{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3407.20.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3407.20.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3407.20.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3407.20.html"}],"law_id":73127,"edition_id":1,"section_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","history":"2019, cc. 661, 662; 2022, cc. 133, 134.","full_text":"A\n\nAs used in this section:\n\t\t\t“Carrier” shall have the meaning set forth in § 38.2-3407.10; however, “carrier” also includes any person required to be licensed under this title that offers or operates a managed care health insurance plan subject to Chapter 58 (§ 38.2-5800 et seq.) or that provides or arranges for the provision of health care services, health plans, networks, or provider panels that are subject to regulation as the business of insurance under this title.\n\t\t\t“Cost sharing” means any coinsurance, copayment, or deductible.\n\t\t\t“Enrollee” means any person entitled to health care services from a carrier.\n\t\t\t“Health care services” means items or services furnished to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability.\n\t\t\t“Health plan” means any individual or group health care plan, subscription contract, evidence of coverage, certificate, health services plan, medical or hospital services plan, accident and sickness insurance policy or certificate, managed care health insurance plan, or other similar certificate, policy, contract, or arrangement, and any endorsement or rider thereto, to cover all or a portion of the cost of persons receiving covered health care services, that is subject to state regulation and that is required to be offered, arranged, or issued in the Commonwealth by a carrier licensed under this title. “Health plan” does not mean (i) coverages issued pursuant to Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. (Medicare), Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid) or Title XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. (CHIP), 5 U.S.C. § 8901 et seq. (federal employees), or 10 U.S.C. § 1071 et seq. (TRICARE); or (ii) accident only, credit or disability insurance, long-term care insurance, TRICARE supplement, Medicare supplement, or workers’ compensation coverages.B\n\nTo the extent permitted by federal law and regulation and except as provided in subsection C, when calculating an enrollee’s overall contribution to any out-of-pocket maximum or any cost-sharing requirement under a health plan, a carrier shall include any amounts paid by the enrollee or paid on behalf of the enrollee by another person.C\n\nIf the application of the provisions of subsection B would result in a health plan’s ineligibility to qualify as a Health Savings Account-qualified High Deductible Health Plan under 26 U.S.C. § 223, then the requirements of subsection B shall not apply with respect to the deductible of such health plan until after the enrollee has satisfied the minimum deductible under 26 U.S.C § 223. However, with respect to items or services that are preventive care pursuant to 26 U.S.C. § 223 (c)(2)(C), the provisions of subsection B shall apply regardless of whether the minimum deductible under 26 U.S.C. § 223 has been satisfied.D\n\nThis section shall apply with respect to health plans that are entered into, amended, extended, or renewed on or after January 1, 2020.E\n\nPursuant to the authority granted by § 38.2-223, the Commission may promulgate such rules and regulations as it may deem necessary to implement this section.","order_by":null,"text":{"0":{"id":263315,"text":"As used in this section:\n\t\t\t“Carrier” shall have the meaning set forth in § 38.2-3407.10; however, “carrier” also includes any person required to be licensed under this title that offers or operates a managed care health insurance plan subject to Chapter 58 (§ 38.2-5800 et seq.) or that provides or arranges for the provision of health care services, health plans, networks, or provider panels that are subject to regulation as the business of insurance under this title.\n\t\t\t“Cost sharing” means any coinsurance, copayment, or deductible.\n\t\t\t“Enrollee” means any person entitled to health care services from a carrier.\n\t\t\t“Health care services” means items or services furnished to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability.\n\t\t\t“Health plan” means any individual or group health care plan, subscription contract, evidence of coverage, certificate, health services plan, medical or hospital services plan, accident and sickness insurance policy or certificate, managed care health insurance plan, or other similar certificate, policy, contract, or arrangement, and any endorsement or rider thereto, to cover all or a portion of the cost of persons receiving covered health care services, that is subject to state regulation and that is required to be offered, arranged, or issued in the Commonwealth by a carrier licensed under this title. “Health plan” does not mean (i) coverages issued pursuant to Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. (Medicare), Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid) or Title XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. (CHIP), 5 U.S.C. § 8901 et seq. (federal employees), or 10 U.S.C. § 1071 et seq. (TRICARE); or (ii) accident only, credit or disability insurance, long-term care insurance, TRICARE supplement, Medicare supplement, or workers’ compensation coverages.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":263316,"text":"To the extent permitted by federal law and regulation and except as provided in subsection C, when calculating an enrollee’s overall contribution to any out-of-pocket maximum or any cost-sharing requirement under a health plan, a carrier shall include any amounts paid by the enrollee or paid on behalf of the enrollee by another person.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":263317,"text":"If the application of the provisions of subsection B would result in a health plan’s ineligibility to qualify as a Health Savings Account-qualified High Deductible Health Plan under 26 U.S.C. § 223, then the requirements of subsection B shall not apply with respect to the deductible of such health plan until after the enrollee has satisfied the minimum deductible under 26 U.S.C § 223. However, with respect to items or services that are preventive care pursuant to 26 U.S.C. § 223 (c)(2)(C), the provisions of subsection B shall apply regardless of whether the minimum deductible under 26 U.S.C. § 223 has been satisfied.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":263318,"text":"This section shall apply with respect to health plans that are entered into, amended, extended, or renewed on or after January 1, 2020.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":263319,"text":"Pursuant to the authority granted by § 38.2-223, the Commission may promulgate such rules and regulations as it may deem necessary to implement this section.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D"}},"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; 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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":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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3407.20\/","history_text":"

This law was first created in 2019. The record of its establishment is cataloged in chapters 661<\/a> and 662<\/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 2022, chapters 133<\/a> and 134<\/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\/"}],"refers_to":[{"id":87496,"section_number":"38.2-223","catch_line":"Rules and regulations; orders","order_by":null,"url":"\/38.2-223\/"},{"id":58079,"section_number":"38.2-3407.10","catch_line":"Health care provider panels","order_by":null,"url":"\/38.2-3407.10\/"},{"id":77304,"section_number":"38.2-5800","catch_line":"Definitions","order_by":null,"url":"\/38.2-5800\/"}],"permalink":{"id":215059,"object_type":"law","relational_id":73127,"identifier":"38.2-3407.20","token":"38.2\/34\/1\/38.2-3407.20","url":"\/38.2-3407.20\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3407.20\/","token":"38.2\/34\/1\/38.2-3407.20","dublin_core":{"Title":"Calculation of enrollee’s contribution to out-of-pocket maximum or cost-sharing requirement","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3407.20","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> As used in this section:\n\t\t\t“Carrier<\/span>” shall have the meaning set forth in § 38.2-3407.10<\/a>; however, “carrier<\/span>” also includes any person<\/span> required to be licensed under this title that offers or operates a managed care health insurance<\/span> plan subject to Chapter 58 (§ 38.2-5800<\/a> et seq.) or that provides or arranges for the provision of health care services<\/span>, health plans<\/span>, networks, or provider panels<\/span> that are subject to regulation as the business of insurance<\/span> under this title.\n\t\t\t“Cost sharing<\/span>” means any coinsurance, copayment, or deductible.\n\t\t\t“Enrollee<\/span>” means any person<\/span> entitled to health care services<\/span> from a carrier<\/span>.\n\t\t\t“Health care services<\/span>” means items or services furnished to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability.\n\t\t\t“Health plan<\/span>” means any individual or group health care plan, subscription contract<\/span>, evidence<\/span> of coverage, certificate, health services plan<\/span>, medical or hospital services plan, accident and sickness insurance<\/span> policy or certificate, managed care health insurance<\/span> plan, or other similar certificate, policy, contract<\/span>, or arrangement, and any endorsement or rider thereto, to cover all or a portion of the cost of persons<\/span> receiving covered health care services<\/span>, that is subject to state<\/span> regulation and that is required to be offered, arranged, or issued in the Commonwealth by a carrier<\/span> licensed under this title. “Health plan<\/span>” does not mean (i) coverages issued pursuant to Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. (Medicare<\/span>), Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid) or Title XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. (CHIP), 5 U.S.C. § 8901 et seq. (federal employees), or 10 U.S.C. § 1071 et seq. (TRICARE); or (ii) accident only, credit or disability insurance<\/span>, long-term care insurance<\/span>, TRICARE supplement, Medicare<\/span> supplement, or workers’ compensation coverages. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> To the extent permitted by federal law<\/span> and regulation and except as provided in subsection C, when calculating an enrollee<\/span>’s overall contribution to any out-of-pocket maximum or any cost-sharing requirement under a health plan<\/span>, a carrier<\/span> shall include any amounts paid by the enrollee<\/span> or paid on behalf of the enrollee<\/span> by another person<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> If the application of the provisions of subsection B would result in a health plan<\/span>’s ineligibility to qualify as a Health Savings Account-qualified High Deductible Health Plan<\/span> under 26 U.S.C. § 223, then the requirements of subsection B shall not apply with respect to the deductible of such health plan<\/span> until after the enrollee<\/span> has satisfied the minimum deductible under 26 U.S.C § 223. However, with respect to items or services that are preventive care pursuant to 26 U.S.C. § 223 (c)(2)(C), the provisions of subsection B shall apply regardless of whether the minimum deductible under 26 U.S.C. § 223 has been satisfied. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> This section shall apply with respect to health plans<\/span> that are entered into, amended, extended, or renewed on or after January 1, 2020. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Pursuant to the authority granted by § 38.2-223<\/a>, the Commission<\/span> may promulgate such rules and regulations as it may deem necessary to implement this section. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nCALCULATION OF ENROLLEE’S CONTRIBUTION TO OUT-OF-POCKET MAXIMUM OR\nCOST-SHARING REQUIREMENT (\u00a7 38.2-3407.20)\n\nA. As used in this section:\n\t\t\t“Carrier” shall have the meaning set forth in §\n38.2-3407.10; however, “carrier” also includes any person required\nto be licensed under this title that offers or operates a managed care health\ninsurance plan subject to Chapter 58 (§ 38.2-5800 et seq.) or that provides\nor arranges for the provision of health care services, health plans, networks,\nor provider panels that are subject to regulation as the business of insurance\nunder this title.\n\t\t\t“Cost sharing” means any coinsurance, copayment, or deductible.\n\t\t\t“Enrollee” means any person entitled to health care services from\na carrier.\n\t\t\t“Health care services” means items or services furnished to any\nindividual for the purpose of preventing, alleviating, curing, or healing human\nillness, injury, or physical disability.\n\t\t\t“Health plan” means any individual or group health care plan,\nsubscription contract, evidence of coverage, certificate, health services plan,\nmedical or hospital services plan, accident and sickness insurance policy or\ncertificate, managed care health insurance plan, or other similar certificate,\npolicy, contract, or arrangement, and any endorsement or rider thereto, to cover\nall or a portion of the cost of persons receiving covered health care services,\nthat is subject to state regulation and that is required to be offered,\narranged, or issued in the Commonwealth by a carrier licensed under this title.\n“Health plan” does not mean (i) coverages issued pursuant to Title\nXVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. (Medicare),\nTitle XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid)\nor Title XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. (CHIP),\n5 U.S.C. § 8901 et seq. (federal employees), or 10 U.S.C. § 1071 et\nseq. (TRICARE); or (ii) accident only, credit or disability insurance, long-term\ncare insurance, TRICARE supplement, Medicare supplement, or workers’\ncompensation coverages.\n\nB. To the extent permitted by federal law and regulation and except as provided\nin subsection C, when calculating an enrollee’s overall contribution to\nany out-of-pocket maximum or any cost-sharing requirement under a health plan, a\ncarrier shall include any amounts paid by the enrollee or paid on behalf of the\nenrollee by another person.\n\nC. If the application of the provisions of subsection B would result in a health\nplan’s ineligibility to qualify as a Health Savings Account-qualified High\nDeductible Health Plan under 26 U.S.C. § 223, then the requirements of\nsubsection B shall not apply with respect to the deductible of such health plan\nuntil after the enrollee has satisfied the minimum deductible under 26 U.S.C\n§ 223. However, with respect to items or services that are preventive care\npursuant to 26 U.S.C. § 223 (c)(2)(C), the provisions of subsection B shall\napply regardless of whether the minimum deductible under 26 U.S.C. § 223\nhas been satisfied.\n\nD. This section shall apply with respect to health plans that are entered into,\namended, extended, or renewed on or after January 1, 2020.\n\nE. Pursuant to the authority granted by § 38.2-223, the Commission may\npromulgate such rules and regulations as it may deem necessary to implement this\nsection.\n\nHISTORY: 2019, cc. 661, 662; 2022, cc. 133, 134.","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}}