{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3461.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3461.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3461.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3461.html"}],"law_id":83999,"edition_id":1,"section_id":83999,"structure_id":16548,"section_number":"38.2-3461","catch_line":"Definitions","history":"2019, cc. 666, 684.","full_text":"As used in this article, unless the context requires a different meaning:\n\t\t“Allowed amount” means the contractually agreed upon amount paid or payable by a health carrier to a health care provider participating in the health carrier’s network.\n\t\t“Average” means mean, median, or mode.\n\t\t“Comparable health care service” means any (i) physical and occupational therapy service, (ii) radiology and imaging service, (iii) laboratory service, (iv) infusion therapy service, and (v) at the discretion of the health carrier, other health care service, provided that with respect to any service described in clauses (i) through (v) the service (a) is a covered non-emergency health care service or bundle of health care services provided by a network provider and (b) is a service for which the health carrier has not demonstrated that the allowed amount variation among participating providers is less than $50.\n\t\t“Covered person” means a policyholder, subscriber, participant, or other individual covered by a health benefit plan.\n\t\t“Health benefit plan” means a policy, contract, certificate, or agreement offered by a health carrier in the small group market to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. “Health benefit plan” does not include the “excepted benefits” as defined in \u00a7 38.2-3431. “Health benefit plan” does not include any health insurance plan administered by the Department of Human Resource Management, including the health coverage offered to state employees pursuant to \u00a7 2.2-2818; health insurance coverage offered to employees of local governments, local officers, teachers, and retirees, and the dependents of such employees, local officers, teachers and retirees pursuant to \u00a7 2.2-1204; or health insurance coverage provided under the Line of Duty Act (\u00a7 9.1-400 et seq.).\n\t\t“Health care provider” means a health care professional or facility.\n\t\t“Health care service” means a service 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“Network” or “provider network” means the group of participating providers providing services to a health benefit plan under which the financing and delivery of health care services are provided, in whole or in part, through a defined set of health care providers.\n\t\t“Network provider” means a health care provider that has contracted with the health carrier, or with its contractor or subcontractor, to provide health care services to covered persons as a member of a network.\n\t\t“Out-of-pocket costs” means any copayment, deductible, or coinsurance that is the responsibility of the covered person with respect to a covered health care service.\n\t\t“Program” means the comparable health care service incentive program established by a health carrier pursuant to this article.\n\t\t“Small group market” means the health insurance market under which individuals obtain health insurance coverage, directly or through any arrangement, on behalf of themselves and their dependents through a group health plan maintained by a small employer.","order_by":null,"text":{"0":{"id":301037,"text":"As used in this article, unless the context requires a different meaning:\n\t\t“Allowed amount” means the contractually agreed upon amount paid or payable by a health carrier to a health care provider participating in the health carrier’s network.\n\t\t“Average” means mean, median, or mode.\n\t\t“Comparable health care service” means any (i) physical and occupational therapy service, (ii) radiology and imaging service, (iii) laboratory service, (iv) infusion therapy service, and (v) at the discretion of the health carrier, other health care service, provided that with respect to any service described in clauses (i) through (v) the service (a) is a covered non-emergency health care service or bundle of health care services provided by a network provider and (b) is a service for which the health carrier has not demonstrated that the allowed amount variation among participating providers is less than $50.\n\t\t“Covered person” means a policyholder, subscriber, participant, or other individual covered by a health benefit plan.\n\t\t“Health benefit plan” means a policy, contract, certificate, or agreement offered by a health carrier in the small group market to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. “Health benefit plan” does not include the “excepted benefits” as defined in \u00a7 38.2-3431. “Health benefit plan” does not include any health insurance plan administered by the Department of Human Resource Management, including the health coverage offered to state employees pursuant to \u00a7 2.2-2818; health insurance coverage offered to employees of local governments, local officers, teachers, and retirees, and the dependents of such employees, local officers, teachers and retirees pursuant to \u00a7 2.2-1204; or health insurance coverage provided under the Line of Duty Act (\u00a7 9.1-400 et seq.).\n\t\t“Health care provider” means a health care professional or facility.\n\t\t“Health care service” means a service 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“Network” or “provider network” means the group of participating providers providing services to a health benefit plan under which the financing and delivery of health care services are provided, in whole or in part, through a defined set of health care providers.\n\t\t“Network provider” means a health care provider that has contracted with the health carrier, or with its contractor or subcontractor, to provide health care services to covered persons as a member of a network.\n\t\t“Out-of-pocket costs” means any copayment, deductible, or coinsurance that is the responsibility of the covered person with respect to a covered health care service.\n\t\t“Program” means the comparable health care service incentive program established by a health carrier pursuant to this article.\n\t\t“Small group market” means the health insurance market under which individuals obtain health insurance coverage, directly or through any arrangement, on behalf of themselves and their dependents through a group health plan maintained by a small employer.","type":"section","prefixes":[""],"prefix":"","entire_prefix":"","prefix_anchor":"","level":1}},"ancestry":[{"id":16548,"edition_id":1,"name":"Health Care Shared Savings","identifier":"8","label":"article","depth":3,"order_by":1,"parent_id":12993,"metadata":{},"date_created":"2026-06-26 04:23:38","date_modified":"2026-06-26 04:23:38","permalink":{"id":215597,"object_type":"structure","relational_id":16548,"identifier":"8","token":"38.2\/34\/8","url":"\/38.2\/34\/8\/","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":83999,"structure_id":16548,"section_number":"38.2-3461","catch_line":"Definitions","url":"\/38.2-3461\/","token":"38.2\/34\/8\/38.2-3461","metadata":false},{"id":86724,"structure_id":16548,"section_number":"38.2-3462","catch_line":"Comparable Health Care Service Incentive Program","url":"\/38.2-3462\/","token":"38.2\/34\/8\/38.2-3462","metadata":false},{"id":83601,"structure_id":16548,"section_number":"38.2-3463","catch_line":"Health care price transparency tools","url":"\/38.2-3463\/","token":"38.2\/34\/8\/38.2-3463","metadata":false},{"id":70954,"structure_id":16548,"section_number":"38.2-3464","catch_line":"Rules and regulations; orders","url":"\/38.2-3464\/","token":"38.2\/34\/8\/38.2-3464","metadata":false}],"next_section":{"id":86724,"structure_id":16548,"section_number":"38.2-3462","catch_line":"Comparable Health Care Service Incentive Program","url":"\/38.2-3462\/","token":"38.2\/34\/8\/38.2-3462","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3461\/","history_text":"

This law was first created in 2019. The record of its establishment is cataloged in chapters 666<\/a> and 684<\/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.<\/p>","references":[{"id":55347,"section_number":"38.2-4214","catch_line":"Application of certain provisions of law","order_by":null,"url":"\/38.2-4214\/"},{"id":67952,"section_number":"38.2-4319","catch_line":"Statutory construction and relationship to other laws","order_by":null,"url":"\/38.2-4319\/"}],"refers_to":[{"id":64954,"section_number":"2.2-1204","catch_line":"Health insurance program for employees of local governments, local officers, teachers, etc.; definitions","order_by":null,"url":"\/2.2-1204\/"},{"id":68317,"section_number":"2.2-2818","catch_line":"Health and related insurance for state employees","order_by":null,"url":"\/2.2-2818\/"},{"id":86404,"section_number":"38.2-3431","catch_line":"Application of article; definitions","order_by":null,"url":"\/38.2-3431\/"},{"id":54405,"section_number":"9.1-400","catch_line":"Title of chapter; definitions","order_by":null,"url":"\/9.1-400\/"}],"permalink":{"id":215599,"object_type":"law","relational_id":83999,"identifier":"38.2-3461","token":"38.2\/34\/8\/38.2-3461","url":"\/38.2-3461\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3461\/","token":"38.2\/34\/8\/38.2-3461","dublin_core":{"Title":"Definitions","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3461","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

As used in this article, unless the context requires a different meaning:\n\t\t“Allowed amount<\/span>” means the contractually agreed upon amount paid or payable by a health carrier<\/span> to a health care provider<\/span> participating in the health carrier<\/span>’s network.\n\t\t“Average<\/span>” means mean, median, or mode.\n\t\t“Comparable health care service<\/span><\/span>” means any (i) physical and occupational therapy service, (ii) radiology and imaging service, (iii) laboratory service, (iv) infusion therapy service, and (v) at the discretion of the health carrier<\/span>, other health care service<\/span>, provided that with respect to any service described in clauses (i) through (v) the service (a) is a covered non-emergency health care service<\/span> or bundle of health care services<\/span> provided by a network provider<\/span> and (b) is a service for which the health carrier<\/span> has not demonstrated that the allowed amount<\/span> variation among participating providers is less than $50.\n\t\t“Covered person<\/span>” means a policyholder, subscriber, participant, or other individual covered by a health benefit plan<\/span>.\n\t\t“Health benefit plan<\/span>” means a policy, contract<\/span>, certificate, or agreement offered by a health carrier<\/span> in the small group market<\/span> to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services<\/span>. “Health benefit plan<\/span>” does not include the “excepted benefits<\/span>” as defined in \u00a7 38.2-3431<\/a>. “Health benefit plan<\/span>” does not include any health insurance<\/span> plan administered by the Department of Human Resource Management, including the health coverage offered to state<\/span> employees pursuant to \u00a7 2.2-2818<\/a>; health insurance<\/span> coverage offered to employees of local governments, local officers, teachers, and retirees, and the dependents of such employees, local officers, teachers and retirees pursuant to \u00a7 2.2-1204<\/a>; or health insurance<\/span> coverage provided under the Line of Duty Act (\u00a7 9.1-400<\/a> et seq.).\n\t\t“Health care provider<\/span>” means a health care professional or facility.\n\t\t“Health care service<\/span>” means a service 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<\/span> 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<\/span>, a health maintenance organization, a health services plan<\/span>, or any other entity providing a plan of health insurance<\/span>, health benefits, or health care services<\/span>.\n\t\t“Network” or “provider network<\/span>” means the group of participating providers providing services to a health benefit plan<\/span> under which the financing and delivery of health care services<\/span> are provided, in whole or in part, through a defined set of health care providers<\/span>.\n\t\t“Network provider<\/span>” means a health care provider<\/span> that has contracted with the health carrier<\/span>, or with its contractor or subcontractor, to provide health care services<\/span> to covered persons<\/span> as a member of a network.\n\t\t“Out-of-pocket costs<\/span>” means any copayment, deductible, or coinsurance that is the responsibility of the covered person<\/span> with respect to a covered health care service<\/span>.\n\t\t“Program<\/span>” means the comparable health care service<\/span><\/span> incentive program<\/span> established by a health carrier<\/span> pursuant to this article.\n\t\t“Small group market<\/span>” means the health insurance<\/span> market under which individuals obtain health insurance<\/span> coverage, directly or through any arrangement, on behalf of themselves and their dependents through a group health plan maintained by a small employer.<\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nDEFINITIONS (\u00a7 38.2-3461)\n\nAs used in this article, unless the context requires a different meaning:\n\t\t“Allowed amount” means the contractually agreed upon amount paid\nor payable by a health carrier to a health care provider participating in the\nhealth carrier’s network.\n\t\t“Average” means mean, median, or mode.\n\t\t“Comparable health care service” means any (i) physical and\noccupational therapy service, (ii) radiology and imaging service, (iii)\nlaboratory service, (iv) infusion therapy service, and (v) at the discretion of\nthe health carrier, other health care service, provided that with respect to any\nservice described in clauses (i) through (v) the service (a) is a covered\nnon-emergency health care service or bundle of health care services provided by\na network provider and (b) is a service for which the health carrier has not\ndemonstrated that the allowed amount variation among participating providers is\nless than $50.\n\t\t“Covered person” means a policyholder, subscriber, participant, or\nother individual covered by a health benefit plan.\n\t\t“Health benefit plan” means a policy, contract, certificate, or\nagreement offered by a health carrier in the small group market to provide,\ndeliver, arrange for, pay for, or reimburse any of the costs of health care\nservices. “Health benefit plan” does not include the “excepted\nbenefits” as defined in \u00a7 38.2-3431. “Health benefit plan”\ndoes not include any health insurance plan administered by the Department of\nHuman Resource Management, including the health coverage offered to state\nemployees pursuant to \u00a7 2.2-2818; health insurance coverage offered to\nemployees of local governments, local officers, teachers, and retirees, and the\ndependents of such employees, local officers, teachers and retirees pursuant to\n\u00a7 2.2-1204; or health insurance coverage provided under the Line of Duty Act\n(\u00a7 9.1-400 et seq.).\n\t\t“Health care provider” means a health care professional or\nfacility.\n\t\t“Health care service” means a service 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“Network” or “provider network” means the group of\nparticipating providers providing services to a health benefit plan under which\nthe financing and delivery of health care services are provided, in whole or in\npart, through a defined set of health care providers.\n\t\t“Network provider” means a health care provider that has\ncontracted with the health carrier, or with its contractor or subcontractor, to\nprovide health care services to covered persons as a member of a network.\n\t\t“Out-of-pocket costs” means any copayment, deductible, or\ncoinsurance that is the responsibility of the covered person with respect to a\ncovered health care service.\n\t\t“Program” means the comparable health care service incentive\nprogram established by a health carrier pursuant to this article.\n\t\t“Small group market” means the health insurance market under which\nindividuals obtain health insurance coverage, directly or through any\narrangement, on behalf of themselves and their dependents through a group health\nplan maintained by a small employer.\n\nHISTORY: 2019, cc. 666, 684.","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}}