{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3406.1.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3406.1.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3406.1.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3406.1.html"}],"law_id":84333,"edition_id":1,"section_id":84333,"structure_id":12994,"section_number":"38.2-3406.1","catch_line":"Application of requirements that policies offered by small employers include state-mandated health benefits","history":"2009, cc. 796, 877; 2010, cc. 155, 515, 687; 2011, c. 882; 2013, c. 751; 2016, c. 1; 2018, c. 782; 2025, cc. 237, 246.","full_text":"A\n\nAs used in this section:\n\t\t\t“Eligible individual” means an individual who is employed by a small employer and has satisfied applicable waiting period requirements.\n\t\t\t“Health insurance coverage” means benefits consisting of coverage for costs of medical care, whether directly, through insurance or reimbursement, or otherwise, and including items and services paid for as medical care under a group policy of accident and sickness insurance, hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract, which coverage is subject to this title or is provided under a plan regulated under the Employee Retirement Income Security Act of 1974.\n\t\t\t“Health insurer” means any insurance company that issues accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis, a corporation that provides accident and sickness subscription contracts, or any health maintenance organization that provides a health care plan that provides, arranges for, pays for, or reimburses any part of the cost of any health care services, that is licensed to engage in such business in the Commonwealth, and that is subject to the laws of the Commonwealth that regulate insurance within the meaning of § 514(b)(2) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. § 1144(b)(2)).\n\t\t\t“Small employer” has the same meaning ascribed to the term in § 38.2-3431.\n\t\t\t“State-mandated health benefit” means coverage required under this title or other laws of the Commonwealth to be provided in a policy of accident and sickness insurance or a contract for a health-related condition that (i) includes coverage for specific health care services or benefits; (ii) places limitations or restrictions on deductibles, coinsurance, copayments, or any annual or lifetime maximum benefit amounts; or (iii) includes a specific category of licensed health care practitioners from whom an insured is entitled to receive care. “State-mandated health benefit” includes, without limitation, any coverage, or the offering of coverage, of a benefit or provider pursuant to §§ 38.2-3407.5 through 38.2-3407.6:1, 38.2-3407.9:01, 38.2-3407.9:02, 38.2-3407.11 through 38.2-3407.11:3, 38.2-3407.16, 38.2-3408, 38.2-3411 through 38.2-3414.1, 38.2-3418 through 38.2-3418.14, or § 38.2-4221. For purposes of this article, “state-mandated health benefit” does not include a benefit that is mandated by federal law.B\n\nNotwithstanding any statute, rule, or regulation to the contrary, and for the purposes of this section, a group accident and sickness insurance policy providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; a group accident and sickness subscription contract providing health insurance coverage for eligible individuals; and a health care plan that provides, arranges for, pays for, or reimburses any part of the cost of any health care services that is offered, sold, or issued by a health insurer to a small employer:1\n\nShall not be required to include coverage, or the offer of coverage, for any state-mandated health benefit, except for:\n\t\t\t\ta. Coverage for mammograms pursuant to § 38.2-3418.1;\n\t\t\t\tb. Coverage for pap smears pursuant to § 38.2-3418.1:2;\n\t\t\t\tc. Coverage for prostate cancer screening pursuant to § 38.2-3418.7; and\n\t\t\t\td. Coverage for colorectal cancer screening pursuant to § 38.2-3418.7:1.2\n\nMay include any, or none, of the state-mandated health benefits not otherwise noted in subdivision B 1 as the health insurer and the small employer shall agree.\n\t\t\t\tNotwithstanding any provision of this section to the contrary, if any plan authorized by this section includes and offers health care services covered by the plan that may be legally rendered by a health care provider listed in § 38.2-3408, that plan shall allow for the reimbursement of such covered services when rendered by such provider. Unless otherwise provided in this section, this provision shall not require any benefit be provided as a covered service.C\n\nAny application and any enrollment form used in connection with coverage under this section shall prominently disclose that the policy, contract, or evidence of coverage is not required to provide state-mandated health benefits, shall prominently disclose any and all state-mandated health benefits that the policy, subscription contract, or evidence of coverage does not provide, and shall clearly describe all eligibility requirements.D\n\nA policy form, subscription contract, or evidence of coverage issued under this section to a small employer shall prominently disclose any and all state-mandated health benefits that the policy, subscription contract, or evidence of coverage does not provide. Such disclosure shall also be included in certificate forms or other evidences of coverage furnished to each participant. Health insurers proposing to issue forms providing coverage under this section shall clearly disclose the intended purposes for such policies, contracts, or evidences of coverage when submitting the forms to the Commission for approval in accordance with § 38.2-316.E\n\nThe Commission shall adopt any regulations necessary to implement this section.F\n\nThe provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.","order_by":null,"text":{"0":{"id":302278,"text":"As used in this section:\n\t\t\t“Eligible individual” means an individual who is employed by a small employer and has satisfied applicable waiting period requirements.\n\t\t\t“Health insurance coverage” means benefits consisting of coverage for costs of medical care, whether directly, through insurance or reimbursement, or otherwise, and including items and services paid for as medical care under a group policy of accident and sickness insurance, hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract, which coverage is subject to this title or is provided under a plan regulated under the Employee Retirement Income Security Act of 1974.\n\t\t\t“Health insurer” means any insurance company that issues accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis, a corporation that provides accident and sickness subscription contracts, or any health maintenance organization that provides a health care plan that provides, arranges for, pays for, or reimburses any part of the cost of any health care services, that is licensed to engage in such business in the Commonwealth, and that is subject to the laws of the Commonwealth that regulate insurance within the meaning of § 514(b)(2) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. § 1144(b)(2)).\n\t\t\t“Small employer” has the same meaning ascribed to the term in § 38.2-3431.\n\t\t\t“State-mandated health benefit” means coverage required under this title or other laws of the Commonwealth to be provided in a policy of accident and sickness insurance or a contract for a health-related condition that (i) includes coverage for specific health care services or benefits; (ii) places limitations or restrictions on deductibles, coinsurance, copayments, or any annual or lifetime maximum benefit amounts; or (iii) includes a specific category of licensed health care practitioners from whom an insured is entitled to receive care. “State-mandated health benefit” includes, without limitation, any coverage, or the offering of coverage, of a benefit or provider pursuant to §§ 38.2-3407.5 through 38.2-3407.6:1, 38.2-3407.9:01, 38.2-3407.9:02, 38.2-3407.11 through 38.2-3407.11:3, 38.2-3407.16, 38.2-3408, 38.2-3411 through 38.2-3414.1, 38.2-3418 through 38.2-3418.14, or § 38.2-4221. For purposes of this article, “state-mandated health benefit” does not include a benefit that is mandated by federal law.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":302279,"text":"Notwithstanding any statute, rule, or regulation to the contrary, and for the purposes of this section, a group accident and sickness insurance policy providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; a group accident and sickness subscription contract providing health insurance coverage for eligible individuals; and a health care plan that provides, arranges for, pays for, or reimburses any part of the cost of any health care services that is offered, sold, or issued by a health insurer to a small employer:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"B1"},"2":{"id":302280,"text":"Shall not be required to include coverage, or the offer of coverage, for any state-mandated health benefit, except for:\n\t\t\t\ta. Coverage for mammograms pursuant to § 38.2-3418.1;\n\t\t\t\tb. Coverage for pap smears pursuant to § 38.2-3418.1:2;\n\t\t\t\tc. Coverage for prostate cancer screening pursuant to § 38.2-3418.7; and\n\t\t\t\td. Coverage for colorectal cancer screening pursuant to § 38.2-3418.7:1.","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B2"},"3":{"id":302281,"text":"May include any, or none, of the state-mandated health benefits not otherwise noted in subdivision B 1 as the health insurer and the small employer shall agree.\n\t\t\t\tNotwithstanding any provision of this section to the contrary, if any plan authorized by this section includes and offers health care services covered by the plan that may be legally rendered by a health care provider listed in § 38.2-3408, that plan shall allow for the reimbursement of such covered services when rendered by such provider. Unless otherwise provided in this section, this provision shall not require any benefit be provided as a covered service.","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B1","next_prefix":"C"},"4":{"id":302282,"text":"Any application and any enrollment form used in connection with coverage under this section shall prominently disclose that the policy, contract, or evidence of coverage is not required to provide state-mandated health benefits, shall prominently disclose any and all state-mandated health benefits that the policy, subscription contract, or evidence of coverage does not provide, and shall clearly describe all eligibility requirements.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B2","next_prefix":"D"},"5":{"id":302283,"text":"A policy form, subscription contract, or evidence of coverage issued under this section to a small employer shall prominently disclose any and all state-mandated health benefits that the policy, subscription contract, or evidence of coverage does not provide. Such disclosure shall also be included in certificate forms or other evidences of coverage furnished to each participant. Health insurers proposing to issue forms providing coverage under this section shall clearly disclose the intended purposes for such policies, contracts, or evidences of coverage when submitting the forms to the Commission for approval in accordance with § 38.2-316.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"6":{"id":302284,"text":"The Commission shall adopt any regulations necessary to implement this section.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"7":{"id":302285,"text":"The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E"}},"ancestry":[{"id":12994,"edition_id":1,"name":"General Provisions","identifier":"1","label":"article","depth":3,"order_by":1,"parent_id":12993,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214889,"object_type":"structure","relational_id":12994,"identifier":"1","token":"38.2\/34\/1","url":"\/38.2\/34\/1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12993,"edition_id":1,"name":"Provisions Relating to Accident and Sickness Insurance","identifier":"34","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214887,"object_type":"structure","relational_id":12993,"identifier":"34","token":"38.2\/34","url":"\/38.2\/34\/","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":57593,"structure_id":12994,"section_number":"38.2-3400","catch_line":"Application of chapter","url":"\/38.2-3400\/","token":"38.2\/34\/1\/38.2-3400","metadata":false},{"id":72072,"structure_id":12994,"section_number":"38.2-3401","catch_line":"Forms of insurance authorized","url":"\/38.2-3401\/","token":"38.2\/34\/1\/38.2-3401","metadata":false},{"id":65240,"structure_id":12994,"section_number":"38.2-3402","catch_line":"Certification to accompany application","url":"\/38.2-3402\/","token":"38.2\/34\/1\/38.2-3402","metadata":false},{"id":83988,"structure_id":12994,"section_number":"38.2-3403","catch_line":"Fraudulent procurement of policy","url":"\/38.2-3403\/","token":"38.2\/34\/1\/38.2-3403","metadata":false},{"id":65279,"structure_id":12994,"section_number":"38.2-3404","catch_line":"Commission may establish rules and regulations for simplified and readable accident and sickness insurance policies","url":"\/38.2-3404\/","token":"38.2\/34\/1\/38.2-3404","metadata":false},{"id":62539,"structure_id":12994,"section_number":"38.2-3405","catch_line":"Certain subrogation provisions and limitations upon recovery in hospital, medical, etc., policies forbidden; limitations on disclosure of medical treatment options prohibited","url":"\/38.2-3405\/","token":"38.2\/34\/1\/38.2-3405","metadata":false},{"id":84136,"structure_id":12994,"section_number":"38.2-3405.1","catch_line":"Commonwealth's right to certain accident and sickness benefits","url":"\/38.2-3405.1\/","token":"38.2\/34\/1\/38.2-3405.1","metadata":false},{"id":70730,"structure_id":12994,"section_number":"38.2-3406","catch_line":"Accident and sickness benefits not subject to legal process","url":"\/38.2-3406\/","token":"38.2\/34\/1\/38.2-3406","metadata":false},{"id":84333,"structure_id":12994,"section_number":"38.2-3406.1","catch_line":"Application of requirements that policies offered by small employers include state-mandated health benefits","url":"\/38.2-3406.1\/","token":"38.2\/34\/1\/38.2-3406.1","metadata":false},{"id":67972,"structure_id":12994,"section_number":"38.2-3406.2","catch_line":"Capped benefits under insurance policies and contracts","url":"\/38.2-3406.2\/","token":"38.2\/34\/1\/38.2-3406.2","metadata":false},{"id":76321,"structure_id":12994,"section_number":"38.2-3407","catch_line":"Health benefit programs","url":"\/38.2-3407\/","token":"38.2\/34\/1\/38.2-3407","metadata":false},{"id":66921,"structure_id":12994,"section_number":"38.2-3407.1","catch_line":"Interest on accident and sickness claim proceeds","url":"\/38.2-3407.1\/","token":"38.2\/34\/1\/38.2-3407.1","metadata":false},{"id":58079,"structure_id":12994,"section_number":"38.2-3407.10","catch_line":"Health care provider panels","url":"\/38.2-3407.10\/","token":"38.2\/34\/1\/38.2-3407.10","metadata":false},{"id":66411,"structure_id":12994,"section_number":"38.2-3407.10:1","catch_line":"Processing of new provider applications and reimbursement for services rendered during pendency of a participating provider's credentialing application","url":"\/38.2-3407.10_1\/","token":"38.2\/34\/1\/38.2-3407.10_1","metadata":false},{"id":56463,"structure_id":12994,"section_number":"38.2-3407.10:2","catch_line":"Credentialing of private mental health agencies","url":"\/38.2-3407.10_2\/","token":"38.2\/34\/1\/38.2-3407.10_2","metadata":false},{"id":82372,"structure_id":12994,"section_number":"38.2-3407.11","catch_line":"Access to obstetrician-gynecologists","url":"\/38.2-3407.11\/","token":"38.2\/34\/1\/38.2-3407.11","metadata":false},{"id":70024,"structure_id":12994,"section_number":"38.2-3407.11:1","catch_line":"Access to specialists; standing referrals","url":"\/38.2-3407.11_1\/","token":"38.2\/34\/1\/38.2-3407.11_1","metadata":false},{"id":71393,"structure_id":12994,"section_number":"38.2-3407.11:2","catch_line":"Standing referral for cancer patients","url":"\/38.2-3407.11_2\/","token":"38.2\/34\/1\/38.2-3407.11_2","metadata":false},{"id":72434,"structure_id":12994,"section_number":"38.2-3407.11:3","catch_line":"Breast cancer underwriting and preexisting condition restrictions","url":"\/38.2-3407.11_3\/","token":"38.2\/34\/1\/38.2-3407.11_3","metadata":false},{"id":64402,"structure_id":12994,"section_number":"38.2-3407.11:4","catch_line":"Disability arising out of childbirth; minimum benefit","url":"\/38.2-3407.11_4\/","token":"38.2\/34\/1\/38.2-3407.11_4","metadata":false},{"id":66706,"structure_id":12994,"section_number":"38.2-3407.11:5","catch_line":"Interhospital transfer for newborn or mother; prior authorization prohibited","url":"\/38.2-3407.11_5\/","token":"38.2\/34\/1\/38.2-3407.11_5","metadata":false},{"id":68442,"structure_id":12994,"section_number":"38.2-3407.12","catch_line":"Patient optional point-of-service benefit","url":"\/38.2-3407.12\/","token":"38.2\/34\/1\/38.2-3407.12","metadata":false},{"id":81634,"structure_id":12994,"section_number":"38.2-3407.13","catch_line":"Refusal to accept assignments prohibited; dentists and oral surgeons","url":"\/38.2-3407.13\/","token":"38.2\/34\/1\/38.2-3407.13","metadata":false},{"id":79541,"structure_id":12994,"section_number":"38.2-3407.13:1","catch_line":"Coordination of benefits; notice of priority of coverage","url":"\/38.2-3407.13_1\/","token":"38.2\/34\/1\/38.2-3407.13_1","metadata":false},{"id":87429,"structure_id":12994,"section_number":"38.2-3407.13:2","catch_line":"Claims paid to insureds for services from nonparticipating physicians","url":"\/38.2-3407.13_2\/","token":"38.2\/34\/1\/38.2-3407.13_2","metadata":false},{"id":60288,"structure_id":12994,"section_number":"38.2-3407.14","catch_line":"Notice of premium or deductible increases","url":"\/38.2-3407.14\/","token":"38.2\/34\/1\/38.2-3407.14","metadata":false},{"id":82945,"structure_id":12994,"section_number":"38.2-3407.14:1","catch_line":"Standard of clinical evidence for decisions on coverage for proton radiation therapy","url":"\/38.2-3407.14_1\/","token":"38.2\/34\/1\/38.2-3407.14_1","metadata":false},{"id":71060,"structure_id":12994,"section_number":"38.2-3407.15","catch_line":"Ethics and fairness in carrier business practices","url":"\/38.2-3407.15\/","token":"38.2\/34\/1\/38.2-3407.15","metadata":false},{"id":79973,"structure_id":12994,"section_number":"38.2-3407.15:1","catch_line":"Carrier contracts with pharmacy providers; required provisions; limit on termination or nonrenewal","url":"\/38.2-3407.15_1\/","token":"38.2\/34\/1\/38.2-3407.15_1","metadata":false},{"id":81930,"structure_id":12994,"section_number":"38.2-3407.15:2","catch_line":"(Effective January 1, 2027) Carrier contracts; required provisions regarding prior authorization for drug benefits","url":"\/38.2-3407.15_2\/","token":"38.2\/34\/1\/38.2-3407.15_2","metadata":false},{"id":77493,"structure_id":12994,"section_number":"38.2-3407.15:3","catch_line":"Carrier and intermediary contracts with pharmacy providers; disclosure and updating of maximum allowable cost of drugs; limit on termination or nonrenewal","url":"\/38.2-3407.15_3\/","token":"38.2\/34\/1\/38.2-3407.15_3","metadata":false},{"id":73491,"structure_id":12994,"section_number":"38.2-3407.15:4","catch_line":"Limit on copayment for prescription drugs; permitted disclosures","url":"\/38.2-3407.15_4\/","token":"38.2\/34\/1\/38.2-3407.15_4","metadata":false},{"id":57527,"structure_id":12994,"section_number":"38.2-3407.15:5","catch_line":"Limit on cost-sharing payments for prescription insulin drugs","url":"\/38.2-3407.15_5\/","token":"38.2\/34\/1\/38.2-3407.15_5","metadata":false},{"id":80337,"structure_id":12994,"section_number":"38.2-3407.15:6","catch_line":"Prescription drug price transparency","url":"\/38.2-3407.15_6\/","token":"38.2\/34\/1\/38.2-3407.15_6","metadata":false},{"id":87317,"structure_id":12994,"section_number":"38.2-3407.15:7","catch_line":"Carrier provision of certain information","url":"\/38.2-3407.15_7\/","token":"38.2\/34\/1\/38.2-3407.15_7","metadata":false},{"id":82040,"structure_id":12994,"section_number":"38.2-3407.15:8","catch_line":"(Effective January 1, 2027) Carrier contracts; required provisions regarding prior authorization for health care services","url":"\/38.2-3407.15_8\/","token":"38.2\/34\/1\/38.2-3407.15_8","metadata":false},{"id":76440,"structure_id":12994,"section_number":"38.2-3407.16","catch_line":"Requirements for obstetrical care","url":"\/38.2-3407.16\/","token":"38.2\/34\/1\/38.2-3407.16","metadata":false},{"id":64799,"structure_id":12994,"section_number":"38.2-3407.17","catch_line":"Payment for services by dentists and oral surgeons","url":"\/38.2-3407.17\/","token":"38.2\/34\/1\/38.2-3407.17","metadata":false},{"id":55530,"structure_id":12994,"section_number":"38.2-3407.17:1","catch_line":"Payment and reimbursement practices for dental services; network access","url":"\/38.2-3407.17_1\/","token":"38.2\/34\/1\/38.2-3407.17_1","metadata":false},{"id":81770,"structure_id":12994,"section_number":"38.2-3407.18","catch_line":"Requirements for orally administered cancer chemotherapy drugs","url":"\/38.2-3407.18\/","token":"38.2\/34\/1\/38.2-3407.18","metadata":false},{"id":83502,"structure_id":12994,"section_number":"38.2-3407.19","catch_line":"Payment for services by optometrists and ophthalmologists","url":"\/38.2-3407.19\/","token":"38.2\/34\/1\/38.2-3407.19","metadata":false},{"id":77646,"structure_id":12994,"section_number":"38.2-3407.2","catch_line":"Coverage for medical child support","url":"\/38.2-3407.2\/","token":"38.2\/34\/1\/38.2-3407.2","metadata":false},{"id":73127,"structure_id":12994,"section_number":"38.2-3407.20","catch_line":"Calculation of enrollee's contribution to out-of-pocket maximum or cost-sharing requirement","url":"\/38.2-3407.20\/","token":"38.2\/34\/1\/38.2-3407.20","metadata":false},{"id":57407,"structure_id":12994,"section_number":"38.2-3407.21","catch_line":"Short-term limited-duration medical plans","url":"\/38.2-3407.21\/","token":"38.2\/34\/1\/38.2-3407.21","metadata":false},{"id":85964,"structure_id":12994,"section_number":"38.2-3407.22","catch_line":"Option for rebates to enrollees; protected information","url":"\/38.2-3407.22\/","token":"38.2\/34\/1\/38.2-3407.22","metadata":false},{"id":81846,"structure_id":12994,"section_number":"38.2-3407.3","catch_line":"Calculation of cost-sharing provisions","url":"\/38.2-3407.3\/","token":"38.2\/34\/1\/38.2-3407.3","metadata":false},{"id":62583,"structure_id":12994,"section_number":"38.2-3407.3:1","catch_line":"Premium payment arrearages; order of crediting payments","url":"\/38.2-3407.3_1\/","token":"38.2\/34\/1\/38.2-3407.3_1","metadata":false},{"id":78457,"structure_id":12994,"section_number":"38.2-3407.4","catch_line":"Explanation of benefits","url":"\/38.2-3407.4\/","token":"38.2\/34\/1\/38.2-3407.4","metadata":false},{"id":72294,"structure_id":12994,"section_number":"38.2-3407.4:1","catch_line":"Repealed","url":"\/38.2-3407.4_1\/","token":"38.2\/34\/1\/38.2-3407.4_1","metadata":false},{"id":57129,"structure_id":12994,"section_number":"38.2-3407.4:2","catch_line":"Requirements for prescription benefit cards","url":"\/38.2-3407.4_2\/","token":"38.2\/34\/1\/38.2-3407.4_2","metadata":false},{"id":62057,"structure_id":12994,"section_number":"38.2-3407.5","catch_line":"Denial of benefits for certain prescription drugs prohibited","url":"\/38.2-3407.5\/","token":"38.2\/34\/1\/38.2-3407.5","metadata":false},{"id":54072,"structure_id":12994,"section_number":"38.2-3407.5:1","catch_line":"Coverage for prescription contraceptives","url":"\/38.2-3407.5_1\/","token":"38.2\/34\/1\/38.2-3407.5_1","metadata":false},{"id":79611,"structure_id":12994,"section_number":"38.2-3407.5:2","catch_line":"Reimbursements for dispensing hormonal contraceptives","url":"\/38.2-3407.5_2\/","token":"38.2\/34\/1\/38.2-3407.5_2","metadata":false},{"id":83778,"structure_id":12994,"section_number":"38.2-3407.6","catch_line":"Exclusion of podiatrist not permitted under certain circumstances","url":"\/38.2-3407.6\/","token":"38.2\/34\/1\/38.2-3407.6","metadata":false},{"id":74649,"structure_id":12994,"section_number":"38.2-3407.6:1","catch_line":"Denial of benefits for certain prescription drugs prohibited","url":"\/38.2-3407.6_1\/","token":"38.2\/34\/1\/38.2-3407.6_1","metadata":false},{"id":72641,"structure_id":12994,"section_number":"38.2-3407.7","catch_line":"Pharmacies; freedom of choice","url":"\/38.2-3407.7\/","token":"38.2\/34\/1\/38.2-3407.7","metadata":false},{"id":73400,"structure_id":12994,"section_number":"38.2-3407.8","catch_line":"Repealed","url":"\/38.2-3407.8\/","token":"38.2\/34\/1\/38.2-3407.8","metadata":false},{"id":72540,"structure_id":12994,"section_number":"38.2-3407.9","catch_line":"Reimbursement for emergency medical services vehicle transportation services","url":"\/38.2-3407.9\/","token":"38.2\/34\/1\/38.2-3407.9","metadata":false},{"id":62232,"structure_id":12994,"section_number":"38.2-3407.9:01","catch_line":"Prescription drug formularies","url":"\/38.2-3407.9_01\/","token":"38.2\/34\/1\/38.2-3407.9_01","metadata":false},{"id":62074,"structure_id":12994,"section_number":"38.2-3407.9:02","catch_line":"Requirement for prescription drug coverage","url":"\/38.2-3407.9_02\/","token":"38.2\/34\/1\/38.2-3407.9_02","metadata":false},{"id":68601,"structure_id":12994,"section_number":"38.2-3407.9:03","catch_line":"Payment of clean claims to administrators of pharmacy benefits","url":"\/38.2-3407.9_03\/","token":"38.2\/34\/1\/38.2-3407.9_03","metadata":false},{"id":56568,"structure_id":12994,"section_number":"38.2-3407.9:04","catch_line":"Medication synchronization","url":"\/38.2-3407.9_04\/","token":"38.2\/34\/1\/38.2-3407.9_04","metadata":false},{"id":71499,"structure_id":12994,"section_number":"38.2-3407.9:05","catch_line":"Step therapy protocols","url":"\/38.2-3407.9_05\/","token":"38.2\/34\/1\/38.2-3407.9_05","metadata":false}],"previous_section":{"id":70730,"structure_id":12994,"section_number":"38.2-3406","catch_line":"Accident and sickness benefits not subject to legal process","url":"\/38.2-3406\/","token":"38.2\/34\/1\/38.2-3406","metadata":false},"next_section":{"id":67972,"structure_id":12994,"section_number":"38.2-3406.2","catch_line":"Capped benefits under insurance policies and contracts","url":"\/38.2-3406.2\/","token":"38.2\/34\/1\/38.2-3406.2","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3406.1\/","history_text":"

This law was first created in 2009. The record of its establishment is cataloged in chapters 796<\/a> and 877<\/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 6 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 2010, chapters 155<\/a>, 515<\/a>, and 687<\/a>; in 2011, chapter 882<\/a>; in 2013, chapter 751<\/a>; in 2016, chapter 1<\/a>; in 2018, chapter 782<\/a>; in 2025, chapters 237<\/a> and 246<\/a>.<\/p>","references":[{"id":59514,"section_number":"38.2-3440","catch_line":"Lifetime and annual limits","order_by":null,"url":"\/38.2-3440\/"},{"id":81548,"section_number":"38.2-3442","catch_line":"Preventive services","order_by":null,"url":"\/38.2-3442\/"},{"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\/"}],"refers_to":[{"id":82372,"section_number":"38.2-3407.11","catch_line":"Access to obstetrician-gynecologists","order_by":null,"url":"\/38.2-3407.11\/"},{"id":72434,"section_number":"38.2-3407.11:3","catch_line":"Breast cancer underwriting and preexisting condition restrictions","order_by":null,"url":"\/38.2-3407.11_3\/"},{"id":76440,"section_number":"38.2-3407.16","catch_line":"Requirements for obstetrical care","order_by":null,"url":"\/38.2-3407.16\/"},{"id":62057,"section_number":"38.2-3407.5","catch_line":"Denial of benefits for certain prescription drugs prohibited","order_by":null,"url":"\/38.2-3407.5\/"},{"id":74649,"section_number":"38.2-3407.6:1","catch_line":"Denial of benefits for certain prescription drugs prohibited","order_by":null,"url":"\/38.2-3407.6_1\/"},{"id":62232,"section_number":"38.2-3407.9:01","catch_line":"Prescription drug formularies","order_by":null,"url":"\/38.2-3407.9_01\/"},{"id":62074,"section_number":"38.2-3407.9:02","catch_line":"Requirement for prescription drug coverage","order_by":null,"url":"\/38.2-3407.9_02\/"},{"id":87046,"section_number":"38.2-3408","catch_line":"Policy providing for reimbursement for services that may be performed by certain practitioners other than physicians","order_by":null,"url":"\/38.2-3408\/"},{"id":76551,"section_number":"38.2-3411","catch_line":"Coverage of newborn children required","order_by":null,"url":"\/38.2-3411\/"},{"id":74497,"section_number":"38.2-3414.1","catch_line":"Obstetrical benefits; coverage for postpartum services","order_by":null,"url":"\/38.2-3414.1\/"},{"id":81514,"section_number":"38.2-3418","catch_line":"Coverage for victims of rape or incest","order_by":null,"url":"\/38.2-3418\/"},{"id":85746,"section_number":"38.2-3418.1","catch_line":"Coverage for mammograms","order_by":null,"url":"\/38.2-3418.1\/"},{"id":85731,"section_number":"38.2-3418.14","catch_line":"Coverage for lymphedema","order_by":null,"url":"\/38.2-3418.14\/"},{"id":72277,"section_number":"38.2-3418.1:2","catch_line":"Coverage for pap smears","order_by":null,"url":"\/38.2-3418.1_2\/"},{"id":71759,"section_number":"38.2-3418.7","catch_line":"Coverage for prostate cancer screening","order_by":null,"url":"\/38.2-3418.7\/"},{"id":86404,"section_number":"38.2-3431","catch_line":"Application of article; definitions","order_by":null,"url":"\/38.2-3431\/"},{"id":57210,"section_number":"38.2-3438","catch_line":"Definitions","order_by":null,"url":"\/38.2-3438\/"},{"id":74708,"section_number":"38.2-4221","catch_line":"Services of certain practitioners other than physicians to be covered","order_by":null,"url":"\/38.2-4221\/"}],"permalink":{"id":214923,"object_type":"law","relational_id":84333,"identifier":"38.2-3406.1","token":"38.2\/34\/1\/38.2-3406.1","url":"\/38.2-3406.1\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3406.1\/","token":"38.2\/34\/1\/38.2-3406.1","dublin_core":{"Title":"Application of requirements that policies offered by small employers include state-mandated health benefits","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3406.1","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> As used in this section:\n\t\t\t“Eligible individual<\/span>” means an individual who is employed by a small employer and has satisfied applicable waiting period requirements.\n\t\t\t“Health insurance coverage<\/span>” means benefits consisting of coverage for costs of medical care, whether directly, through insurance or reimbursement, or otherwise, and including items and services paid for as medical care under a group policy of accident and sickness insurance, hospital or medical service policy or certificate, hospital or medical service plan contract<\/span>, or health maintenance organization contract<\/span>, which coverage is subject to this title or is provided under a plan regulated under the Employee Retirement Income Security Act of 1974.\n\t\t\t“Health insurer<\/span>” means any insurance company<\/span> that issues<\/span> accident and sickness insurance policies<\/span> providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis, a corporation that provides accident and sickness subscription contracts<\/span>, or any health maintenance organization that provides a health care plan that provides, arranges for, pays for, or reimburses any part of the cost of any health care services, that is licensed to engage in such business in the Commonwealth, and that is subject to the laws<\/span> of the Commonwealth that regulate insurance within the meaning of § 514(b)(2) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. § 1144(b)(2)).\n\t\t\t“Small employer” has the same meaning ascribed to the term in § 38.2-3431<\/a>.\n\t\t\t“State<\/span>-mandated health benefit<\/span>” means coverage required under this title or other laws<\/span> of the Commonwealth to be provided in a policy of accident and sickness insurance or a contract<\/span> for a health-related condition that (i) includes coverage for specific health care services or benefits; (ii) places limitations or restrictions on deductibles, coinsurance, copayments, or any annual or lifetime maximum benefit amounts; or (iii) includes a specific category of licensed health care practitioners from whom an insured is entitled to receive care. “State<\/span>-mandated health benefit<\/span>” includes, without limitation, any coverage, or the offering of coverage, of a benefit or provider pursuant to §§ 38.2-3407.5<\/a> through 38.2-3407.6:1<\/a>, 38.2-3407.9:01<\/a>, 38.2-3407.9:02<\/a>, 38.2-3407.11<\/a> through 38.2-3407.11:3<\/a>, 38.2-3407.16<\/a>, 38.2-3408<\/a>, 38.2-3411<\/a> through 38.2-3414.1<\/a>, 38.2-3418<\/a> through 38.2-3418.14<\/a>, or § 38.2-4221<\/a>. For purposes of this article, “state<\/span>-mandated health benefit<\/span>” does not include a benefit that is mandated by federal law<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> Notwithstanding any statute<\/span>, rule, or regulation to the contrary, and for the purposes of this section, a group accident and sickness insurance policy providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; a group accident and sickness subscription contract<\/span> providing health insurance coverage<\/span> for eligible individuals<\/span>; and a health care plan that provides, arranges for, pays for, or reimburses any part of the cost of any health care services that is offered, sold, or issued by a health insurer<\/span> to a small employer: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Shall not be required to include coverage, or the offer of coverage, for any state<\/span>-mandated health benefit<\/span>, except for:\n\t\t\t\ta. Coverage for mammograms pursuant to § 38.2-3418.1<\/a>;\n\t\t\t\tb. Coverage for pap smears pursuant to § 38.2-3418.1:2<\/a>;\n\t\t\t\tc. Coverage for prostate cancer screening pursuant to § 38.2-3418.7<\/a>; and\n\t\t\t\td. Coverage for colorectal cancer screening pursuant to § 38.2-3418.7:1<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> May include any, or none, of the state<\/span>-mandated health benefits<\/span> not otherwise noted in subdivision B 1 as the health insurer<\/span> and the small employer shall agree.\n\t\t\t\tNotwithstanding any provision of this section to the contrary, if any plan authorized by this section includes and offers health care services covered by the plan that may be legally rendered by a health care provider listed in § 38.2-3408<\/a>, that plan shall allow for the reimbursement of such covered services when rendered by such provider. Unless otherwise provided in this section, this provision shall not require any benefit be provided as a covered service. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Any application and any enrollment form used in connection with coverage under this section shall prominently disclose that the policy, contract<\/span>, or evidence<\/span> of coverage is not required to provide state<\/span>-mandated health benefits<\/span>, shall prominently disclose any and all state<\/span>-mandated health benefits<\/span> that the policy, subscription contract<\/span>, or evidence<\/span> of coverage does not provide, and shall clearly describe all eligibility requirements. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> A policy form, subscription contract<\/span>, or evidence<\/span> of coverage issued under this section to a small employer shall prominently disclose any and all state<\/span>-mandated health benefits<\/span> that the policy, subscription contract<\/span>, or evidence<\/span> of coverage does not provide. Such disclosure shall also be included in certificate forms or other evidences<\/span> of coverage furnished to each participant. Health insurers<\/span> proposing to issue<\/span> forms providing coverage under this section shall clearly disclose the intended purposes for such policies, contracts<\/span>, or evidences<\/span> of coverage when submitting the forms to the Commission<\/span> for approval in accordance with § 38.2-316<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> The Commission<\/span> shall adopt any regulations necessary to implement this section. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438<\/a> et seq.) of Chapter 34. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nAPPLICATION OF REQUIREMENTS THAT POLICIES OFFERED BY SMALL EMPLOYERS INCLUDE\nSTATE-MANDATED HEALTH BENEFITS (\u00a7 38.2-3406.1)\n\nA. As used in this section:\n\t\t\t“Eligible individual” means an individual who is employed by a\nsmall employer and has satisfied applicable waiting period requirements.\n\t\t\t“Health insurance coverage” means benefits consisting of coverage\nfor costs of medical care, whether directly, through insurance or reimbursement,\nor otherwise, and including items and services paid for as medical care under a\ngroup policy of accident and sickness insurance, hospital or medical service\npolicy or certificate, hospital or medical service plan contract, or health\nmaintenance organization contract, which coverage is subject to this title or is\nprovided under a plan regulated under the Employee Retirement Income Security\nAct of 1974.\n\t\t\t“Health insurer” means any insurance company that issues accident\nand sickness insurance policies providing hospital, medical and surgical, or\nmajor medical coverage on an expense-incurred basis, a corporation that provides\naccident and sickness subscription contracts, or any health maintenance\norganization that provides a health care plan that provides, arranges for, pays\nfor, or reimburses any part of the cost of any health care services, that is\nlicensed to engage in such business in the Commonwealth, and that is subject to\nthe laws of the Commonwealth that regulate insurance within the meaning of\n§ 514(b)(2) of the Employee Retirement Income Security Act of 1974 (29\nU.S.C. § 1144(b)(2)).\n\t\t\t“Small employer” has the same meaning ascribed to the term in\n§ 38.2-3431.\n\t\t\t“State-mandated health benefit” means coverage required under\nthis title or other laws of the Commonwealth to be provided in a policy of\naccident and sickness insurance or a contract for a health-related condition\nthat (i) includes coverage for specific health care services or benefits; (ii)\nplaces limitations or restrictions on deductibles, coinsurance, copayments, or\nany annual or lifetime maximum benefit amounts; or (iii) includes a specific\ncategory of licensed health care practitioners from whom an insured is entitled\nto receive care. “State-mandated health benefit” includes, without\nlimitation, any coverage, or the offering of coverage, of a benefit or provider\npursuant to §§ 38.2-3407.5 through 38.2-3407.6:1, 38.2-3407.9:01,\n38.2-3407.9:02, 38.2-3407.11 through 38.2-3407.11:3, 38.2-3407.16, 38.2-3408,\n38.2-3411 through 38.2-3414.1, 38.2-3418 through 38.2-3418.14, or §\n38.2-4221. For purposes of this article, “state-mandated health\nbenefit” does not include a benefit that is mandated by federal law.\n\nB. Notwithstanding any statute, rule, or regulation to the contrary, and for the\npurposes of this section, a group accident and sickness insurance policy\nproviding hospital, medical and surgical, or major medical coverage on an\nexpense-incurred basis; a group accident and sickness subscription contract\nproviding health insurance coverage for eligible individuals; and a health care\nplan that provides, arranges for, pays for, or reimburses any part of the cost\nof any health care services that is offered, sold, or issued by a health insurer\nto a small employer:\n\n 1. Shall not be required to include coverage, or the offer of coverage, for\n any state-mandated health benefit, except for:\n \t\t\t\ta. Coverage for mammograms pursuant to § 38.2-3418.1;\n \t\t\t\tb. Coverage for pap smears pursuant to § 38.2-3418.1:2;\n \t\t\t\tc. Coverage for prostate cancer screening pursuant to § 38.2-3418.7;\n and\n \t\t\t\td. Coverage for colorectal cancer screening pursuant to §\n 38.2-3418.7:1.\n\n 2. May include any, or none, of the state-mandated health benefits not\n otherwise noted in subdivision B 1 as the health insurer and the small\n employer shall agree.\n \t\t\t\tNotwithstanding any provision of this section to the contrary, if any plan\n authorized by this section includes and offers health care services covered by\n the plan that may be legally rendered by a health care provider listed in\n § 38.2-3408, that plan shall allow for the reimbursement of such covered\n services when rendered by such provider. Unless otherwise provided in this\n section, this provision shall not require any benefit be provided as a covered\n service.\n\nC. Any application and any enrollment form used in connection with coverage\nunder this section shall prominently disclose that the policy, contract, or\nevidence of coverage is not required to provide state-mandated health benefits,\nshall prominently disclose any and all state-mandated health benefits that the\npolicy, subscription contract, or evidence of coverage does not provide, and\nshall clearly describe all eligibility requirements.\n\nD. A policy form, subscription contract, or evidence of coverage issued under\nthis section to a small employer shall prominently disclose any and all\nstate-mandated health benefits that the policy, subscription contract, or\nevidence of coverage does not provide. Such disclosure shall also be included in\ncertificate forms or other evidences of coverage furnished to each participant.\nHealth insurers proposing to issue forms providing coverage under this section\nshall clearly disclose the intended purposes for such policies, contracts, or\nevidences of coverage when submitting the forms to the Commission for approval\nin accordance with § 38.2-316.\n\nE. The Commission shall adopt any regulations necessary to implement this\nsection.\n\nF. The provisions of this section shall not apply in any instance in which the\nprovisions of this section are inconsistent or in conflict with a provision of\nArticle 6 (§ 38.2-3438 et seq.) of Chapter 34.\n\nHISTORY: 2009, cc. 796, 877; 2010, cc. 155, 515, 687; 2011, c. 882; 2013, c.\n751; 2016, c. 1; 2018, c. 782; 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}}