{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-4312.3.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-4312.3.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-4312.3.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-4312.3.html"}],"law_id":79585,"edition_id":1,"section_id":79585,"structure_id":12833,"section_number":"38.2-4312.3","catch_line":"Patient access to emergency services","history":"1997, c. 139; 2011, c. 882.","full_text":"A\n\nA health maintenance organization shall have a system to provide to its members, on a 24-hour basis: (i) access to medical care or (ii) access by telephone to a physician or licensed health care professional with appropriate medical training who can refer or direct a member for prompt medical care in cases where there is an immediate, urgent need or medical emergency. Access to a nonmedical professional who provides appropriate responses to calls from members and providers concerning after-hours care and covered benefits is not sufficient to meet the requirements of this section.B\n\nA health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable copayments, deductibles, or coinsurance, for medical screening and stabilization services rendered to meet the requirements of the Federal Emergency Medical Treatment and Active Labor Act (42 U.S.C. § 1395dd) and related to the condition for which the member presented in the hospital emergency facility if (i) the health maintenance organization or its designee or the member’s primary care physician or its designee authorized, directed, or referred a member to use the hospital emergency facility; or (ii) the health maintenance organization fails to have a system for provision of 24-hour access in accordance with subsection A above. For purposes of (i) above, a primary care physician may include a physician with whom the primary care physician has made arrangements for on-call backup coverage.C\n\nEach evidence of coverage provided by a health maintenance organization shall include a description of procedures to be followed by the member for emergency services, including: (i) the appropriate use of hospital emergency facilities; (ii) the appropriate use of any urgent care facilities with which the health maintenance organization may contract; (iii) the potential responsibility of the member for payment for nonemergency services rendered in a hospital emergency facility; and (iv) the member’s covered benefits for emergency services, including an explanation of the prudent layperson standard included in the definition of emergency services in § 38.2-4300.D\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":285153,"text":"A health maintenance organization shall have a system to provide to its members, on a 24-hour basis: (i) access to medical care or (ii) access by telephone to a physician or licensed health care professional with appropriate medical training who can refer or direct a member for prompt medical care in cases where there is an immediate, urgent need or medical emergency. Access to a nonmedical professional who provides appropriate responses to calls from members and providers concerning after-hours care and covered benefits is not sufficient to meet the requirements of this section.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":285154,"text":"A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable copayments, deductibles, or coinsurance, for medical screening and stabilization services rendered to meet the requirements of the Federal Emergency Medical Treatment and Active Labor Act (42 U.S.C. § 1395dd) and related to the condition for which the member presented in the hospital emergency facility if (i) the health maintenance organization or its designee or the member’s primary care physician or its designee authorized, directed, or referred a member to use the hospital emergency facility; or (ii) the health maintenance organization fails to have a system for provision of 24-hour access in accordance with subsection A above. For purposes of (i) above, a primary care physician may include a physician with whom the primary care physician has made arrangements for on-call backup coverage.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":285155,"text":"Each evidence of coverage provided by a health maintenance organization shall include a description of procedures to be followed by the member for emergency services, including: (i) the appropriate use of hospital emergency facilities; (ii) the appropriate use of any urgent care facilities with which the health maintenance organization may contract; (iii) the potential responsibility of the member for payment for nonemergency services rendered in a hospital emergency facility; and (iv) the member’s covered benefits for emergency services, including an explanation of the prudent layperson standard included in the definition of emergency services in § 38.2-4300.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":285156,"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":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C"}},"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":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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-4312.3\/","history_text":"

This law was first created in 1997. The record of its establishment is cataloged in chapter 139<\/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. It has been modified 1 time. 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. That modification is as follows: in 2011, chapter 882<\/a>.<\/p>","references":[{"id":54833,"section_number":"38.2-3443","catch_line":"Choice of a health care professional","order_by":null,"url":"\/38.2-3443\/"},{"id":60836,"section_number":"38.2-3445","catch_line":"Patient access to emergency services","order_by":null,"url":"\/38.2-3445\/"}],"refers_to":[{"id":57210,"section_number":"38.2-3438","catch_line":"Definitions","order_by":null,"url":"\/38.2-3438\/"}],"permalink":{"id":216909,"object_type":"law","relational_id":79585,"identifier":"38.2-4312.3","token":"38.2\/43\/38.2-4312.3","url":"\/38.2-4312.3\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-4312.3\/","token":"38.2\/43\/38.2-4312.3","dublin_core":{"Title":"Patient access to emergency services","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-4312.3","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> A health maintenance organization<\/span> shall have a system to provide to its members<\/span>, on a 24-hour basis: (i) access to medical care or (ii) access by telephone to a physician or licensed health care professional with appropriate medical training who can refer or direct a member<\/span> for prompt medical care in cases where there is an immediate, urgent need or medical emergency. Access to a nonmedical professional who provides appropriate responses to calls from members<\/span> and providers<\/span> concerning after-hours care and covered benefits is not sufficient to meet the requirements of this section. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> A health maintenance organization<\/span> shall reimburse a hospital emergency facility and provider<\/span>, less any applicable copayments<\/span>, deductibles<\/span>, or coinsurance, for medical screening and stabilization services rendered to meet the requirements of the Federal Emergency Medical Treatment and Active Labor Act (42 U.S.C. § 1395dd) and related to the condition for which the member<\/span> presented in the hospital emergency facility if (i) the health maintenance organization<\/span> or its designee or the member<\/span>’s primary care physician or its designee authorized, directed, or referred a member<\/span> to use the hospital emergency facility; or (ii) the health maintenance organization<\/span> fails to have a system for provision of 24-hour access in accordance with subsection A above. For purposes of (i) above, a primary care physician may include a physician with whom the primary care physician has made arrangements for on-call backup coverage. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Each evidence of coverage<\/span> provided by a health maintenance organization<\/span> shall include a description of procedures to be followed by the member<\/span> for emergency services<\/span>, including: (i) the appropriate use of hospital emergency facilities; (ii) the appropriate use of any urgent care facilities with which the health maintenance organization<\/span> may contract<\/span>; (iii) the potential responsibility of the member<\/span> for payment for nonemergency services rendered in a hospital emergency facility; and (iv) the member<\/span>’s covered benefits for emergency services<\/span>, including an explanation of the prudent layperson standard included in the definition of emergency services<\/span> in § 38.2-4300<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/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\nPATIENT ACCESS TO EMERGENCY SERVICES (\u00a7 38.2-4312.3)\n\nA. A health maintenance organization shall have a system to provide to its\nmembers, on a 24-hour basis: (i) access to medical care or (ii) access by\ntelephone to a physician or licensed health care professional with appropriate\nmedical training who can refer or direct a member for prompt medical care in\ncases where there is an immediate, urgent need or medical emergency. Access to a\nnonmedical professional who provides appropriate responses to calls from members\nand providers concerning after-hours care and covered benefits is not sufficient\nto meet the requirements of this section.\n\nB. A health maintenance organization shall reimburse a hospital emergency\nfacility and provider, less any applicable copayments, deductibles, or\ncoinsurance, for medical screening and stabilization services rendered to meet\nthe requirements of the Federal Emergency Medical Treatment and Active Labor Act\n(42 U.S.C. § 1395dd) and related to the condition for which the member\npresented in the hospital emergency facility if (i) the health maintenance\norganization or its designee or the member’s primary care physician or its\ndesignee authorized, directed, or referred a member to use the hospital\nemergency facility; or (ii) the health maintenance organization fails to have a\nsystem for provision of 24-hour access in accordance with subsection A above.\nFor purposes of (i) above, a primary care physician may include a physician with\nwhom the primary care physician has made arrangements for on-call backup\ncoverage.\n\nC. Each evidence of coverage provided by a health maintenance organization shall\ninclude a description of procedures to be followed by the member for emergency\nservices, including: (i) the appropriate use of hospital emergency facilities;\n(ii) the appropriate use of any urgent care facilities with which the health\nmaintenance organization may contract; (iii) the potential responsibility of the\nmember for payment for nonemergency services rendered in a hospital emergency\nfacility; and (iv) the member’s covered benefits for emergency services,\nincluding an explanation of the prudent layperson standard included in the\ndefinition of emergency services in § 38.2-4300.\n\nD. 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: 1997, c. 139; 2011, c. 882.","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}}