{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3407.11_1.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3407.11_1.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3407.11_1.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3407.11_1.html"}],"law_id":70024,"edition_id":1,"section_id":70024,"structure_id":12994,"section_number":"38.2-3407.11:1","catch_line":"Access to specialists; standing referrals","history":"1999, cc. 643, 649; 2000, c. 922.","full_text":"A\n\nEach (i) insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, (ii) corporation providing individual or group accident and sickness subscription contracts, and (iii) health maintenance organization providing a health care plan for health care services shall permit any individual covered thereunder a standing referral, as provided in subsection B, to the health care services of a participating specialist (i) authorized to provide services under such policy, contract or plan and (ii) selected by such individual.B\n\nIf the care of a covered individual who has an ongoing special condition would, as determined by the primary care physician, most appropriately be coordinated by a specialist for such condition, each insurer, corporation, or health maintenance organization, in connection with the provision of health insurance coverage, shall have a procedure by which such individual shall, after consultation with the primary care physician, receive a referral to a specialist for such condition. Within the treatment period authorized by the referral, such specialist shall be permitted to treat the individual for the special condition without a further referral from the individual’s primary care provider and may authorize such referrals, procedures, tests, and other medical services related to the special condition as the individual’s primary care provider would otherwise be permitted to provide or authorize. For the purposes of this section, “special condition” means a condition or disease that is (i) life-threatening, degenerative, or disabling and (ii) requires specialized medical care over a prolonged period of time.C\n\nAn insurer, corporation, or health maintenance organization, in connection with the provision of health insurance coverage, shall have a procedure by which an individual who is a participant, beneficiary, or enrollee and who has an ongoing special condition that requires ongoing care from a specialist may receive a standing referral to a participating specialist for the treatment of the special condition. If the plan or issuer, or if the primary care provider in consultation with the plan or issuer and the participating specialist, if any, determines that such a standing referral is appropriate, the plan or issuer shall make such a referral to a specialist.D\n\nNothing contained herein shall prohibit an insurer, corporation, or health maintenance organization from requiring a participating specialist to provide written notification to the covered individual’s primary care physician of any visit to such specialist. Such notification may include a description of the health care services rendered at the time of the visit.E\n\nEach insurer, corporation or health maintenance organization subject to the provisions of this section shall inform subscribers of the provisions of this section. Such notice shall be provided in writing, and included in the policy or evidence of coverage.F\n\nThe requirements of this section shall apply to all insurance policies, contracts, and plans delivered, issued for delivery, reissued, renewed, or extended or at any time when any term of any such policy, contract, or plan is changed or any premium adjustment is made. The provisions of this section shall not apply to short-term travel or accident-only policies, to short-term nonrenewable policies of not more than six months’ duration, or policies or contracts issued to persons eligible under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal governmental plans.","order_by":null,"text":{"0":{"id":252985,"text":"Each (i) insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, (ii) corporation providing individual or group accident and sickness subscription contracts, and (iii) health maintenance organization providing a health care plan for health care services shall permit any individual covered thereunder a standing referral, as provided in subsection B, to the health care services of a participating specialist (i) authorized to provide services under such policy, contract or plan and (ii) selected by such individual.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":252986,"text":"If the care of a covered individual who has an ongoing special condition would, as determined by the primary care physician, most appropriately be coordinated by a specialist for such condition, each insurer, corporation, or health maintenance organization, in connection with the provision of health insurance coverage, shall have a procedure by which such individual shall, after consultation with the primary care physician, receive a referral to a specialist for such condition. Within the treatment period authorized by the referral, such specialist shall be permitted to treat the individual for the special condition without a further referral from the individual’s primary care provider and may authorize such referrals, procedures, tests, and other medical services related to the special condition as the individual’s primary care provider would otherwise be permitted to provide or authorize. For the purposes of this section, “special condition” means a condition or disease that is (i) life-threatening, degenerative, or disabling and (ii) requires specialized medical care over a prolonged period of time.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":252987,"text":"An insurer, corporation, or health maintenance organization, in connection with the provision of health insurance coverage, shall have a procedure by which an individual who is a participant, beneficiary, or enrollee and who has an ongoing special condition that requires ongoing care from a specialist may receive a standing referral to a participating specialist for the treatment of the special condition. If the plan or issuer, or if the primary care provider in consultation with the plan or issuer and the participating specialist, if any, determines that such a standing referral is appropriate, the plan or issuer shall make such a referral to a specialist.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":252988,"text":"Nothing contained herein shall prohibit an insurer, corporation, or health maintenance organization from requiring a participating specialist to provide written notification to the covered individual’s primary care physician of any visit to such specialist. Such notification may include a description of the health care services rendered at the time of the visit.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":252989,"text":"Each insurer, corporation or health maintenance organization subject to the provisions of this section shall inform subscribers of the provisions of this section. Such notice shall be provided in writing, and included in the policy or evidence of coverage.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"5":{"id":252990,"text":"The requirements of this section shall apply to all insurance policies, contracts, and plans delivered, issued for delivery, reissued, renewed, or extended or at any time when any term of any such policy, contract, or plan is changed or any premium adjustment is made. The provisions of this section shall not apply to short-term travel or accident-only policies, to short-term nonrenewable policies of not more than six months’ duration, or policies or contracts issued to persons eligible under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal governmental plans.","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; 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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; 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This law was first created in 1999. The record of its establishment is cataloged in chapters 643<\/a> and 649<\/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 1 time. 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. That modification is as follows: in 2000, chapter 922<\/a>.<\/p>","references":false,"refers_to":false,"permalink":{"id":214955,"object_type":"law","relational_id":70024,"identifier":"38.2-3407.11:1","token":"38.2\/34\/1\/38.2-3407.11_1","url":"\/38.2-3407.11_1\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3407.11_1\/","token":"38.2\/34\/1\/38.2-3407.11_1","dublin_core":{"Title":"Access to specialists; standing referrals","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3407.11:1","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> Each (i) insurer<\/span> proposing to issue<\/span> individual or group accident and sickness insurance policies<\/span> providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, (ii) corporation providing individual or group accident and sickness subscription contracts<\/span>, and (iii) health maintenance organization providing a health care plan for health care services shall permit any individual covered thereunder a standing referral, as provided in subsection B, to the health care services of a participating specialist (i) authorized to provide services under such policy, contract<\/span> or plan and (ii) selected by such individual. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> If the care of a covered individual who has an ongoing special condition<\/span> would, as determined by the primary care physician, most appropriately be coordinated by a specialist for such condition, each insurer<\/span>, corporation, or health maintenance organization, in connection with the provision of health insurance coverage, shall have a procedure by which such individual shall, after consultation with the primary care physician, receive a referral to a specialist for such condition. Within the treatment period authorized by the referral, such specialist shall be permitted to treat the individual for the special condition<\/span> without a further referral from the individual’s primary care provider and may authorize such referrals, procedures, tests, and other medical services related to the special condition<\/span> as the individual’s primary care provider would otherwise be permitted to provide or authorize. For the purposes of this section, “special condition<\/span>” means a condition or disease that is (i) life-threatening, degenerative, or disabling and (ii) requires specialized medical care over a prolonged period of time. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> An insurer<\/span>, corporation, or health maintenance organization, in connection with the provision of health insurance coverage, shall have a procedure by which an individual who is a participant, beneficiary, or enrollee and who has an ongoing special condition<\/span> that requires ongoing care from a specialist may receive a standing referral to a participating specialist for the treatment of the special condition<\/span>. If the plan or issuer, or if the primary care provider in consultation with the plan or issuer and the participating specialist, if any, determines that such a standing referral is appropriate, the plan or issuer shall make such a referral to a specialist. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> Nothing contained herein shall prohibit an insurer<\/span>, corporation, or health maintenance organization from requiring a participating specialist to provide written notification to the covered individual’s primary care physician of any visit to such specialist. Such notification may include a description of the health care services rendered at the time of the visit. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Each insurer<\/span>, corporation or health maintenance organization subject to the provisions of this section shall inform subscribers of the provisions of this section. Such notice shall be provided in writing, and included in the policy or evidence<\/span> of coverage. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> The requirements of this section shall apply to all insurance policies<\/span>, contracts<\/span>, and plans delivered, issued for delivery, reissued, renewed, or extended or at any time when any term of any such policy, contract<\/span>, or plan is changed or any premium adjustment is made. The provisions of this section shall not apply to short-term travel or accident-only policies, to short-term nonrenewable policies of not more than six months’ duration, or policies or contracts<\/span> issued to persons<\/span> eligible under Title XVIII of the Social Security Act, known as Medicare<\/span>, or any other similar coverage under state<\/span> or federal governmental plans. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nACCESS TO SPECIALISTS; STANDING REFERRALS (\u00a7 38.2-3407.11:1)\n\nA. Each (i) insurer proposing to issue individual or group accident and sickness\ninsurance policies providing hospital, medical and surgical or major medical\ncoverage on an expense-incurred basis, (ii) corporation providing individual or\ngroup accident and sickness subscription contracts, and (iii) health maintenance\norganization providing a health care plan for health care services shall permit\nany individual covered thereunder a standing referral, as provided in subsection\nB, to the health care services of a participating specialist (i) authorized to\nprovide services under such policy, contract or plan and (ii) selected by such\nindividual.\n\nB. If the care of a covered individual who has an ongoing special condition\nwould, as determined by the primary care physician, most appropriately be\ncoordinated by a specialist for such condition, each insurer, corporation, or\nhealth maintenance organization, in connection with the provision of health\ninsurance coverage, shall have a procedure by which such individual shall, after\nconsultation with the primary care physician, receive a referral to a specialist\nfor such condition. Within the treatment period authorized by the referral, such\nspecialist shall be permitted to treat the individual for the special condition\nwithout a further referral from the individual’s primary care provider and\nmay authorize such referrals, procedures, tests, and other medical services\nrelated to the special condition as the individual’s primary care provider\nwould otherwise be permitted to provide or authorize. For the purposes of this\nsection, “special condition” means a condition or disease that is\n(i) life-threatening, degenerative, or disabling and (ii) requires specialized\nmedical care over a prolonged period of time.\n\nC. An insurer, corporation, or health maintenance organization, in connection\nwith the provision of health insurance coverage, shall have a procedure by which\nan individual who is a participant, beneficiary, or enrollee and who has an\nongoing special condition that requires ongoing care from a specialist may\nreceive a standing referral to a participating specialist for the treatment of\nthe special condition. If the plan or issuer, or if the primary care provider in\nconsultation with the plan or issuer and the participating specialist, if any,\ndetermines that such a standing referral is appropriate, the plan or issuer\nshall make such a referral to a specialist.\n\nD. Nothing contained herein shall prohibit an insurer, corporation, or health\nmaintenance organization from requiring a participating specialist to provide\nwritten notification to the covered individual’s primary care physician of\nany visit to such specialist. Such notification may include a description of the\nhealth care services rendered at the time of the visit.\n\nE. Each insurer, corporation or health maintenance organization subject to the\nprovisions of this section shall inform subscribers of the provisions of this\nsection. Such notice shall be provided in writing, and included in the policy or\nevidence of coverage.\n\nF. The requirements of this section shall apply to all insurance policies,\ncontracts, and plans delivered, issued for delivery, reissued, renewed, or\nextended or at any time when any term of any such policy, contract, or plan is\nchanged or any premium adjustment is made. The provisions of this section shall\nnot apply to short-term travel or accident-only policies, to short-term\nnonrenewable policies of not more than six months’ duration, or policies\nor contracts issued to persons eligible under Title XVIII of the Social Security\nAct, known as Medicare, or any other similar coverage under state or federal\ngovernmental plans.\n\nHISTORY: 1999, cc. 643, 649; 2000, c. 922.","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}}