{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3438.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3438.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3438.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3438.html"}],"law_id":57210,"edition_id":1,"section_id":57210,"structure_id":13819,"section_number":"38.2-3438","catch_line":"Definitions","history":"2011, c. 882; 2013, c. 751; 2014, c. 814; 2020, cc. 1080, 1081, 1160; 2024, cc. 199, 360.","full_text":"As used this article, unless the context requires a different meaning:\n\t\t“Allowed amount” means the maximum portion of a billed charge a health carrier will pay, including any applicable cost-sharing requirements, for a covered service or item rendered by a participating provider or by a nonparticipating provider.\n\t\t“Balance bill” means a bill sent to an enrollee by an out-of-network provider for health care services provided to the enrollee after the provider’s billed amount is not fully reimbursed by the carrier, exclusive of applicable cost-sharing requirements.\n\t\t“Behavioral health crisis service provider” means a provider licensed by the Department of Behavioral Health and Developmental Services to provide mental health or substance abuse services as a provider of mobile crisis response, residential crisis stabilization, or a crisis receiving center.\n\t\t“Child” means a son, daughter, stepchild, adopted child, including a child placed for adoption, foster child, or any other child eligible for coverage under the health benefit plan.\n\t\t“Cost-sharing requirement” means an enrollee’s deductible, copayment amount, or coinsurance rate.\n\t\t“Covered benefits” or “benefits” means those health care services to which an individual is entitled under the terms of a health benefit plan.\n\t\t“Covered person” means a policyholder, subscriber, enrollee, participant, or other individual covered by a health benefit plan.\n\t\t“Dependent” means the spouse or child of an eligible employee, subject to the applicable terms of the policy, contract, or plan covering the eligible employee.\n\t\t“Emergency medical condition” means, regardless of the final diagnosis rendered to a covered person, a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (i) serious jeopardy to the mental or physical health of the individual, (ii) danger of serious impairment to bodily functions, (iii) serious dysfunction of any bodily organ or part, or (iv) in the case of a pregnant woman, serious jeopardy to the health of the fetus.\n\t\t“Emergency services” means with respect to an emergency medical condition (i) (a) a medical screening examination as required under \u00a7 1867 of the Social Security Act (42 U.S.C. \u00a7 1395dd) that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition, and (b) such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital, as are required under \u00a7 1867 of the Social Security Act (42 U.S.C. \u00a7 1395dd (e)(3)) to stabilize the patient and (ii) as it relates to any mental health services or substance abuse services, as those terms are defined in \u00a7 38.2-3412.1, rendered at a behavioral health crisis service provider (a) a behavioral health assessment that is within the capability of a behavioral health crisis service provider, including ancillary services routinely available to evaluate such emergency medical condition, and (b) such further examination and treatment, to the extent that they are within the capabilities of the staff and facilities available at the behavioral health crisis service provider, as are required so that the patient’s condition does not deteriorate.\n\t\t“ERISA” means the Employee Retirement Income Security Act of 1974.\n\t\t“Essential health benefits” include the following general categories and the items and services covered within the categories in accordance with regulations issued pursuant to the PPACA as of January 1, 2019: (i) ambulatory patient services; (ii) emergency services; (iii) hospitalization; (iv) laboratory services; (v) maternity and newborn care; (vi) mental health and substance abuse disorder services, including behavioral health treatment; (vii) pediatric services, including oral and vision care; (viii) prescription drugs; (ix) preventive and wellness services and chronic disease management; and (x) rehabilitative and habilitative services and devices.\n\t\t“Facility” means an institution providing health care related services or a health care setting, including hospitals and other licensed inpatient centers; ambulatory surgical or treatment centers; skilled nursing centers; residential treatment centers; diagnostic, laboratory, and imaging centers; and rehabilitation and other therapeutic health settings.\n\t\t“Genetic information” means, with respect to an individual, information about: (i) the individual’s genetic tests; (ii) the genetic tests of the individual’s family members; (iii) the manifestation of a disease or disorder in family members of the individual; or (iv) any request for, or receipt of, genetic services, or participation in clinical research that includes genetic services, by the individual or any family member of the individual. “Genetic information” does not include information about the sex or age of any individual. As used in this definition, “family member” includes a first-degree, second-degree, third-degree, or fourth-degree relative of a covered person.\n\t\t“Genetic services” means (i) a genetic test; (ii) genetic counseling, including obtaining, interpreting, or assessing genetic information; or (iii) genetic education.\n\t\t“Genetic test” means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if the analysis detects genotypes, mutations, or chromosomal changes. “Genetic test” does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition.\n\t\t“Grandfathered plan” means coverage provided by a health carrier to (i) a small employer on March 23, 2010, or (ii) an individual that was enrolled on March 23, 2010, including any extension of coverage to an individual who becomes a dependent of a grandfathered enrollee after March 23, 2010, for as long as such plan maintains that status in accordance with federal law.\n\t\t“Group health insurance coverage” means health insurance coverage offered in connection with a group health benefit plan.\n\t\t“Group health plan” means an employee welfare benefit plan as defined in \u00a7 3(1) of ERISA to the extent that the plan provides medical care within the meaning of \u00a7 733(a) of ERISA to employees, including both current and former employees, or their dependents as defined under the terms of the plan directly or through insurance, reimbursement, or otherwise.\n\t\t“Health benefit plan” means a policy, contract, certificate, or agreement offered by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. “Health benefit plan” includes short-term and catastrophic health insurance policies, and a policy that pays on a cost-incurred basis, except as otherwise specifically exempted in this definition. “Health benefit plan” does not include the “excepted benefits” as defined in \u00a7 38.2-3431.\n\t\t“Health care professional” means a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with state law.\n\t\t“Health care provider” or “provider” means a health care professional or facility.\n\t\t“Health care services” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.\n\t\t“Health carrier” means an entity subject to the insurance laws and regulations of the Commonwealth and subject to the jurisdiction of the Commission that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an insurer licensed to sell accident and sickness insurance, a health maintenance organization, a health services plan, or any other entity providing a plan of health insurance, health benefits, or health care services.\n\t\t“Health maintenance organization” means a person licensed pursuant to Chapter 43 (\u00a7 38.2-4300 et seq.).\n\t\t“Health status-related factor” means any of the following factors: health status; medical condition, including physical and mental illnesses; claims experience; receipt of health care services; medical history; genetic information; evidence of insurability, including conditions arising out of acts of domestic violence; disability; or any other health status-related factor as determined by federal regulation.\n\t\t“Individual health insurance coverage” means health insurance coverage offered to individuals in the individual market, which includes a health benefit plan provided to individuals through a trust arrangement, association, or other discretionary group that is not an employer plan, but does not include coverage defined as “excepted benefits” in \u00a7 38.2-3431 or short-term limited duration insurance. Student health insurance coverage shall be considered a type of individual health insurance coverage.\n\t\t“Individual market” means the market for health insurance coverage offered to individuals other than in connection with a group health plan.\n\t\t“In-network” or “participating” means a provider that has contracted with a carrier or a carrier’s contractor or subcontractor to provide health care services to enrollees and be reimbursed by the carrier at a contracted rate as payment in full for the health care services, including applicable cost-sharing requirements.\n\t\t“Managed care plan” means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with, or employed by the health carrier.\n\t\t“Network” means the group of participating providers providing services to a managed care plan.\n\t\t“Nonprofit data services organization” means the nonprofit organization with which the Commissioner of Health negotiates and enters into contracts or agreements for the compilation, storage, analysis, and evaluation of data submitted by data suppliers pursuant to \u00a7 32.1-276.4.\n\t\t“Offer to pay” or “payment notification” means a claim that has been adjudicated and paid by a carrier or determined by a carrier to be payable by an enrollee to an out-of-network provider for services described in subsection A of \u00a7 38.2-3445.01.\n\t\t“Open enrollment” means, with respect to individual health insurance coverage, the period of time during which any individual has the opportunity to apply for coverage under a health benefit plan offered by a health carrier and must be accepted for coverage under the plan without regard to a preexisting condition exclusion.\n\t\t“Out-of-network” or “nonparticipating” means a provider that has not contracted with a carrier or a carrier’s contractor or subcontractor to provide health care services to enrollees.\n\t\t“Out-of-pocket maximum” or “maximum out-of-pocket” means the maximum amount an enrollee is required to pay in the form of cost-sharing requirements for covered benefits in a plan year, after which the carrier covers the entirety of the allowed amount of covered benefits under the contract of coverage.\n\t\t“Participating health care professional” means a health care professional who, under contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier.\n\t\t“PPACA” means the Patient Protection and Affordable Care Act (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152), and as it may be further amended.\n\t\t“Preexisting condition exclusion” means a limitation or exclusion of benefits, including a denial of coverage, based on the fact that the condition was present before the effective date of coverage, or if the coverage is denied, the date of denial, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before the effective date of coverage. “Preexisting condition exclusion” also includes a condition identified as a result of a pre-enrollment questionnaire or physical examination given to an individual, or review of medical records relating to the pre-enrollment period.\n\t\t“Premium” means all moneys paid by an employer, eligible employee, or covered person as a condition of coverage from a health carrier, including fees and other contributions associated with the health benefit plan.\n\t\t“Preventive services” means (i) evidence-based items or services for which a rating of A or B is in effect in the recommendations of the U.S. Preventive Services Task Force with respect to the individual involved; (ii) immunizations for routine use in children, adolescents, and adults for which a recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is in effect with respect to the individual involved; (iii) evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration with respect to infants, children, and adolescents; and (iv) evidence-informed preventive care and screenings recommended in comprehensive guidelines supported by the Health Resources and Services Administration with respect to women. For purposes of this definition, a recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered in effect after it has been adopted by the Director of the Centers for Disease Control and Prevention, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention.\n\t\t“Primary care health care professional” means a health care professional designated by a covered person to supervise, coordinate, or provide initial care or continuing care to the covered person and who may be required by the health carrier to initiate a referral for specialty care and maintain supervision of health care services rendered to the covered person.\n\t\t“Rescission” means a cancellation or discontinuance of coverage under a health benefit plan that has a retroactive effect. “Rescission” does not include:\n\n1\n\nA cancellation or discontinuance of coverage under a health benefit plan if the cancellation or discontinuance of coverage has only a prospective effect, or the cancellation or discontinuance of coverage is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage; or2\n\nA cancellation or discontinuance of coverage when the health benefit plan covers active employees and, if applicable, dependents and those covered under continuation coverage provisions, if the employee pays no premiums for coverage after termination of employment and the cancellation or discontinuance of coverage is effective retroactively back to the date of termination of employment due to a delay in administrative recordkeeping.\n\t\t\t“Stabilize” means with respect to an emergency medical condition, to provide such medical treatment as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or, with respect to a pregnant woman, that the woman has delivered, including the placenta.\n\t\t\t“Student health insurance coverage” means a type of individual health insurance coverage that is provided pursuant to a written agreement between an institution of higher education, as defined by the Higher Education Act of 1965, and a health carrier and provided to students enrolled in that institution of higher education and their dependents, and that does not make health insurance coverage available other than in connection with enrollment as a student, or as a dependent of a student, in the institution of higher education, and does not condition eligibility for health insurance coverage on any health status-related factor related to a student or a dependent of the student.\n\t\t\t“Surgical or ancillary services” means professional services, including surgery, anesthesiology, pathology, radiology, or hospitalist services and laboratory services.\n\t\t\t“Wellness program” means a program offered by an employer that is designed to promote health or prevent disease.","order_by":null,"text":{"0":{"id":209573,"text":"As used this article, unless the context requires a different meaning:\n\t\t“Allowed amount” means the maximum portion of a billed charge a health carrier will pay, including any applicable cost-sharing requirements, for a covered service or item rendered by a participating provider or by a nonparticipating provider.\n\t\t“Balance bill” means a bill sent to an enrollee by an out-of-network provider for health care services provided to the enrollee after the provider’s billed amount is not fully reimbursed by the carrier, exclusive of applicable cost-sharing requirements.\n\t\t“Behavioral health crisis service provider” means a provider licensed by the Department of Behavioral Health and Developmental Services to provide mental health or substance abuse services as a provider of mobile crisis response, residential crisis stabilization, or a crisis receiving center.\n\t\t“Child” means a son, daughter, stepchild, adopted child, including a child placed for adoption, foster child, or any other child eligible for coverage under the health benefit plan.\n\t\t“Cost-sharing requirement” means an enrollee’s deductible, copayment amount, or coinsurance rate.\n\t\t“Covered benefits” or “benefits” means those health care services to which an individual is entitled under the terms of a health benefit plan.\n\t\t“Covered person” means a policyholder, subscriber, enrollee, participant, or other individual covered by a health benefit plan.\n\t\t“Dependent” means the spouse or child of an eligible employee, subject to the applicable terms of the policy, contract, or plan covering the eligible employee.\n\t\t“Emergency medical condition” means, regardless of the final diagnosis rendered to a covered person, a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (i) serious jeopardy to the mental or physical health of the individual, (ii) danger of serious impairment to bodily functions, (iii) serious dysfunction of any bodily organ or part, or (iv) in the case of a pregnant woman, serious jeopardy to the health of the fetus.\n\t\t“Emergency services” means with respect to an emergency medical condition (i) (a) a medical screening examination as required under \u00a7 1867 of the Social Security Act (42 U.S.C. \u00a7 1395dd) that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition, and (b) such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital, as are required under \u00a7 1867 of the Social Security Act (42 U.S.C. \u00a7 1395dd (e)(3)) to stabilize the patient and (ii) as it relates to any mental health services or substance abuse services, as those terms are defined in \u00a7 38.2-3412.1, rendered at a behavioral health crisis service provider (a) a behavioral health assessment that is within the capability of a behavioral health crisis service provider, including ancillary services routinely available to evaluate such emergency medical condition, and (b) such further examination and treatment, to the extent that they are within the capabilities of the staff and facilities available at the behavioral health crisis service provider, as are required so that the patient’s condition does not deteriorate.\n\t\t“ERISA” means the Employee Retirement Income Security Act of 1974.\n\t\t“Essential health benefits” include the following general categories and the items and services covered within the categories in accordance with regulations issued pursuant to the PPACA as of January 1, 2019: (i) ambulatory patient services; (ii) emergency services; (iii) hospitalization; (iv) laboratory services; (v) maternity and newborn care; (vi) mental health and substance abuse disorder services, including behavioral health treatment; (vii) pediatric services, including oral and vision care; (viii) prescription drugs; (ix) preventive and wellness services and chronic disease management; and (x) rehabilitative and habilitative services and devices.\n\t\t“Facility” means an institution providing health care related services or a health care setting, including hospitals and other licensed inpatient centers; ambulatory surgical or treatment centers; skilled nursing centers; residential treatment centers; diagnostic, laboratory, and imaging centers; and rehabilitation and other therapeutic health settings.\n\t\t“Genetic information” means, with respect to an individual, information about: (i) the individual’s genetic tests; (ii) the genetic tests of the individual’s family members; (iii) the manifestation of a disease or disorder in family members of the individual; or (iv) any request for, or receipt of, genetic services, or participation in clinical research that includes genetic services, by the individual or any family member of the individual. “Genetic information” does not include information about the sex or age of any individual. As used in this definition, “family member” includes a first-degree, second-degree, third-degree, or fourth-degree relative of a covered person.\n\t\t“Genetic services” means (i) a genetic test; (ii) genetic counseling, including obtaining, interpreting, or assessing genetic information; or (iii) genetic education.\n\t\t“Genetic test” means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if the analysis detects genotypes, mutations, or chromosomal changes. “Genetic test” does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition.\n\t\t“Grandfathered plan” means coverage provided by a health carrier to (i) a small employer on March 23, 2010, or (ii) an individual that was enrolled on March 23, 2010, including any extension of coverage to an individual who becomes a dependent of a grandfathered enrollee after March 23, 2010, for as long as such plan maintains that status in accordance with federal law.\n\t\t“Group health insurance coverage” means health insurance coverage offered in connection with a group health benefit plan.\n\t\t“Group health plan” means an employee welfare benefit plan as defined in \u00a7 3(1) of ERISA to the extent that the plan provides medical care within the meaning of \u00a7 733(a) of ERISA to employees, including both current and former employees, or their dependents as defined under the terms of the plan directly or through insurance, reimbursement, or otherwise.\n\t\t“Health benefit plan” means a policy, contract, certificate, or agreement offered by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. “Health benefit plan” includes short-term and catastrophic health insurance policies, and a policy that pays on a cost-incurred basis, except as otherwise specifically exempted in this definition. “Health benefit plan” does not include the “excepted benefits” as defined in \u00a7 38.2-3431.\n\t\t“Health care professional” means a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with state law.\n\t\t“Health care provider” or “provider” means a health care professional or facility.\n\t\t“Health care services” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.\n\t\t“Health carrier” means an entity subject to the insurance laws and regulations of the Commonwealth and subject to the jurisdiction of the Commission that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an insurer licensed to sell accident and sickness insurance, a health maintenance organization, a health services plan, or any other entity providing a plan of health insurance, health benefits, or health care services.\n\t\t“Health maintenance organization” means a person licensed pursuant to Chapter 43 (\u00a7 38.2-4300 et seq.).\n\t\t“Health status-related factor” means any of the following factors: health status; medical condition, including physical and mental illnesses; claims experience; receipt of health care services; medical history; genetic information; evidence of insurability, including conditions arising out of acts of domestic violence; disability; or any other health status-related factor as determined by federal regulation.\n\t\t“Individual health insurance coverage” means health insurance coverage offered to individuals in the individual market, which includes a health benefit plan provided to individuals through a trust arrangement, association, or other discretionary group that is not an employer plan, but does not include coverage defined as “excepted benefits” in \u00a7 38.2-3431 or short-term limited duration insurance. Student health insurance coverage shall be considered a type of individual health insurance coverage.\n\t\t“Individual market” means the market for health insurance coverage offered to individuals other than in connection with a group health plan.\n\t\t“In-network” or “participating” means a provider that has contracted with a carrier or a carrier’s contractor or subcontractor to provide health care services to enrollees and be reimbursed by the carrier at a contracted rate as payment in full for the health care services, including applicable cost-sharing requirements.\n\t\t“Managed care plan” means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with, or employed by the health carrier.\n\t\t“Network” means the group of participating providers providing services to a managed care plan.\n\t\t“Nonprofit data services organization” means the nonprofit organization with which the Commissioner of Health negotiates and enters into contracts or agreements for the compilation, storage, analysis, and evaluation of data submitted by data suppliers pursuant to \u00a7 32.1-276.4.\n\t\t“Offer to pay” or “payment notification” means a claim that has been adjudicated and paid by a carrier or determined by a carrier to be payable by an enrollee to an out-of-network provider for services described in subsection A of \u00a7 38.2-3445.01.\n\t\t“Open enrollment” means, with respect to individual health insurance coverage, the period of time during which any individual has the opportunity to apply for coverage under a health benefit plan offered by a health carrier and must be accepted for coverage under the plan without regard to a preexisting condition exclusion.\n\t\t“Out-of-network” or “nonparticipating” means a provider that has not contracted with a carrier or a carrier’s contractor or subcontractor to provide health care services to enrollees.\n\t\t“Out-of-pocket maximum” or “maximum out-of-pocket” means the maximum amount an enrollee is required to pay in the form of cost-sharing requirements for covered benefits in a plan year, after which the carrier covers the entirety of the allowed amount of covered benefits under the contract of coverage.\n\t\t“Participating health care professional” means a health care professional who, under contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier.\n\t\t“PPACA” means the Patient Protection and Affordable Care Act (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152), and as it may be further amended.\n\t\t“Preexisting condition exclusion” means a limitation or exclusion of benefits, including a denial of coverage, based on the fact that the condition was present before the effective date of coverage, or if the coverage is denied, the date of denial, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before the effective date of coverage. “Preexisting condition exclusion” also includes a condition identified as a result of a pre-enrollment questionnaire or physical examination given to an individual, or review of medical records relating to the pre-enrollment period.\n\t\t“Premium” means all moneys paid by an employer, eligible employee, or covered person as a condition of coverage from a health carrier, including fees and other contributions associated with the health benefit plan.\n\t\t“Preventive services” means (i) evidence-based items or services for which a rating of A or B is in effect in the recommendations of the U.S. Preventive Services Task Force with respect to the individual involved; (ii) immunizations for routine use in children, adolescents, and adults for which a recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is in effect with respect to the individual involved; (iii) evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration with respect to infants, children, and adolescents; and (iv) evidence-informed preventive care and screenings recommended in comprehensive guidelines supported by the Health Resources and Services Administration with respect to women. For purposes of this definition, a recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered in effect after it has been adopted by the Director of the Centers for Disease Control and Prevention, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention.\n\t\t“Primary care health care professional” means a health care professional designated by a covered person to supervise, coordinate, or provide initial care or continuing care to the covered person and who may be required by the health carrier to initiate a referral for specialty care and maintain supervision of health care services rendered to the covered person.\n\t\t“Rescission” means a cancellation or discontinuance of coverage under a health benefit plan that has a retroactive effect. “Rescission” does not include:","type":"section","prefixes":[""],"prefix":"","entire_prefix":"","prefix_anchor":"","level":1,"next_prefix":"1"},"1":{"id":209574,"text":"A cancellation or discontinuance of coverage under a health benefit plan if the cancellation or discontinuance of coverage has only a prospective effect, or the cancellation or discontinuance of coverage is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage; or","type":"section","prefixes":["1"],"prefix":"1","entire_prefix":"1","prefix_anchor":"1","level":1,"prior_prefix":"","next_prefix":"2"},"2":{"id":209575,"text":"A cancellation or discontinuance of coverage when the health benefit plan covers active employees and, if applicable, dependents and those covered under continuation coverage provisions, if the employee pays no premiums for coverage after termination of employment and the cancellation or discontinuance of coverage is effective retroactively back to the date of termination of employment due to a delay in administrative recordkeeping.\n\t\t\t“Stabilize” means with respect to an emergency medical condition, to provide such medical treatment as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or, with respect to a pregnant woman, that the woman has delivered, including the placenta.\n\t\t\t“Student health insurance coverage” means a type of individual health insurance coverage that is provided pursuant to a written agreement between an institution of higher education, as defined by the Higher Education Act of 1965, and a health carrier and provided to students enrolled in that institution of higher education and their dependents, and that does not make health insurance coverage available other than in connection with enrollment as a student, or as a dependent of a student, in the institution of higher education, and does not condition eligibility for health insurance coverage on any health status-related factor related to a student or a dependent of the student.\n\t\t\t“Surgical or ancillary services” means professional services, including surgery, anesthesiology, pathology, radiology, or hospitalist services and laboratory services.\n\t\t\t“Wellness program” means a program offered by an employer that is designed to promote health or prevent disease.","type":"section","prefixes":["2"],"prefix":"2","entire_prefix":"2","prefix_anchor":"2","level":1,"prior_prefix":"1"}},"ancestry":[{"id":13819,"edition_id":1,"name":"Federal Market Reforms","identifier":"6","label":"article","depth":3,"order_by":1,"parent_id":12993,"metadata":{},"date_created":"2026-06-26 03:45:59","date_modified":"2026-06-26 03:45:59","permalink":{"id":215457,"object_type":"structure","relational_id":13819,"identifier":"6","token":"38.2\/34\/6","url":"\/38.2\/34\/6\/","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":57210,"structure_id":13819,"section_number":"38.2-3438","catch_line":"Definitions","url":"\/38.2-3438\/","token":"38.2\/34\/6\/38.2-3438","metadata":false},{"id":55902,"structure_id":13819,"section_number":"38.2-3439","catch_line":"Dependent coverage for individuals to age 26","url":"\/38.2-3439\/","token":"38.2\/34\/6\/38.2-3439","metadata":false},{"id":59514,"structure_id":13819,"section_number":"38.2-3440","catch_line":"Lifetime and annual limits","url":"\/38.2-3440\/","token":"38.2\/34\/6\/38.2-3440","metadata":false},{"id":74720,"structure_id":13819,"section_number":"38.2-3441","catch_line":"Rescissions","url":"\/38.2-3441\/","token":"38.2\/34\/6\/38.2-3441","metadata":false},{"id":81548,"structure_id":13819,"section_number":"38.2-3442","catch_line":"Preventive services","url":"\/38.2-3442\/","token":"38.2\/34\/6\/38.2-3442","metadata":false},{"id":54833,"structure_id":13819,"section_number":"38.2-3443","catch_line":"Choice of a health care professional","url":"\/38.2-3443\/","token":"38.2\/34\/6\/38.2-3443","metadata":false},{"id":68187,"structure_id":13819,"section_number":"38.2-3444","catch_line":"Preexisting condition exclusions","url":"\/38.2-3444\/","token":"38.2\/34\/6\/38.2-3444","metadata":false},{"id":60836,"structure_id":13819,"section_number":"38.2-3445","catch_line":"Patient access to emergency services","url":"\/38.2-3445\/","token":"38.2\/34\/6\/38.2-3445","metadata":false},{"id":57195,"structure_id":13819,"section_number":"38.2-3445.01","catch_line":"Balance billing for certain services; 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reporting requirements","url":"\/38.2-3445.2\/","token":"38.2\/34\/6\/38.2-3445.2","metadata":false},{"id":86937,"structure_id":13819,"section_number":"38.2-3446","catch_line":"Applicability of federal law","url":"\/38.2-3446\/","token":"38.2\/34\/6\/38.2-3446","metadata":false},{"id":66501,"structure_id":13819,"section_number":"38.2-3447","catch_line":"(Effective January 1, 2026) Restrictions relating to premium rates","url":"\/38.2-3447\/","token":"38.2\/34\/6\/38.2-3447","metadata":false},{"id":79799,"structure_id":13819,"section_number":"38.2-3448","catch_line":"Guaranteed availability","url":"\/38.2-3448\/","token":"38.2\/34\/6\/38.2-3448","metadata":false},{"id":78815,"structure_id":13819,"section_number":"38.2-3449","catch_line":"Prohibiting discrimination based on health status","url":"\/38.2-3449\/","token":"38.2\/34\/6\/38.2-3449","metadata":false},{"id":67706,"structure_id":13819,"section_number":"38.2-3449.1","catch_line":"Prohibited discrimination based on gender identity or status as a transgender individual","url":"\/38.2-3449.1\/","token":"38.2\/34\/6\/38.2-3449.1","metadata":false},{"id":64622,"structure_id":13819,"section_number":"38.2-3450","catch_line":"Genetic information and testing","url":"\/38.2-3450\/","token":"38.2\/34\/6\/38.2-3450","metadata":false},{"id":83154,"structure_id":13819,"section_number":"38.2-3451","catch_line":"Essential health benefits","url":"\/38.2-3451\/","token":"38.2\/34\/6\/38.2-3451","metadata":false},{"id":76537,"structure_id":13819,"section_number":"38.2-3452","catch_line":"Waiting periods","url":"\/38.2-3452\/","token":"38.2\/34\/6\/38.2-3452","metadata":false},{"id":86395,"structure_id":13819,"section_number":"38.2-3453","catch_line":"Clinical trials","url":"\/38.2-3453\/","token":"38.2\/34\/6\/38.2-3453","metadata":false},{"id":81951,"structure_id":13819,"section_number":"38.2-3454","catch_line":"Wellness programs","url":"\/38.2-3454\/","token":"38.2\/34\/6\/38.2-3454","metadata":false},{"id":84250,"structure_id":13819,"section_number":"38.2-3454.1","catch_line":"Renewal of health benefit plans; special exception","url":"\/38.2-3454.1\/","token":"38.2\/34\/6\/38.2-3454.1","metadata":false}],"next_section":{"id":55902,"structure_id":13819,"section_number":"38.2-3439","catch_line":"Dependent coverage for individuals to age 26","url":"\/38.2-3439\/","token":"38.2\/34\/6\/38.2-3439","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3438\/","history_text":"

This law was first created in 2011. The record of its establishment is cataloged in chapter 882<\/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 4 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 2013, chapter 751<\/a>; in 2014, chapter 814<\/a>; in 2020, chapters 1080<\/a>, 1081<\/a>, and 1160<\/a>; in 2024, chapters 199<\/a> and 360<\/a>.<\/p>","references":[{"id":76816,"section_number":"32.1-137.010","catch_line":"Financial assistance; payment plans","order_by":null,"url":"\/32.1-137.010\/"},{"id":80679,"section_number":"32.1-137.2","catch_line":"Certification of quality assurance; application; issuance; denial; renewal","order_by":null,"url":"\/32.1-137.2\/"},{"id":84333,"section_number":"38.2-3406.1","catch_line":"Application of requirements that policies offered by small employers include state-mandated health benefits","order_by":null,"url":"\/38.2-3406.1\/"},{"id":67972,"section_number":"38.2-3406.2","catch_line":"Capped benefits under insurance policies and contracts","order_by":null,"url":"\/38.2-3406.2\/"},{"id":82372,"section_number":"38.2-3407.11","catch_line":"Access to obstetrician-gynecologists","order_by":null,"url":"\/38.2-3407.11\/"},{"id":73491,"section_number":"38.2-3407.15:4","catch_line":"Limit on copayment for prescription drugs; permitted disclosures","order_by":null,"url":"\/38.2-3407.15_4\/"},{"id":57527,"section_number":"38.2-3407.15:5","catch_line":"Limit on cost-sharing payments for prescription insulin drugs","order_by":null,"url":"\/38.2-3407.15_5\/"},{"id":80337,"section_number":"38.2-3407.15:6","catch_line":"Prescription drug price transparency","order_by":null,"url":"\/38.2-3407.15_6\/"},{"id":55530,"section_number":"38.2-3407.17:1","catch_line":"Payment and reimbursement practices for dental services; network access","order_by":null,"url":"\/38.2-3407.17_1\/"},{"id":57407,"section_number":"38.2-3407.21","catch_line":"Short-term limited-duration medical plans","order_by":null,"url":"\/38.2-3407.21\/"},{"id":71629,"section_number":"38.2-3411.1","catch_line":"Coverage for child health supervision services","order_by":null,"url":"\/38.2-3411.1\/"},{"id":84153,"section_number":"38.2-3412.1","catch_line":"Coverage for mental health and substance use disorders","order_by":null,"url":"\/38.2-3412.1\/"},{"id":59007,"section_number":"38.2-3417","catch_line":"Deductibles and coinsurance options required","order_by":null,"url":"\/38.2-3417\/"},{"id":87401,"section_number":"38.2-3418.5","catch_line":"Coverage for early intervention services","order_by":null,"url":"\/38.2-3418.5\/"},{"id":63576,"section_number":"38.2-3418.8","catch_line":"Coverage for clinical trials for treatment studies on cancer","order_by":null,"url":"\/38.2-3418.8\/"},{"id":86672,"section_number":"38.2-3430.3","catch_line":"Guaranteed availability of individual health insurance coverage to certain individuals with prior group coverage","order_by":null,"url":"\/38.2-3430.3\/"},{"id":86404,"section_number":"38.2-3431","catch_line":"Application of article; definitions","order_by":null,"url":"\/38.2-3431\/"},{"id":85868,"section_number":"38.2-3432.2","catch_line":"Availability","order_by":null,"url":"\/38.2-3432.2\/"},{"id":63783,"section_number":"38.2-3432.3","catch_line":"Limitation on preexisting condition exclusion period","order_by":null,"url":"\/38.2-3432.3\/"},{"id":77749,"section_number":"38.2-3436","catch_line":"Eligibility to enroll","order_by":null,"url":"\/38.2-3436\/"},{"id":68187,"section_number":"38.2-3444","catch_line":"Preexisting condition exclusions","order_by":null,"url":"\/38.2-3444\/"},{"id":66501,"section_number":"38.2-3447","catch_line":"(Effective January 1, 2026) Restrictions relating to premium rates","order_by":null,"url":"\/38.2-3447\/"},{"id":64550,"section_number":"38.2-3455","catch_line":"Definitions","order_by":null,"url":"\/38.2-3455\/"},{"id":60000,"section_number":"38.2-3465","catch_line":"Definitions","order_by":null,"url":"\/38.2-3465\/"},{"id":81706,"section_number":"38.2-3500","catch_line":"Form of policy","order_by":null,"url":"\/38.2-3500\/"},{"id":54330,"section_number":"38.2-3501","catch_line":"Policy forms; powers of Commission","order_by":null,"url":"\/38.2-3501\/"},{"id":67765,"section_number":"38.2-3503","catch_line":"Required accident and sickness policy provisions","order_by":null,"url":"\/38.2-3503\/"},{"id":74003,"section_number":"38.2-3516","catch_line":"Purpose","order_by":null,"url":"\/38.2-3516\/"},{"id":62169,"section_number":"38.2-3520","catch_line":"Coverage of preexisting conditions","order_by":null,"url":"\/38.2-3520\/"},{"id":83222,"section_number":"38.2-3521.1","catch_line":"Group accident and sickness insurance definitions","order_by":null,"url":"\/38.2-3521.1\/"},{"id":67462,"section_number":"38.2-3522.1","catch_line":"Limits of group accident and sickness insurance","order_by":null,"url":"\/38.2-3522.1\/"},{"id":84584,"section_number":"38.2-3523.4","catch_line":"Minimum number of persons covered","order_by":null,"url":"\/38.2-3523.4\/"},{"id":78059,"section_number":"38.2-3525","catch_line":"Group accident and sickness insurance coverages of spouses, dependent children or other persons","order_by":null,"url":"\/38.2-3525\/"},{"id":82316,"section_number":"38.2-3540.2","catch_line":"Employee wellness program","order_by":null,"url":"\/38.2-3540.2\/"},{"id":76670,"section_number":"38.2-3551","catch_line":"Definitions","order_by":null,"url":"\/38.2-3551\/"},{"id":59432,"section_number":"38.2-4109","catch_line":"Organization of domestic society on or after October 1, 1986","order_by":null,"url":"\/38.2-4109\/"},{"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\/"},{"id":79585,"section_number":"38.2-4312.3","catch_line":"Patient access to emergency services","order_by":null,"url":"\/38.2-4312.3\/"},{"id":80488,"section_number":"38.2-508.1","catch_line":"Unfair discrimination; members of the armed forces","order_by":null,"url":"\/38.2-508.1\/"},{"id":77794,"section_number":"38.2-508.5","catch_line":"Re-underwriting individual under existing group or individual accident and sickness insurance policy prohibited; exceptions","order_by":null,"url":"\/38.2-508.5\/"},{"id":76403,"section_number":"38.2-6600","catch_line":"Definitions","order_by":null,"url":"\/38.2-6600\/"},{"id":78764,"section_number":"59.1-611","catch_line":"(Effective July 1, 2026) Definitions","order_by":null,"url":"\/59.1-611\/"}],"refers_to":[{"id":56739,"section_number":"32.1-276.4","catch_line":"Agreements for certain data services","order_by":null,"url":"\/32.1-276.4\/"},{"id":84153,"section_number":"38.2-3412.1","catch_line":"Coverage for mental health and substance use disorders","order_by":null,"url":"\/38.2-3412.1\/"},{"id":86404,"section_number":"38.2-3431","catch_line":"Application of article; definitions","order_by":null,"url":"\/38.2-3431\/"},{"id":57195,"section_number":"38.2-3445.01","catch_line":"Balance billing for certain services; 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As used this article, unless the context requires a different meaning:\n\t\t“Allowed amount<\/span>” means the maximum portion of a billed charge a health carrier<\/span> will pay, including any applicable cost-sharing requirements<\/span>, for a covered service or item rendered by a participating provider or by a nonparticipating<\/span> provider.\n\t\t“Balance bill<\/span>” means a bill sent to an enrollee by an out-of-network<\/span><\/span> provider for health care services<\/span> provided to the enrollee after the provider’s billed amount is not fully reimbursed by the carrier, exclusive of applicable cost-sharing requirements<\/span>.\n\t\t“Behavioral health crisis service provider<\/span>” means a provider licensed by the Department of Behavioral Health and Developmental Services to provide mental health or substance abuse services as a provider of mobile crisis response, residential crisis stabilization, or a crisis receiving center.\n\t\t“Child<\/span>” means a son, daughter, stepchild, adopted child<\/span>, including a child<\/span> placed for adoption, foster child<\/span>, or any other child<\/span> eligible for coverage under the health benefit plan<\/span>.\n\t\t“Cost-sharing requirement<\/span>” means an enrollee’s deductible, copayment amount, or coinsurance rate<\/span>.\n\t\t“Covered benefits<\/span>” or “benefits” means those health care services<\/span> to which an individual is entitled under the terms of a health benefit plan<\/span>.\n\t\t“Covered person<\/span>” means a policyholder, subscriber, enrollee, participant, or other individual covered by a health benefit plan<\/span>.\n\t\t“Dependent<\/span>” means the spouse or child<\/span> of an eligible employee, subject to the applicable terms of the policy, contract<\/span>, or plan covering the eligible employee.\n\t\t“Emergency medical condition” means, regardless of the final diagnosis rendered to a covered person<\/span>, a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (i) serious jeopardy to the mental or physical health of the individual, (ii) danger of serious impairment to bodily functions, (iii) serious dysfunction of any bodily organ or part, or (iv) in the case of a pregnant woman, serious jeopardy to the health of the fetus.\n\t\t“Emergency services<\/span>” means with respect to an emergency medical condition (i) (a) a medical screening examination as required under \u00a7 1867 of the Social Security Act (42 U.S.C. \u00a7 1395dd) that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition, and (b) such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital, as are required under \u00a7 1867 of the Social Security Act (42 U.S.C. \u00a7 1395dd (e)(3)) to stabilize<\/span> the patient and (ii) as it relates to any mental health services or substance abuse services, as those terms are defined in \u00a7 38.2-3412.1<\/a>, rendered at a behavioral health crisis service provider<\/span> (a) a behavioral health assessment that is within the capability of a behavioral health crisis service provider<\/span>, including ancillary services routinely available to evaluate such emergency medical condition, and (b) such further examination and treatment, to the extent that they are within the capabilities of the staff and facilities available at the behavioral health crisis service provider<\/span>, as are required so that the patient’s condition does not deteriorate.\n\t\t“ERISA<\/span>” means the Employee Retirement Income Security Act of 1974.\n\t\t“Essential health benefits” include the following general categories and the items and services covered within the categories in accordance with regulations issued pursuant to the PPACA<\/span> as of January 1, 2019: (i) ambulatory patient services; (ii) emergency services<\/span>; (iii) hospitalization; (iv) laboratory services; (v) maternity and newborn care; (vi) mental health and substance abuse disorder services, including behavioral health treatment; (vii) pediatric services, including oral and vision care; (viii) prescription drugs; (ix) preventive and wellness services and chronic disease management; and (x) rehabilitative and habilitative services and devices.\n\t\t“Facility<\/span>” means an institution providing health care related services or a health care setting, including hospitals and other licensed inpatient centers; ambulatory surgical or treatment centers; skilled nursing centers; residential treatment centers; diagnostic, laboratory, and imaging centers; and rehabilitation and other therapeutic health settings.\n\t\t“Genetic information<\/span>” means, with respect to an individual, information about: (i) the individual’s genetic tests<\/span>; (ii) the genetic tests<\/span> of the individual’s family members<\/span>; (iii) the manifestation of a disease or disorder in family members<\/span> of the individual; or (iv) any request for, or receipt of, genetic services<\/span>, or participation in clinical research that includes genetic services<\/span>, by the individual or any family member<\/span> of the individual. “Genetic information<\/span>” does not include information about the sex or age of any individual. As used in this definition, “family member<\/span>” includes a first-degree, second-degree, third-degree, or fourth-degree relative of a covered person<\/span>.\n\t\t“Genetic services<\/span>” means (i) a genetic test<\/span>; (ii) genetic counseling, including obtaining, interpreting, or assessing genetic information<\/span>; or (iii) genetic education.\n\t\t“Genetic test<\/span>” means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if the analysis detects genotypes, mutations, or chromosomal changes. “Genetic test<\/span>” does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition.\n\t\t“Grandfathered plan<\/span>” means coverage provided by a health carrier<\/span> to (i) a small employer on March 23, 2010, or (ii) an individual that was enrolled on March 23, 2010, including any extension of coverage to an individual who becomes a dependent<\/span> of a grandfathered enrollee after March 23, 2010, for as long as such plan maintains that status in accordance with federal law<\/span>.\n\t\t“Group health insurance coverage<\/span>” means health insurance coverage offered in connection with a group health benefit plan<\/span>.\n\t\t“Group health plan<\/span>” means an employee welfare benefit plan as defined in \u00a7 3(1) of ERISA<\/span> to the extent that the plan provides medical care within the meaning of \u00a7 733(a) of ERISA<\/span> to employees, including both current and former employees, or their dependents<\/span> as defined under the terms of the plan directly or through insurance, reimbursement, or otherwise.\n\t\t“Health benefit plan<\/span>” means a policy, contract<\/span>, certificate, or agreement offered by a health carrier<\/span> to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services<\/span>. “Health benefit plan<\/span>” includes short-term and catastrophic health insurance policies<\/span>, and a policy that pays on a cost-incurred basis, except as otherwise specifically exempted in this definition. “Health benefit plan<\/span>” does not include the “excepted benefits<\/span>” as defined in \u00a7 38.2-3431<\/a>.\n\t\t“Health care professional<\/span>” means a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services<\/span> consistent with state<\/span> law<\/span>.\n\t\t“Health care provider<\/span>” or “provider” means a health care professional<\/span> or facility<\/span>.\n\t\t“Health care services<\/span>” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.\n\t\t“Health carrier<\/span>” means an entity subject to the insurance laws<\/span> and regulations of the Commonwealth and subject to the jurisdiction<\/span> of the Commission<\/span> that contracts<\/span> or offers to contract<\/span> to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services<\/span>, including an insurer<\/span> licensed to sell accident and sickness insurance, a health maintenance organization<\/span>, a health services plan<\/span>, or any other entity providing a plan of health insurance, health benefits, or health care services<\/span>.\n\t\t“Health maintenance organization<\/span>” means a person licensed pursuant to Chapter 43 (\u00a7 38.2-4300<\/a> et seq.).\n\t\t“Health status-related factor<\/span>” means any of the following factors: health status; medical condition, including physical and mental illnesses; claims experience; receipt of health care services<\/span>; medical history; genetic information<\/span>; evidence<\/span> of insurability, including conditions arising out of acts of domestic violence; disability; or any other health status-related factor<\/span> as determined by federal regulation.\n\t\t“Individual health insurance coverage<\/span>” means health insurance coverage offered to individuals in the individual market<\/span>, which includes a health benefit plan<\/span> provided to individuals through a trust arrangement, association, or other discretionary group that is not an employer plan, but does not include coverage defined as “excepted benefits<\/span>” in \u00a7 38.2-3431<\/a> or short-term limited duration insurance. Student health insurance coverage<\/span> shall be considered a type of individual health insurance coverage<\/span>.\n\t\t“Individual market<\/span>” means the market for health insurance coverage offered to individuals other than in connection with a group health plan<\/span>.\n\t\t“In-network<\/span><\/span>” or “participating” means a provider that has contracted with a carrier or a carrier’s contractor or subcontractor to provide health care services<\/span> to enrollees and be reimbursed by the carrier at a contracted rate<\/span> as payment in full for the health care services<\/span>, including applicable cost-sharing requirements<\/span>.\n\t\t“Managed care plan<\/span>” means a health benefit plan<\/span> that either requires a covered person<\/span> to use, or creates incentives, including financial incentives, for a covered person<\/span> to use health care providers<\/span> managed, owned, under contract<\/span> with, or employed by the health carrier<\/span>.\n\t\t“Network<\/span>” means the group of participating providers providing services to a managed care plan<\/span>.\n\t\t“Nonprofit data services organization<\/span>” means the nonprofit organization with which the Commissioner<\/span> of Health negotiates and enters into contracts<\/span> or agreements for the compilation, storage, analysis, and evaluation of data submitted by data suppliers pursuant to \u00a7 32.1-276.4<\/a>.\n\t\t“Offer to pay<\/span>” or “payment notification<\/span>” means a claim that has been adjudicated and paid by a carrier or determined by a carrier to be payable by an enrollee to an out-of-network<\/span><\/span> provider for services described in subsection A of \u00a7 38.2-3445.01<\/a>.\n\t\t“Open enrollment” means, with respect to individual health insurance coverage<\/span>, the period of time during which any individual has the opportunity to apply for coverage under a health benefit plan<\/span> offered by a health carrier<\/span> and must be accepted for coverage under the plan without regard to a preexisting condition exclusion<\/span>.\n\t\t“Out-of-network<\/span><\/span>” or “nonparticipating<\/span>” means a provider that has not contracted with a carrier or a carrier’s contractor or subcontractor to provide health care services<\/span> to enrollees.\n\t\t“Out-of-pocket maximum<\/span>” or “maximum out-of-pocket<\/span>” means the maximum amount an enrollee is required to pay in the form of cost-sharing requirements<\/span> for covered benefits<\/span> in a plan year, after which the carrier covers the entirety of the allowed amount<\/span> of covered benefits<\/span> under the contract<\/span> of coverage.\n\t\t“Participating health care professional<\/span><\/span>” means a health care professional<\/span> who, under contract<\/span> with the health carrier<\/span> or with its contractor or subcontractor, has agreed to provide health care services<\/span> to covered persons<\/span> with an expectation of receiving payments, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier<\/span>.\n\t\t“PPACA<\/span>” means the Patient Protection and Affordable Care Act (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152), and as it may be further amended.\n\t\t“Preexisting condition exclusion<\/span>” means a limitation or exclusion of benefits, including a denial of coverage, based on the fact<\/span> that the condition was present before the effective date of coverage, or if the coverage is denied, the date of denial, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before the effective date of coverage. “Preexisting condition exclusion<\/span>” also includes a condition identified as a result of a pre-enrollment questionnaire or physical examination given to an individual, or review of medical records relating to the pre-enrollment period.\n\t\t“Premium<\/span>” means all moneys paid by an employer, eligible employee, or covered person<\/span> as a condition of coverage from a health carrier<\/span>, including fees and other contributions associated with the health benefit plan<\/span>.\n\t\t“Preventive services<\/span>” means (i) evidence<\/span>-based items or services for which a rating of A or B is in effect in the recommendations of the U.S. Preventive Services<\/span> Task Force with respect to the individual involved; (ii) immunizations for routine use in children, adolescents, and adults for which a recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is in effect with respect to the individual involved; (iii) evidence<\/span>-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration with respect to infants, children, and adolescents; and (iv) evidence<\/span>-informed preventive care and screenings recommended in comprehensive guidelines supported by the Health Resources and Services Administration with respect to women. For purposes of this definition, a recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered in effect after it has been adopted by the Director of the Centers for Disease Control and Prevention, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedules<\/span> of the Centers for Disease Control and Prevention.\n\t\t“Primary care health care professional<\/span><\/span>” means a health care professional<\/span> designated by a covered person<\/span> to supervise, coordinate, or provide initial care or continuing care to the covered person<\/span> and who may be required by the health carrier<\/span> to initiate a referral for specialty care and maintain supervision of health care services<\/span> rendered to the covered person<\/span>.\n\t\t“Rescission<\/span>” means a cancellation or discontinuance of coverage under a health benefit plan<\/span> that has a retroactive effect. “Rescission<\/span>” does not include:<\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> A cancellation or discontinuance of coverage under a health benefit plan<\/span> if the cancellation or discontinuance of coverage has only a prospective effect, or the cancellation or discontinuance of coverage is effective retroactively to the extent it is attributable to a failure to timely pay required premiums<\/span> or contributions towards the cost of coverage; or <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> A cancellation or discontinuance of coverage when the health benefit plan<\/span> covers active employees and, if applicable, dependents<\/span> and those covered under continuation coverage provisions, if the employee pays no premiums<\/span> for coverage after termination of employment and the cancellation or discontinuance of coverage is effective retroactively back to the date of termination of employment due to a delay in administrative recordkeeping.\n\t\t\t“Stabilize<\/span>” means with respect to an emergency medical condition, to provide such medical treatment as may be necessary to assure, within reasonable medical probability, that no material<\/span> deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility<\/span>, or, with respect to a pregnant woman, that the woman has delivered, including the placenta.\n\t\t\t“Student health insurance coverage<\/span>” means a type of individual health insurance coverage<\/span> that is provided pursuant to a written agreement between an institution of higher education, as defined by the Higher Education Act of 1965, and a health carrier<\/span> and provided to students enrolled in that institution of higher education and their dependents<\/span>, and that does not make health insurance coverage available other than in connection with enrollment as a student, or as a dependent<\/span> of a student, in the institution of higher education, and does not condition eligibility for health insurance coverage on any health status-related factor<\/span> related to a student or a dependent<\/span> of the student.\n\t\t\t“Surgical or ancillary services<\/span>” means professional services, including surgery, anesthesiology, pathology, radiology, or hospitalist services and laboratory services.\n\t\t\t“Wellness program<\/span>” means a program offered by an employer that is designed to promote health or prevent disease. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nDEFINITIONS (\u00a7 38.2-3438)\n\nAs used this article, unless the context requires a different meaning:\n\t\t“Allowed amount” means the maximum portion of a billed charge a\nhealth carrier will pay, including any applicable cost-sharing requirements, for\na covered service or item rendered by a participating provider or by a\nnonparticipating provider.\n\t\t“Balance bill” means a bill sent to an enrollee by an\nout-of-network provider for health care services provided to the enrollee after\nthe provider’s billed amount is not fully reimbursed by the carrier,\nexclusive of applicable cost-sharing requirements.\n\t\t“Behavioral health crisis service provider” means a provider\nlicensed by the Department of Behavioral Health and Developmental Services to\nprovide mental health or substance abuse services as a provider of mobile crisis\nresponse, residential crisis stabilization, or a crisis receiving center.\n\t\t“Child” means a son, daughter, stepchild, adopted child, including\na child placed for adoption, foster child, or any other child eligible for\ncoverage under the health benefit plan.\n\t\t“Cost-sharing requirement” means an enrollee’s deductible,\ncopayment amount, or coinsurance rate.\n\t\t“Covered benefits” or “benefits” means those health\ncare services to which an individual is entitled under the terms of a health\nbenefit plan.\n\t\t“Covered person” means a policyholder, subscriber, enrollee,\nparticipant, or other individual covered by a health benefit plan.\n\t\t“Dependent” means the spouse or child of an eligible employee,\nsubject to the applicable terms of the policy, contract, or plan covering the\neligible employee.\n\t\t“Emergency medical condition” means, regardless of the final\ndiagnosis rendered to a covered person, a medical condition manifesting itself\nby acute symptoms of sufficient severity, including severe pain, so that a\nprudent layperson, who possesses an average knowledge of health and medicine,\ncould reasonably expect the absence of immediate medical attention to result in\n(i) serious jeopardy to the mental or physical health of the individual, (ii)\ndanger of serious impairment to bodily functions, (iii) serious dysfunction of\nany bodily organ or part, or (iv) in the case of a pregnant woman, serious\njeopardy to the health of the fetus.\n\t\t“Emergency services” means with respect to an emergency medical\ncondition (i) (a) a medical screening examination as required under \u00a7 1867 of\nthe Social Security Act (42 U.S.C. \u00a7 1395dd) that is within the capability of\nthe emergency department of a hospital, including ancillary services routinely\navailable to the emergency department to evaluate such emergency medical\ncondition, and (b) such further medical examination and treatment, to the extent\nthey are within the capabilities of the staff and facilities available at the\nhospital, as are required under \u00a7 1867 of the Social Security Act (42 U.S.C. \u00a7\n1395dd (e)(3)) to stabilize the patient and (ii) as it relates to any mental\nhealth services or substance abuse services, as those terms are defined in \u00a7\n38.2-3412.1, rendered at a behavioral health crisis service provider (a) a\nbehavioral health assessment that is within the capability of a behavioral\nhealth crisis service provider, including ancillary services routinely available\nto evaluate such emergency medical condition, and (b) such further examination\nand treatment, to the extent that they are within the capabilities of the staff\nand facilities available at the behavioral health crisis service provider, as\nare required so that the patient’s condition does not deteriorate.\n\t\t“ERISA” means the Employee Retirement Income Security Act of 1974.\n\t\t“Essential health benefits” include the following general\ncategories and the items and services covered within the categories in\naccordance with regulations issued pursuant to the PPACA as of January 1, 2019:\n(i) ambulatory patient services; (ii) emergency services; (iii) hospitalization;\n(iv) laboratory services; (v) maternity and newborn care; (vi) mental health and\nsubstance abuse disorder services, including behavioral health treatment; (vii)\npediatric services, including oral and vision care; (viii) prescription drugs;\n(ix) preventive and wellness services and chronic disease management; and (x)\nrehabilitative and habilitative services and devices.\n\t\t“Facility” means an institution providing health care related\nservices or a health care setting, including hospitals and other licensed\ninpatient centers; ambulatory surgical or treatment centers; skilled nursing\ncenters; residential treatment centers; diagnostic, laboratory, and imaging\ncenters; and rehabilitation and other therapeutic health settings.\n\t\t“Genetic information” means, with respect to an individual,\ninformation about: (i) the individual’s genetic tests; (ii) the genetic\ntests of the individual’s family members; (iii) the manifestation of a\ndisease or disorder in family members of the individual; or (iv) any request\nfor, or receipt of, genetic services, or participation in clinical research that\nincludes genetic services, by the individual or any family member of the\nindividual. “Genetic information” does not include information about\nthe sex or age of any individual. As used in this definition, “family\nmember” includes a first-degree, second-degree, third-degree, or\nfourth-degree relative of a covered person.\n\t\t“Genetic services” means (i) a genetic test; (ii) genetic\ncounseling, including obtaining, interpreting, or assessing genetic information;\nor (iii) genetic education.\n\t\t“Genetic test” means an analysis of human DNA, RNA, chromosomes,\nproteins, or metabolites, if the analysis detects genotypes, mutations, or\nchromosomal changes. “Genetic test” does not include an analysis of\nproteins or metabolites that is directly related to a manifested disease,\ndisorder, or pathological condition.\n\t\t“Grandfathered plan” means coverage provided by a health carrier\nto (i) a small employer on March 23, 2010, or (ii) an individual that was\nenrolled on March 23, 2010, including any extension of coverage to an individual\nwho becomes a dependent of a grandfathered enrollee after March 23, 2010, for as\nlong as such plan maintains that status in accordance with federal law.\n\t\t“Group health insurance coverage” means health insurance coverage\noffered in connection with a group health benefit plan.\n\t\t“Group health plan” means an employee welfare benefit plan as\ndefined in \u00a7 3(1) of ERISA to the extent that the plan provides medical care\nwithin the meaning of \u00a7 733(a) of ERISA to employees, including both current\nand former employees, or their dependents as defined under the terms of the plan\ndirectly or through insurance, reimbursement, or otherwise.\n\t\t“Health benefit plan” means a policy, contract, certificate, or\nagreement offered by a health carrier to provide, deliver, arrange for, pay for,\nor reimburse any of the costs of health care services. “Health benefit\nplan” includes short-term and catastrophic health insurance policies, and\na policy that pays on a cost-incurred basis, except as otherwise specifically\nexempted in this definition. “Health benefit plan” does not include\nthe “excepted benefits” as defined in \u00a7 38.2-3431.\n\t\t“Health care professional” means a physician or other health care\npractitioner licensed, accredited, or certified to perform specified health care\nservices consistent with state law.\n\t\t“Health care provider” or “provider” means a health\ncare professional or facility.\n\t\t“Health care services” means services for the diagnosis,\nprevention, treatment, cure, or relief of a health condition, illness, injury,\nor disease.\n\t\t“Health carrier” means an entity subject to the insurance laws and\nregulations of the Commonwealth and subject to the jurisdiction of the\nCommission that contracts or offers to contract to provide, deliver, arrange\nfor, pay for, or reimburse any of the costs of health care services, including\nan insurer licensed to sell accident and sickness insurance, a health\nmaintenance organization, a health services plan, or any other entity providing\na plan of health insurance, health benefits, or health care services.\n\t\t“Health maintenance organization” means a person licensed pursuant\nto Chapter 43 (\u00a7 38.2-4300 et seq.).\n\t\t“Health status-related factor” means any of the following factors:\nhealth status; medical condition, including physical and mental illnesses;\nclaims experience; receipt of health care services; medical history; genetic\ninformation; evidence of insurability, including conditions arising out of acts\nof domestic violence; disability; or any other health status-related factor as\ndetermined by federal regulation.\n\t\t“Individual health insurance coverage” means health insurance\ncoverage offered to individuals in the individual market, which includes a\nhealth benefit plan provided to individuals through a trust arrangement,\nassociation, or other discretionary group that is not an employer plan, but does\nnot include coverage defined as “excepted benefits” in \u00a7 38.2-3431\nor short-term limited duration insurance. Student health insurance coverage\nshall be considered a type of individual health insurance coverage.\n\t\t“Individual market” means the market for health insurance coverage\noffered to individuals other than in connection with a group health plan.\n\t\t“In-network” or “participating” means a provider that\nhas contracted with a carrier or a carrier’s contractor or subcontractor\nto provide health care services to enrollees and be reimbursed by the carrier at\na contracted rate as payment in full for the health care services, including\napplicable cost-sharing requirements.\n\t\t“Managed care plan” means a health benefit plan that either\nrequires a covered person to use, or creates incentives, including financial\nincentives, for a covered person to use health care providers managed, owned,\nunder contract with, or employed by the health carrier.\n\t\t“Network” means the group of participating providers providing\nservices to a managed care plan.\n\t\t“Nonprofit data services organization” means the nonprofit\norganization with which the Commissioner of Health negotiates and enters into\ncontracts or agreements for the compilation, storage, analysis, and evaluation\nof data submitted by data suppliers pursuant to \u00a7 32.1-276.4.\n\t\t“Offer to pay” or “payment notification” means a claim\nthat has been adjudicated and paid by a carrier or determined by a carrier to be\npayable by an enrollee to an out-of-network provider for services described in\nsubsection A of \u00a7 38.2-3445.01.\n\t\t“Open enrollment” means, with respect to individual health\ninsurance coverage, the period of time during which any individual has the\nopportunity to apply for coverage under a health benefit plan offered by a\nhealth carrier and must be accepted for coverage under the plan without regard\nto a preexisting condition exclusion.\n\t\t“Out-of-network” or “nonparticipating” means a\nprovider that has not contracted with a carrier or a carrier’s contractor\nor subcontractor to provide health care services to enrollees.\n\t\t“Out-of-pocket maximum” or “maximum out-of-pocket”\nmeans the maximum amount an enrollee is required to pay in the form of\ncost-sharing requirements for covered benefits in a plan year, after which the\ncarrier covers the entirety of the allowed amount of covered benefits under the\ncontract of coverage.\n\t\t“Participating health care professional” means a health care\nprofessional who, under contract with the health carrier or with its contractor\nor subcontractor, has agreed to provide health care services to covered persons\nwith an expectation of receiving payments, other than coinsurance, copayments,\nor deductibles, directly or indirectly from the health carrier.\n\t\t“PPACA” means the Patient Protection and Affordable Care Act (P.L.\n111-148), as amended by the Health Care and Education Reconciliation Act of 2010\n(P.L. 111-152), and as it may be further amended.\n\t\t“Preexisting condition exclusion” means a limitation or exclusion\nof benefits, including a denial of coverage, based on the fact that the\ncondition was present before the effective date of coverage, or if the coverage\nis denied, the date of denial, whether or not any medical advice, diagnosis,\ncare, or treatment was recommended or received before the effective date of\ncoverage. “Preexisting condition exclusion” also includes a\ncondition identified as a result of a pre-enrollment questionnaire or physical\nexamination given to an individual, or review of medical records relating to the\npre-enrollment period.\n\t\t“Premium” means all moneys paid by an employer, eligible employee,\nor covered person as a condition of coverage from a health carrier, including\nfees and other contributions associated with the health benefit plan.\n\t\t“Preventive services” means (i) evidence-based items or services\nfor which a rating of A or B is in effect in the recommendations of the U.S.\nPreventive Services Task Force with respect to the individual involved; (ii)\nimmunizations for routine use in children, adolescents, and adults for which a\nrecommendation of the Advisory Committee on Immunization Practices of the\nCenters for Disease Control and Prevention is in effect with respect to the\nindividual involved; (iii) evidence-informed preventive care and screenings\nprovided for in comprehensive guidelines supported by the Health Resources and\nServices Administration with respect to infants, children, and adolescents; and\n(iv) evidence-informed preventive care and screenings recommended in\ncomprehensive guidelines supported by the Health Resources and Services\nAdministration with respect to women. For purposes of this definition, a\nrecommendation of the Advisory Committee on Immunization Practices of the\nCenters for Disease Control and Prevention is considered in effect after it has\nbeen adopted by the Director of the Centers for Disease Control and Prevention,\nand a recommendation is considered to be for routine use if it is listed on the\nImmunization Schedules of the Centers for Disease Control and Prevention.\n\t\t“Primary care health care professional” means a health care\nprofessional designated by a covered person to supervise, coordinate, or provide\ninitial care or continuing care to the covered person and who may be required by\nthe health carrier to initiate a referral for specialty care and maintain\nsupervision of health care services rendered to the covered person.\n\t\t“Rescission” means a cancellation or discontinuance of coverage\nunder a health benefit plan that has a retroactive effect.\n“Rescission” does not include:\n\n1. A cancellation or discontinuance of coverage under a health benefit plan if\nthe cancellation or discontinuance of coverage has only a prospective effect, or\nthe cancellation or discontinuance of coverage is effective retroactively to the\nextent it is attributable to a failure to timely pay required premiums or\ncontributions towards the cost of coverage; or\n\n2. A cancellation or discontinuance of coverage when the health benefit plan\ncovers active employees and, if applicable, dependents and those covered under\ncontinuation coverage provisions, if the employee pays no premiums for coverage\nafter termination of employment and the cancellation or discontinuance of\ncoverage is effective retroactively back to the date of termination of\nemployment due to a delay in administrative recordkeeping.\n\t\t\t“Stabilize” means with respect to an emergency medical condition,\nto provide such medical treatment as may be necessary to assure, within\nreasonable medical probability, that no material deterioration of the condition\nis likely to result from or occur during the transfer of the individual from a\nfacility, or, with respect to a pregnant woman, that the woman has delivered,\nincluding the placenta.\n\t\t\t“Student health insurance coverage” means a type of individual\nhealth insurance coverage that is provided pursuant to a written agreement\nbetween an institution of higher education, as defined by the Higher Education\nAct of 1965, and a health carrier and provided to students enrolled in that\ninstitution of higher education and their dependents, and that does not make\nhealth insurance coverage available other than in connection with enrollment as\na student, or as a dependent of a student, in the institution of higher\neducation, and does not condition eligibility for health insurance coverage on\nany health status-related factor related to a student or a dependent of the\nstudent.\n\t\t\t“Surgical or ancillary services” means professional services,\nincluding surgery, anesthesiology, pathology, radiology, or hospitalist services\nand laboratory services.\n\t\t\t“Wellness program” means a program offered by an employer that is\ndesigned to promote health or prevent disease.\n\nHISTORY: 2011, c. 882; 2013, c. 751; 2014, c. 814; 2020, cc. 1080, 1081, 1160;\n2024, cc. 199, 360.","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}}