{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3447.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3447.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3447.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3447.html"}],"law_id":66501,"edition_id":1,"section_id":66501,"structure_id":13819,"section_number":"38.2-3447","catch_line":"(Effective January 1, 2026) Restrictions relating to premium rates","history":"2013, c. 751; 2019, cc. 439, 440; 2023, cc. 682, 683.","full_text":"A\n\nNotwithstanding any provision of \u00a7 38.2-3432.2, 38.2-3501, 38.2-4306, or any other section of this title to the contrary, a health carrier offering a health benefit plan providing individual or small group health insurance coverage shall develop its premium rates based on the following:1\n\nWhether the health benefit plan covers an individual or family;2\n\nRating areas, as may be established by the Commission;3\n\nAge, except that the rate shall not vary by more than 3 to 1 for adults; and4\n\nTobacco use, except that the rate shall not vary by more than 1.5 to 1.B\n\nA premium rate shall not vary with respect to any particular health benefit plan by any other factor not described in subsection A.C\n\nRating variations for family coverage shall be applied based on the portion of the premium that is attributable to each family member covered under the health benefit plan.D\n\nIf the proposed area rate factors set forth in a rate filing for individual or small group health insurance coverage by a health carrier for a rating area exceed by more than 15 percent the weighted average of the proposed area rate factors among all rating areas in which the health carrier offers health benefit plans in that market, then:1\n\nThe health carrier’s rate filing shall include in a publicly available and unredacted form:\n\t\t\t\ta. A comparison of the area rate factor for individual and small group health benefit plans that utilize the same provider network and provider reimbursement levels of the health benefit plans that are subject to the filing;\n\t\t\t\tb. A detailed disclosure of the area rate factor methodology, which disclosure shall include any third-party resources or representations from a person other than the signing actuary, on which the signing actuary relied, provided that disclosure of third-party resources shall address that the source data only reflects differences in unit cost and provider practice patterns; and\n\t\t\t\tc. To the extent that the health carrier is deriving any area rate factor from experience data, by rating area for the experience period used:1\n\nThe (i) total enrollment; (ii) total premiums; (iii) allowed claims; (iv) incurred claims excluding anticipated or, if available, actual risk adjustment payments or receipts; (v) incurred claims including anticipated or, if available, actual risk adjustment payments or receipts; and (vi) loss ratio for each of their rating areas in that market; and2\n\nAggregated incurred claims for any health system exceeding 30 percent of total incurred claims for that rating area in that market.2\n\nThe Commission shall hold a public hearing on the proposed premium rates prior to the approval of the rate filing.3\n\nThe Commission shall not approve the proposed rate filing if (i) a variance in area rate factors, indexed to the same rating region for both the individual and small group markets, of 15 percent or more exists between health benefit plans a carrier intends to offer in the individual market and health benefit plans intended to be offered in the small group market, when those plans utilize the same provider network and provider reimbursement levels and (ii) the methodologies used to calculate the area rate factors are different between the two markets.E\n\nBeginning for plan year 2020, a health carrier with an approved rate filing that contains at least one area rate factor that exceeds by more than 25 percent the weighted average of the area rate factors among all rating areas in a market in which the health carrier offers individual or small group health insurance coverage shall file with the Commission for each calendar quarter during that plan year a report that provides, for each rating area within the market in which the health carrier operates, the plan’s (i) enrollment; (ii) total premiums; (iii) allowed claims; (iv) incurred claims excluding anticipated or, if available, actual risk adjustment payments or receipts; (v) incurred claims including anticipated or, if available, actual risk adjustment payments or receipts; (vi) loss ratio; and (vii) aggregate incurred claims, for each health system exceeding 25 percent of total incurred claims for that rating area. The health carrier shall make each such quarterly report publicly available, without redaction, not later than 45 days after the end of the calendar quarter.F\n\nAs used in subdivisions D and E:\n\t\t\t“Allowed claims” means the amount of claims of a covered person for health care services that are owed pursuant to the terms of the covered person’s health benefits plan, including payment made by the covered person’s health carrier, and cost-sharing obligations owed by or on behalf of the covered person.\n\t\t\t“Health system” means an organization that consists of either (i) at least one hospital plus at least one group of physicians or (ii) more than one group of physicians.\n\t\t\t“Incurred claims” means allowed claims less copayments, deductible amounts, and other cost-sharing obligations owed by or on behalf of a covered person.\n\t\t\t“Methodologies,” when referring to the calculation of area rate factors, includes (i) the types of inputs, including experience period claims data, third-party database, other sources of data, and (ii) the series of calculations that are used to derive area rate factors. This definition shall not preclude a health carrier from calculating area rate factors for rates for the individual market, based on the cost and care delivery practices associated with the providers expected to be utilized by covered persons that reside in a given rating area, while calculating area rate factors for rates for the small group market, based on those providers that are expected to be utilized by individuals employed by small employers that are located in the rating area without regard to where the covered persons reside.\n\t\t\t“Provider” means a health care provider, as defined in § 38.2-3438, that is affiliated or in-network with a health carrier.\n\t\t\t“Weighted average,” when referring to area rate factors, means the mean of the area rate factors when weighted based on the projected number of covered persons distributed by rating area.","order_by":null,"text":{"0":{"id":241326,"text":"Notwithstanding any provision of \u00a7 38.2-3432.2, 38.2-3501, 38.2-4306, or any other section of this title to the contrary, a health carrier offering a health benefit plan providing individual or small group health insurance coverage shall develop its premium rates based on the following:","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"A1"},"1":{"id":241327,"text":"Whether the health benefit plan covers an individual or family;","type":"section","prefixes":["A","1"],"prefix":"1","entire_prefix":"A1","prefix_anchor":"A1","level":2,"prior_prefix":"A","next_prefix":"A2"},"2":{"id":241328,"text":"Rating areas, as may be established by the Commission;","type":"section","prefixes":["A","2"],"prefix":"2","entire_prefix":"A2","prefix_anchor":"A2","level":2,"prior_prefix":"A1","next_prefix":"A3"},"3":{"id":241329,"text":"Age, except that the rate shall not vary by more than 3 to 1 for adults; and","type":"section","prefixes":["A","3"],"prefix":"3","entire_prefix":"A3","prefix_anchor":"A3","level":2,"prior_prefix":"A2","next_prefix":"A4"},"4":{"id":241330,"text":"Tobacco use, except that the rate shall not vary by more than 1.5 to 1.","type":"section","prefixes":["A","4"],"prefix":"4","entire_prefix":"A4","prefix_anchor":"A4","level":2,"prior_prefix":"A3","next_prefix":"B"},"5":{"id":241331,"text":"A premium rate shall not vary with respect to any particular health benefit plan by any other factor not described in subsection A.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A4","next_prefix":"C"},"6":{"id":241332,"text":"Rating variations for family coverage shall be applied based on the portion of the premium that is attributable to each family member covered under the health benefit plan.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"7":{"id":241333,"text":"If the proposed area rate factors set forth in a rate filing for individual or small group health insurance coverage by a health carrier for a rating area exceed by more than 15 percent the weighted average of the proposed area rate factors among all rating areas in which the health carrier offers health benefit plans in that market, then:","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"D1"},"8":{"id":241334,"text":"The health carrier’s rate filing shall include in a publicly available and unredacted form:\n\t\t\t\ta. A comparison of the area rate factor for individual and small group health benefit plans that utilize the same provider network and provider reimbursement levels of the health benefit plans that are subject to the filing;\n\t\t\t\tb. A detailed disclosure of the area rate factor methodology, which disclosure shall include any third-party resources or representations from a person other than the signing actuary, on which the signing actuary relied, provided that disclosure of third-party resources shall address that the source data only reflects differences in unit cost and provider practice patterns; and\n\t\t\t\tc. To the extent that the health carrier is deriving any area rate factor from experience data, by rating area for the experience period used:","type":"section","prefixes":["D","1"],"prefix":"1","entire_prefix":"D1","prefix_anchor":"D1","level":2,"prior_prefix":"D","next_prefix":"D11"},"9":{"id":241335,"text":"The (i) total enrollment; (ii) total premiums; (iii) allowed claims; (iv) incurred claims excluding anticipated or, if available, actual risk adjustment payments or receipts; (v) incurred claims including anticipated or, if available, actual risk adjustment payments or receipts; and (vi) loss ratio for each of their rating areas in that market; and","type":"section","prefixes":["D","1","1"],"prefix":"1","entire_prefix":"D11","prefix_anchor":"D11","level":3,"prior_prefix":"D1","next_prefix":"D12"},"10":{"id":241336,"text":"Aggregated incurred claims for any health system exceeding 30 percent of total incurred claims for that rating area in that market.","type":"section","prefixes":["D","1","2"],"prefix":"2","entire_prefix":"D12","prefix_anchor":"D12","level":3,"prior_prefix":"D11","next_prefix":"D2"},"11":{"id":241337,"text":"The Commission shall hold a public hearing on the proposed premium rates prior to the approval of the rate filing.","type":"section","prefixes":["D","2"],"prefix":"2","entire_prefix":"D2","prefix_anchor":"D2","level":2,"prior_prefix":"D12","next_prefix":"D3"},"12":{"id":241338,"text":"The Commission shall not approve the proposed rate filing if (i) a variance in area rate factors, indexed to the same rating region for both the individual and small group markets, of 15 percent or more exists between health benefit plans a carrier intends to offer in the individual market and health benefit plans intended to be offered in the small group market, when those plans utilize the same provider network and provider reimbursement levels and (ii) the methodologies used to calculate the area rate factors are different between the two markets.","type":"section","prefixes":["D","3"],"prefix":"3","entire_prefix":"D3","prefix_anchor":"D3","level":2,"prior_prefix":"D2","next_prefix":"E"},"13":{"id":241339,"text":"Beginning for plan year 2020, a health carrier with an approved rate filing that contains at least one area rate factor that exceeds by more than 25 percent the weighted average of the area rate factors among all rating areas in a market in which the health carrier offers individual or small group health insurance coverage shall file with the Commission for each calendar quarter during that plan year a report that provides, for each rating area within the market in which the health carrier operates, the plan’s (i) enrollment; (ii) total premiums; (iii) allowed claims; (iv) incurred claims excluding anticipated or, if available, actual risk adjustment payments or receipts; (v) incurred claims including anticipated or, if available, actual risk adjustment payments or receipts; (vi) loss ratio; and (vii) aggregate incurred claims, for each health system exceeding 25 percent of total incurred claims for that rating area. The health carrier shall make each such quarterly report publicly available, without redaction, not later than 45 days after the end of the calendar quarter.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D3","next_prefix":"F"},"14":{"id":241340,"text":"As used in subdivisions D and E:\n\t\t\t“Allowed claims” means the amount of claims of a covered person for health care services that are owed pursuant to the terms of the covered person’s health benefits plan, including payment made by the covered person’s health carrier, and cost-sharing obligations owed by or on behalf of the covered person.\n\t\t\t“Health system” means an organization that consists of either (i) at least one hospital plus at least one group of physicians or (ii) more than one group of physicians.\n\t\t\t“Incurred claims” means allowed claims less copayments, deductible amounts, and other cost-sharing obligations owed by or on behalf of a covered person.\n\t\t\t“Methodologies,” when referring to the calculation of area rate factors, includes (i) the types of inputs, including experience period claims data, third-party database, other sources of data, and (ii) the series of calculations that are used to derive area rate factors. This definition shall not preclude a health carrier from calculating area rate factors for rates for the individual market, based on the cost and care delivery practices associated with the providers expected to be utilized by covered persons that reside in a given rating area, while calculating area rate factors for rates for the small group market, based on those providers that are expected to be utilized by individuals employed by small employers that are located in the rating area without regard to where the covered persons reside.\n\t\t\t“Provider” means a health care provider, as defined in § 38.2-3438, that is affiliated or in-network with a health carrier.\n\t\t\t“Weighted average,” when referring to area rate factors, means the mean of the area rate factors when weighted based on the projected number of covered persons distributed by rating area.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E"}},"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; prohibited","url":"\/38.2-3445.01\/","token":"38.2\/34\/6\/38.2-3445.01","metadata":false},{"id":74656,"structure_id":13819,"section_number":"38.2-3445.02","catch_line":"Arbitration","url":"\/38.2-3445.02\/","token":"38.2\/34\/6\/38.2-3445.02","metadata":false},{"id":57491,"structure_id":13819,"section_number":"38.2-3445.03","catch_line":"Data sets for determining commercially reasonable payments","url":"\/38.2-3445.03\/","token":"38.2\/34\/6\/38.2-3445.03","metadata":false},{"id":55717,"structure_id":13819,"section_number":"38.2-3445.04","catch_line":"Transparency","url":"\/38.2-3445.04\/","token":"38.2\/34\/6\/38.2-3445.04","metadata":false},{"id":67926,"structure_id":13819,"section_number":"38.2-3445.05","catch_line":"Enforcement","url":"\/38.2-3445.05\/","token":"38.2\/34\/6\/38.2-3445.05","metadata":false},{"id":66467,"structure_id":13819,"section_number":"38.2-3445.06","catch_line":"Applicability of certain sections","url":"\/38.2-3445.06\/","token":"38.2\/34\/6\/38.2-3445.06","metadata":false},{"id":72898,"structure_id":13819,"section_number":"38.2-3445.07","catch_line":"Rules and regulations","url":"\/38.2-3445.07\/","token":"38.2\/34\/6\/38.2-3445.07","metadata":false},{"id":68114,"structure_id":13819,"section_number":"38.2-3445.1","catch_line":"Repealed","url":"\/38.2-3445.1\/","token":"38.2\/34\/6\/38.2-3445.1","metadata":false},{"id":63588,"structure_id":13819,"section_number":"38.2-3445.2","catch_line":"Out-of-network claims; 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}],"previous_section":{"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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3447\/","history_text":"

This law was first created in 2013. The record of its establishment is cataloged in chapter 751<\/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 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 2019, chapters 439<\/a> and 440<\/a>; in 2023, chapters 682<\/a> and 683<\/a>.<\/p>","references":false,"refers_to":[{"id":85868,"section_number":"38.2-3432.2","catch_line":"Availability","order_by":null,"url":"\/38.2-3432.2\/"},{"id":57210,"section_number":"38.2-3438","catch_line":"Definitions","order_by":null,"url":"\/38.2-3438\/"},{"id":54330,"section_number":"38.2-3501","catch_line":"Policy forms; powers of Commission","order_by":null,"url":"\/38.2-3501\/"},{"id":81322,"section_number":"38.2-4306","catch_line":"Evidence of coverage and charges for health care services","order_by":null,"url":"\/38.2-4306\/"}],"permalink":{"id":215531,"object_type":"law","relational_id":66501,"identifier":"38.2-3447","token":"38.2\/34\/6\/38.2-3447","url":"\/38.2-3447\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3447\/","token":"38.2\/34\/6\/38.2-3447","dublin_core":{"Title":"(Effective January 1, 2026) Restrictions relating to premium rates","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3447","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> Notwithstanding any provision of \u00a7 38.2-3432.2<\/a>, 38.2-3501<\/a>, 38.2-4306<\/a>, or any other section of this title to the contrary, a health carrier offering a health benefit plan providing individual or small group health insurance<\/span> coverage shall develop its premium rates<\/span><\/span> based on the following: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Whether the health benefit plan covers an individual or family; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Rating areas, as may be established by the Commission<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Age, except that the rate<\/span> shall not vary by more than 3 to 1 for adults; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Tobacco use, except that the rate<\/span> shall not vary by more than 1.5 to 1. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> A premium rate<\/span> shall not vary with respect to any particular health benefit plan by any other factor not described in subsection A. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Rating variations for family coverage shall be applied based on the portion of the premium that is attributable to each family member covered under the health benefit plan. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> If the proposed area rate<\/span> factors set forth in a rate<\/span> filing for individual or small group health insurance<\/span> coverage by a health carrier for a rating area exceed by more than 15 percent the weighted average of the proposed area rate<\/span> factors among all rating areas in which the health carrier offers health benefit plans in that market, then: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> The health carrier’s rate<\/span> filing shall include in a publicly available and unredacted form:\n\t\t\t\ta. A comparison of the area rate<\/span> factor for individual and small group health benefit plans that utilize the same provider<\/span> network and provider<\/span> reimbursement levels of the health benefit plans that are subject to the filing;\n\t\t\t\tb. A detailed disclosure of the area rate<\/span> factor methodology, which disclosure shall include any third-party<\/span> resources or representations from a person<\/span> other than the signing actuary, on which the signing actuary relied, provided that disclosure of third-party<\/span> resources shall address that the source data only reflects differences in unit cost and provider<\/span> practice patterns; and\n\t\t\t\tc. To the extent that the health carrier is deriving any area rate<\/span> factor from experience data, by rating area for the experience period used: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> The (i) total enrollment; (ii) total premiums; (iii) allowed claims<\/span>; (iv) incurred claims<\/span> excluding anticipated or, if available, actual risk adjustment payments or receipts; (v) incurred claims<\/span> including anticipated or, if available, actual risk adjustment payments or receipts; and (vi) loss ratio for each of their rating areas in that market; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Aggregated incurred claims<\/span> for any health system<\/span> exceeding 30 percent of total incurred claims<\/span> for that rating area in that market. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> The Commission<\/span> shall hold a public hearing<\/span> on the proposed premium rates<\/span><\/span> prior to the approval of the rate<\/span> filing. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> The Commission<\/span> shall not approve the proposed rate<\/span> filing if (i) a variance in area rate<\/span> factors, indexed to the same rating region for both the individual and small group markets, of 15 percent or more exists between health benefit plans a carrier intends to offer in the individual market and health benefit plans intended to be offered in the small group market, when those plans utilize the same provider<\/span> network and provider<\/span> reimbursement levels and (ii) the methodologies used to calculate the area rate<\/span> factors are different between the two markets. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Beginning for plan year 2020, a health carrier with an approved rate<\/span> filing that contains at least one area rate<\/span> factor that exceeds by more than 25 percent the weighted average of the area rate<\/span> factors among all rating areas in a market in which the health carrier offers individual or small group health insurance<\/span> coverage shall file with the Commission<\/span> for each calendar quarter during that plan year a report that provides, for each rating area within the market in which the health carrier operates, the plan’s (i) enrollment; (ii) total premiums; (iii) allowed claims<\/span>; (iv) incurred claims<\/span> excluding anticipated or, if available, actual risk adjustment payments or receipts; (v) incurred claims<\/span> including anticipated or, if available, actual risk adjustment payments or receipts; (vi) loss ratio; and (vii) aggregate incurred claims<\/span>, for each health system<\/span> exceeding 25 percent of total incurred claims<\/span> for that rating area. The health carrier shall make each such quarterly report publicly available, without redaction, not later than 45 days after the end of the calendar quarter. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> As used in subdivisions D and E:\n\t\t\t“Allowed claims<\/span>” means the amount of claims of a covered person<\/span> for health care services that are owed pursuant to the terms of the covered person<\/span>’s health benefits plan, including payment made by the covered person<\/span>’s health carrier, and cost-sharing obligations owed by or on behalf of the covered person<\/span>.\n\t\t\t“Health system<\/span>” means an organization that consists of either (i) at least one hospital plus at least one group of physicians or (ii) more than one group of physicians.\n\t\t\t“Incurred claims<\/span>” means allowed claims<\/span> less copayments, deductible amounts, and other cost-sharing obligations owed by or on behalf of a covered person<\/span>.\n\t\t\t“Methodologies,” when referring to the calculation of area rate<\/span> factors, includes (i) the types of inputs, including experience period claims data, third-party<\/span> database, other sources of data, and (ii) the series of calculations that are used to derive area rate<\/span> factors. This definition shall not preclude a health carrier from calculating area rate<\/span> factors for rates<\/span><\/span> for the individual market, based on the cost and care delivery practices associated with the providers<\/span> expected to be utilized by covered persons<\/span> that reside in a given rating area, while calculating area rate<\/span> factors for rates<\/span><\/span> for the small group market, based on those providers<\/span> that are expected to be utilized by individuals employed by small employers that are located in the rating area without regard to where the covered persons<\/span> reside.\n\t\t\t“Provider<\/span>” means a health care provider<\/span>, as defined in § 38.2-3438<\/a>, that is affiliated or in-network with a health carrier.\n\t\t\t“Weighted average,” when referring to area rate<\/span> factors, means the mean of the area rate<\/span> factors when weighted based on the projected number of covered persons<\/span> distributed by rating area. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\n(EFFECTIVE JANUARY 1, 2026) RESTRICTIONS RELATING TO PREMIUM RATES (\u00a7\n38.2-3447)\n\nA. Notwithstanding any provision of \u00a7 38.2-3432.2, 38.2-3501, 38.2-4306, or any\nother section of this title to the contrary, a health carrier offering a health\nbenefit plan providing individual or small group health insurance coverage shall\ndevelop its premium rates based on the following:\n\n 1. Whether the health benefit plan covers an individual or family;\n\n 2. Rating areas, as may be established by the Commission;\n\n 3. Age, except that the rate shall not vary by more than 3 to 1 for adults;\n and\n\n 4. Tobacco use, except that the rate shall not vary by more than 1.5 to 1.\n\nB. A premium rate shall not vary with respect to any particular health benefit\nplan by any other factor not described in subsection A.\n\nC. Rating variations for family coverage shall be applied based on the portion\nof the premium that is attributable to each family member covered under the\nhealth benefit plan.\n\nD. If the proposed area rate factors set forth in a rate filing for individual\nor small group health insurance coverage by a health carrier for a rating area\nexceed by more than 15 percent the weighted average of the proposed area rate\nfactors among all rating areas in which the health carrier offers health benefit\nplans in that market, then:\n\n 1. The health carrier’s rate filing shall include in a publicly\n available and unredacted form:\n \t\t\t\ta. A comparison of the area rate factor for individual and small group\n health benefit plans that utilize the same provider network and provider\n reimbursement levels of the health benefit plans that are subject to the\n filing;\n \t\t\t\tb. A detailed disclosure of the area rate factor methodology, which\n disclosure shall include any third-party resources or representations from a\n person other than the signing actuary, on which the signing actuary relied,\n provided that disclosure of third-party resources shall address that the\n source data only reflects differences in unit cost and provider practice\n patterns; and\n \t\t\t\tc. To the extent that the health carrier is deriving any area rate factor\n from experience data, by rating area for the experience period used:\n\n 1. The (i) total enrollment; (ii) total premiums; (iii) allowed claims; (iv)\n incurred claims excluding anticipated or, if available, actual risk\n adjustment payments or receipts; (v) incurred claims including anticipated\n or, if available, actual risk adjustment payments or receipts; and (vi) loss\n ratio for each of their rating areas in that market; and\n\n 2. Aggregated incurred claims for any health system exceeding 30 percent of\n total incurred claims for that rating area in that market.\n\n 2. The Commission shall hold a public hearing on the proposed premium rates\n prior to the approval of the rate filing.\n\n 3. The Commission shall not approve the proposed rate filing if (i) a variance\n in area rate factors, indexed to the same rating region for both the\n individual and small group markets, of 15 percent or more exists between\n health benefit plans a carrier intends to offer in the individual market and\n health benefit plans intended to be offered in the small group market, when\n those plans utilize the same provider network and provider reimbursement\n levels and (ii) the methodologies used to calculate the area rate factors are\n different between the two markets.\n\nE. Beginning for plan year 2020, a health carrier with an approved rate filing\nthat contains at least one area rate factor that exceeds by more than 25 percent\nthe weighted average of the area rate factors among all rating areas in a market\nin which the health carrier offers individual or small group health insurance\ncoverage shall file with the Commission for each calendar quarter during that\nplan year a report that provides, for each rating area within the market in\nwhich the health carrier operates, the plan’s (i) enrollment; (ii) total\npremiums; (iii) allowed claims; (iv) incurred claims excluding anticipated or,\nif available, actual risk adjustment payments or receipts; (v) incurred claims\nincluding anticipated or, if available, actual risk adjustment payments or\nreceipts; (vi) loss ratio; and (vii) aggregate incurred claims, for each health\nsystem exceeding 25 percent of total incurred claims for that rating area. The\nhealth carrier shall make each such quarterly report publicly available, without\nredaction, not later than 45 days after the end of the calendar quarter.\n\nF. As used in subdivisions D and E:\n\t\t\t“Allowed claims” means the amount of claims of a covered person\nfor health care services that are owed pursuant to the terms of the covered\nperson’s health benefits plan, including payment made by the covered\nperson’s health carrier, and cost-sharing obligations owed by or on behalf\nof the covered person.\n\t\t\t“Health system” means an organization that consists of either (i)\nat least one hospital plus at least one group of physicians or (ii) more than\none group of physicians.\n\t\t\t“Incurred claims” means allowed claims less copayments,\ndeductible amounts, and other cost-sharing obligations owed by or on behalf of a\ncovered person.\n\t\t\t“Methodologies,” when referring to the calculation of area rate\nfactors, includes (i) the types of inputs, including experience period claims\ndata, third-party database, other sources of data, and (ii) the series of\ncalculations that are used to derive area rate factors. This definition shall\nnot preclude a health carrier from calculating area rate factors for rates for\nthe individual market, based on the cost and care delivery practices associated\nwith the providers expected to be utilized by covered persons that reside in a\ngiven rating area, while calculating area rate factors for rates for the small\ngroup market, based on those providers that are expected to be utilized by\nindividuals employed by small employers that are located in the rating area\nwithout regard to where the covered persons reside.\n\t\t\t“Provider” means a health care provider, as defined in §\n38.2-3438, that is affiliated or in-network with a health carrier.\n\t\t\t“Weighted average,” when referring to area rate factors, means\nthe mean of the area rate factors when weighted based on the projected number of\ncovered persons distributed by rating area.\n\nHISTORY: 2013, c. 751; 2019, cc. 439, 440; 2023, cc. 682, 683.","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}}