, that, to the extent appropriate for the type of managed care health insurance plan under examination, the managed care health insurance plan licensee has in place and complies with: (i) a complaint system for reasonable and adequate procedures for the timely resolution of written complaints pursuant to § 32.1-137.6; (ii) a reasonable and adequate system for assessing the satisfaction of its covered persons; (iii) a system to provide for reasonable and adequate availability of and accessibility to health care services for its covered persons; (iv) reasonable and adequate policies and procedures to encourage the appropriate provision and use of preventive services for its covered persons; (v) reasonable and adequate standards and procedures for credentialing and recredentialing the providers with whom it contracts; (vi) reasonable and adequate procedures to inform its covered persons and providers of the managed care health insurance plan licensee’s policies and procedures; (vii) reasonable and adequate systems to assess, measure, and improve the health status of covered persons, including outcome measures, (viii) reasonable and adequate policies and procedures to ensure confidentiality of medical records and patient information to permit effective and confidential patient care and quality review; (ix) reasonable, timely and adequate requirements and standards pursuant to § 32.1-137.9; and (x) such other requirements as the Board may establish by regulation consistent with this article.\n\t\t\tUpon the issuance or reissuance of a certificate, the Commissioner shall provide a copy of such certificate to the Bureau of Insurance.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":289157,"text":"Upon determining to deny a certificate, the Commissioner shall notify such applicant in writing stating the reasons for the denial of a certificate. A copy of such notification of denial shall be provided to the Bureau of Insurance. Appeals from a notification of denial shall be brought by a certificate applicant pursuant to the process set forth in § 32.1-137.5.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":289158,"text":"The State Corporation Commission shall give notice to the Commissioner of its intention to issue an order based upon a finding of insolvency, hazardous financial condition, or impairment of net worth or surplus to policyholders or an order suspending or revoking the license of a managed care health insurance plan licensee; and the Commissioner shall notify the Bureau of Insurance when he has reasonable cause to believe that a recommendation for the suspension or revocation of a certificate of quality assurance or the denial or nonrenewal of such a certificate may be made pursuant to this article. Such notifications shall be privileged and confidential and shall not be subject to subpoena.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"5":{"id":289159,"text":"No certificate of quality assurance issued pursuant to this article may be transferred or assigned without approval of the Commissioner.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"6":{"id":289160,"text":"When determining the adequacy of a managed care health insurance plan proposed provider network or the ongoing adequacy of an in-force provider network, the Commissioner shall consider whether the managed care health insurance plan proposed provider network or in-force provider network includes a sufficient number of contracted providers of emergency services and surgical or ancillary services, as those terms are defined in § 38.2-3438, at or for the managed care health insurance plan’s contracted in-network hospitals to reasonably ensure that enrollees have in-network access to covered benefits delivered at that facility.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F"}},"ancestry":[{"id":15832,"edition_id":1,"name":"Certificate of Quality Assurance of Managed Care Health Insurance Plan Licensees","identifier":"1.1","label":"article","depth":3,"order_by":1,"parent_id":12728,"metadata":{},"date_created":"2026-06-26 04:00:17","date_modified":"2026-06-26 04:00:17","permalink":{"id":203095,"object_type":"structure","relational_id":15832,"identifier":"1.1","token":"32.1\/5\/1.1","url":"\/32.1\/5\/1.1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12728,"edition_id":1,"name":"Regulation of Medical Care Facilities and Services","identifier":"5","label":"chapter","depth":2,"order_by":1,"parent_id":12727,"metadata":{},"date_created":"2026-06-26 03:43:50","date_modified":"2026-06-26 03:43:50","permalink":{"id":202855,"object_type":"structure","relational_id":12728,"identifier":"5","token":"32.1\/5","url":"\/32.1\/5\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12727,"edition_id":1,"name":"Health","identifier":"32.1","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:50","date_modified":"2026-06-26 03:43:50","permalink":{"id":201099,"object_type":"structure","relational_id":12727,"identifier":"32.1","token":"32.1","url":"\/32.1\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":61229,"structure_id":15832,"section_number":"32.1-137.1","catch_line":"Definitions","url":"\/32.1-137.1\/","token":"32.1\/5\/1.1\/32.1-137.1","metadata":false},{"id":80679,"structure_id":15832,"section_number":"32.1-137.2","catch_line":"Certification of quality assurance; application; issuance; denial; renewal","url":"\/32.1-137.2\/","token":"32.1\/5\/1.1\/32.1-137.2","metadata":false},{"id":84080,"structure_id":15832,"section_number":"32.1-137.3","catch_line":"Regulations","url":"\/32.1-137.3\/","token":"32.1\/5\/1.1\/32.1-137.3","metadata":false},{"id":80091,"structure_id":15832,"section_number":"32.1-137.4","catch_line":"Examination, review or investigation","url":"\/32.1-137.4\/","token":"32.1\/5\/1.1\/32.1-137.4","metadata":false},{"id":61098,"structure_id":15832,"section_number":"32.1-137.5","catch_line":"Civil penalties; probation; suspension; restriction or prohibition of new enrollments to managed care health insurance plan licensee; revocation or nonrenewal of certificate of quality assurance; appeal process; correction","url":"\/32.1-137.5\/","token":"32.1\/5\/1.1\/32.1-137.5","metadata":false},{"id":74118,"structure_id":15832,"section_number":"32.1-137.6","catch_line":"Complaint system","url":"\/32.1-137.6\/","token":"32.1\/5\/1.1\/32.1-137.6","metadata":false}],"previous_section":{"id":61229,"structure_id":15832,"section_number":"32.1-137.1","catch_line":"Definitions","url":"\/32.1-137.1\/","token":"32.1\/5\/1.1\/32.1-137.1","metadata":false},"next_section":{"id":84080,"structure_id":15832,"section_number":"32.1-137.3","catch_line":"Regulations","url":"\/32.1-137.3\/","token":"32.1\/5\/1.1\/32.1-137.3","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/32.1-137.2\/","history_text":"

This law was first created in 1998. The record of its establishment is cataloged in chapter 891<\/a> 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. It has been modified 2 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 2013, chapters 670<\/a> and 679<\/a>; in 2020, chapters 1080<\/a> and 1081<\/a>.<\/p>","references":[{"id":74118,"section_number":"32.1-137.6","catch_line":"Complaint system","order_by":null,"url":"\/32.1-137.6\/"}],"refers_to":[{"id":74118,"section_number":"32.1-137.6","catch_line":"Complaint system","order_by":null,"url":"\/32.1-137.6\/"},{"id":59792,"section_number":"32.1-137.9","catch_line":"Requirements and standards for utilization review entities","order_by":null,"url":"\/32.1-137.9\/"},{"id":64412,"section_number":"32.1-16","catch_line":"State Department of Health","order_by":null,"url":"\/32.1-16\/"},{"id":57210,"section_number":"38.2-3438","catch_line":"Definitions","order_by":null,"url":"\/38.2-3438\/"}],"permalink":{"id":203101,"object_type":"law","relational_id":80679,"identifier":"32.1-137.2","token":"32.1\/5\/1.1\/32.1-137.2","url":"\/32.1-137.2\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/32.1-137.2\/","token":"32.1\/5\/1.1\/32.1-137.2","dublin_core":{"Title":"Certification of quality assurance; application; issuance; denial; renewal","Type":"Text","Format":"text\/html","Identifier":"\u00a7 32.1-137.2","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> Every managed care health insurance plan licensee shall request a certificate of quality assurance with reference to its managed care health insurance plans simultaneously with filing an initial application to the Bureau of Insurance for licensure. If already licensed by the Bureau of Insurance, every managed care health insurance plan licensee may file an application for quality assurance certification with the Department<\/span> of Health by December 1, 1998, and shall file an application for quality assurance certification with the Department<\/span> of Health by December 1, 1999, in order<\/span> to obtain its certificate of quality assurance by July 1, 2000.\n\t\t\tOn or before July 1, 2000, the State Health Commissioner<\/span> shall certify to the Bureau of Insurance that a managed care health insurance plan licensee has been issued a certificate of quality assurance by providing the Bureau of Insurance with a copy of each certificate at the time of issuance.\n\t\t\tApplication for a certificate of quality assurance shall be made on a form prescribed by the Board<\/span> and shall be accompanied by a fee based upon a percentage, not to exceed one-tenth of one percent, of the proportion of direct gross premium income on business done in this Commonwealth attributable to the operation of managed care health insurance plans in the preceding biennium, sufficient to cover reasonable costs for the administration of the quality assurance program. Such fee shall not exceed $10,000 per licensee. Whenever the account of the program shows expenses for the past biennium to be more than 10 percent greater or lesser than the funds collected, the Board<\/span> shall revise the fees levied by it for certification so that the fees are sufficient, but not excessive, to cover expenses; provided that such fees shall not exceed the limits set forth in this section. Until July 1, 2014, the Department<\/span> may utilize such certification funds as are needed in fulfilling its responsibilities pursuant to subsection B of § 32.1-16<\/a>.\n\t\t\tAll applications, including those for renewal, shall require (i) a description of the geographic area to be served, with a map clearly delineating the boundaries of the service area or areas, (ii) a description of the complaint system required under § 32.1-137.6<\/a>, (iii) a description of the procedures and programs established by the licensee to assure both availability and accessibility of adequate personnel and facilities and to assess the quality of health care services provided, and (iv) a list of the licensee’s managed care health insurance plans. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> Every managed care health insurance plan licensee certified under this article shall renew its certificate of quality assurance with the Commissioner<\/span> biennially by July 1, subject to payment of the fee. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> The Commissioner<\/span> shall periodically examine or review each applicant for certificate of quality assurance or for renewal thereof.\n\t\t\tNo certificate of quality assurance may be issued or renewed unless a managed care health insurance plan licensee has filed a completed application and made payment of a fee pursuant to subsection A and the Commissioner<\/span> is satisfied, based upon his examination, that, to the extent appropriate for the type of managed care health insurance plan under examination, the managed care health insurance plan licensee has in place and complies with: (i) a complaint system for reasonable and adequate procedures for the timely resolution of written complaints pursuant to § 32.1-137.6<\/a>; (ii) a reasonable and adequate system for assessing the satisfaction of its covered persons<\/span>; (iii) a system to provide for reasonable and adequate availability of and accessibility to health care services for its covered persons<\/span>; (iv) reasonable and adequate policies and procedures to encourage the appropriate provision and use of preventive services for its covered persons<\/span>; (v) reasonable and adequate standards and procedures for credentialing and recredentialing the providers with whom it contracts<\/span>; (vi) reasonable and adequate procedures to inform its covered persons<\/span> and providers of the managed care health insurance plan licensee’s policies and procedures; (vii) reasonable and adequate systems to assess, measure, and improve the health status of covered persons<\/span>, including outcome measures, (viii) reasonable and adequate policies and procedures to ensure confidentiality of medical records and patient information to permit effective and confidential patient care and quality review; (ix) reasonable, timely and adequate requirements and standards pursuant to § 32.1-137.9<\/a>; and (x) such other requirements as the Board<\/span> may establish by regulation consistent with this article.\n\t\t\tUpon the issuance or reissuance of a certificate, the Commissioner<\/span> shall provide a copy of such certificate to the Bureau of Insurance. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> Upon determining to deny a certificate, the Commissioner<\/span> shall notify such applicant in writing stating the reasons for the denial of a certificate. A copy of such notification of denial shall be provided to the Bureau of Insurance. Appeals<\/span> from a notification of denial shall be brought by a certificate applicant pursuant to the process set forth in § 32.1-137.5<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> The State Corporation Commission shall give notice to the Commissioner<\/span> of its intention to issue<\/span> an order<\/span> based upon a finding<\/span> of insolvency, hazardous financial condition, or impairment of net worth or surplus to policyholders or an order<\/span> suspending or revoking the license of a managed care health insurance plan licensee; and the Commissioner<\/span> shall notify the Bureau of Insurance when he has reasonable cause to believe that a recommendation for the suspension or revocation<\/span> of a certificate of quality assurance or the denial or nonrenewal of such a certificate may be made pursuant to this article. Such notifications shall be privileged and confidential and shall not be subject to subpoena<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> No certificate of quality assurance issued pursuant to this article may be transferred or assigned without approval of the Commissioner<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> When determining the adequacy of a managed care health insurance plan proposed provider network or the ongoing adequacy of an in-force provider network, the Commissioner<\/span> shall consider whether the managed care health insurance plan proposed provider network or in-force provider network includes a sufficient number of contracted providers of emergency services and surgical or ancillary services, as those terms are defined in § 38.2-3438<\/a>, at or for the managed care health insurance plan’s contracted in-network hospitals to reasonably ensure that enrollees have in-network access to covered benefits delivered at that facility. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nCERTIFICATION OF QUALITY ASSURANCE; APPLICATION; ISSUANCE; DENIAL; RENEWAL (\u00a7\n32.1-137.2)\n\nA. Every managed care health insurance plan licensee shall request a certificate\nof quality assurance with reference to its managed care health insurance plans\nsimultaneously with filing an initial application to the Bureau of Insurance for\nlicensure. If already licensed by the Bureau of Insurance, every managed care\nhealth insurance plan licensee may file an application for quality assurance\ncertification with the Department of Health by December 1, 1998, and shall file\nan application for quality assurance certification with the Department of Health\nby December 1, 1999, in order to obtain its certificate of quality assurance by\nJuly 1, 2000.\n\t\t\tOn or before July 1, 2000, the State Health Commissioner shall certify to the\nBureau of Insurance that a managed care health insurance plan licensee has been\nissued a certificate of quality assurance by providing the Bureau of Insurance\nwith a copy of each certificate at the time of issuance.\n\t\t\tApplication for a certificate of quality assurance shall be made on a form\nprescribed by the Board and shall be accompanied by a fee based upon a\npercentage, not to exceed one-tenth of one percent, of the proportion of direct\ngross premium income on business done in this Commonwealth attributable to the\noperation of managed care health insurance plans in the preceding biennium,\nsufficient to cover reasonable costs for the administration of the quality\nassurance program. Such fee shall not exceed $10,000 per licensee. Whenever the\naccount of the program shows expenses for the past biennium to be more than 10\npercent greater or lesser than the funds collected, the Board shall revise the\nfees levied by it for certification so that the fees are sufficient, but not\nexcessive, to cover expenses; provided that such fees shall not exceed the\nlimits set forth in this section. Until July 1, 2014, the Department may utilize\nsuch certification funds as are needed in fulfilling its responsibilities\npursuant to subsection B of § 32.1-16.\n\t\t\tAll applications, including those for renewal, shall require (i) a\ndescription of the geographic area to be served, with a map clearly delineating\nthe boundaries of the service area or areas, (ii) a description of the complaint\nsystem required under § 32.1-137.6, (iii) a description of the procedures\nand programs established by the licensee to assure both availability and\naccessibility of adequate personnel and facilities and to assess the quality of\nhealth care services provided, and (iv) a list of the licensee’s managed\ncare health insurance plans.\n\nB. Every managed care health insurance plan licensee certified under this\narticle shall renew its certificate of quality assurance with the Commissioner\nbiennially by July 1, subject to payment of the fee.\n\nC. The Commissioner shall periodically examine or review each applicant for\ncertificate of quality assurance or for renewal thereof.\n\t\t\tNo certificate of quality assurance may be issued or renewed unless a managed\ncare health insurance plan licensee has filed a completed application and made\npayment of a fee pursuant to subsection A and the Commissioner is satisfied,\nbased upon his examination, that, to the extent appropriate for the type of\nmanaged care health insurance plan under examination, the managed care health\ninsurance plan licensee has in place and complies with: (i) a complaint system\nfor reasonable and adequate procedures for the timely resolution of written\ncomplaints pursuant to § 32.1-137.6; (ii) a reasonable and adequate system\nfor assessing the satisfaction of its covered persons; (iii) a system to provide\nfor reasonable and adequate availability of and accessibility to health care\nservices for its covered persons; (iv) reasonable and adequate policies and\nprocedures to encourage the appropriate provision and use of preventive services\nfor its covered persons; (v) reasonable and adequate standards and procedures\nfor credentialing and recredentialing the providers with whom it contracts; (vi)\nreasonable and adequate procedures to inform its covered persons and providers\nof the managed care health insurance plan licensee’s policies and\nprocedures; (vii) reasonable and adequate systems to assess, measure, and\nimprove the health status of covered persons, including outcome measures, (viii)\nreasonable and adequate policies and procedures to ensure confidentiality of\nmedical records and patient information to permit effective and confidential\npatient care and quality review; (ix) reasonable, timely and adequate\nrequirements and standards pursuant to § 32.1-137.9; and (x) such other\nrequirements as the Board may establish by regulation consistent with this\narticle.\n\t\t\tUpon the issuance or reissuance of a certificate, the Commissioner shall\nprovide a copy of such certificate to the Bureau of Insurance.\n\nD. Upon determining to deny a certificate, the Commissioner shall notify such\napplicant in writing stating the reasons for the denial of a certificate. A copy\nof such notification of denial shall be provided to the Bureau of Insurance.\nAppeals from a notification of denial shall be brought by a certificate\napplicant pursuant to the process set forth in § 32.1-137.5.\n\nE. The State Corporation Commission shall give notice to the Commissioner of its\nintention to issue an order based upon a finding of insolvency, hazardous\nfinancial condition, or impairment of net worth or surplus to policyholders or\nan order suspending or revoking the license of a managed care health insurance\nplan licensee; and the Commissioner shall notify the Bureau of Insurance when he\nhas reasonable cause to believe that a recommendation for the suspension or\nrevocation of a certificate of quality assurance or the denial or nonrenewal of\nsuch a certificate may be made pursuant to this article. Such notifications\nshall be privileged and confidential and shall not be subject to subpoena.\n\nF. No certificate of quality assurance issued pursuant to this article may be\ntransferred or assigned without approval of the Commissioner.\n\nG. When determining the adequacy of a managed care health insurance plan\nproposed provider network or the ongoing adequacy of an in-force provider\nnetwork, the Commissioner shall consider whether the managed care health\ninsurance plan proposed provider network or in-force provider network includes a\nsufficient number of contracted providers of emergency services and surgical or\nancillary services, as those terms are defined in § 38.2-3438, at or for\nthe managed care health insurance plan’s contracted in-network hospitals\nto reasonably ensure that enrollees have in-network access to covered benefits\ndelivered at that facility.\n\nHISTORY: 1998, c. 891; 2013, cc. 670, 679; 2020, cc. 1080, 1081.","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}}