{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-4209.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-4209.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-4209.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-4209.html"}],"law_id":80669,"edition_id":1,"section_id":80669,"structure_id":12968,"section_number":"38.2-4209","catch_line":"Preferred provider subscription contracts","history":"1983, c. 464, \u00a7 38.1-813.4; 1986, c. 562; 1999, cc. 643, 649.","full_text":"A\n\nAs used in this section, a “preferred provider subscription contract” is a contract that specifies how services are to be covered when rendered by providers participating in a plan, by nonparticipating providers, and by preferred providers.B\n\nNotwithstanding the provisions of §§ 38.2-4218 and 38.2-4221, any nonstock corporation may, as a feature of its plan, offer preferred provider subscription contracts pursuant to the requirements of this section that limit the numbers and types of providers of health care services eligible for payment as preferred providers.C\n\nAny such nonstock corporation shall establish terms and conditions that shall be met by a hospital, physician or other type of provider listed in § 38.2-4221 in order to qualify for payment as a preferred provider under the subscription contracts. These terms and conditions shall not discriminate unreasonably against or among health care providers. No hospital, physician or type of provider listed in § 38.2-4221 willing to meet the terms and conditions offered to it or him shall be excluded. Differences in prices among hospitals or other institutional providers produced by a process of individual negotiations with the providers or based on market conditions, or price differences among providers in different geographical areas shall not be deemed unreasonable discrimination. The Commission shall have no jurisdiction to adjudicate controversies growing out of this subsection.D\n\nMandated types of providers listed in § 38.2-4221 and types of providers whose services are required to be made available and which have been specifically contracted for by the holder of any subscription contract shall, to the extent required by § 38.2-4221, have the same opportunity as do doctors of medicine to qualify for payment as preferred providers.E\n\nPreferred provider subscription contracts shall provide for payment for services rendered by nonpreferred providers, but the payments need not be the same as for preferred providers.F\n\nNo contract between a nonstock corporation and a provider shall include provisions which require a health care provider or health care provider group to deny covered services that such provider or group knows to be medically necessary and appropriate that are provided with respect to a specific enrollee or group of enrollees with similar medical conditions.","order_by":null,"text":{"0":{"id":289121,"text":"As used in this section, a “preferred provider subscription contract” is a contract that specifies how services are to be covered when rendered by providers participating in a plan, by nonparticipating providers, and by preferred providers.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":289122,"text":"Notwithstanding the provisions of §§ 38.2-4218 and 38.2-4221, any nonstock corporation may, as a feature of its plan, offer preferred provider subscription contracts pursuant to the requirements of this section that limit the numbers and types of providers of health care services eligible for payment as preferred providers.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":289123,"text":"Any such nonstock corporation shall establish terms and conditions that shall be met by a hospital, physician or other type of provider listed in § 38.2-4221 in order to qualify for payment as a preferred provider under the subscription contracts. These terms and conditions shall not discriminate unreasonably against or among health care providers. No hospital, physician or type of provider listed in § 38.2-4221 willing to meet the terms and conditions offered to it or him shall be excluded. Differences in prices among hospitals or other institutional providers produced by a process of individual negotiations with the providers or based on market conditions, or price differences among providers in different geographical areas shall not be deemed unreasonable discrimination. The Commission shall have no jurisdiction to adjudicate controversies growing out of this subsection.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":289124,"text":"Mandated types of providers listed in § 38.2-4221 and types of providers whose services are required to be made available and which have been specifically contracted for by the holder of any subscription contract shall, to the extent required by § 38.2-4221, have the same opportunity as do doctors of medicine to qualify for payment as preferred providers.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":289125,"text":"Preferred provider subscription contracts shall provide for payment for services rendered by nonpreferred providers, but the payments need not be the same as for preferred providers.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"5":{"id":289126,"text":"No contract between a nonstock corporation and a provider shall include provisions which require a health care provider or health care provider group to deny covered services that such provider or group knows to be medically necessary and appropriate that are provided with respect to a specific enrollee or group of enrollees with similar medical conditions.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E"}},"ancestry":[{"id":12968,"edition_id":1,"name":"In General","identifier":"1","label":"article","depth":3,"order_by":1,"parent_id":12967,"metadata":{},"date_created":"2026-06-26 03:44:05","date_modified":"2026-06-26 03:44:05","permalink":{"id":216659,"object_type":"structure","relational_id":12968,"identifier":"1","token":"38.2\/42\/1","url":"\/38.2\/42\/1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12967,"edition_id":1,"name":"Health Services Plans","identifier":"42","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:44:05","date_modified":"2026-06-26 03:44:05","permalink":{"id":216657,"object_type":"structure","relational_id":12967,"identifier":"42","token":"38.2\/42","url":"\/38.2\/42\/","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":78890,"structure_id":12968,"section_number":"38.2-4200","catch_line":"Applicability of chapter","url":"\/38.2-4200\/","token":"38.2\/42\/1\/38.2-4200","metadata":false},{"id":76897,"structure_id":12968,"section_number":"38.2-4201","catch_line":"Definitions","url":"\/38.2-4201\/","token":"38.2\/42\/1\/38.2-4201","metadata":false},{"id":71531,"structure_id":12968,"section_number":"38.2-4202","catch_line":"Hospital services plans","url":"\/38.2-4202\/","token":"38.2\/42\/1\/38.2-4202","metadata":false},{"id":80676,"structure_id":12968,"section_number":"38.2-4203","catch_line":"Medical or surgical services plans","url":"\/38.2-4203\/","token":"38.2\/42\/1\/38.2-4203","metadata":false},{"id":68874,"structure_id":12968,"section_number":"38.2-4204","catch_line":"Merger of nonstock 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corporation not required to act as agent","url":"\/38.2-4208\/","token":"38.2\/42\/1\/38.2-4208","metadata":false},{"id":80669,"structure_id":12968,"section_number":"38.2-4209","catch_line":"Preferred provider subscription contracts","url":"\/38.2-4209\/","token":"38.2\/42\/1\/38.2-4209","metadata":false},{"id":67453,"structure_id":12968,"section_number":"38.2-4209.1","catch_line":"Pharmacies; freedom of choice","url":"\/38.2-4209.1\/","token":"38.2\/42\/1\/38.2-4209.1","metadata":false},{"id":79670,"structure_id":12968,"section_number":"38.2-4209.2","catch_line":"Repealed","url":"\/38.2-4209.2\/","token":"38.2\/42\/1\/38.2-4209.2","metadata":false},{"id":65462,"structure_id":12968,"section_number":"38.2-4210","catch_line":"Liability of participants","url":"\/38.2-4210\/","token":"38.2\/42\/1\/38.2-4210","metadata":false},{"id":65554,"structure_id":12968,"section_number":"38.2-4211","catch_line":"Change of participants","url":"\/38.2-4211\/","token":"38.2\/42\/1\/38.2-4211","metadata":false},{"id":80058,"structure_id":12968,"section_number":"38.2-4212","catch_line":"Board of directors of nonstock corporation operating plan","url":"\/38.2-4212\/","token":"38.2\/42\/1\/38.2-4212","metadata":false},{"id":57906,"structure_id":12968,"section_number":"38.2-4213","catch_line":"Liability of participating providers upon merger of nonstock corporation","url":"\/38.2-4213\/","token":"38.2\/42\/1\/38.2-4213","metadata":false},{"id":55347,"structure_id":12968,"section_number":"38.2-4214","catch_line":"Application of certain provisions of law","url":"\/38.2-4214\/","token":"38.2\/42\/1\/38.2-4214","metadata":false},{"id":70935,"structure_id":12968,"section_number":"38.2-4214.1","catch_line":"Rehabilitation, liquidation, conservation","url":"\/38.2-4214.1\/","token":"38.2\/42\/1\/38.2-4214.1","metadata":false},{"id":69479,"structure_id":12968,"section_number":"38.2-4215","catch_line":"Payments by nonstock corporation","url":"\/38.2-4215\/","token":"38.2\/42\/1\/38.2-4215","metadata":false},{"id":83790,"structure_id":12968,"section_number":"38.2-4216","catch_line":"Repealed","url":"\/38.2-4216\/","token":"38.2\/42\/1\/38.2-4216","metadata":false},{"id":75758,"structure_id":12968,"section_number":"38.2-4216.1","catch_line":"Repealed","url":"\/38.2-4216.1\/","token":"38.2\/42\/1\/38.2-4216.1","metadata":false},{"id":76300,"structure_id":12968,"section_number":"38.2-4217","catch_line":"Reports","url":"\/38.2-4217\/","token":"38.2\/42\/1\/38.2-4217","metadata":false},{"id":73797,"structure_id":12968,"section_number":"38.2-4218","catch_line":"Subscriber to have free choice of medical practitioners available","url":"\/38.2-4218\/","token":"38.2\/42\/1\/38.2-4218","metadata":false},{"id":73334,"structure_id":12968,"section_number":"38.2-4219","catch_line":"Subscriber to be advised in writing as to benefits and limitations thereon","url":"\/38.2-4219\/","token":"38.2\/42\/1\/38.2-4219","metadata":false},{"id":57164,"structure_id":12968,"section_number":"38.2-4220","catch_line":"Interplan arrangements","url":"\/38.2-4220\/","token":"38.2\/42\/1\/38.2-4220","metadata":false},{"id":74708,"structure_id":12968,"section_number":"38.2-4221","catch_line":"Services of certain practitioners other than physicians to be covered","url":"\/38.2-4221\/","token":"38.2\/42\/1\/38.2-4221","metadata":false},{"id":70849,"structure_id":12968,"section_number":"38.2-4222","catch_line":"Licensing of nonstock corporations","url":"\/38.2-4222\/","token":"38.2\/42\/1\/38.2-4222","metadata":false},{"id":68899,"structure_id":12968,"section_number":"38.2-4223","catch_line":"Renewal of license","url":"\/38.2-4223\/","token":"38.2\/42\/1\/38.2-4223","metadata":false},{"id":63881,"structure_id":12968,"section_number":"38.2-4224","catch_line":"Licensing of agents","url":"\/38.2-4224\/","token":"38.2\/42\/1\/38.2-4224","metadata":false},{"id":75183,"structure_id":12968,"section_number":"38.2-4225","catch_line":"Repealed","url":"\/38.2-4225\/","token":"38.2\/42\/1\/38.2-4225","metadata":false},{"id":61125,"structure_id":12968,"section_number":"38.2-4226","catch_line":"Taxation","url":"\/38.2-4226\/","token":"38.2\/42\/1\/38.2-4226","metadata":false},{"id":78423,"structure_id":12968,"section_number":"38.2-4227","catch_line":"Misleading applications or contracts","url":"\/38.2-4227\/","token":"38.2\/42\/1\/38.2-4227","metadata":false},{"id":68671,"structure_id":12968,"section_number":"38.2-4228","catch_line":"Controversies involving subscription contracts","url":"\/38.2-4228\/","token":"38.2\/42\/1\/38.2-4228","metadata":false},{"id":60792,"structure_id":12968,"section_number":"38.2-4229","catch_line":"Reinsurance","url":"\/38.2-4229\/","token":"38.2\/42\/1\/38.2-4229","metadata":false},{"id":86012,"structure_id":12968,"section_number":"38.2-4229.1","catch_line":"Conversion to domestic mutual insurer","url":"\/38.2-4229.1\/","token":"38.2\/42\/1\/38.2-4229.1","metadata":false},{"id":82144,"structure_id":12968,"section_number":"38.2-4229.2","catch_line":"Hearings and investigations on effect of other state's law","url":"\/38.2-4229.2\/","token":"38.2\/42\/1\/38.2-4229.2","metadata":false}],"previous_section":{"id":61631,"structure_id":12968,"section_number":"38.2-4208","catch_line":"Nonstock corporation not required to act as agent","url":"\/38.2-4208\/","token":"38.2\/42\/1\/38.2-4208","metadata":false},"next_section":{"id":67453,"structure_id":12968,"section_number":"38.2-4209.1","catch_line":"Pharmacies; freedom of choice","url":"\/38.2-4209.1\/","token":"38.2\/42\/1\/38.2-4209.1","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-4209\/","history_text":"

This law was first created in 1983. The record of its establishment is cataloged in chapter 464 of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year. Unfortunately, the 1983 \u201cActs\u201d aren\u2019t available online. It has been modified 2 times. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. Those modifications are as follows: in 1986, chapter 562; in 1999, chapters 643<\/a> and 649<\/a>.<\/p>","references":[{"id":61229,"section_number":"32.1-137.1","catch_line":"Definitions","order_by":null,"url":"\/32.1-137.1\/"},{"id":58079,"section_number":"38.2-3407.10","catch_line":"Health care provider panels","order_by":null,"url":"\/38.2-3407.10\/"},{"id":68442,"section_number":"38.2-3407.12","catch_line":"Patient optional point-of-service benefit","order_by":null,"url":"\/38.2-3407.12\/"},{"id":67453,"section_number":"38.2-4209.1","catch_line":"Pharmacies; freedom of choice","order_by":null,"url":"\/38.2-4209.1\/"},{"id":74708,"section_number":"38.2-4221","catch_line":"Services of certain practitioners other than physicians to be covered","order_by":null,"url":"\/38.2-4221\/"},{"id":77304,"section_number":"38.2-5800","catch_line":"Definitions","order_by":null,"url":"\/38.2-5800\/"}],"refers_to":[{"id":73797,"section_number":"38.2-4218","catch_line":"Subscriber to have free choice of medical practitioners available","order_by":null,"url":"\/38.2-4218\/"},{"id":74708,"section_number":"38.2-4221","catch_line":"Services of certain practitioners other than physicians to be covered","order_by":null,"url":"\/38.2-4221\/"}],"permalink":{"id":216701,"object_type":"law","relational_id":80669,"identifier":"38.2-4209","token":"38.2\/42\/1\/38.2-4209","url":"\/38.2-4209\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-4209\/","token":"38.2\/42\/1\/38.2-4209","dublin_core":{"Title":"Preferred provider subscription contracts","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-4209","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> As used in this section, a “preferred provider subscription contract<\/span>” is a contract that specifies how services are to be covered when rendered by providers participating in a plan<\/span>, by nonparticipating providers, and by preferred providers. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> Notwithstanding the provisions of §§ 38.2-4218<\/a> and 38.2-4221<\/a>, any nonstock corporation<\/span> may, as a feature of its plan<\/span>, offer preferred provider subscription contracts<\/span> pursuant to the requirements of this section that limit the numbers and types of providers of health care services eligible for payment as preferred providers. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Any such nonstock corporation<\/span> shall establish terms and conditions that shall be met by a hospital, physician or other type of provider listed in § 38.2-4221<\/a> in order<\/span> to qualify for payment as a preferred provider under the subscription contracts<\/span>. These terms and conditions shall not discriminate unreasonably against or among health care providers. No hospital, physician or type of provider listed in § 38.2-4221<\/a> willing to meet the terms and conditions offered to it or him shall be excluded. Differences in prices among hospitals or other institutional providers produced by a process of individual negotiations with the providers or based on market conditions, or price differences among providers in different geographical areas shall not be deemed unreasonable discrimination. The Commission<\/span> shall have no jurisdiction<\/span> to adjudicate<\/span> controversies growing out of this subsection. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> Mandated types of providers listed in § 38.2-4221<\/a> and types of providers whose services are required to be made available and which have been specifically contracted for by the holder of any subscription contract<\/span> shall, to the extent required by § 38.2-4221<\/a>, have the same opportunity as do doctors of medicine to qualify for payment as preferred providers. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

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

F.<\/span> No contract between a nonstock corporation<\/span> and a provider shall include provisions which require a health care provider or health care provider group to deny covered services that such provider or group knows to be medically necessary and appropriate that are provided with respect to a specific enrollee or group of enrollees with similar medical conditions. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nPREFERRED PROVIDER SUBSCRIPTION CONTRACTS (\u00a7 38.2-4209)\n\nA. As used in this section, a “preferred provider subscription\ncontract” is a contract that specifies how services are to be covered when\nrendered by providers participating in a plan, by nonparticipating providers,\nand by preferred providers.\n\nB. Notwithstanding the provisions of §§ 38.2-4218 and 38.2-4221, any\nnonstock corporation may, as a feature of its plan, offer preferred provider\nsubscription contracts pursuant to the requirements of this section that limit\nthe numbers and types of providers of health care services eligible for payment\nas preferred providers.\n\nC. Any such nonstock corporation shall establish terms and conditions that shall\nbe met by a hospital, physician or other type of provider listed in §\n38.2-4221 in order to qualify for payment as a preferred provider under the\nsubscription contracts. These terms and conditions shall not discriminate\nunreasonably against or among health care providers. No hospital, physician or\ntype of provider listed in § 38.2-4221 willing to meet the terms and\nconditions offered to it or him shall be excluded. Differences in prices among\nhospitals or other institutional providers produced by a process of individual\nnegotiations with the providers or based on market conditions, or price\ndifferences among providers in different geographical areas shall not be deemed\nunreasonable discrimination. The Commission shall have no jurisdiction to\nadjudicate controversies growing out of this subsection.\n\nD. Mandated types of providers listed in § 38.2-4221 and types of providers\nwhose services are required to be made available and which have been\nspecifically contracted for by the holder of any subscription contract shall, to\nthe extent required by § 38.2-4221, have the same opportunity as do doctors\nof medicine to qualify for payment as preferred providers.\n\nE. Preferred provider subscription contracts shall provide for payment for\nservices rendered by nonpreferred providers, but the payments need not be the\nsame as for preferred providers.\n\nF. No contract between a nonstock corporation and a provider shall include\nprovisions which require a health care provider or health care provider group to\ndeny covered services that such provider or group knows to be medically\nnecessary and appropriate that are provided with respect to a specific enrollee\nor group of enrollees with similar medical conditions.\n\nHISTORY: 1983, c. 464, \u00a7 38.1-813.4; 1986, c. 562; 1999, cc. 643, 649.","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}}