{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-4300.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-4300.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-4300.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-4300.html"}],"law_id":72005,"edition_id":1,"section_id":72005,"structure_id":12833,"section_number":"38.2-4300","catch_line":"Definitions","history":"1980, c. 720, \u00a7 38.1-863; 1986, cc. 76, 528, 562; 1990, c. 224; 1992, cc. 241, 481; 1993, c. 305; 1995, cc. 182, 345; 2000, c. 503; 2003, cc. 752, 767; 2004, c. 175; 2006, c. 448; 2015, c. 649.","full_text":"As used in this chapter:\n\t\t“Acceptable securities” means securities that (i) are legal investments under the laws of the Commonwealth for public sinking funds or for other public funds, (ii) are not in default as to principal or interest, (iii) have a current market value of not less than $50,000 nor more than $500,000, and (iv) are issued pursuant to a system of book-entry evidencing ownership interests of the securities with transfers of ownership effected on the records of the depository and its participants pursuant to rules and procedures established by the depository.\n\t\t“Basic health care services” means in and out-of-area emergency services, inpatient hospital and physician care, outpatient medical services, laboratory and radiologic services, mental health and substance use disorder benefits, and preventive health services. In the case of a health maintenance organization that has contracted with the Commonwealth to furnish basic health services to recipients of medical assistance under Title XIX of the United States Social Security Act pursuant to \u00a7 38.2-4320, the basic health services to be provided by the health maintenance organization to program recipients may differ from the basic health services required by this section to the extent necessary to meet the benefit standards prescribed by the state plan for medical assistance services authorized pursuant to \u00a7 32.1-325.\n\t\t“Copayment” means an amount an enrollee is required to pay in order to receive a specific health care service.\n\t\t“Deductible” means an amount an enrollee is required to pay out-of-pocket before the health care plan begins to pay the costs associated with health care services.\n\t\t“Emergency services” means those health care services that are rendered by affiliated or nonaffiliated providers after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in (i) serious jeopardy to the mental or physical health of the individual, (ii) danger of serious impairment of the individual’s bodily functions, (iii) serious dysfunction of any of the individual’s bodily organs, or (iv) in the case of a pregnant woman, serious jeopardy to the health of the fetus. Emergency services provided within the plan’s service area shall include covered health care services from nonaffiliated providers only when delay in receiving care from a provider affiliated with the health maintenance organization could reasonably be expected to cause the enrollee’s condition to worsen if left unattended.\n\t\t“Enrollee” or “member” means an individual who is enrolled in a health care plan.\n\t\t“Evidence of coverage” means any certificate or individual or group agreement or contract issued in conjunction with the certificate, agreement or contract, issued to a subscriber setting out the coverage and other rights to which an enrollee is entitled.\n\t\t“Excess insurance” or “stop loss insurance” means insurance issued to a health maintenance organization by an insurer licensed in the Commonwealth, on a form approved by the Commission, or a risk assumption transaction acceptable to the Commission, providing indemnity or reimbursement against the cost of health care services provided by the health maintenance organization.\n\t\t“Health care plan” means any arrangement in which any person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services. A significant part of the arrangement shall consist of arranging for or providing health care services, including emergency services and services rendered by nonparticipating referral providers, as distinguished from mere indemnification against the cost of the services, on a prepaid basis. For purposes of this section, a significant part shall mean at least 90 percent of total costs of health care services.\n\t\t“Health care services” means the furnishing of services to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability.\n\t\t“Health maintenance organization” means any person who undertakes to provide or arrange for one or more health care plans.\n\t\t“Limited health care services” means dental care services, vision care services, and such other services as may be determined by the Commission to be limited health care services. Limited health care services shall not include hospital, medical, surgical, or emergency services except as such services are provided incident to the limited health care services set forth in the preceding sentence.\n\t\t“Net worth” or “capital and surplus” means the excess of total admitted assets over the total liabilities of the health maintenance organization, provided that surplus notes shall be reported and accounted for in accordance with guidance set forth in the National Association of Insurance Commissioners (NAIC) accounting practice and procedures manuals.\n\t\t“Nonparticipating referral provider” means a provider who is not a participating provider but with whom a health maintenance organization has arranged, through referral by its participating providers, to provide health care services to enrollees. Payment or reimbursement by a health maintenance organization for health care services provided by nonparticipating referral providers may exceed five percent of total costs of health care services, only to the extent that any such excess payment or reimbursement over five percent shall be combined with the costs for services which represent mere indemnification, with the combined amount subject to the combination of limitations set forth in this definition and in this section’s definition of health care plan.\n\t\t“Participating provider” means a provider who has agreed to provide health care services to enrollees and to hold those enrollees harmless from payment with an expectation of receiving payment, other than copayments or deductibles, directly or indirectly from the health maintenance organization.\n\t\t“Provider” or “health care provider” means any physician, hospital, or other person that is licensed or otherwise authorized in the Commonwealth to furnish health care services.\n\t\t“Subscriber” means a contract holder, an individual enrollee, or the enrollee in an enrolled family who is responsible for payment to the health maintenance organization or on whose behalf such payment is made.","order_by":null,"text":{"0":{"id":259446,"text":"As used in this chapter:\n\t\t“Acceptable securities” means securities that (i) are legal investments under the laws of the Commonwealth for public sinking funds or for other public funds, (ii) are not in default as to principal or interest, (iii) have a current market value of not less than $50,000 nor more than $500,000, and (iv) are issued pursuant to a system of book-entry evidencing ownership interests of the securities with transfers of ownership effected on the records of the depository and its participants pursuant to rules and procedures established by the depository.\n\t\t“Basic health care services” means in and out-of-area emergency services, inpatient hospital and physician care, outpatient medical services, laboratory and radiologic services, mental health and substance use disorder benefits, and preventive health services. In the case of a health maintenance organization that has contracted with the Commonwealth to furnish basic health services to recipients of medical assistance under Title XIX of the United States Social Security Act pursuant to \u00a7 38.2-4320, the basic health services to be provided by the health maintenance organization to program recipients may differ from the basic health services required by this section to the extent necessary to meet the benefit standards prescribed by the state plan for medical assistance services authorized pursuant to \u00a7 32.1-325.\n\t\t“Copayment” means an amount an enrollee is required to pay in order to receive a specific health care service.\n\t\t“Deductible” means an amount an enrollee is required to pay out-of-pocket before the health care plan begins to pay the costs associated with health care services.\n\t\t“Emergency services” means those health care services that are rendered by affiliated or nonaffiliated providers after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in (i) serious jeopardy to the mental or physical health of the individual, (ii) danger of serious impairment of the individual’s bodily functions, (iii) serious dysfunction of any of the individual’s bodily organs, or (iv) in the case of a pregnant woman, serious jeopardy to the health of the fetus. Emergency services provided within the plan’s service area shall include covered health care services from nonaffiliated providers only when delay in receiving care from a provider affiliated with the health maintenance organization could reasonably be expected to cause the enrollee’s condition to worsen if left unattended.\n\t\t“Enrollee” or “member” means an individual who is enrolled in a health care plan.\n\t\t“Evidence of coverage” means any certificate or individual or group agreement or contract issued in conjunction with the certificate, agreement or contract, issued to a subscriber setting out the coverage and other rights to which an enrollee is entitled.\n\t\t“Excess insurance” or “stop loss insurance” means insurance issued to a health maintenance organization by an insurer licensed in the Commonwealth, on a form approved by the Commission, or a risk assumption transaction acceptable to the Commission, providing indemnity or reimbursement against the cost of health care services provided by the health maintenance organization.\n\t\t“Health care plan” means any arrangement in which any person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services. A significant part of the arrangement shall consist of arranging for or providing health care services, including emergency services and services rendered by nonparticipating referral providers, as distinguished from mere indemnification against the cost of the services, on a prepaid basis. For purposes of this section, a significant part shall mean at least 90 percent of total costs of health care services.\n\t\t“Health care services” means the furnishing of services to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability.\n\t\t“Health maintenance organization” means any person who undertakes to provide or arrange for one or more health care plans.\n\t\t“Limited health care services” means dental care services, vision care services, and such other services as may be determined by the Commission to be limited health care services. Limited health care services shall not include hospital, medical, surgical, or emergency services except as such services are provided incident to the limited health care services set forth in the preceding sentence.\n\t\t“Net worth” or “capital and surplus” means the excess of total admitted assets over the total liabilities of the health maintenance organization, provided that surplus notes shall be reported and accounted for in accordance with guidance set forth in the National Association of Insurance Commissioners (NAIC) accounting practice and procedures manuals.\n\t\t“Nonparticipating referral provider” means a provider who is not a participating provider but with whom a health maintenance organization has arranged, through referral by its participating providers, to provide health care services to enrollees. Payment or reimbursement by a health maintenance organization for health care services provided by nonparticipating referral providers may exceed five percent of total costs of health care services, only to the extent that any such excess payment or reimbursement over five percent shall be combined with the costs for services which represent mere indemnification, with the combined amount subject to the combination of limitations set forth in this definition and in this section’s definition of health care plan.\n\t\t“Participating provider” means a provider who has agreed to provide health care services to enrollees and to hold those enrollees harmless from payment with an expectation of receiving payment, other than copayments or deductibles, directly or indirectly from the health maintenance organization.\n\t\t“Provider” or “health care provider” means any physician, hospital, or other person that is licensed or otherwise authorized in the Commonwealth to furnish health care services.\n\t\t“Subscriber” means a contract holder, an individual enrollee, or the enrollee in an enrolled family who is responsible for payment to the health maintenance organization or on whose behalf such payment is made.","type":"section","prefixes":[""],"prefix":"","entire_prefix":"","prefix_anchor":"","level":1}},"ancestry":[{"id":12833,"edition_id":1,"name":"Health Maintenance Organizations","identifier":"43","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:43:55","date_modified":"2026-06-26 03:43:55","permalink":{"id":216835,"object_type":"structure","relational_id":12833,"identifier":"43","token":"38.2\/43","url":"\/38.2\/43\/","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":72005,"structure_id":12833,"section_number":"38.2-4300","catch_line":"Definitions","url":"\/38.2-4300\/","token":"38.2\/43\/38.2-4300","metadata":false},{"id":80882,"structure_id":12833,"section_number":"38.2-4301","catch_line":"Establishment of health maintenance organizations","url":"\/38.2-4301\/","token":"38.2\/43\/38.2-4301","metadata":false},{"id":64417,"structure_id":12833,"section_number":"38.2-4302","catch_line":"Issuance of license; fee; minimum net worth; impairment","url":"\/38.2-4302\/","token":"38.2\/43\/38.2-4302","metadata":false},{"id":73205,"structure_id":12833,"section_number":"38.2-4303","catch_line":"Powers","url":"\/38.2-4303\/","token":"38.2\/43\/38.2-4303","metadata":false},{"id":68216,"structure_id":12833,"section_number":"38.2-4304","catch_line":"Governing body","url":"\/38.2-4304\/","token":"38.2\/43\/38.2-4304","metadata":false},{"id":54130,"structure_id":12833,"section_number":"38.2-4305","catch_line":"Fiduciary responsibilities","url":"\/38.2-4305\/","token":"38.2\/43\/38.2-4305","metadata":false},{"id":81322,"structure_id":12833,"section_number":"38.2-4306","catch_line":"Evidence of coverage and charges for health care services","url":"\/38.2-4306\/","token":"38.2\/43\/38.2-4306","metadata":false},{"id":73640,"structure_id":12833,"section_number":"38.2-4306.1","catch_line":"Interest on claim proceeds","url":"\/38.2-4306.1\/","token":"38.2\/43\/38.2-4306.1","metadata":false},{"id":65829,"structure_id":12833,"section_number":"38.2-4307","catch_line":"Annual statement","url":"\/38.2-4307\/","token":"38.2\/43\/38.2-4307","metadata":false},{"id":85130,"structure_id":12833,"section_number":"38.2-4307.1","catch_line":"Additional reports","url":"\/38.2-4307.1\/","token":"38.2\/43\/38.2-4307.1","metadata":false},{"id":77610,"structure_id":12833,"section_number":"38.2-4308","catch_line":"Repealed","url":"\/38.2-4308\/","token":"38.2\/43\/38.2-4308","metadata":false},{"id":80159,"structure_id":12833,"section_number":"38.2-4309","catch_line":"Investments","url":"\/38.2-4309\/","token":"38.2\/43\/38.2-4309","metadata":false},{"id":84555,"structure_id":12833,"section_number":"38.2-4310","catch_line":"Protection against insolvency","url":"\/38.2-4310\/","token":"38.2\/43\/38.2-4310","metadata":false},{"id":59833,"structure_id":12833,"section_number":"38.2-4310.1","catch_line":"Deposits","url":"\/38.2-4310.1\/","token":"38.2\/43\/38.2-4310.1","metadata":false},{"id":53983,"structure_id":12833,"section_number":"38.2-4311","catch_line":"Repealed","url":"\/38.2-4311\/","token":"38.2\/43\/38.2-4311","metadata":false},{"id":62703,"structure_id":12833,"section_number":"38.2-4312","catch_line":"Prohibited practices","url":"\/38.2-4312\/","token":"38.2\/43\/38.2-4312","metadata":false},{"id":82617,"structure_id":12833,"section_number":"38.2-4312.1","catch_line":"Pharmacies; freedom of choice","url":"\/38.2-4312.1\/","token":"38.2\/43\/38.2-4312.1","metadata":false},{"id":71246,"structure_id":12833,"section_number":"38.2-4312.2","catch_line":"Repealed","url":"\/38.2-4312.2\/","token":"38.2\/43\/38.2-4312.2","metadata":false},{"id":79585,"structure_id":12833,"section_number":"38.2-4312.3","catch_line":"Patient access to emergency services","url":"\/38.2-4312.3\/","token":"38.2\/43\/38.2-4312.3","metadata":false},{"id":70762,"structure_id":12833,"section_number":"38.2-4313","catch_line":"Licensing of agents","url":"\/38.2-4313\/","token":"38.2\/43\/38.2-4313","metadata":false},{"id":73994,"structure_id":12833,"section_number":"38.2-4314","catch_line":"Powers of insurers and health services plans","url":"\/38.2-4314\/","token":"38.2\/43\/38.2-4314","metadata":false},{"id":60856,"structure_id":12833,"section_number":"38.2-4315","catch_line":"Examinations","url":"\/38.2-4315\/","token":"38.2\/43\/38.2-4315","metadata":false},{"id":61029,"structure_id":12833,"section_number":"38.2-4316","catch_line":"Suspension or revocation of license","url":"\/38.2-4316\/","token":"38.2\/43\/38.2-4316","metadata":false},{"id":82370,"structure_id":12833,"section_number":"38.2-4317","catch_line":"Repealed","url":"\/38.2-4317\/","token":"38.2\/43\/38.2-4317","metadata":false},{"id":84618,"structure_id":12833,"section_number":"38.2-4318","catch_line":"License renewals","url":"\/38.2-4318\/","token":"38.2\/43\/38.2-4318","metadata":false},{"id":67952,"structure_id":12833,"section_number":"38.2-4319","catch_line":"Statutory construction and relationship to other laws","url":"\/38.2-4319\/","token":"38.2\/43\/38.2-4319","metadata":false},{"id":74856,"structure_id":12833,"section_number":"38.2-4320","catch_line":"Authority of Commonwealth to contract with health maintenance organizations","url":"\/38.2-4320\/","token":"38.2\/43\/38.2-4320","metadata":false},{"id":74357,"structure_id":12833,"section_number":"38.2-4320.1","catch_line":"Explanation of benefits for health maintenance organization enrollees who are recipients of medical assistance services or covered by the Family Access to Medical Insurance Security (FAMIS) Plan","url":"\/38.2-4320.1\/","token":"38.2\/43\/38.2-4320.1","metadata":false},{"id":74331,"structure_id":12833,"section_number":"38.2-4321","catch_line":"Health maintenance organization affected by chapter","url":"\/38.2-4321\/","token":"38.2\/43\/38.2-4321","metadata":false},{"id":63129,"structure_id":12833,"section_number":"38.2-4322","catch_line":"Affiliation period","url":"\/38.2-4322\/","token":"38.2\/43\/38.2-4322","metadata":false},{"id":67176,"structure_id":12833,"section_number":"38.2-4323","catch_line":"Alternative methods","url":"\/38.2-4323\/","token":"38.2\/43\/38.2-4323","metadata":false}],"next_section":{"id":80882,"structure_id":12833,"section_number":"38.2-4301","catch_line":"Establishment of health maintenance organizations","url":"\/38.2-4301\/","token":"38.2\/43\/38.2-4301","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-4300\/","history_text":"

This law was first created in 1980. The record of its establishment is cataloged in chapter 720 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 1980 \u201cActs\u201d aren\u2019t available online. It has been modified 10 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, chapters 76, 528, and 562; in 1990, chapter 224; in 1992, chapters 241 and 481; in 1993, chapter 305; in 1995, chapters 182<\/a> and 345<\/a>; in 2000, chapter 503<\/a>; in 2003, chapters 752<\/a> and 767<\/a>; in 2004, chapter 175<\/a>; in 2006, chapter 448<\/a>; in 2015, chapter 649<\/a>.<\/p>","references":[{"id":61229,"section_number":"32.1-137.1","catch_line":"Definitions","order_by":null,"url":"\/32.1-137.1\/"},{"id":67276,"section_number":"32.1-276.3","catch_line":"Definitions","order_by":null,"url":"\/32.1-276.3\/"},{"id":56976,"section_number":"32.1-373","catch_line":"Definitions","order_by":null,"url":"\/32.1-373\/"},{"id":59918,"section_number":"38.2-100","catch_line":"Definitions","order_by":null,"url":"\/38.2-100\/"},{"id":55817,"section_number":"38.2-1016.1","catch_line":"Conversion of a health maintenance organization to an accident and sickness insurer","order_by":null,"url":"\/38.2-1016.1\/"},{"id":57145,"section_number":"38.2-1401","catch_line":"Definitions","order_by":null,"url":"\/38.2-1401\/"},{"id":58116,"section_number":"38.2-1837","catch_line":"Definitions","order_by":null,"url":"\/38.2-1837\/"},{"id":82480,"section_number":"38.2-2201","catch_line":"Provisions for payment of medical expense and loss of income benefits; assignment of certain benefits","order_by":null,"url":"\/38.2-2201\/"},{"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":57129,"section_number":"38.2-3407.4:2","catch_line":"Requirements for prescription benefit cards","order_by":null,"url":"\/38.2-3407.4_2\/"},{"id":83778,"section_number":"38.2-3407.6","catch_line":"Exclusion of podiatrist not permitted under certain circumstances","order_by":null,"url":"\/38.2-3407.6\/"},{"id":57210,"section_number":"38.2-3438","catch_line":"Definitions","order_by":null,"url":"\/38.2-3438\/"},{"id":76670,"section_number":"38.2-3551","catch_line":"Definitions","order_by":null,"url":"\/38.2-3551\/"},{"id":79956,"section_number":"38.2-501","catch_line":"Definitions","order_by":null,"url":"\/38.2-501\/"},{"id":68244,"section_number":"38.2-5500","catch_line":"Applicability","order_by":null,"url":"\/38.2-5500\/"},{"id":67232,"section_number":"38.2-5501","catch_line":"Definitions","order_by":null,"url":"\/38.2-5501\/"},{"id":77304,"section_number":"38.2-5800","catch_line":"Definitions","order_by":null,"url":"\/38.2-5800\/"},{"id":54793,"section_number":"38.2-5802","catch_line":"Establishment of an MCHIP","order_by":null,"url":"\/38.2-5802\/"},{"id":64365,"section_number":"38.2-6100","catch_line":"Applicability of chapter","order_by":null,"url":"\/38.2-6100\/"},{"id":59177,"section_number":"54.1-2404","catch_line":"Itemized statements required upon request","order_by":null,"url":"\/54.1-2404\/"},{"id":71560,"section_number":"8.01-27.5","catch_line":"Duty of in-network providers to submit claims to health insurers; liability of covered patients for unbilled health care services","order_by":null,"url":"\/8.01-27.5\/"},{"id":79489,"section_number":"8.01-581.1","catch_line":"Definitions","order_by":null,"url":"\/8.01-581.1\/"}],"refers_to":[{"id":77747,"section_number":"32.1-325","catch_line":"Board to submit plan for medical assistance services to U.S. Secretary of Health and Human Services pursuant to federal law; administration of plan; contracts with health care providers","order_by":null,"url":"\/32.1-325\/"},{"id":74856,"section_number":"38.2-4320","catch_line":"Authority of Commonwealth to contract with health maintenance organizations","order_by":null,"url":"\/38.2-4320\/"}],"permalink":{"id":216837,"object_type":"law","relational_id":72005,"identifier":"38.2-4300","token":"38.2\/43\/38.2-4300","url":"\/38.2-4300\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-4300\/","token":"38.2\/43\/38.2-4300","dublin_core":{"Title":"Definitions","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-4300","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

As used in this chapter:\n\t\t“Acceptable securities<\/span>” means securities that (i) are legal investments under the laws<\/span> of the Commonwealth for public sinking funds or for other public funds, (ii) are not in default<\/span> as to principal or interest, (iii) have a current market value of not less than $50,000 nor more than $500,000, and (iv) are issued pursuant to a system of book-entry evidencing ownership interests of the securities with transfers of ownership effected on the records of the depository and its participants pursuant to rules and procedures established by the depository.\n\t\t“Basic health care services<\/span><\/span>” means in and out-of-area emergency services<\/span>, inpatient hospital and physician care, outpatient medical services, laboratory and radiologic services, mental health and substance use disorder benefits, and preventive health services. In the case of a health maintenance organization<\/span> that has contracted with the Commonwealth to furnish basic health services to recipients of medical assistance under Title XIX of the United States<\/span> Social Security Act pursuant to \u00a7 38.2-4320<\/a>, the basic health services to be provided by the health maintenance organization<\/span> to program recipients may differ from the basic health services required by this section to the extent necessary to meet the benefit standards prescribed by the state<\/span> plan for medical assistance services authorized pursuant to \u00a7 32.1-325<\/a>.\n\t\t“Copayment<\/span>” means an amount an enrollee<\/span> is required to pay in order<\/span> to receive a specific health care service.\n\t\t“Deductible<\/span>” means an amount an enrollee<\/span> is required to pay out-of-pocket before the health care plan<\/span> begins to pay the costs associated with health care services<\/span>.\n\t\t“Emergency services<\/span>” means those health care services<\/span> that are rendered by affiliated or nonaffiliated providers after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in (i) serious jeopardy to the mental or physical health of the individual, (ii) danger of serious impairment of the individual’s bodily functions, (iii) serious dysfunction of any of the individual’s bodily organs, or (iv) in the case of a pregnant woman, serious jeopardy to the health of the fetus. Emergency services<\/span> provided within the plan’s service area shall include covered health care services<\/span> from nonaffiliated providers only when delay in receiving care from a provider affiliated with the health maintenance organization<\/span> could reasonably be expected to cause the enrollee<\/span>’s condition to worsen if left unattended.\n\t\t“Enrollee<\/span>” or “member<\/span>” means an individual who is enrolled in a health care plan<\/span>.\n\t\t“Evidence of coverage<\/span>” means any certificate or individual or group agreement or contract<\/span> issued in conjunction with the certificate, agreement or contract<\/span>, issued to a subscriber<\/span> setting out the coverage and other rights to which an enrollee<\/span> is entitled.\n\t\t“Excess insurance<\/span>” or “stop loss insurance<\/span>” means insurance issued to a health maintenance organization<\/span> by an insurer<\/span> licensed in the Commonwealth, on a form approved by the Commission<\/span>, or a risk assumption transaction acceptable to the Commission<\/span>, providing indemnity or reimbursement against the cost of health care services<\/span> provided by the health maintenance organization<\/span>.\n\t\t“Health care plan<\/span>” means any arrangement in which any person<\/span> undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services<\/span>. A significant part of the arrangement shall consist of arranging for or providing health care services<\/span>, including emergency services<\/span> and services rendered by nonparticipating referral providers<\/span>, as distinguished from mere indemnification against the cost of the services, on a prepaid basis. For purposes of this section, a significant part shall mean at least 90 percent of total costs of health care services<\/span>.\n\t\t“Health care services<\/span>” means the furnishing of services to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability.\n\t\t“Health maintenance organization<\/span>” means any person<\/span> who undertakes to provide or arrange for one or more health care plans<\/span>.\n\t\t“Limited health care services<\/span><\/span>” means dental care services, vision care services, and such other services as may be determined by the Commission<\/span> to be limited health care services<\/span><\/span>. Limited health care services<\/span><\/span> shall not include hospital, medical, surgical, or emergency services<\/span> except as such services are provided incident to the limited health care services<\/span><\/span> set forth in the preceding sentence.\n\t\t“Net worth<\/span>” or “capital and surplus<\/span>” means the excess of total admitted assets<\/span> over the total liabilities of the health maintenance organization<\/span>, provided that surplus notes shall be reported and accounted for in accordance with guidance set forth in the National Association of Insurance Commissioners<\/span> (NAIC) accounting practice and procedures manuals.\n\t\t“Nonparticipating referral provider<\/span>” means a provider who is not a participating provider<\/span> but with whom a health maintenance organization<\/span> has arranged, through referral by its participating providers<\/span>, to provide health care services<\/span> to enrollees<\/span>. Payment or reimbursement by a health maintenance organization<\/span> for health care services<\/span> provided by nonparticipating referral providers<\/span> may exceed five percent of total costs of health care services<\/span>, only to the extent that any such excess payment or reimbursement over five percent shall be combined with the costs for services which represent mere indemnification, with the combined amount subject to the combination of limitations set forth in this definition and in this section’s definition of health care plan<\/span>.\n\t\t“Participating provider<\/span>” means a provider who has agreed to provide health care services<\/span> to enrollees<\/span> and to hold those enrollees<\/span> harmless from payment with an expectation of receiving payment, other than copayments<\/span> or deductibles<\/span>, directly or indirectly from the health maintenance organization<\/span>.\n\t\t“Provider” or “health care provider<\/span>” means any physician, hospital, or other person<\/span> that is licensed or otherwise authorized in the Commonwealth to furnish health care services<\/span>.\n\t\t“Subscriber<\/span>” means a contract<\/span> holder, an individual enrollee<\/span>, or the enrollee<\/span> in an enrolled family who is responsible for payment to the health maintenance organization<\/span> or on whose behalf such payment is made.<\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nDEFINITIONS (\u00a7 38.2-4300)\n\nAs used in this chapter:\n\t\t“Acceptable securities” means securities that (i) are legal\ninvestments under the laws of the Commonwealth for public sinking funds or for\nother public funds, (ii) are not in default as to principal or interest, (iii)\nhave a current market value of not less than $50,000 nor more than $500,000, and\n(iv) are issued pursuant to a system of book-entry evidencing ownership\ninterests of the securities with transfers of ownership effected on the records\nof the depository and its participants pursuant to rules and procedures\nestablished by the depository.\n\t\t“Basic health care services” means in and out-of-area emergency\nservices, inpatient hospital and physician care, outpatient medical services,\nlaboratory and radiologic services, mental health and substance use disorder\nbenefits, and preventive health services. In the case of a health maintenance\norganization that has contracted with the Commonwealth to furnish basic health\nservices to recipients of medical assistance under Title XIX of the United\nStates Social Security Act pursuant to \u00a7 38.2-4320, the basic health services\nto be provided by the health maintenance organization to program recipients may\ndiffer from the basic health services required by this section to the extent\nnecessary to meet the benefit standards prescribed by the state plan for medical\nassistance services authorized pursuant to \u00a7 32.1-325.\n\t\t“Copayment” means an amount an enrollee is required to pay in\norder to receive a specific health care service.\n\t\t“Deductible” means an amount an enrollee is required to pay\nout-of-pocket before the health care plan begins to pay the costs associated\nwith health care services.\n\t\t“Emergency services” means those health care services that are\nrendered by affiliated or nonaffiliated providers after the sudden onset of a\nmedical condition that manifests itself by symptoms of sufficient severity,\nincluding severe pain, that the absence of immediate medical attention could\nreasonably be expected by a prudent layperson who possesses an average knowledge\nof health and medicine to result in (i) serious jeopardy to the mental or\nphysical health of the individual, (ii) danger of serious impairment of the\nindividual’s bodily functions, (iii) serious dysfunction of any of the\nindividual’s bodily organs, or (iv) in the case of a pregnant woman,\nserious jeopardy to the health of the fetus. Emergency services provided within\nthe plan’s service area shall include covered health care services from\nnonaffiliated providers only when delay in receiving care from a provider\naffiliated with the health maintenance organization could reasonably be expected\nto cause the enrollee’s condition to worsen if left unattended.\n\t\t“Enrollee” or “member” means an individual who is\nenrolled in a health care plan.\n\t\t“Evidence of coverage” means any certificate or individual or\ngroup agreement or contract issued in conjunction with the certificate,\nagreement or contract, issued to a subscriber setting out the coverage and other\nrights to which an enrollee is entitled.\n\t\t“Excess insurance” or “stop loss insurance” means\ninsurance issued to a health maintenance organization by an insurer licensed in\nthe Commonwealth, on a form approved by the Commission, or a risk assumption\ntransaction acceptable to the Commission, providing indemnity or reimbursement\nagainst the cost of health care services provided by the health maintenance\norganization.\n\t\t“Health care plan” means any arrangement in which any person\nundertakes to provide, arrange for, pay for, or reimburse any part of the cost\nof any health care services. A significant part of the arrangement shall consist\nof arranging for or providing health care services, including emergency services\nand services rendered by nonparticipating referral providers, as distinguished\nfrom mere indemnification against the cost of the services, on a prepaid basis.\nFor purposes of this section, a significant part shall mean at least 90 percent\nof total costs of health care services.\n\t\t“Health care services” means the furnishing of services to any\nindividual for the purpose of preventing, alleviating, curing, or healing human\nillness, injury, or physical disability.\n\t\t“Health maintenance organization” means any person who undertakes\nto provide or arrange for one or more health care plans.\n\t\t“Limited health care services” means dental care services, vision\ncare services, and such other services as may be determined by the Commission to\nbe limited health care services. Limited health care services shall not include\nhospital, medical, surgical, or emergency services except as such services are\nprovided incident to the limited health care services set forth in the preceding\nsentence.\n\t\t“Net worth” or “capital and surplus” means the excess\nof total admitted assets over the total liabilities of the health maintenance\norganization, provided that surplus notes shall be reported and accounted for in\naccordance with guidance set forth in the National Association of Insurance\nCommissioners (NAIC) accounting practice and procedures manuals.\n\t\t“Nonparticipating referral provider” means a provider who is not a\nparticipating provider but with whom a health maintenance organization has\narranged, through referral by its participating providers, to provide health\ncare services to enrollees. Payment or reimbursement by a health maintenance\norganization for health care services provided by nonparticipating referral\nproviders may exceed five percent of total costs of health care services, only\nto the extent that any such excess payment or reimbursement over five percent\nshall be combined with the costs for services which represent mere\nindemnification, with the combined amount subject to the combination of\nlimitations set forth in this definition and in this section’s definition\nof health care plan.\n\t\t“Participating provider” means a provider who has agreed to\nprovide health care services to enrollees and to hold those enrollees harmless\nfrom payment with an expectation of receiving payment, other than copayments or\ndeductibles, directly or indirectly from the health maintenance organization.\n\t\t“Provider” or “health care provider” means any\nphysician, hospital, or other person that is licensed or otherwise authorized in\nthe Commonwealth to furnish health care services.\n\t\t“Subscriber” means a contract holder, an individual enrollee, or\nthe enrollee in an enrolled family who is responsible for payment to the health\nmaintenance organization or on whose behalf such payment is made.\n\nHISTORY: 1980, c. 720, \u00a7 38.1-863; 1986, cc. 76, 528, 562; 1990, c. 224; 1992,\ncc. 241, 481; 1993, c. 305; 1995, cc. 182, 345; 2000, c. 503; 2003, cc. 752,\n767; 2004, c. 175; 2006, c. 448; 2015, c. 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}}