{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3407.4.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3407.4.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3407.4.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3407.4.html"}],"law_id":78457,"edition_id":1,"section_id":78457,"structure_id":12994,"section_number":"38.2-3407.4","catch_line":"Explanation of benefits","history":"1994, c. 320; 2020, cc. 715, 716.","full_text":"A\n\nEach insurer issuing an accident and sickness insurance policy, a corporation issuing subscription contracts, and each health maintenance organization shall file for approval explanation of benefits forms. These explanation of benefit forms shall be subject to the requirements of § 38.2-316 or § 38.2-4306 as applicable.B\n\nThe explanation of benefits shall accurately and clearly set forth the benefits payable under the contract.C\n\nThe Commission may issue regulations to establish (i) standards for the accuracy and clarity of the information presented in an explanation of benefits and (ii) alternative methods of delivery of the explanation of benefits that permit (a) a subscriber who is legally authorized to consent to care for a covered person or recipient, (b) a covered person or recipient who is legally authorized to consent to that covered person’s or recipient’s own care, or (c) another party who has the exclusive legal authorization to consent to care for the covered person or recipient to receive the explanation of benefits by an alternative method, provided that each such alternative method is in compliance with the provisions of 45 C.F.R. § 164.522 regarding the right to request privacy protection for protected health information.D\n\nThe term “explanation of benefits” as used in this section shall include any form provided by an insurer, health services plan, or health maintenance organization which explains the amounts covered under a policy or plan or shows the amounts payable by a covered person to a health care provider.","order_by":null,"text":{"0":{"id":281238,"text":"Each insurer issuing an accident and sickness insurance policy, a corporation issuing subscription contracts, and each health maintenance organization shall file for approval explanation of benefits forms. These explanation of benefit forms shall be subject to the requirements of § 38.2-316 or § 38.2-4306 as applicable.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":281239,"text":"The explanation of benefits shall accurately and clearly set forth the benefits payable under the contract.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":281240,"text":"The Commission may issue regulations to establish (i) standards for the accuracy and clarity of the information presented in an explanation of benefits and (ii) alternative methods of delivery of the explanation of benefits that permit (a) a subscriber who is legally authorized to consent to care for a covered person or recipient, (b) a covered person or recipient who is legally authorized to consent to that covered person’s or recipient’s own care, or (c) another party who has the exclusive legal authorization to consent to care for the covered person or recipient to receive the explanation of benefits by an alternative method, provided that each such alternative method is in compliance with the provisions of 45 C.F.R. § 164.522 regarding the right to request privacy protection for protected health information.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":281241,"text":"The term “explanation of benefits” as used in this section shall include any form provided by an insurer, health services plan, or health maintenance organization which explains the amounts covered under a policy or plan or shows the amounts payable by a covered person to a health care provider.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C"}},"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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order of crediting payments","url":"\/38.2-3407.3_1\/","token":"38.2\/34\/1\/38.2-3407.3_1","metadata":false},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3407.4\/","history_text":"

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 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 2020, chapters 715<\/a> and 716<\/a>.<\/p>","references":[{"id":62548,"section_number":"38.2-4509","catch_line":"Application of certain laws","order_by":null,"url":"\/38.2-4509\/"}],"refers_to":[{"id":60466,"section_number":"38.2-316","catch_line":"Policy forms to be filed with Commission; notice of approval or disapproval; exceptions","order_by":null,"url":"\/38.2-316\/"},{"id":81322,"section_number":"38.2-4306","catch_line":"Evidence of coverage and charges for health care services","order_by":null,"url":"\/38.2-4306\/"}],"permalink":{"id":215079,"object_type":"law","relational_id":78457,"identifier":"38.2-3407.4","token":"38.2\/34\/1\/38.2-3407.4","url":"\/38.2-3407.4\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3407.4\/","token":"38.2\/34\/1\/38.2-3407.4","dublin_core":{"Title":"Explanation of benefits","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3407.4","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> Each insurer<\/span> issuing an accident and sickness insurance<\/span> policy, a corporation issuing subscription contracts<\/span>, and each health maintenance organization shall file for approval explanation of benefits<\/span> forms. These explanation of benefit forms shall be subject to the requirements of § 38.2-316<\/a> or § 38.2-4306<\/a> as applicable. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> The explanation of benefits<\/span> shall accurately and clearly set forth the benefits payable under the contract<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> The Commission<\/span> may issue<\/span> regulations to establish (i) standards for the accuracy and clarity of the information presented in an explanation of benefits<\/span> and (ii) alternative methods of delivery of the explanation of benefits<\/span> that permit (a) a subscriber who is legally authorized to consent to care for a covered person<\/span> or recipient, (b) a covered person<\/span> or recipient who is legally authorized to consent to that covered person<\/span>’s or recipient’s own care, or (c) another party<\/span> who has the exclusive legal authorization to consent to care for the covered person<\/span> or recipient to receive the explanation of benefits<\/span> by an alternative method, provided that each such alternative method is in compliance with the provisions of 45 C.F.R. § 164.522 regarding the right to request privacy protection for protected health information. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> The term “explanation of benefits<\/span>” as used in this section shall include any form provided by an insurer<\/span>, health services plan<\/span>, or health maintenance organization which explains the amounts covered under a policy or plan or shows the amounts payable by a covered person<\/span> to a health care provider. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nEXPLANATION OF BENEFITS (\u00a7 38.2-3407.4)\n\nA. Each insurer issuing an accident and sickness insurance policy, a corporation\nissuing subscription contracts, and each health maintenance organization shall\nfile for approval explanation of benefits forms. These explanation of benefit\nforms shall be subject to the requirements of § 38.2-316 or §\n38.2-4306 as applicable.\n\nB. The explanation of benefits shall accurately and clearly set forth the\nbenefits payable under the contract.\n\nC. The Commission may issue regulations to establish (i) standards for the\naccuracy and clarity of the information presented in an explanation of benefits\nand (ii) alternative methods of delivery of the explanation of benefits that\npermit (a) a subscriber who is legally authorized to consent to care for a\ncovered person or recipient, (b) a covered person or recipient who is legally\nauthorized to consent to that covered person’s or recipient’s own\ncare, or (c) another party who has the exclusive legal authorization to consent\nto care for the covered person or recipient to receive the explanation of\nbenefits by an alternative method, provided that each such alternative method is\nin compliance with the provisions of 45 C.F.R. § 164.522 regarding the\nright to request privacy protection for protected health information.\n\nD. The term “explanation of benefits” as used in this section shall\ninclude any form provided by an insurer, health services plan, or health\nmaintenance organization which explains the amounts covered under a policy or\nplan or shows the amounts payable by a covered person to a health care provider.\n\nHISTORY: 1994, c. 320; 2020, cc. 715, 716.","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}}