{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3407.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3407.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3407.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3407.html"}],"law_id":76321,"edition_id":1,"section_id":76321,"structure_id":12994,"section_number":"38.2-3407","catch_line":"Health benefit programs","history":"1983, c. 464, \u00a7 38.1-347.2; 1986, c. 562; 2008, c. 215.","full_text":"A\n\nOne or more insurers may offer or administer a health benefit program under which the insurer or insurers may offer preferred provider policies or contracts that limit the numbers and types of providers of health care services eligible for payment as preferred providers.B\n\nAny such insurer shall establish terms and conditions that shall be met by a hospital, physician or type of provider listed in § 38.2-3408 in order to qualify for payment as a preferred provider under the policies or contracts. These terms and conditions shall not discriminate unreasonably against or among such health care providers. No hospital, physician or type of provider listed in § 38.2-3408 willing to meet the terms and conditions offered to it or him shall be excluded. Neither differences in prices among hospitals or other institutional providers produced by a process of individual negotiations with providers or based on market conditions, or price differences among providers in different geographical areas, shall be deemed unreasonable discrimination. The Commission shall have no jurisdiction to adjudicate controversies growing out of this subsection.C\n\nMandated types of providers set forth in § 38.2-3408, and types of providers whose services are required to be made available and that have been specifically contracted for by the holder of any such policy or contract shall, to the extent required by § 38.2-3408, have the same opportunity to qualify for payment as a preferred provider as do doctors of medicine.D\n\nPreferred provider policies or contracts shall provide for payment for services rendered by nonpreferred providers, but the payments need not be the same as for preferred providers.E\n\nAn insurer may offer individual or group exclusive provider policies or contracts if:1\n\nThe insurer provides or includes a benefit for preferred and nonpreferred providers in accordance with the provisions of subsection D to a group contract holder to be provided or offered as a benefit for the enrollee, at the enrollee’s option, individually to accept or reject. In connection with its group enrollment application, every insurer shall, at no additional cost to the group contract holder, make available or arrange with a carrier to make available to the prospective group contract holder and to all prospective enrollees, in advance of initial enrollment and in advance of each reenrollment, a notice in form and substance approved by the Commission as required under § 38.2-316, that accurately and completely explains to the group contract holder and prospective enrollee the benefit for preferred and nonpreferred providers and permits each enrollee to make his election. The form of notice provided in connection with any reenrollment may be the same as the approved form of notice filed under § 38.2-316 used in connection with initial enrollment and may be made available to the group contract holder and prospective enrollee by the carrier in any reasonable manner; and2\n\nThe insurer provides out-of-network emergency services at the minimum level required by the preferred provider policy or contract.F\n\nFor the purposes of this section, “exclusive provider policies or contracts” are insurance policies or contracts that condition the payment of benefits on the use of preferred providers, and “preferred provider policies or contracts” are insurance policies or contracts that specify how services are to be covered when rendered by preferred and nonpreferred classifications of providers.","order_by":null,"text":{"0":{"id":273983,"text":"One or more insurers may offer or administer a health benefit program under which the insurer or insurers may offer preferred provider policies or contracts that limit the numbers and types of providers of health care services eligible for payment as preferred providers.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":273984,"text":"Any such insurer shall establish terms and conditions that shall be met by a hospital, physician or type of provider listed in § 38.2-3408 in order to qualify for payment as a preferred provider under the policies or contracts. These terms and conditions shall not discriminate unreasonably against or among such health care providers. No hospital, physician or type of provider listed in § 38.2-3408 willing to meet the terms and conditions offered to it or him shall be excluded. Neither differences in prices among hospitals or other institutional providers produced by a process of individual negotiations with providers or based on market conditions, or price differences among providers in different geographical areas, shall be deemed unreasonable discrimination. The Commission shall have no jurisdiction to adjudicate controversies growing out of this subsection.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":273985,"text":"Mandated types of providers set forth in § 38.2-3408, and types of providers whose services are required to be made available and that have been specifically contracted for by the holder of any such policy or contract shall, to the extent required by § 38.2-3408, have the same opportunity to qualify for payment as a preferred provider as do doctors of medicine.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":273986,"text":"Preferred provider policies or contracts shall provide for payment for services rendered by nonpreferred providers, but the payments need not be the same as for preferred providers.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":273987,"text":"An insurer may offer individual or group exclusive provider policies or contracts if:","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"E1"},"5":{"id":273988,"text":"The insurer provides or includes a benefit for preferred and nonpreferred providers in accordance with the provisions of subsection D to a group contract holder to be provided or offered as a benefit for the enrollee, at the enrollee’s option, individually to accept or reject. In connection with its group enrollment application, every insurer shall, at no additional cost to the group contract holder, make available or arrange with a carrier to make available to the prospective group contract holder and to all prospective enrollees, in advance of initial enrollment and in advance of each reenrollment, a notice in form and substance approved by the Commission as required under § 38.2-316, that accurately and completely explains to the group contract holder and prospective enrollee the benefit for preferred and nonpreferred providers and permits each enrollee to make his election. The form of notice provided in connection with any reenrollment may be the same as the approved form of notice filed under § 38.2-316 used in connection with initial enrollment and may be made available to the group contract holder and prospective enrollee by the carrier in any reasonable manner; and","type":"section","prefixes":["E","1"],"prefix":"1","entire_prefix":"E1","prefix_anchor":"E1","level":2,"prior_prefix":"E","next_prefix":"E2"},"6":{"id":273989,"text":"The insurer provides out-of-network emergency services at the minimum level required by the preferred provider policy or contract.","type":"section","prefixes":["E","2"],"prefix":"2","entire_prefix":"E2","prefix_anchor":"E2","level":2,"prior_prefix":"E1","next_prefix":"F"},"7":{"id":273990,"text":"For the purposes of this section, “exclusive provider policies or contracts” are insurance policies or contracts that condition the payment of benefits on the use of preferred providers, and “preferred provider policies or contracts” are insurance policies or contracts that specify how services are to be covered when rendered by preferred and nonpreferred classifications of providers.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E2"}},"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":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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3407\/","history_text":"

This law was first created in 1983. The record of its establishment is cataloged in chapter 464 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. Unfortunately, the 1983 \u201cActs\u201d aren\u2019t available online. It has been modified 2 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 1986, chapter 562; in 2008, chapter 215<\/a>.<\/p>","references":[{"id":61229,"section_number":"32.1-137.1","catch_line":"Definitions","order_by":null,"url":"\/32.1-137.1\/"},{"id":58079,"section_number":"38.2-3407.10","catch_line":"Health care provider panels","order_by":null,"url":"\/38.2-3407.10\/"},{"id":68442,"section_number":"38.2-3407.12","catch_line":"Patient optional point-of-service benefit","order_by":null,"url":"\/38.2-3407.12\/"},{"id":72641,"section_number":"38.2-3407.7","catch_line":"Pharmacies; freedom of choice","order_by":null,"url":"\/38.2-3407.7\/"},{"id":77304,"section_number":"38.2-5800","catch_line":"Definitions","order_by":null,"url":"\/38.2-5800\/"},{"id":80352,"section_number":"38.2-6108","catch_line":"Plan dentist contracts; preferred providers; assignment of benefits","order_by":null,"url":"\/38.2-6108\/"}],"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":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\/"}],"permalink":{"id":214931,"object_type":"law","relational_id":76321,"identifier":"38.2-3407","token":"38.2\/34\/1\/38.2-3407","url":"\/38.2-3407\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3407\/","token":"38.2\/34\/1\/38.2-3407","dublin_core":{"Title":"Health benefit programs","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3407","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> One or more insurers<\/span> may offer or administer a health benefit program under which the insurer<\/span> or insurers<\/span> may offer preferred provider policies or contracts<\/span> that limit the numbers and types of providers of health care services eligible for payment as preferred providers. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> Any such insurer<\/span> shall establish terms and conditions that shall be met by a hospital, physician or type of provider listed in § 38.2-3408<\/a> in order<\/span> to qualify for payment as a preferred provider under the policies or contracts<\/span>. These terms and conditions shall not discriminate unreasonably against or among such health care providers. No hospital, physician or type of provider listed in § 38.2-3408<\/a> willing to meet the terms and conditions offered to it or him shall be excluded. Neither differences in prices among hospitals or other institutional providers produced by a process of individual negotiations with providers or based on market conditions, or price differences among providers in different geographical areas, shall be deemed unreasonable discrimination. The Commission<\/span> shall have no jurisdiction<\/span> to adjudicate<\/span> controversies growing out of this subsection. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Mandated types of providers set forth in § 38.2-3408<\/a>, and types of providers whose services are required to be made available and that have been specifically contracted for by the holder of any such policy or contract<\/span> shall, to the extent required by § 38.2-3408<\/a>, have the same opportunity to qualify for payment as a preferred provider as do doctors of medicine. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> Preferred provider policies or contracts<\/span> shall provide for payment for services rendered by nonpreferred providers, but the payments need not be the same as for preferred providers. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> An insurer<\/span> may offer individual or group exclusive provider policies or contracts<\/span> if: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> The insurer<\/span> provides or includes a benefit for preferred and nonpreferred providers in accordance with the provisions of subsection D to a group contract<\/span> holder to be provided or offered as a benefit for the enrollee, at the enrollee’s option, individually to accept or reject. In connection with its group enrollment application, every insurer<\/span> shall, at no additional cost to the group contract<\/span> holder, make available or arrange with a carrier to make available to the prospective group contract<\/span> holder and to all prospective enrollees, in advance of initial enrollment and in advance of each reenrollment, a notice in form and substance approved by the Commission<\/span> as required under § 38.2-316<\/a>, that accurately and completely explains to the group contract<\/span> holder and prospective enrollee the benefit for preferred and nonpreferred providers and permits each enrollee to make his election. The form of notice provided in connection with any reenrollment may be the same as the approved form of notice filed under § 38.2-316<\/a> used in connection with initial enrollment and may be made available to the group contract<\/span> holder and prospective enrollee by the carrier in any reasonable manner; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> The insurer<\/span> provides out-of-network emergency services at the minimum level required by the preferred provider policy or contract<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> For the purposes of this section, “exclusive provider policies or contracts<\/span>” are insurance policies<\/span> or contracts<\/span> that condition the payment of benefits on the use of preferred providers, and “preferred provider policies or contracts<\/span>” are insurance policies<\/span> or contracts<\/span> that specify how services are to be covered when rendered by preferred and nonpreferred classifications of providers. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nHEALTH BENEFIT PROGRAMS (\u00a7 38.2-3407)\n\nA. One or more insurers may offer or administer a health benefit program under\nwhich the insurer or insurers may offer preferred provider policies or contracts\nthat limit the numbers and types of providers of health care services eligible\nfor payment as preferred providers.\n\nB. Any such insurer shall establish terms and conditions that shall be met by a\nhospital, physician or type of provider listed in § 38.2-3408 in order to\nqualify for payment as a preferred provider under the policies or contracts.\nThese terms and conditions shall not discriminate unreasonably against or among\nsuch health care providers. No hospital, physician or type of provider listed in\n§ 38.2-3408 willing to meet the terms and conditions offered to it or him\nshall be excluded. Neither differences in prices among hospitals or other\ninstitutional providers produced by a process of individual negotiations with\nproviders or based on market conditions, or price differences among providers in\ndifferent geographical areas, shall be deemed unreasonable discrimination. The\nCommission shall have no jurisdiction to adjudicate controversies growing out of\nthis subsection.\n\nC. Mandated types of providers set forth in § 38.2-3408, and types of\nproviders whose services are required to be made available and that have been\nspecifically contracted for by the holder of any such policy or contract shall,\nto the extent required by § 38.2-3408, have the same opportunity to qualify\nfor payment as a preferred provider as do doctors of medicine.\n\nD. Preferred provider policies or contracts shall provide for payment for\nservices rendered by nonpreferred providers, but the payments need not be the\nsame as for preferred providers.\n\nE. An insurer may offer individual or group exclusive provider policies or\ncontracts if:\n\n 1. The insurer provides or includes a benefit for preferred and nonpreferred\n providers in accordance with the provisions of subsection D to a group\n contract holder to be provided or offered as a benefit for the enrollee, at\n the enrollee’s option, individually to accept or reject. In connection\n with its group enrollment application, every insurer shall, at no additional\n cost to the group contract holder, make available or arrange with a carrier to\n make available to the prospective group contract holder and to all prospective\n enrollees, in advance of initial enrollment and in advance of each\n reenrollment, a notice in form and substance approved by the Commission as\n required under § 38.2-316, that accurately and completely explains to the\n group contract holder and prospective enrollee the benefit for preferred and\n nonpreferred providers and permits each enrollee to make his election. The\n form of notice provided in connection with any reenrollment may be the same as\n the approved form of notice filed under § 38.2-316 used in connection\n with initial enrollment and may be made available to the group contract holder\n and prospective enrollee by the carrier in any reasonable manner; and\n\n 2. The insurer provides out-of-network emergency services at the minimum level\n required by the preferred provider policy or contract.\n\nF. For the purposes of this section, “exclusive provider policies or\ncontracts” are insurance policies or contracts that condition the payment\nof benefits on the use of preferred providers, and “preferred provider\npolicies or contracts” are insurance policies or contracts that specify\nhow services are to be covered when rendered by preferred and nonpreferred\nclassifications of providers.\n\nHISTORY: 1983, c. 464, \u00a7 38.1-347.2; 1986, c. 562; 2008, c. 215.","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}}