{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-4312.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-4312.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-4312.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-4312.html"}],"law_id":62703,"edition_id":1,"section_id":62703,"structure_id":12833,"section_number":"38.2-4312","catch_line":"Prohibited practices","history":"1980, c. 720, \u00a7 38.1-876; 1985, c. 588; 1986, c. 562; 1989, c. 221; 1997, c. 297; 1998, c. 891; 1999, cc. 643, 649.","full_text":"A\n\nNo health maintenance organization or its representative may cause or knowingly permit the use of (i) advertising that is untrue or misleading, (ii) solicitation that is untrue or misleading, or (iii) any form of evidence of coverage that is deceptive. For the purposes of this chapter:1\n\nA statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect that is or may be significant to an enrollee or person considering enrollment in a health care plan;2\n\nA statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if the statement or item of information may be understood by a reasonable person who has no special knowledge of health care coverage as indicating (i) a benefit or advantage if that benefit or advantage does not in fact exist or (ii) the absence of any exclusion, limitation or disadvantage of possible significance to an enrollee or person considering enrollment in a health care plan if the absence of that exclusion, limitation, or disadvantage does not in fact exist; consideration shall be given to the total context in which the statement is made or the item of information is communicated; and3\n\nAn evidence of coverage shall be deemed to be deceptive if it causes a reasonable person who has no special knowledge of health care plans to expect benefits, services, charges, or other advantages that the evidence of coverage does not provide or that the health care plan issuing the evidence of coverage does not regularly make available for enrollees covered under the evidence of coverage; consideration shall be given to the evidence of coverage taken as a whole and to the typography, format, and language.B\n\nThe provisions of Chapter 5 (&#xA7; 38.2-500 et seq.) of this title shall apply to health maintenance organizations, health care plans, and evidences of coverage except to the extent that the Commission determines that the nature of health maintenance organizations, health care plans, and evidences of coverage render any of the provisions clearly inappropriate.C\n\nNo health maintenance organization, unless licensed as an insurer, may use in its name, contracts, or literature (i) any of the words &#8220;insurance,&#8221; &#8220;casualty,&#8221; &#8220;surety,&#8221; &#8220;mutual,&#8221; or (ii) any other words descriptive of the insurance, casualty, or surety business or deceptively similar to the name or description of any insurance or fidelity and surety insurer doing business in this Commonwealth.D\n\nNo health maintenance organization shall discriminate on the basis of race, creed, color, sex or religion in the selection of health care providers for participation in the organization.E\n\nNo health maintenance organization shall unreasonably discriminate against physicians as a class or any class of providers listed in &#xA7; 38.2-4221 or pharmacists when contracting for specialty or referral practitioners or providers, provided the plan covers services which the members of such classes are licensed to render. Nothing contained in this section shall prevent a health maintenance organization from selecting, in the judgment of the health maintenance organization, the numbers of providers necessary to render the services offered by the health maintenance organization.F\n\nNo contract between a health maintenance organization 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":228621,"text":"No health maintenance organization or its representative may cause or knowingly permit the use of (i) advertising that is untrue or misleading, (ii) solicitation that is untrue or misleading, or (iii) any form of evidence of coverage that is deceptive. For the purposes of this chapter:","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"A1"},"1":{"id":228622,"text":"A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect that is or may be significant to an enrollee or person considering enrollment in a health care plan;","type":"section","prefixes":["A","1"],"prefix":"1","entire_prefix":"A1","prefix_anchor":"A1","level":2,"prior_prefix":"A","next_prefix":"A2"},"2":{"id":228623,"text":"A statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if the statement or item of information may be understood by a reasonable person who has no special knowledge of health care coverage as indicating (i) a benefit or advantage if that benefit or advantage does not in fact exist or (ii) the absence of any exclusion, limitation or disadvantage of possible significance to an enrollee or person considering enrollment in a health care plan if the absence of that exclusion, limitation, or disadvantage does not in fact exist; consideration shall be given to the total context in which the statement is made or the item of information is communicated; and","type":"section","prefixes":["A","2"],"prefix":"2","entire_prefix":"A2","prefix_anchor":"A2","level":2,"prior_prefix":"A1","next_prefix":"A3"},"3":{"id":228624,"text":"An evidence of coverage shall be deemed to be deceptive if it causes a reasonable person who has no special knowledge of health care plans to expect benefits, services, charges, or other advantages that the evidence of coverage does not provide or that the health care plan issuing the evidence of coverage does not regularly make available for enrollees covered under the evidence of coverage; consideration shall be given to the evidence of coverage taken as a whole and to the typography, format, and language.","type":"section","prefixes":["A","3"],"prefix":"3","entire_prefix":"A3","prefix_anchor":"A3","level":2,"prior_prefix":"A2","next_prefix":"B"},"4":{"id":228625,"text":"The provisions of Chapter 5 (&#xA7; 38.2-500 et seq.) of this title shall apply to health maintenance organizations, health care plans, and evidences of coverage except to the extent that the Commission determines that the nature of health maintenance organizations, health care plans, and evidences of coverage render any of the provisions clearly inappropriate.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A3","next_prefix":"C"},"5":{"id":228626,"text":"No health maintenance organization, unless licensed as an insurer, may use in its name, contracts, or literature (i) any of the words &#8220;insurance,&#8221; &#8220;casualty,&#8221; &#8220;surety,&#8221; &#8220;mutual,&#8221; or (ii) any other words descriptive of the insurance, casualty, or surety business or deceptively similar to the name or description of any insurance or fidelity and surety insurer doing business in this Commonwealth.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"6":{"id":228627,"text":"No health maintenance organization shall discriminate on the basis of race, creed, color, sex or religion in the selection of health care providers for participation in the organization.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"7":{"id":228628,"text":"No health maintenance organization shall unreasonably discriminate against physicians as a class or any class of providers listed in &#xA7; 38.2-4221 or pharmacists when contracting for specialty or referral practitioners or providers, provided the plan covers services which the members of such classes are licensed to render. Nothing contained in this section shall prevent a health maintenance organization from selecting, in the judgment of the health maintenance organization, the numbers of providers necessary to render the services offered by the health maintenance organization.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"8":{"id":228629,"text":"No contract between a health maintenance organization 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":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":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},"next_section":{"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},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-4312\/","history_text":"<p>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 6 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 1985, chapter 588; in 1986, chapter 562; in 1989, chapter 221; in 1997, chapter <a href=\"https:\/\/legacylis.virginia.gov\/cgi-bin\/legp604.exe?971+ful+CHAP0297\">297<\/a>; in 1998, chapter <a href=\"https:\/\/legacylis.virginia.gov\/cgi-bin\/legp604.exe?981+ful+CHAP0891\">891<\/a>; in 1999, chapters <a href=\"https:\/\/legacylis.virginia.gov\/cgi-bin\/legp604.exe?991+ful+CHAP0643\">643<\/a> and <a href=\"https:\/\/legacylis.virginia.gov\/cgi-bin\/legp604.exe?991+ful+CHAP0649\">649<\/a>.<\/p>","references":[{"id":68442,"section_number":"38.2-3407.12","catch_line":"Patient optional point-of-service benefit","order_by":null,"url":"\/38.2-3407.12\/"}],"refers_to":[{"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":66905,"section_number":"38.2-500","catch_line":"Declaration of purpose","order_by":null,"url":"\/38.2-500\/"}],"permalink":{"id":216897,"object_type":"law","relational_id":62703,"identifier":"38.2-4312","token":"38.2\/43\/38.2-4312","url":"\/38.2-4312\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-4312\/","token":"38.2\/43\/38.2-4312","dublin_core":{"Title":"Prohibited practices","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-4312","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t<section id=\"A\"><p><span class=\"prefix-number\">A.<\/span> No <span class=\"dictionary\">health maintenance organization<\/span> or its representative may cause or knowingly permit the use of (i) advertising that is untrue or misleading, (ii) solicitation that is untrue or misleading, or (iii) any form of <span class=\"dictionary\">evidence of coverage<\/span> that is deceptive. For the purposes of this chapter: <a id=\"paragraph-228621\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-4312\/#A\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"A1\" class=\"indent-1\"><p><span class=\"prefix-number\">1.<\/span> A statement or item of information shall be deemed to be untrue if it does not conform to <span class=\"dictionary\">fact<\/span> in any respect that is or may be significant to an <span class=\"dictionary\">enrollee<\/span> or <span class=\"dictionary\">person<\/span> considering enrollment in a <span class=\"dictionary\">health care plan<\/span>; <a id=\"paragraph-228622\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-4312\/#A1\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"A2\" class=\"indent-1\"><p><span class=\"prefix-number\">2.<\/span> A statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if the statement or item of information may be understood by a reasonable <span class=\"dictionary\">person<\/span> who has no special knowledge of health care coverage as indicating (i) a benefit or advantage if that benefit or advantage does not in <span class=\"dictionary\">fact<\/span> exist or (ii) the absence of any exclusion, limitation or disadvantage of possible significance to an <span class=\"dictionary\">enrollee<\/span> or <span class=\"dictionary\">person<\/span> considering enrollment in a <span class=\"dictionary\">health care plan<\/span> if the absence of that exclusion, limitation, or disadvantage does not in <span class=\"dictionary\">fact<\/span> exist; consideration shall be given to the total context in which the statement is made or the item of information is communicated; and <a id=\"paragraph-228623\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-4312\/#A2\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"A3\" class=\"indent-1\"><p><span class=\"prefix-number\">3.<\/span> An <span class=\"dictionary\">evidence of coverage<\/span> shall be deemed to be deceptive if it causes a reasonable <span class=\"dictionary\">person<\/span> who has no special knowledge of <span class=\"dictionary\">health care plans<\/span> to expect benefits, services, charges, or other advantages that the <span class=\"dictionary\">evidence of coverage<\/span> does not provide or that the <span class=\"dictionary\">health care plan<\/span> issuing the <span class=\"dictionary\">evidence of coverage<\/span> does not regularly make available for <span class=\"dictionary\">enrollees<\/span> covered under the <span class=\"dictionary\">evidence of coverage<\/span>; consideration shall be given to the <span class=\"dictionary\">evidence of coverage<\/span> taken as a whole and to the typography, format, and language. <a id=\"paragraph-228624\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-4312\/#A3\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"B\"><p><span class=\"prefix-number\">B.<\/span> The provisions of Chapter 5 (&#xA7; <a class=\"law\" title=\"Declaration of purpose\" href=\"\/38.2-500\/\">38.2-500<\/a> et seq.) of this title shall apply to <span class=\"dictionary\">health maintenance organizations<\/span>, <span class=\"dictionary\">health care plans<\/span>, and <span class=\"dictionary\">evidences<\/span> of coverage except to the extent that the <span class=\"dictionary\">Commission<\/span> determines that the nature of <span class=\"dictionary\">health maintenance organizations<\/span>, <span class=\"dictionary\">health care plans<\/span>, and <span class=\"dictionary\">evidences<\/span> of coverage render any of the provisions clearly inappropriate. <a id=\"paragraph-228625\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-4312\/#B\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"C\"><p><span class=\"prefix-number\">C.<\/span> No <span class=\"dictionary\">health maintenance organization<\/span>, unless licensed as an <span class=\"dictionary\">insurer<\/span>, may use in its name, <span class=\"dictionary\">contracts<\/span>, or literature (i) any of the words &#8220;<span class=\"dictionary\">insurance<\/span>,&#8221; &#8220;casualty,&#8221; &#8220;<span class=\"dictionary\">surety<\/span>,&#8221; &#8220;mutual,&#8221; or (ii) any other words descriptive of the <span class=\"dictionary\">insurance<\/span>, casualty, or <span class=\"dictionary\">surety<\/span> business or deceptively similar to the name or description of any <span class=\"dictionary\">insurance<\/span> or fidelity and <span class=\"dictionary\">surety<\/span> <span class=\"dictionary\">insurer<\/span> doing business in this Commonwealth. <a id=\"paragraph-228626\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-4312\/#C\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"D\"><p><span class=\"prefix-number\">D.<\/span> No <span class=\"dictionary\">health maintenance organization<\/span> shall discriminate on the basis of race, creed, color, sex or religion in the selection of <span class=\"dictionary\">health care providers<\/span> for participation in the organization. <a id=\"paragraph-228627\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-4312\/#D\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"E\"><p><span class=\"prefix-number\">E.<\/span> No <span class=\"dictionary\">health maintenance organization<\/span> shall unreasonably discriminate against physicians as a class or any class of providers listed in &#xA7; <a class=\"law\" title=\"Services of certain practitioners other than physicians to be covered\" href=\"\/38.2-4221\/\">38.2-4221<\/a> or pharmacists when contracting for specialty or referral practitioners or providers, provided the plan covers services which the <span class=\"dictionary\">members<\/span> of such classes are licensed to render. Nothing contained in this section shall prevent a <span class=\"dictionary\">health maintenance organization<\/span> from selecting, in the <span class=\"dictionary\">judgment<\/span> of the <span class=\"dictionary\">health maintenance organization<\/span>, the numbers of providers necessary to render the services offered by the <span class=\"dictionary\">health maintenance organization<\/span>. <a id=\"paragraph-228628\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-4312\/#E\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"F\"><p><span class=\"prefix-number\">F.<\/span> No <span class=\"dictionary\">contract<\/span> between a <span class=\"dictionary\">health maintenance organization<\/span> and a provider shall include provisions which require a <span class=\"dictionary\">health care provider<\/span> or <span class=\"dictionary\">health care provider<\/span> 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 <span class=\"dictionary\">enrollee<\/span> or group of <span class=\"dictionary\">enrollees<\/span> with similar medical conditions. <a id=\"paragraph-228629\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-4312\/#F\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>","plain_text":"                                 CODE OF VIRGINIA\n\nPROHIBITED PRACTICES (\u00a7 38.2-4312)\n\nA. No health maintenance organization or its representative may cause or\nknowingly permit the use of (i) advertising that is untrue or misleading, (ii)\nsolicitation that is untrue or misleading, or (iii) any form of evidence of\ncoverage that is deceptive. For the purposes of this chapter:\n\n   1. A statement or item of information shall be deemed to be untrue if it does\n   not conform to fact in any respect that is or may be significant to an\n   enrollee or person considering enrollment in a health care plan;\n\n   2. A statement or item of information shall be deemed to be misleading,\n   whether or not it may be literally untrue, if the statement or item of\n   information may be understood by a reasonable person who has no special\n   knowledge of health care coverage as indicating (i) a benefit or advantage if\n   that benefit or advantage does not in fact exist or (ii) the absence of any\n   exclusion, limitation or disadvantage of possible significance to an enrollee\n   or person considering enrollment in a health care plan if the absence of that\n   exclusion, limitation, or disadvantage does not in fact exist; consideration\n   shall be given to the total context in which the statement is made or the item\n   of information is communicated; and\n\n   3. An evidence of coverage shall be deemed to be deceptive if it causes a\n   reasonable person who has no special knowledge of health care plans to expect\n   benefits, services, charges, or other advantages that the evidence of coverage\n   does not provide or that the health care plan issuing the evidence of coverage\n   does not regularly make available for enrollees covered under the evidence of\n   coverage; consideration shall be given to the evidence of coverage taken as a\n   whole and to the typography, format, and language.\n\nB. The provisions of Chapter 5 (&#xA7; 38.2-500 et seq.) of this title shall\napply to health maintenance organizations, health care plans, and evidences of\ncoverage except to the extent that the Commission determines that the nature of\nhealth maintenance organizations, health care plans, and evidences of coverage\nrender any of the provisions clearly inappropriate.\n\nC. No health maintenance organization, unless licensed as an insurer, may use in\nits name, contracts, or literature (i) any of the words &#8220;insurance,&#8221;\n&#8220;casualty,&#8221; &#8220;surety,&#8221; &#8220;mutual,&#8221; or (ii) any\nother words descriptive of the insurance, casualty, or surety business or\ndeceptively similar to the name or description of any insurance or fidelity and\nsurety insurer doing business in this Commonwealth.\n\nD. No health maintenance organization shall discriminate on the basis of race,\ncreed, color, sex or religion in the selection of health care providers for\nparticipation in the organization.\n\nE. No health maintenance organization shall unreasonably discriminate against\nphysicians as a class or any class of providers listed in &#xA7; 38.2-4221 or\npharmacists when contracting for specialty or referral practitioners or\nproviders, provided the plan covers services which the members of such classes\nare licensed to render. Nothing contained in this section shall prevent a health\nmaintenance organization from selecting, in the judgment of the health\nmaintenance organization, the numbers of providers necessary to render the\nservices offered by the health maintenance organization.\n\nF. No contract between a health maintenance organization and a provider shall\ninclude provisions which require a health care provider or health care provider\ngroup to deny 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: 1980, c. 720, \u00a7 38.1-876; 1985, c. 588; 1986, c. 562; 1989, c. 221;\n1997, c. 297; 1998, c. 891; 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}}