{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3462.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3462.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3462.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3462.html"}],"law_id":86724,"edition_id":1,"section_id":86724,"structure_id":16548,"section_number":"38.2-3462","catch_line":"Comparable Health Care Service Incentive Program","history":"2019, cc. 666, 684.","full_text":"A\n\nBeginning with health benefit plans offered or renewed on or after January 1, 2021, each health carrier offering a health benefit plan in the Commonwealth shall develop and implement a program that provides incentives for covered persons in its health benefit plan who elect to receive a comparable health care service that is covered by the health benefit plan from health care providers that are paid less than the average in-network allowed amount paid or payable by that health carrier to network providers for that comparable health care service. A health carrier may base the average paid to a network provider on what that health carrier pays to providers in the network applicable to the covered person&#8217;s specific health benefit plan, or across all of its health benefit plans offered in the Commonwealth.B\n\nIncentives may include, but are not limited to, cash payments, gift cards, or credits or reductions of premiums, copayments, or deductibles. Health carriers may let covered persons decide which method they prefer to receive the incentive.C\n\nThe incentive program shall provide covered persons with an incentive for each service or category of comparable health care service resulting from comparison shopping by covered persons. A health carrier is not required to provide a payment or credit to a covered person when the health carrier&#8217;s saved cost is $25 or less.D\n\nA health carrier shall determine the allowed amount paid or payable by that health carrier to network providers for that comparable health care service on the basis of the average allowed amount for the procedure or service under the covered person&#8217;s health benefit plan. Such determination shall be made on the basis of the average of the allowed amounts using data collected over a reasonable period not to exceed one year. A health carrier may determine an alternate methodology for calculating the average allowed amount if approved by the Commission. A health carrier shall, at minimum, inform covered persons of their eligibility for an incentive payment and the process to request the average allowed amount for a procedure or service on the health carrier&#8217;s website and in health benefit plan materials.E\n\nEligibility for an incentive payment may require a covered person to demonstrate, through reasonable documentation such as a quote from the health care provider, that the covered person shopped prior to receiving care from the health care provider who charges less for the comparable health care service than the average allowed amount paid or payable by that health carrier. Health carriers shall provide additional mechanisms for the covered person to satisfy this requirement by utilizing the health carrier&#8217;s cost transparency website or toll-free number, established under this article.F\n\nEach health carrier shall make the program available as a component of all small group health benefit plans offered by the health carrier in the Commonwealth. Annually at enrollment or renewal, each health carrier shall provide to any covered person who is enrolled in a small group health benefit plan eligible for the program (i) notice about the availability of the program, (ii) a description of the incentives available to a covered person, (iii) instructions on how to earn such incentives, and (iv) notification that tax treatment of the shared savings amounts or awards will be compliant with the rules of the Internal Revenue Service and treated as taxable income.G\n\nA comparable health care service incentive payment made by a health carrier in accordance with this section shall not constitute an administrative expense of the health carrier for rate development or rate filing purposes.H\n\nPrior to offering the program to any covered person, a health carrier shall file with the Commission a description of the program in the manner determined by the Commission. The description shall include a demonstration by the health carrier that the program is cost-effective, including any data relied upon by the health carrier in making such determination. The Commission may review the filing made by the health carrier to determine if the health carrier&#8217;s program complies with the requirements of this article.I\n\nA health carrier may petition the Commission to be excluded from participation in the program. The Commission shall exempt from the program a health plan with a limited provider network that demonstrates that the network is incompatible with a shared savings program. In making its determination, the Commission shall consider the impact on premiums related to the administration of the program.J\n\nAnnually by April 1, each health carrier shall file with the Commission, for the most recent calendar year, the total number of comparable health care service incentive payments made pursuant to this article, the use of comparable health care services by category of service for which comparable health care service incentives are made, the total payments made to covered persons, the average amount of incentive payments made by service for such transactions, the total savings achieved below the average allowed amount by service for such transactions, and the total number and percentage of a health carrier&#8217;s covered persons in small group health benefit plans that participated in such transactions.K\n\nBeginning no later than 18 months after implementation of comparable health care service incentive programs under this section and annually by November 1 of each year thereafter, the Commission shall submit an aggregate report for all health carriers filing the information required by this section to the chairs of the House Committee on Labor and Commerce and Senate Committee on Commerce and Labor.","order_by":null,"text":{"0":{"id":310572,"text":"Beginning with health benefit plans offered or renewed on or after January 1, 2021, each health carrier offering a health benefit plan in the Commonwealth shall develop and implement a program that provides incentives for covered persons in its health benefit plan who elect to receive a comparable health care service that is covered by the health benefit plan from health care providers that are paid less than the average in-network allowed amount paid or payable by that health carrier to network providers for that comparable health care service. A health carrier may base the average paid to a network provider on what that health carrier pays to providers in the network applicable to the covered person&#8217;s specific health benefit plan, or across all of its health benefit plans offered in the Commonwealth.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":310573,"text":"Incentives may include, but are not limited to, cash payments, gift cards, or credits or reductions of premiums, copayments, or deductibles. Health carriers may let covered persons decide which method they prefer to receive the incentive.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":310574,"text":"The incentive program shall provide covered persons with an incentive for each service or category of comparable health care service resulting from comparison shopping by covered persons. A health carrier is not required to provide a payment or credit to a covered person when the health carrier&#8217;s saved cost is $25 or less.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":310575,"text":"A health carrier shall determine the allowed amount paid or payable by that health carrier to network providers for that comparable health care service on the basis of the average allowed amount for the procedure or service under the covered person&#8217;s health benefit plan. Such determination shall be made on the basis of the average of the allowed amounts using data collected over a reasonable period not to exceed one year. A health carrier may determine an alternate methodology for calculating the average allowed amount if approved by the Commission. A health carrier shall, at minimum, inform covered persons of their eligibility for an incentive payment and the process to request the average allowed amount for a procedure or service on the health carrier&#8217;s website and in health benefit plan materials.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":310576,"text":"Eligibility for an incentive payment may require a covered person to demonstrate, through reasonable documentation such as a quote from the health care provider, that the covered person shopped prior to receiving care from the health care provider who charges less for the comparable health care service than the average allowed amount paid or payable by that health carrier. Health carriers shall provide additional mechanisms for the covered person to satisfy this requirement by utilizing the health carrier&#8217;s cost transparency website or toll-free number, established under this article.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"5":{"id":310577,"text":"Each health carrier shall make the program available as a component of all small group health benefit plans offered by the health carrier in the Commonwealth. Annually at enrollment or renewal, each health carrier shall provide to any covered person who is enrolled in a small group health benefit plan eligible for the program (i) notice about the availability of the program, (ii) a description of the incentives available to a covered person, (iii) instructions on how to earn such incentives, and (iv) notification that tax treatment of the shared savings amounts or awards will be compliant with the rules of the Internal Revenue Service and treated as taxable income.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"6":{"id":310578,"text":"A comparable health care service incentive payment made by a health carrier in accordance with this section shall not constitute an administrative expense of the health carrier for rate development or rate filing purposes.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F","next_prefix":"H"},"7":{"id":310579,"text":"Prior to offering the program to any covered person, a health carrier shall file with the Commission a description of the program in the manner determined by the Commission. The description shall include a demonstration by the health carrier that the program is cost-effective, including any data relied upon by the health carrier in making such determination. The Commission may review the filing made by the health carrier to determine if the health carrier&#8217;s program complies with the requirements of this article.","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G","next_prefix":"I"},"8":{"id":310580,"text":"A health carrier may petition the Commission to be excluded from participation in the program. The Commission shall exempt from the program a health plan with a limited provider network that demonstrates that the network is incompatible with a shared savings program. In making its determination, the Commission shall consider the impact on premiums related to the administration of the program.","type":"section","prefixes":["I"],"prefix":"I","entire_prefix":"I","prefix_anchor":"I","level":1,"prior_prefix":"H","next_prefix":"J"},"9":{"id":310581,"text":"Annually by April 1, each health carrier shall file with the Commission, for the most recent calendar year, the total number of comparable health care service incentive payments made pursuant to this article, the use of comparable health care services by category of service for which comparable health care service incentives are made, the total payments made to covered persons, the average amount of incentive payments made by service for such transactions, the total savings achieved below the average allowed amount by service for such transactions, and the total number and percentage of a health carrier&#8217;s covered persons in small group health benefit plans that participated in such transactions.","type":"section","prefixes":["J"],"prefix":"J","entire_prefix":"J","prefix_anchor":"J","level":1,"prior_prefix":"I","next_prefix":"K"},"10":{"id":310582,"text":"Beginning no later than 18 months after implementation of comparable health care service incentive programs under this section and annually by November 1 of each year thereafter, the Commission shall submit an aggregate report for all health carriers filing the information required by this section to the chairs of the House Committee on Labor and Commerce and Senate Committee on Commerce and Labor.","type":"section","prefixes":["K"],"prefix":"K","entire_prefix":"K","prefix_anchor":"K","level":1,"prior_prefix":"J"}},"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}],"previous_section":{"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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3462\/","history_text":"<p>This law was first created in 2019. The record of its establishment is cataloged in chapters <a href=\"https:\/\/legacylis.virginia.gov\/cgi-bin\/legp604.exe?191+ful+CHAP0666\">666<\/a> and <a href=\"https:\/\/legacylis.virginia.gov\/cgi-bin\/legp604.exe?191+ful+CHAP0684\">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":false,"refers_to":false,"permalink":{"id":215603,"object_type":"law","relational_id":86724,"identifier":"38.2-3462","token":"38.2\/34\/8\/38.2-3462","url":"\/38.2-3462\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3462\/","token":"38.2\/34\/8\/38.2-3462","dublin_core":{"Title":"Comparable Health Care Service Incentive Program","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3462","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t<section id=\"A\"><p><span class=\"prefix-number\">A.<\/span> Beginning with <span class=\"dictionary\">health benefit plans<\/span> offered or renewed on or after January 1, 2021, each <span class=\"dictionary\">health carrier<\/span> offering a <span class=\"dictionary\">health benefit plan<\/span> in the Commonwealth shall develop and implement a <span class=\"dictionary\">program<\/span> that provides incentives for <span class=\"dictionary\">covered persons<\/span> in its <span class=\"dictionary\">health benefit plan<\/span> who elect to receive a <span class=\"dictionary\">comparable <span class=\"dictionary\">health care service<\/span><\/span> that is covered by the <span class=\"dictionary\">health benefit plan<\/span> from <span class=\"dictionary\">health care providers<\/span> that are paid less than the <span class=\"dictionary\">average<\/span> in-network <span class=\"dictionary\">allowed amount<\/span> paid or payable by that <span class=\"dictionary\">health carrier<\/span> to <span class=\"dictionary\">network providers<\/span> for that <span class=\"dictionary\">comparable <span class=\"dictionary\">health care service<\/span><\/span>. A <span class=\"dictionary\">health carrier<\/span> may base the <span class=\"dictionary\">average<\/span> paid to a <span class=\"dictionary\">network provider<\/span> on what that <span class=\"dictionary\">health carrier<\/span> pays to providers in the network applicable to the <span class=\"dictionary\">covered person<\/span>&#8217;s specific <span class=\"dictionary\">health benefit plan<\/span>, or across all of its <span class=\"dictionary\">health benefit plans<\/span> offered in the Commonwealth. <a id=\"paragraph-310572\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3462\/#A\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"B\"><p><span class=\"prefix-number\">B.<\/span> Incentives may include, but are not limited to, cash payments, gift cards, or credits or reductions of premiums, copayments, or deductibles. <span class=\"dictionary\">Health carriers<\/span> may let <span class=\"dictionary\">covered persons<\/span> decide which method they prefer to receive the incentive. <a id=\"paragraph-310573\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3462\/#B\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"C\"><p><span class=\"prefix-number\">C.<\/span> The incentive <span class=\"dictionary\">program<\/span> shall provide <span class=\"dictionary\">covered persons<\/span> with an incentive for each service or category of <span class=\"dictionary\">comparable <span class=\"dictionary\">health care service<\/span><\/span> resulting from comparison shopping by <span class=\"dictionary\">covered persons<\/span>. A <span class=\"dictionary\">health carrier<\/span> is not required to provide a payment or credit to a <span class=\"dictionary\">covered person<\/span> when the <span class=\"dictionary\">health carrier<\/span>&#8217;s saved cost is $25 or less. <a id=\"paragraph-310574\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3462\/#C\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"D\"><p><span class=\"prefix-number\">D.<\/span> A <span class=\"dictionary\">health carrier<\/span> shall determine the <span class=\"dictionary\">allowed amount<\/span> paid or payable by that <span class=\"dictionary\">health carrier<\/span> to <span class=\"dictionary\">network providers<\/span> for that <span class=\"dictionary\">comparable <span class=\"dictionary\">health care service<\/span><\/span> on the basis of the <span class=\"dictionary\">average<\/span> <span class=\"dictionary\">allowed amount<\/span> for the procedure or service under the <span class=\"dictionary\">covered person<\/span>&#8217;s <span class=\"dictionary\">health benefit plan<\/span>. Such determination shall be made on the basis of the <span class=\"dictionary\">average<\/span> of the <span class=\"dictionary\">allowed amounts<\/span> using data collected over a reasonable period not to exceed one year. A <span class=\"dictionary\">health carrier<\/span> may determine an alternate methodology for calculating the <span class=\"dictionary\">average<\/span> <span class=\"dictionary\">allowed amount<\/span> if approved by the <span class=\"dictionary\">Commission<\/span>. A <span class=\"dictionary\">health carrier<\/span> shall, at minimum, inform <span class=\"dictionary\">covered persons<\/span> of their eligibility for an incentive payment and the process to request the <span class=\"dictionary\">average<\/span> <span class=\"dictionary\">allowed amount<\/span> for a procedure or service on the <span class=\"dictionary\">health carrier<\/span>&#8217;s website and in <span class=\"dictionary\">health benefit plan<\/span> <span class=\"dictionary\">materials<\/span>. <a id=\"paragraph-310575\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3462\/#D\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"E\"><p><span class=\"prefix-number\">E.<\/span> Eligibility for an incentive payment may require a <span class=\"dictionary\">covered person<\/span> to demonstrate, through reasonable documentation such as a quote from the <span class=\"dictionary\">health care provider<\/span>, that the <span class=\"dictionary\">covered person<\/span> shopped prior to receiving care from the <span class=\"dictionary\">health care provider<\/span> who charges less for the <span class=\"dictionary\">comparable <span class=\"dictionary\">health care service<\/span><\/span> than the <span class=\"dictionary\">average<\/span> <span class=\"dictionary\">allowed amount<\/span> paid or payable by that <span class=\"dictionary\">health carrier<\/span>. <span class=\"dictionary\">Health carriers<\/span> shall provide additional mechanisms for the <span class=\"dictionary\">covered person<\/span> to satisfy this requirement by utilizing the <span class=\"dictionary\">health carrier<\/span>&#8217;s cost transparency website or toll-free number, established under this article. <a id=\"paragraph-310576\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3462\/#E\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"F\"><p><span class=\"prefix-number\">F.<\/span> Each <span class=\"dictionary\">health carrier<\/span> shall make the <span class=\"dictionary\">program<\/span> available as a component of all small group <span class=\"dictionary\">health benefit plans<\/span> offered by the <span class=\"dictionary\">health carrier<\/span> in the Commonwealth. Annually at enrollment or renewal, each <span class=\"dictionary\">health carrier<\/span> shall provide to any <span class=\"dictionary\">covered person<\/span> who is enrolled in a small group <span class=\"dictionary\">health benefit plan<\/span> eligible for the <span class=\"dictionary\">program<\/span> (i) notice about the availability of the <span class=\"dictionary\">program<\/span>, (ii) a description of the incentives available to a <span class=\"dictionary\">covered person<\/span>, (iii) instructions on how to earn such incentives, and (iv) notification that tax treatment of the shared savings amounts or awards will be compliant with the rules of the Internal Revenue Service and treated as taxable income. <a id=\"paragraph-310577\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3462\/#F\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"G\"><p><span class=\"prefix-number\">G.<\/span> A <span class=\"dictionary\">comparable <span class=\"dictionary\">health care service<\/span><\/span> incentive payment made by a <span class=\"dictionary\">health carrier<\/span> in accordance with this section shall not constitute an administrative expense of the <span class=\"dictionary\">health carrier<\/span> for <span class=\"dictionary\">rate<\/span> development or <span class=\"dictionary\">rate<\/span> filing purposes. <a id=\"paragraph-310578\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3462\/#G\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"H\"><p><span class=\"prefix-number\">H.<\/span> Prior to offering the <span class=\"dictionary\">program<\/span> to any <span class=\"dictionary\">covered person<\/span>, a <span class=\"dictionary\">health carrier<\/span> shall file with the <span class=\"dictionary\">Commission<\/span> a description of the <span class=\"dictionary\">program<\/span> in the manner determined by the <span class=\"dictionary\">Commission<\/span>. The description shall include a demonstration by the <span class=\"dictionary\">health carrier<\/span> that the <span class=\"dictionary\">program<\/span> is cost-effective, including any data relied upon by the <span class=\"dictionary\">health carrier<\/span> in making such determination. The <span class=\"dictionary\">Commission<\/span> may review the filing made by the <span class=\"dictionary\">health carrier<\/span> to determine if the <span class=\"dictionary\">health carrier<\/span>&#8217;s <span class=\"dictionary\">program<\/span> complies with the requirements of this article. <a id=\"paragraph-310579\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3462\/#H\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"I\"><p><span class=\"prefix-number\">I.<\/span> A <span class=\"dictionary\">health carrier<\/span> may <span class=\"dictionary\">petition<\/span> the <span class=\"dictionary\">Commission<\/span> to be excluded from participation in the <span class=\"dictionary\">program<\/span>. The <span class=\"dictionary\">Commission<\/span> shall exempt from the <span class=\"dictionary\">program<\/span> a health plan with a limited <span class=\"dictionary\">provider network<\/span> that demonstrates that the network is incompatible with a shared savings <span class=\"dictionary\">program<\/span>. In making its determination, the <span class=\"dictionary\">Commission<\/span> shall consider the impact on premiums related to the administration of the <span class=\"dictionary\">program<\/span>. <a id=\"paragraph-310580\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3462\/#I\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"J\"><p><span class=\"prefix-number\">J.<\/span> Annually by April 1, each <span class=\"dictionary\">health carrier<\/span> shall file with the <span class=\"dictionary\">Commission<\/span>, for the most recent calendar year, the total number of <span class=\"dictionary\">comparable <span class=\"dictionary\">health care service<\/span><\/span> incentive payments made pursuant to this article, the use of <span class=\"dictionary\">comparable <span class=\"dictionary\">health care services<\/span><\/span> by category of service for which <span class=\"dictionary\">comparable <span class=\"dictionary\">health care service<\/span><\/span> incentives are made, the total payments made to <span class=\"dictionary\">covered persons<\/span>, the <span class=\"dictionary\">average<\/span> amount of incentive payments made by service for such transactions, the total savings achieved below the <span class=\"dictionary\">average<\/span> <span class=\"dictionary\">allowed amount<\/span> by service for such transactions, and the total number and percentage of a <span class=\"dictionary\">health carrier<\/span>&#8217;s <span class=\"dictionary\">covered persons<\/span> in small group <span class=\"dictionary\">health benefit plans<\/span> that participated in such transactions. <a id=\"paragraph-310581\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3462\/#J\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"K\"><p><span class=\"prefix-number\">K.<\/span> Beginning no later than 18 months after implementation of <span class=\"dictionary\">comparable <span class=\"dictionary\">health care service<\/span><\/span> incentive <span class=\"dictionary\">programs<\/span> under this section and annually by November 1 of each year thereafter, the <span class=\"dictionary\">Commission<\/span> shall submit an aggregate report for all <span class=\"dictionary\">health carriers<\/span> filing the information required by this section to the chairs of the House Committee on Labor and Commerce and Senate Committee on Commerce and Labor. <a id=\"paragraph-310582\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3462\/#K\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>","plain_text":"                                 CODE OF VIRGINIA\n\nCOMPARABLE HEALTH CARE SERVICE INCENTIVE PROGRAM (\u00a7 38.2-3462)\n\nA. Beginning with health benefit plans offered or renewed on or after January 1,\n2021, each health carrier offering a health benefit plan in the Commonwealth\nshall develop and implement a program that provides incentives for covered\npersons in its health benefit plan who elect to receive a comparable health care\nservice that is covered by the health benefit plan from health care providers\nthat are paid less than the average in-network allowed amount paid or payable by\nthat health carrier to network providers for that comparable health care\nservice. A health carrier may base the average paid to a network provider on\nwhat that health carrier pays to providers in the network applicable to the\ncovered person&#8217;s specific health benefit plan, or across all of its health\nbenefit plans offered in the Commonwealth.\n\nB. Incentives may include, but are not limited to, cash payments, gift cards, or\ncredits or reductions of premiums, copayments, or deductibles. Health carriers\nmay let covered persons decide which method they prefer to receive the\nincentive.\n\nC. The incentive program shall provide covered persons with an incentive for\neach service or category of comparable health care service resulting from\ncomparison shopping by covered persons. A health carrier is not required to\nprovide a payment or credit to a covered person when the health carrier&#8217;s\nsaved cost is $25 or less.\n\nD. A health carrier shall determine the allowed amount paid or payable by that\nhealth carrier to network providers for that comparable health care service on\nthe basis of the average allowed amount for the procedure or service under the\ncovered person&#8217;s health benefit plan. Such determination shall be made on\nthe basis of the average of the allowed amounts using data collected over a\nreasonable period not to exceed one year. A health carrier may determine an\nalternate methodology for calculating the average allowed amount if approved by\nthe Commission. A health carrier shall, at minimum, inform covered persons of\ntheir eligibility for an incentive payment and the process to request the\naverage allowed amount for a procedure or service on the health carrier&#8217;s\nwebsite and in health benefit plan materials.\n\nE. Eligibility for an incentive payment may require a covered person to\ndemonstrate, through reasonable documentation such as a quote from the health\ncare provider, that the covered person shopped prior to receiving care from the\nhealth care provider who charges less for the comparable health care service\nthan the average allowed amount paid or payable by that health carrier. Health\ncarriers shall provide additional mechanisms for the covered person to satisfy\nthis requirement by utilizing the health carrier&#8217;s cost transparency\nwebsite or toll-free number, established under this article.\n\nF. Each health carrier shall make the program available as a component of all\nsmall group health benefit plans offered by the health carrier in the\nCommonwealth. Annually at enrollment or renewal, each health carrier shall\nprovide to any covered person who is enrolled in a small group health benefit\nplan eligible for the program (i) notice about the availability of the program,\n(ii) a description of the incentives available to a covered person, (iii)\ninstructions on how to earn such incentives, and (iv) notification that tax\ntreatment of the shared savings amounts or awards will be compliant with the\nrules of the Internal Revenue Service and treated as taxable income.\n\nG. A comparable health care service incentive payment made by a health carrier\nin accordance with this section shall not constitute an administrative expense\nof the health carrier for rate development or rate filing purposes.\n\nH. Prior to offering the program to any covered person, a health carrier shall\nfile with the Commission a description of the program in the manner determined\nby the Commission. The description shall include a demonstration by the health\ncarrier that the program is cost-effective, including any data relied upon by\nthe health carrier in making such determination. The Commission may review the\nfiling made by the health carrier to determine if the health carrier&#8217;s\nprogram complies with the requirements of this article.\n\nI. A health carrier may petition the Commission to be excluded from\nparticipation in the program. The Commission shall exempt from the program a\nhealth plan with a limited provider network that demonstrates that the network\nis incompatible with a shared savings program. In making its determination, the\nCommission shall consider the impact on premiums related to the administration\nof the program.\n\nJ. Annually by April 1, each health carrier shall file with the Commission, for\nthe most recent calendar year, the total number of comparable health care\nservice incentive payments made pursuant to this article, the use of comparable\nhealth care services by category of service for which comparable health care\nservice incentives are made, the total payments made to covered persons, the\naverage amount of incentive payments made by service for such transactions, the\ntotal savings achieved below the average allowed amount by service for such\ntransactions, and the total number and percentage of a health carrier&#8217;s\ncovered persons in small group health benefit plans that participated in such\ntransactions.\n\nK. Beginning no later than 18 months after implementation of comparable health\ncare service incentive programs under this section and annually by November 1 of\neach year thereafter, the Commission shall submit an aggregate report for all\nhealth carriers filing the information required by this section to the chairs of\nthe House Committee on Labor and Commerce and Senate Committee on Commerce and\nLabor.\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}}