{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3407.3.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3407.3.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3407.3.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3407.3.html"}],"law_id":81846,"edition_id":1,"section_id":81846,"structure_id":12994,"section_number":"38.2-3407.3","catch_line":"Calculation of cost-sharing provisions","history":"1994, c. 320; 1997, c. 56; 1998, c. 49; 2017, c. 588.","full_text":"A\n\nAn insurer, health services plan, or health maintenance organization that issues an accident and sickness insurance policy or contract pursuant to which the insured, subscriber or enrollee is required to pay a specified percentage of the cost of covered services, shall calculate such amount payable based upon an amount not to exceed the total amount actually paid or payable to the provider of such services for the services provided to the insured, subscriber, or enrollee. When there is no amount actually paid or payable to the provider by the insurer, health services plan, or health maintenance organization for the services provided, the insurer, health services plan, or health maintenance organization shall use such insurer’s, health services plan’s, or health maintenance organization’s pre-established allowed amount to calculate the amount payable by the insured for such services. When an insured, subscriber, or enrollee receives covered services outside the insurer’s, health services plan’s, or health maintenance organization’s provider network, and such entity utilizes another insurer’s, health services plan’s, or health maintenance organization’s provider network located outside the Commonwealth, such entity may satisfy the obligation of this section by using the cost of services as reported by the out-of-state insurer, health services plan, or health maintenance organization when calculating the insured’s, subscriber’s, or enrollee’s percentage of the cost of covered services.B\n\nAny insurer, health services plan, or health maintenance organization failing to administer its contracts as set forth herein shall be deemed to have committed a knowing and willful violation of this section, and shall be punished as set forth in subsection A of § 38.2-218. Each claim payment found to have been calculated in noncompliance with this section shall be deemed a separate and distinct violation, and shall further be deemed a violation subject to subdivision D 1 c of § 38.2-218, permitting the Commission to require restitution in addition to any other penalties.","order_by":null,"text":{"0":{"id":293211,"text":"An insurer, health services plan, or health maintenance organization that issues an accident and sickness insurance policy or contract pursuant to which the insured, subscriber or enrollee is required to pay a specified percentage of the cost of covered services, shall calculate such amount payable based upon an amount not to exceed the total amount actually paid or payable to the provider of such services for the services provided to the insured, subscriber, or enrollee. When there is no amount actually paid or payable to the provider by the insurer, health services plan, or health maintenance organization for the services provided, the insurer, health services plan, or health maintenance organization shall use such insurer’s, health services plan’s, or health maintenance organization’s pre-established allowed amount to calculate the amount payable by the insured for such services. When an insured, subscriber, or enrollee receives covered services outside the insurer’s, health services plan’s, or health maintenance organization’s provider network, and such entity utilizes another insurer’s, health services plan’s, or health maintenance organization’s provider network located outside the Commonwealth, such entity may satisfy the obligation of this section by using the cost of services as reported by the out-of-state insurer, health services plan, or health maintenance organization when calculating the insured’s, subscriber’s, or enrollee’s percentage of the cost of covered services.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":293212,"text":"Any insurer, health services plan, or health maintenance organization failing to administer its contracts as set forth herein shall be deemed to have committed a knowing and willful violation of this section, and shall be punished as set forth in subsection A of § 38.2-218. Each claim payment found to have been calculated in noncompliance with this section shall be deemed a separate and distinct violation, and shall further be deemed a violation subject to subdivision D 1 c of § 38.2-218, permitting the Commission to require restitution in addition to any other penalties.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A"}},"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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This law was first created in 1994. The record of its establishment is cataloged in chapter 320<\/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 3 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 1997, chapter 56<\/a>; in 1998, chapter 49<\/a>; in 2017, chapter 588<\/a>.<\/p>","references":false,"refers_to":[{"id":64490,"section_number":"38.2-218","catch_line":"Penalties and restitution payments","order_by":null,"url":"\/38.2-218\/"}],"permalink":{"id":215071,"object_type":"law","relational_id":81846,"identifier":"38.2-3407.3","token":"38.2\/34\/1\/38.2-3407.3","url":"\/38.2-3407.3\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3407.3\/","token":"38.2\/34\/1\/38.2-3407.3","dublin_core":{"Title":"Calculation of cost-sharing provisions","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3407.3","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> An insurer<\/span>, health services plan<\/span>, or health maintenance organization that issues<\/span> an accident and sickness insurance<\/span> policy or contract<\/span> pursuant to which the insured, subscriber or enrollee is required to pay a specified percentage of the cost of covered services, shall calculate such amount payable based upon an amount not to exceed the total amount actually paid or payable to the provider of such services for the services provided to the insured, subscriber, or enrollee. When there is no amount actually paid or payable to the provider by the insurer<\/span>, health services plan<\/span>, or health maintenance organization for the services provided, the insurer<\/span>, health services plan<\/span>, or health maintenance organization shall use such insurer<\/span>’s, health services plan<\/span>’s, or health maintenance organization’s pre-established allowed amount to calculate the amount payable by the insured for such services. When an insured, subscriber, or enrollee receives covered services outside the insurer<\/span>’s, health services plan<\/span>’s, or health maintenance organization’s provider network, and such entity utilizes another insurer<\/span>’s, health services plan<\/span>’s, or health maintenance organization’s provider network located outside the Commonwealth, such entity may satisfy the obligation of this section by using the cost of services as reported by the out-of-state<\/span> insurer<\/span>, health services plan<\/span>, or health maintenance organization when calculating the insured’s, subscriber’s, or enrollee’s percentage of the cost of covered services. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> Any insurer<\/span>, health services plan<\/span>, or health maintenance organization failing to administer its contracts<\/span> as set forth herein shall be deemed to have committed a knowing and willful violation of this section, and shall be punished as set forth in subsection A of § 38.2-218<\/a>. Each claim payment found to have been calculated in noncompliance with this section shall be deemed a separate and distinct violation, and shall further be deemed a violation subject to subdivision D 1 c of § 38.2-218<\/a>, permitting the Commission<\/span> to require restitution<\/span> in addition to any other penalties. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nCALCULATION OF COST-SHARING PROVISIONS (\u00a7 38.2-3407.3)\n\nA. An insurer, health services plan, or health maintenance organization that\nissues an accident and sickness insurance policy or contract pursuant to which\nthe insured, subscriber or enrollee is required to pay a specified percentage of\nthe cost of covered services, shall calculate such amount payable based upon an\namount not to exceed the total amount actually paid or payable to the provider\nof such services for the services provided to the insured, subscriber, or\nenrollee. When there is no amount actually paid or payable to the provider by\nthe insurer, health services plan, or health maintenance organization for the\nservices provided, the insurer, health services plan, or health maintenance\norganization shall use such insurer’s, health services plan’s, or\nhealth maintenance organization’s pre-established allowed amount to\ncalculate the amount payable by the insured for such services. When an insured,\nsubscriber, or enrollee receives covered services outside the insurer’s,\nhealth services plan’s, or health maintenance organization’s\nprovider network, and such entity utilizes another insurer’s, health\nservices plan’s, or health maintenance organization’s provider\nnetwork located outside the Commonwealth, such entity may satisfy the obligation\nof this section by using the cost of services as reported by the out-of-state\ninsurer, health services plan, or health maintenance organization when\ncalculating the insured’s, subscriber’s, or enrollee’s\npercentage of the cost of covered services.\n\nB. Any insurer, health services plan, or health maintenance organization failing\nto administer its contracts as set forth herein shall be deemed to have\ncommitted a knowing and willful violation of this section, and shall be punished\nas set forth in subsection A of § 38.2-218. Each claim payment found to\nhave been calculated in noncompliance with this section shall be deemed a\nseparate and distinct violation, and shall further be deemed a violation subject\nto subdivision D 1 c of § 38.2-218, permitting the Commission to require\nrestitution in addition to any other penalties.\n\nHISTORY: 1994, c. 320; 1997, c. 56; 1998, c. 49; 2017, c. 588.","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}}