{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-316.1.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-316.1.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-316.1.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-316.1.html"}],"law_id":85582,"edition_id":1,"section_id":85582,"structure_id":13680,"section_number":"38.2-316.1","catch_line":"Premium rates","history":"2013, cc. 670, 679; 2018, c. 708; 2019, c. 607.","full_text":"A\n\nAs used in this section:\n\t\t\t“Anticipated loss ratio” means the ratio of the present value of the future benefits to the present value of the future premiums of a policy form over the entire period for which rates are computed to provide coverage.\n\t\t\t“Student health insurance coverage” means a type of individual health insurance coverage offered in the individual market that is provided pursuant to a written agreement between an institution of higher education, as defined by the Higher Education Act of 1965, P.L. 89-329, and a health carrier to students enrolled in that institution of higher education and their dependents; that does not make health insurance coverage available other than in connection with enrollment as a student or as a dependent of a student in the institution of higher education; and that does not condition eligibility for health insurance coverage on any health status-related factor related to a student or a dependent of the student.B\n\nThe Commission shall review and approve accident and sickness insurance premium rates applicable to (i) health benefit plans issued in the Commonwealth in the individual and small group markets, as those terms are defined in § 38.2-3431, and (ii) health benefit plans providing health insurance coverage, as defined in § 38.2-3431, in the individual market to residents of the Commonwealth through a group trust, association, purchasing cooperative, or other group that is not an employer plan. In connection therewith, the Commission is authorized to establish minimum loss ratios to assure that the benefits provided by accident and sickness insurance policies are or are likely to be reasonable in relation to the premiums charged. The Commission shall promulgate regulations to establish standards applicable to such review and approval.C\n\nPremium rate filings for a health benefit plan issued in the Commonwealth in the individual and small group markets shall include a description of agent commissions and any limitations or exceptions as they relate to the payment of such commissions.D\n\nEvery policy, rider, or endorsement form affecting benefits that is submitted for approval shall be accompanied by a rate filing, as required by § 38.2-316. Any subsequent addition to or change in rates applicable to such policy, rider, or endorsement form shall also be filed. Each rate submission shall comply with the requirements of 14VAC5-130.E\n\nBenefits shall be deemed reasonable in relation to premiums, provided that the anticipated loss ratio of the policy form, including riders and endorsements, is at least as great as provided in 14VAC5-130. The reasonableness of benefits with respect to filings of rate revisions for a previously approved form shall be determined as provided in 14VAC5-130.F\n\nA health insurance issuer shall consider the claims experience of all enrollees in all health benefit plans, other than grandfathered plans and student health insurance coverage, in the individual market to be members of a single risk pool. A health insurance issuer shall consider the claims experience of all enrollees in all health plans, other than grandfathered plans, in the small group market to be members of a single risk pool. Each plan year or policy year, as applicable, a health insurance issuer shall establish an index rate based on the total combined claims costs for providing essential health benefits within the single risk pool of the individual or small group market as provided in 14VAC5-130. A health insurance issuer may vary premium rates for a particular plan from its index rate for a relevant state market only on the basis of an actuarially justified plan-specific factor permitted under 14VAC5-130.G\n\nIf the Commission finds that the premium rate filed in accordance with this section is not meeting or will not meet the originally filed and approved loss ratio, the Commission may require appropriate rate adjustments, premium refunds, or premium credits (i) as deemed necessary for the coverage to conform with the minimum loss ratio standards established pursuant to subsection B and (ii) that are expected to result in a loss ratio at least as great as that originally anticipated in the rates used to produce current rates by the health insurance issuer for the coverage. The Commission may take into consideration any previous or expected premium refunds or credits. The Commission may require the submission of detailed supporting documents as necessary to justify the adjustment.H\n\nThe Commission may request information subsequent to approval of a policy form or rate revision so that it may determine whether premium rates are reasonable in relation to the benefits provided as specified in 14VAC5-130.I\n\nExcept as otherwise provided, nothing contained in this section shall be construed to relieve a health insurance issuer from complying with other statutory requirements set forth in this title.J\n\nThe Commission may prescribe procedures for the effective monitoring of actual experience under any form subject to 14VAC5-130.","order_by":null,"text":{"0":{"id":306589,"text":"As used in this section:\n\t\t\t“Anticipated loss ratio” means the ratio of the present value of the future benefits to the present value of the future premiums of a policy form over the entire period for which rates are computed to provide coverage.\n\t\t\t“Student health insurance coverage” means a type of individual health insurance coverage offered in the individual market that is provided pursuant to a written agreement between an institution of higher education, as defined by the Higher Education Act of 1965, P.L. 89-329, and a health carrier to students enrolled in that institution of higher education and their dependents; that does not make health insurance coverage available other than in connection with enrollment as a student or as a dependent of a student in the institution of higher education; and that does not condition eligibility for health insurance coverage on any health status-related factor related to a student or a dependent of the student.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":306590,"text":"The Commission shall review and approve accident and sickness insurance premium rates applicable to (i) health benefit plans issued in the Commonwealth in the individual and small group markets, as those terms are defined in § 38.2-3431, and (ii) health benefit plans providing health insurance coverage, as defined in § 38.2-3431, in the individual market to residents of the Commonwealth through a group trust, association, purchasing cooperative, or other group that is not an employer plan. In connection therewith, the Commission is authorized to establish minimum loss ratios to assure that the benefits provided by accident and sickness insurance policies are or are likely to be reasonable in relation to the premiums charged. The Commission shall promulgate regulations to establish standards applicable to such review and approval.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":306591,"text":"Premium rate filings for a health benefit plan issued in the Commonwealth in the individual and small group markets shall include a description of agent commissions and any limitations or exceptions as they relate to the payment of such commissions.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":306592,"text":"Every policy, rider, or endorsement form affecting benefits that is submitted for approval shall be accompanied by a rate filing, as required by § 38.2-316. Any subsequent addition to or change in rates applicable to such policy, rider, or endorsement form shall also be filed. Each rate submission shall comply with the requirements of 14VAC5-130.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":306593,"text":"Benefits shall be deemed reasonable in relation to premiums, provided that the anticipated loss ratio of the policy form, including riders and endorsements, is at least as great as provided in 14VAC5-130. The reasonableness of benefits with respect to filings of rate revisions for a previously approved form shall be determined as provided in 14VAC5-130.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"5":{"id":306594,"text":"A health insurance issuer shall consider the claims experience of all enrollees in all health benefit plans, other than grandfathered plans and student health insurance coverage, in the individual market to be members of a single risk pool. A health insurance issuer shall consider the claims experience of all enrollees in all health plans, other than grandfathered plans, in the small group market to be members of a single risk pool. Each plan year or policy year, as applicable, a health insurance issuer shall establish an index rate based on the total combined claims costs for providing essential health benefits within the single risk pool of the individual or small group market as provided in 14VAC5-130. A health insurance issuer may vary premium rates for a particular plan from its index rate for a relevant state market only on the basis of an actuarially justified plan-specific factor permitted under 14VAC5-130.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"6":{"id":306595,"text":"If the Commission finds that the premium rate filed in accordance with this section is not meeting or will not meet the originally filed and approved loss ratio, the Commission may require appropriate rate adjustments, premium refunds, or premium credits (i) as deemed necessary for the coverage to conform with the minimum loss ratio standards established pursuant to subsection B and (ii) that are expected to result in a loss ratio at least as great as that originally anticipated in the rates used to produce current rates by the health insurance issuer for the coverage. The Commission may take into consideration any previous or expected premium refunds or credits. The Commission may require the submission of detailed supporting documents as necessary to justify the adjustment.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F","next_prefix":"H"},"7":{"id":306596,"text":"The Commission may request information subsequent to approval of a policy form or rate revision so that it may determine whether premium rates are reasonable in relation to the benefits provided as specified in 14VAC5-130.","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G","next_prefix":"I"},"8":{"id":306597,"text":"Except as otherwise provided, nothing contained in this section shall be construed to relieve a health insurance issuer from complying with other statutory requirements set forth in this title.","type":"section","prefixes":["I"],"prefix":"I","entire_prefix":"I","prefix_anchor":"I","level":1,"prior_prefix":"H","next_prefix":"J"},"9":{"id":306598,"text":"The Commission may prescribe procedures for the effective monitoring of actual experience under any form subject to 14VAC5-130.","type":"section","prefixes":["J"],"prefix":"J","entire_prefix":"J","prefix_anchor":"J","level":1,"prior_prefix":"I"}},"ancestry":[{"id":13680,"edition_id":1,"name":"Provisions Relating to Insurance Policies and Contracts","identifier":"3","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:45:32","date_modified":"2026-06-26 03:45:32","permalink":{"id":214203,"object_type":"structure","relational_id":13680,"identifier":"3","token":"38.2\/3","url":"\/38.2\/3\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12698,"edition_id":1,"name":"Insurance","identifier":"38.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:49","date_modified":"2026-06-26 03:43:49","permalink":{"id":210661,"object_type":"structure","relational_id":12698,"identifier":"38.2","token":"38.2","url":"\/38.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":67920,"structure_id":13680,"section_number":"38.2-300","catch_line":"Scope of chapter","url":"\/38.2-300\/","token":"38.2\/3\/38.2-300","metadata":false},{"id":66037,"structure_id":13680,"section_number":"38.2-301","catch_line":"Insurable interest required; life, accident and sickness insurance","url":"\/38.2-301\/","token":"38.2\/3\/38.2-301","metadata":false},{"id":76812,"structure_id":13680,"section_number":"38.2-302","catch_line":"Life, accident, and sickness insurance; application required","url":"\/38.2-302\/","token":"38.2\/3\/38.2-302","metadata":false},{"id":58792,"structure_id":13680,"section_number":"38.2-303","catch_line":"Insurable interest required; property insurance","url":"\/38.2-303\/","token":"38.2\/3\/38.2-303","metadata":false},{"id":79372,"structure_id":13680,"section_number":"38.2-304","catch_line":"Contracts of temporary insurance; duration; what deemed to include","url":"\/38.2-304\/","token":"38.2\/3\/38.2-304","metadata":false},{"id":68773,"structure_id":13680,"section_number":"38.2-305","catch_line":"Contents of policies","url":"\/38.2-305\/","token":"38.2\/3\/38.2-305","metadata":false},{"id":76860,"structure_id":13680,"section_number":"38.2-306","catch_line":"Additional contents","url":"\/38.2-306\/","token":"38.2\/3\/38.2-306","metadata":false},{"id":84098,"structure_id":13680,"section_number":"38.2-307","catch_line":"Charter and bylaw provisions in policies","url":"\/38.2-307\/","token":"38.2\/3\/38.2-307","metadata":false},{"id":69279,"structure_id":13680,"section_number":"38.2-308","catch_line":"Contingent liability provisions in policies issued by certain mutual insurers","url":"\/38.2-308\/","token":"38.2\/3\/38.2-308","metadata":false},{"id":65281,"structure_id":13680,"section_number":"38.2-309","catch_line":"When answers or statements of applicant do not bar recovery on policy","url":"\/38.2-309\/","token":"38.2\/3\/38.2-309","metadata":false},{"id":67536,"structure_id":13680,"section_number":"38.2-310","catch_line":"All fees, charges, etc., to be stated in policy","url":"\/38.2-310\/","token":"38.2\/3\/38.2-310","metadata":false},{"id":72176,"structure_id":13680,"section_number":"38.2-311","catch_line":"Type size in which conditions and restrictions to be printed","url":"\/38.2-311\/","token":"38.2\/3\/38.2-311","metadata":false},{"id":75172,"structure_id":13680,"section_number":"38.2-312","catch_line":"Provisions limiting jurisdiction, or requiring construction of contracts by law of other states, prohibited","url":"\/38.2-312\/","token":"38.2\/3\/38.2-312","metadata":false},{"id":74805,"structure_id":13680,"section_number":"38.2-313","catch_line":"Where certain contracts deemed made","url":"\/38.2-313\/","token":"38.2\/3\/38.2-313","metadata":false},{"id":56872,"structure_id":13680,"section_number":"38.2-314","catch_line":"Limitation of action and proof of loss","url":"\/38.2-314\/","token":"38.2\/3\/38.2-314","metadata":false},{"id":69924,"structure_id":13680,"section_number":"38.2-315","catch_line":"Intervening breach","url":"\/38.2-315\/","token":"38.2\/3\/38.2-315","metadata":false},{"id":60466,"structure_id":13680,"section_number":"38.2-316","catch_line":"Policy forms to be filed with Commission; notice of approval or disapproval; exceptions","url":"\/38.2-316\/","token":"38.2\/3\/38.2-316","metadata":false},{"id":85582,"structure_id":13680,"section_number":"38.2-316.1","catch_line":"Premium rates","url":"\/38.2-316.1\/","token":"38.2\/3\/38.2-316.1","metadata":false},{"id":71148,"structure_id":13680,"section_number":"38.2-316.2","catch_line":"Dental carriers; annual actual loss ratio report","url":"\/38.2-316.2\/","token":"38.2\/3\/38.2-316.2","metadata":false},{"id":77188,"structure_id":13680,"section_number":"38.2-317","catch_line":"Delivery and use of certain policies and endorsements","url":"\/38.2-317\/","token":"38.2\/3\/38.2-317","metadata":false},{"id":64949,"structure_id":13680,"section_number":"38.2-318","catch_line":"Validity of noncomplying forms","url":"\/38.2-318\/","token":"38.2\/3\/38.2-318","metadata":false},{"id":67693,"structure_id":13680,"section_number":"38.2-319","catch_line":"Validity of contracts in violation of law","url":"\/38.2-319\/","token":"38.2\/3\/38.2-319","metadata":false},{"id":71052,"structure_id":13680,"section_number":"38.2-320","catch_line":"Insurer to furnish forms for proof of loss","url":"\/38.2-320\/","token":"38.2\/3\/38.2-320","metadata":false},{"id":60210,"structure_id":13680,"section_number":"38.2-321","catch_line":"Payment discharges insurer","url":"\/38.2-321\/","token":"38.2\/3\/38.2-321","metadata":false},{"id":65634,"structure_id":13680,"section_number":"38.2-322","catch_line":"Standardized claims forms","url":"\/38.2-322\/","token":"38.2\/3\/38.2-322","metadata":false},{"id":54659,"structure_id":13680,"section_number":"38.2-323","catch_line":"Repealed","url":"\/38.2-323\/","token":"38.2\/3\/38.2-323","metadata":false},{"id":87300,"structure_id":13680,"section_number":"38.2-324","catch_line":"Disclosure of property damage information","url":"\/38.2-324\/","token":"38.2\/3\/38.2-324","metadata":false},{"id":72048,"structure_id":13680,"section_number":"38.2-325","catch_line":"Electronic delivery","url":"\/38.2-325\/","token":"38.2\/3\/38.2-325","metadata":false},{"id":55944,"structure_id":13680,"section_number":"38.2-326","catch_line":"Plan management functions","url":"\/38.2-326\/","token":"38.2\/3\/38.2-326","metadata":false}],"previous_section":{"id":60466,"structure_id":13680,"section_number":"38.2-316","catch_line":"Policy forms to be filed with Commission; notice of approval or disapproval; exceptions","url":"\/38.2-316\/","token":"38.2\/3\/38.2-316","metadata":false},"next_section":{"id":71148,"structure_id":13680,"section_number":"38.2-316.2","catch_line":"Dental carriers; annual actual loss ratio report","url":"\/38.2-316.2\/","token":"38.2\/3\/38.2-316.2","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-316.1\/","history_text":"

This law was first created in 2013. The record of its establishment is cataloged in chapters 670<\/a> and 679<\/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 2018, chapter 708<\/a>; in 2019, chapter 607<\/a>.<\/p>","references":[{"id":55347,"section_number":"38.2-4214","catch_line":"Application of certain provisions of law","order_by":null,"url":"\/38.2-4214\/"},{"id":67952,"section_number":"38.2-4319","catch_line":"Statutory construction and relationship to other laws","order_by":null,"url":"\/38.2-4319\/"},{"id":81163,"section_number":"38.2-6506","catch_line":"Certification of health benefit plans as qualified health plans","order_by":null,"url":"\/38.2-6506\/"}],"refers_to":[{"id":60466,"section_number":"38.2-316","catch_line":"Policy forms to be filed with Commission; notice of approval or disapproval; exceptions","order_by":null,"url":"\/38.2-316\/"},{"id":86404,"section_number":"38.2-3431","catch_line":"Application of article; definitions","order_by":null,"url":"\/38.2-3431\/"}],"permalink":{"id":214273,"object_type":"law","relational_id":85582,"identifier":"38.2-316.1","token":"38.2\/3\/38.2-316.1","url":"\/38.2-316.1\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-316.1\/","token":"38.2\/3\/38.2-316.1","dublin_core":{"Title":"Premium rates","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-316.1","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> As used in this section:\n\t\t\t“Anticipated loss ratio<\/span>” means the ratio of the present value of the future benefits to the present value of the future premiums of a policy form over the entire period for which rates<\/span><\/span> are computed to provide coverage.\n\t\t\t“Student health insurance coverage<\/span>” means a type of individual health insurance coverage offered in the individual market that is provided pursuant to a written agreement between an institution of higher education, as defined by the Higher Education Act of 1965, P.L. 89-329, and a health carrier to students enrolled in that institution of higher education and their dependents; that does not make health insurance coverage available other than in connection with enrollment as a student or as a dependent of a student in the institution of higher education; and that does not condition eligibility for health insurance coverage on any health status-related factor related to a student or a dependent of the student. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> The Commission<\/span> shall review and approve accident and sickness insurance premium rates<\/span><\/span> applicable to (i) health benefit plans issued in the Commonwealth in the individual and small group markets, as those terms are defined in § 38.2-3431<\/a>, and (ii) health benefit plans providing health insurance coverage, as defined in § 38.2-3431<\/a>, in the individual market to residents of the Commonwealth through a group trust, association, purchasing cooperative, or other group that is not an employer plan. In connection therewith, the Commission<\/span> is authorized to establish minimum loss ratios to assure that the benefits provided by accident and sickness insurance policies<\/span> are or are likely to be reasonable in relation to the premiums charged. The Commission<\/span> shall promulgate regulations to establish standards applicable to such review and approval. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Premium rate<\/span> filings for a health benefit plan issued in the Commonwealth in the individual and small group markets shall include a description of agent commissions<\/span> and any limitations or exceptions as they relate to the payment of such commissions<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> Every policy, rider, or endorsement form affecting benefits that is submitted for approval shall be accompanied by a rate<\/span> filing, as required by § 38.2-316<\/a>. Any subsequent addition to or change in rates<\/span><\/span> applicable to such policy, rider, or endorsement form shall also be filed. Each rate<\/span> submission shall comply with the requirements of 14VAC5-130. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Benefits shall be deemed reasonable in relation to premiums, provided that the anticipated loss ratio<\/span> of the policy form, including riders and endorsements, is at least as great as provided in 14VAC5-130. The reasonableness of benefits with respect to filings of rate<\/span> revisions for a previously approved form shall be determined as provided in 14VAC5-130. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> A health insurance issuer shall consider the claims experience of all enrollees in all health benefit plans, other than grandfathered plans and student health insurance coverage<\/span>, in the individual market to be members of a single risk pool. A health insurance issuer shall consider the claims experience of all enrollees in all health plans, other than grandfathered plans, in the small group market to be members of a single risk pool. Each plan year or policy year, as applicable, a health insurance issuer shall establish an index rate<\/span> based on the total combined claims costs for providing essential health benefits within the single risk pool of the individual or small group market as provided in 14VAC5-130. A health insurance issuer may vary premium rates<\/span><\/span> for a particular plan from its index rate<\/span> for a relevant state<\/span> market only on the basis of an actuarially justified plan-specific factor permitted under 14VAC5-130. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> If the Commission<\/span> finds that the premium rate<\/span> filed in accordance with this section is not meeting or will not meet the originally filed and approved loss ratio, the Commission<\/span> may require appropriate rate<\/span> adjustments, premium refunds, or premium credits (i) as deemed necessary for the coverage to conform with the minimum loss ratio standards established pursuant to subsection B and (ii) that are expected to result in a loss ratio at least as great as that originally anticipated in the rates<\/span><\/span> used to produce current rates<\/span><\/span> by the health insurance issuer for the coverage. The Commission<\/span> may take into consideration any previous or expected premium refunds or credits. The Commission<\/span> may require the submission of detailed supporting documents as necessary to justify the adjustment. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

H.<\/span> The Commission<\/span> may request information subsequent to approval of a policy form or rate<\/span> revision so that it may determine whether premium rates<\/span><\/span> are reasonable in relation to the benefits provided as specified in 14VAC5-130. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

I.<\/span> Except as otherwise provided, nothing contained in this section shall be construed to relieve a health insurance issuer from complying with other statutory requirements set forth in this title. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

J.<\/span> The Commission<\/span> may prescribe procedures for the effective monitoring of actual experience under any form subject to 14VAC5-130. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nPREMIUM RATES (\u00a7 38.2-316.1)\n\nA. As used in this section:\n\t\t\t“Anticipated loss ratio” means the ratio of the present value of\nthe future benefits to the present value of the future premiums of a policy form\nover the entire period for which rates are computed to provide coverage.\n\t\t\t“Student health insurance coverage” means a type of individual\nhealth insurance coverage offered in the individual market that is provided\npursuant to a written agreement between an institution of higher education, as\ndefined by the Higher Education Act of 1965, P.L. 89-329, and a health carrier\nto students enrolled in that institution of higher education and their\ndependents; that does not make health insurance coverage available other than in\nconnection with enrollment as a student or as a dependent of a student in the\ninstitution of higher education; and that does not condition eligibility for\nhealth insurance coverage on any health status-related factor related to a\nstudent or a dependent of the student.\n\nB. The Commission shall review and approve accident and sickness insurance\npremium rates applicable to (i) health benefit plans issued in the Commonwealth\nin the individual and small group markets, as those terms are defined in §\n38.2-3431, and (ii) health benefit plans providing health insurance coverage, as\ndefined in § 38.2-3431, in the individual market to residents of the\nCommonwealth through a group trust, association, purchasing cooperative, or\nother group that is not an employer plan. In connection therewith, the\nCommission is authorized to establish minimum loss ratios to assure that the\nbenefits provided by accident and sickness insurance policies are or are likely\nto be reasonable in relation to the premiums charged. The Commission shall\npromulgate regulations to establish standards applicable to such review and\napproval.\n\nC. Premium rate filings for a health benefit plan issued in the Commonwealth in\nthe individual and small group markets shall include a description of agent\ncommissions and any limitations or exceptions as they relate to the payment of\nsuch commissions.\n\nD. Every policy, rider, or endorsement form affecting benefits that is submitted\nfor approval shall be accompanied by a rate filing, as required by §\n38.2-316. Any subsequent addition to or change in rates applicable to such\npolicy, rider, or endorsement form shall also be filed. Each rate submission\nshall comply with the requirements of 14VAC5-130.\n\nE. Benefits shall be deemed reasonable in relation to premiums, provided that\nthe anticipated loss ratio of the policy form, including riders and\nendorsements, is at least as great as provided in 14VAC5-130. The reasonableness\nof benefits with respect to filings of rate revisions for a previously approved\nform shall be determined as provided in 14VAC5-130.\n\nF. A health insurance issuer shall consider the claims experience of all\nenrollees in all health benefit plans, other than grandfathered plans and\nstudent health insurance coverage, in the individual market to be members of a\nsingle risk pool. A health insurance issuer shall consider the claims experience\nof all enrollees in all health plans, other than grandfathered plans, in the\nsmall group market to be members of a single risk pool. Each plan year or policy\nyear, as applicable, a health insurance issuer shall establish an index rate\nbased on the total combined claims costs for providing essential health benefits\nwithin the single risk pool of the individual or small group market as provided\nin 14VAC5-130. A health insurance issuer may vary premium rates for a particular\nplan from its index rate for a relevant state market only on the basis of an\nactuarially justified plan-specific factor permitted under 14VAC5-130.\n\nG. If the Commission finds that the premium rate filed in accordance with this\nsection is not meeting or will not meet the originally filed and approved loss\nratio, the Commission may require appropriate rate adjustments, premium refunds,\nor premium credits (i) as deemed necessary for the coverage to conform with the\nminimum loss ratio standards established pursuant to subsection B and (ii) that\nare expected to result in a loss ratio at least as great as that originally\nanticipated in the rates used to produce current rates by the health insurance\nissuer for the coverage. The Commission may take into consideration any previous\nor expected premium refunds or credits. The Commission may require the\nsubmission of detailed supporting documents as necessary to justify the\nadjustment.\n\nH. The Commission may request information subsequent to approval of a policy\nform or rate revision so that it may determine whether premium rates are\nreasonable in relation to the benefits provided as specified in 14VAC5-130.\n\nI. Except as otherwise provided, nothing contained in this section shall be\nconstrued to relieve a health insurance issuer from complying with other\nstatutory requirements set forth in this title.\n\nJ. The Commission may prescribe procedures for the effective monitoring of\nactual experience under any form subject to 14VAC5-130.\n\nHISTORY: 2013, cc. 670, 679; 2018, c. 708; 2019, c. 607.","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}}