{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-4306.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-4306.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-4306.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-4306.html"}],"law_id":81322,"edition_id":1,"section_id":81322,"structure_id":12833,"section_number":"38.2-4306","catch_line":"Evidence of coverage and charges for health care services","history":"1980, c. 720, \u00a7 38.1-869; 1986, c. 562; 1997, cc. 807, 913; 2003, cc. 752, 767; 2004, c. 185; 2006, c. 866; 2013, c. 751; 2014, c. 814.","full_text":"A\n\n1. Each subscriber shall be entitled to evidence of coverage under a health care plan.2\n\nNo evidence of coverage, or amendment to it, shall be delivered or issued for delivery in this Commonwealth until a copy of the form of the evidence of coverage, or amendment to it, has been filed with and approved by the Commission, subject to the provisions of subsection C of this section. Any evidence of coverage for enrollees in the plans administered by the Department of Medical Assistance Services that provide benefits pursuant to Title XIX or Title XXI of the Social Security Act, as amended, is excluded from the provisions of this section.3\n\nNo evidence of coverage shall contain provisions or statements which are unjust, unfair, untrue, inequitable, misleading, deceptive or misrepresentative.4\n\nAn evidence of coverage shall contain a clear and complete statement if a contract, or a reasonably complete summary if a certificate, of:\n\t\t\t\ta. The health care services and any insurance or other benefits to which the enrollee is entitled under the health care plan;\n\t\t\t\tb. Any limitations on the services, kind of services, benefits, or kind of benefits to be provided, including any deductible or copayment feature, or both;\n\t\t\t\tc. Where and in what manner information is available as to how services may be obtained;\n\t\t\t\td. The total amount of payment for health care services and any indemnity or service benefits that the enrollee is obligated to pay with respect to individual contracts, or an indication whether the plan is contributory or noncontributory for group certificates;\n\t\t\t\te. A description of the health maintenance organization’s method for resolving enrollee complaints. Any subsequent change may be evidenced in a separate document issued to the enrollee; and\n\t\t\t\tf. A list of providers and a description of the service area which shall be provided with the evidence of coverage, if such information is not given to the subscriber at the time of enrollment.B\n\nPursuant to this subsection:1\n\nNo schedule of charges or amendment to the schedule of charges for enrollee coverage for health care services may be used in conjunction with any health care plan until a copy of the schedule, or its amendment, has been filed with the Commission. Any schedule of charges or amendment to the schedule of charges for enrollees in the plans administered by the Department of Medical Assistance Services that provide benefits pursuant to Title XIX or Title XXI of the Social Security Act, as amended, is excluded from the provisions of this subsection.2\n\nThe charges may be established for various categories of enrollees based upon sound actuarial principles, provided that charges applying to an enrollee in a group health plan shall not be individually determined based on the status of his health. A certification on the appropriateness of the charges, based upon reasonable assumptions, may be required by the Commission to be filed along with adequate supporting information. This certification shall be prepared by a qualified actuary or other qualified professional approved by the Commission.C\n\nThe Commission shall, within a reasonable period, approve any form if the requirements of subsection A of this section are met. It shall be unlawful to issue a form until approved. If the Commission disapproves a filing, it shall notify the filer. The Commission shall specify the reasons for its disapproval in the notice. A written request for a hearing on the disapproval may be made to the Commission within 30 days after notice of the disapproval. If the Commission does not disapprove any form within 30 days of the filing of such form, it shall be deemed approved unless the filer is notified in writing that the waiting period is extended by the Commission for an additional 30 days. Filing of the form means actual receipt by the Commission.D\n\nThe Commission may require the submission of any relevant information it considers necessary in determining whether to approve or disapprove a filing made under this section.E\n\nThe provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.","order_by":null,"text":{"0":{"id":291453,"text":"1. Each subscriber shall be entitled to evidence of coverage under a health care plan.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"A2"},"1":{"id":291454,"text":"No evidence of coverage, or amendment to it, shall be delivered or issued for delivery in this Commonwealth until a copy of the form of the evidence of coverage, or amendment to it, has been filed with and approved by the Commission, subject to the provisions of subsection C of this section. Any evidence of coverage for enrollees in the plans administered by the Department of Medical Assistance Services that provide benefits pursuant to Title XIX or Title XXI of the Social Security Act, as amended, is excluded from the provisions of this section.","type":"section","prefixes":["A","2"],"prefix":"2","entire_prefix":"A2","prefix_anchor":"A2","level":2,"prior_prefix":"A","next_prefix":"A3"},"2":{"id":291455,"text":"No evidence of coverage shall contain provisions or statements which are unjust, unfair, untrue, inequitable, misleading, deceptive or misrepresentative.","type":"section","prefixes":["A","3"],"prefix":"3","entire_prefix":"A3","prefix_anchor":"A3","level":2,"prior_prefix":"A2","next_prefix":"A4"},"3":{"id":291456,"text":"An evidence of coverage shall contain a clear and complete statement if a contract, or a reasonably complete summary if a certificate, of:\n\t\t\t\ta. The health care services and any insurance or other benefits to which the enrollee is entitled under the health care plan;\n\t\t\t\tb. Any limitations on the services, kind of services, benefits, or kind of benefits to be provided, including any deductible or copayment feature, or both;\n\t\t\t\tc. Where and in what manner information is available as to how services may be obtained;\n\t\t\t\td. The total amount of payment for health care services and any indemnity or service benefits that the enrollee is obligated to pay with respect to individual contracts, or an indication whether the plan is contributory or noncontributory for group certificates;\n\t\t\t\te. A description of the health maintenance organization’s method for resolving enrollee complaints. Any subsequent change may be evidenced in a separate document issued to the enrollee; and\n\t\t\t\tf. A list of providers and a description of the service area which shall be provided with the evidence of coverage, if such information is not given to the subscriber at the time of enrollment.","type":"section","prefixes":["A","4"],"prefix":"4","entire_prefix":"A4","prefix_anchor":"A4","level":2,"prior_prefix":"A3","next_prefix":"B"},"4":{"id":291457,"text":"Pursuant to this subsection:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A4","next_prefix":"B1"},"5":{"id":291458,"text":"No schedule of charges or amendment to the schedule of charges for enrollee coverage for health care services may be used in conjunction with any health care plan until a copy of the schedule, or its amendment, has been filed with the Commission. Any schedule of charges or amendment to the schedule of charges for enrollees in the plans administered by the Department of Medical Assistance Services that provide benefits pursuant to Title XIX or Title XXI of the Social Security Act, as amended, is excluded from the provisions of this subsection.","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B2"},"6":{"id":291459,"text":"The charges may be established for various categories of enrollees based upon sound actuarial principles, provided that charges applying to an enrollee in a group health plan shall not be individually determined based on the status of his health. A certification on the appropriateness of the charges, based upon reasonable assumptions, may be required by the Commission to be filed along with adequate supporting information. This certification shall be prepared by a qualified actuary or other qualified professional approved by the Commission.","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B1","next_prefix":"C"},"7":{"id":291460,"text":"The Commission shall, within a reasonable period, approve any form if the requirements of subsection A of this section are met. It shall be unlawful to issue a form until approved. If the Commission disapproves a filing, it shall notify the filer. The Commission shall specify the reasons for its disapproval in the notice. A written request for a hearing on the disapproval may be made to the Commission within 30 days after notice of the disapproval. If the Commission does not disapprove any form within 30 days of the filing of such form, it shall be deemed approved unless the filer is notified in writing that the waiting period is extended by the Commission for an additional 30 days. Filing of the form means actual receipt by the Commission.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B2","next_prefix":"D"},"8":{"id":291461,"text":"The Commission may require the submission of any relevant information it considers necessary in determining whether to approve or disapprove a filing made under this section.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"9":{"id":291462,"text":"The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D"}},"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}],"previous_section":{"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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-4306\/","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 7 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 1997, chapters 807<\/a> and 913<\/a>; in 2003, chapters 752<\/a> and 767<\/a>; in 2004, chapter 185<\/a>; in 2006, chapter 866<\/a>; in 2013, chapter 751<\/a>; in 2014, chapter 814<\/a>.<\/p>","references":[{"id":78457,"section_number":"38.2-3407.4","catch_line":"Explanation of benefits","order_by":null,"url":"\/38.2-3407.4\/"},{"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":66501,"section_number":"38.2-3447","catch_line":"(Effective January 1, 2026) Restrictions relating to premium rates","order_by":null,"url":"\/38.2-3447\/"},{"id":61029,"section_number":"38.2-4316","catch_line":"Suspension or revocation of license","order_by":null,"url":"\/38.2-4316\/"}],"refers_to":[{"id":57210,"section_number":"38.2-3438","catch_line":"Definitions","order_by":null,"url":"\/38.2-3438\/"}],"permalink":{"id":216861,"object_type":"law","relational_id":81322,"identifier":"38.2-4306","token":"38.2\/43\/38.2-4306","url":"\/38.2-4306\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-4306\/","token":"38.2\/43\/38.2-4306","dublin_core":{"Title":"Evidence of coverage and charges for health care services","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-4306","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> 1. Each subscriber<\/span> shall be entitled to evidence of coverage<\/span> under a health care plan<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> No evidence of coverage<\/span>, or amendment to it, shall be delivered or issued for delivery in this Commonwealth until a copy of the form of the evidence of coverage<\/span>, or amendment to it, has been filed with and approved by the Commission<\/span>, subject to the provisions of subsection C of this section. Any evidence of coverage<\/span> for enrollees<\/span> in the plans administered by the Department of Medical Assistance Services that provide benefits pursuant to Title XIX or Title XXI of the Social Security Act, as amended, is excluded from the provisions of this section. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> No evidence of coverage<\/span> shall contain provisions or statements which are unjust, unfair, untrue, inequitable, misleading, deceptive or misrepresentative. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> An evidence of coverage<\/span> shall contain a clear and complete statement if a contract<\/span>, or a reasonably complete summary if a certificate, of:\n\t\t\t\ta. The health care services<\/span> and any insurance<\/span> or other benefits to which the enrollee<\/span> is entitled under the health care plan<\/span>;\n\t\t\t\tb. Any limitations on the services, kind of services, benefits, or kind of benefits to be provided, including any deductible<\/span> or copayment<\/span> feature, or both;\n\t\t\t\tc. Where and in what manner information is available as to how services may be obtained;\n\t\t\t\td. The total amount of payment for health care services<\/span> and any indemnity or service benefits that the enrollee<\/span> is obligated to pay with respect to individual contracts<\/span>, or an indication whether the plan is contributory or noncontributory for group certificates;\n\t\t\t\te. A description of the health maintenance organization<\/span>’s method for resolving enrollee<\/span> complaints. Any subsequent change may be evidenced in a separate document issued to the enrollee<\/span>; and\n\t\t\t\tf. A list of providers<\/span> and a description of the service area which shall be provided with the evidence of coverage<\/span>, if such information is not given to the subscriber<\/span> at the time of enrollment. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> Pursuant to this subsection: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> No schedule of charges or amendment to the schedule of charges for enrollee<\/span> coverage for health care services<\/span> may be used in conjunction with any health care plan<\/span> until a copy of the schedule, or its amendment, has been filed with the Commission<\/span>. Any schedule of charges or amendment to the schedule of charges for enrollees<\/span> in the plans administered by the Department of Medical Assistance Services that provide benefits pursuant to Title XIX or Title XXI of the Social Security Act, as amended, is excluded from the provisions of this subsection. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> The charges may be established for various categories of enrollees<\/span> based upon sound actuarial principles, provided that charges applying to an enrollee<\/span> in a group health plan shall not be individually determined based on the status of his health. A certification on the appropriateness of the charges, based upon reasonable assumptions, may be required by the Commission<\/span> to be filed along with adequate supporting information. This certification shall be prepared by a qualified actuary or other qualified professional approved by the Commission<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> The Commission<\/span> shall, within a reasonable period, approve any form if the requirements of subsection A of this section are met. It shall be unlawful to issue<\/span> a form until approved. If the Commission<\/span> disapproves a filing, it shall notify the filer. The Commission<\/span> shall specify the reasons for its disapproval in the notice. A written request for a hearing<\/span> on the disapproval may be made to the Commission<\/span> within 30 days after notice of the disapproval. If the Commission<\/span> does not disapprove any form within 30 days of the filing of such form, it shall be deemed approved unless the filer is notified in writing that the waiting period is extended by the Commission<\/span> for an additional 30 days. Filing of the form means actual receipt by the Commission<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> The Commission<\/span> may require the submission of any relevant information it considers necessary in determining whether to approve or disapprove a filing made under this section. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438<\/a> et seq.) of Chapter 34. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nEVIDENCE OF COVERAGE AND CHARGES FOR HEALTH CARE SERVICES (\u00a7 38.2-4306)\n\nA. 1. Each subscriber shall be entitled to evidence of coverage under a health\ncare plan.\n\n 2. No evidence of coverage, or amendment to it, shall be delivered or issued\n for delivery in this Commonwealth until a copy of the form of the evidence of\n coverage, or amendment to it, has been filed with and approved by the\n Commission, subject to the provisions of subsection C of this section. Any\n evidence of coverage for enrollees in the plans administered by the Department\n of Medical Assistance Services that provide benefits pursuant to Title XIX or\n Title XXI of the Social Security Act, as amended, is excluded from the\n provisions of this section.\n\n 3. No evidence of coverage shall contain provisions or statements which are\n unjust, unfair, untrue, inequitable, misleading, deceptive or\n misrepresentative.\n\n 4. An evidence of coverage shall contain a clear and complete statement if a\n contract, or a reasonably complete summary if a certificate, of:\n \t\t\t\ta. The health care services and any insurance or other benefits to which\n the enrollee is entitled under the health care plan;\n \t\t\t\tb. Any limitations on the services, kind of services, benefits, or kind of\n benefits to be provided, including any deductible or copayment feature, or\n both;\n \t\t\t\tc. Where and in what manner information is available as to how services\n may be obtained;\n \t\t\t\td. The total amount of payment for health care services and any indemnity\n or service benefits that the enrollee is obligated to pay with respect to\n individual contracts, or an indication whether the plan is contributory or\n noncontributory for group certificates;\n \t\t\t\te. A description of the health maintenance organization’s method for\n resolving enrollee complaints. Any subsequent change may be evidenced in a\n separate document issued to the enrollee; and\n \t\t\t\tf. A list of providers and a description of the service area which shall\n be provided with the evidence of coverage, if such information is not given to\n the subscriber at the time of enrollment.\n\nB. Pursuant to this subsection:\n\n 1. No schedule of charges or amendment to the schedule of charges for enrollee\n coverage for health care services may be used in conjunction with any health\n care plan until a copy of the schedule, or its amendment, has been filed with\n the Commission. Any schedule of charges or amendment to the schedule of\n charges for enrollees in the plans administered by the Department of Medical\n Assistance Services that provide benefits pursuant to Title XIX or Title XXI\n of the Social Security Act, as amended, is excluded from the provisions of\n this subsection.\n\n 2. The charges may be established for various categories of enrollees based\n upon sound actuarial principles, provided that charges applying to an enrollee\n in a group health plan shall not be individually determined based on the\n status of his health. A certification on the appropriateness of the charges,\n based upon reasonable assumptions, may be required by the Commission to be\n filed along with adequate supporting information. This certification shall be\n prepared by a qualified actuary or other qualified professional approved by\n the Commission.\n\nC. The Commission shall, within a reasonable period, approve any form if the\nrequirements of subsection A of this section are met. It shall be unlawful to\nissue a form until approved. If the Commission disapproves a filing, it shall\nnotify the filer. The Commission shall specify the reasons for its disapproval\nin the notice. A written request for a hearing on the disapproval may be made to\nthe Commission within 30 days after notice of the disapproval. If the Commission\ndoes not disapprove any form within 30 days of the filing of such form, it shall\nbe deemed approved unless the filer is notified in writing that the waiting\nperiod is extended by the Commission for an additional 30 days. Filing of the\nform means actual receipt by the Commission.\n\nD. The Commission may require the submission of any relevant information it\nconsiders necessary in determining whether to approve or disapprove a filing\nmade under this section.\n\nE. The provisions of this section shall not apply in any instance in which the\nprovisions of this section are inconsistent or in conflict with a provision of\nArticle 6 (§ 38.2-3438 et seq.) of Chapter 34.\n\nHISTORY: 1980, c. 720, \u00a7 38.1-869; 1986, c. 562; 1997, cc. 807, 913; 2003, cc.\n752, 767; 2004, c. 185; 2006, c. 866; 2013, c. 751; 2014, c. 814.","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}}