{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-5800.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-5800.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-5800.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-5800.html"}],"law_id":77304,"edition_id":1,"section_id":77304,"structure_id":13783,"section_number":"38.2-5800","catch_line":"Definitions","history":"1998, c. 891; 2006, c. 448; 2015, c. 649.","full_text":"As used in this chapter:\n\t\t“Accident and sickness insurance company” means a person subject to licensing in accordance with provisions in Chapter 10 (\u00a7 38.2-1000 et seq.) or Chapter 41 (\u00a7 38.2-4100 et seq.) seeking or having authorization (i) to issue accident and sickness insurance as defined in \u00a7 38.2-109, (ii) to issue the benefit certificates or policies of accident and sickness insurance described in \u00a7 38.2-3801, or (iii) to provide hospital, medical and nursing benefits pursuant to \u00a7\u00a7 38.2-4116 and 38.2-4123.\n\t\t“Affiliated provider” means any provider that is employed by or has entered into a contractual agreement either directly or indirectly with a health carrier to provide health care services to members of a managed care health insurance plan for which the health carrier is responsible under this chapter.\n\t\t“Basic health care services” means emergency services, inpatient hospital and physician care, outpatient medical services, laboratory and radiological services, mental health and substance use disorder benefits, and preventive health services.\n\t\t“Copayment” means a payment required of covered persons as a condition of the receipt of specific health services.\n\t\t“Covered person” means an individual, whether a policyholder, subscriber, enrollee, or member of a managed care health insurance plan (MCHIP) who is entitled to health care services or benefits provided, arranged for, paid for or reimbursed pursuant to an MCHIP.\n\t\t“Evidence of coverage” includes any certificate, individual or group agreement or contract or related documents issued in conjunction with the certificate, agreement or contract, issued to a subscriber setting out the coverage and other rights to which a covered person is entitled.\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 carrier” means an entity subject to Title 38.2 that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including an entity providing a plan of health insurance, health benefits or health services, an accident and sickness insurance company, a health maintenance organization, or a nonstock corporation offering or administering a health services plan, a hospital services plan, or a medical or surgical services plan, or operating a plan subject to regulation under Chapter 45 (\u00a7 38.2-4500 et seq.).\n\t\t“Health maintenance organization” means a person licensed pursuant to Chapter 43 (\u00a7 38.2-4300 et seq.).\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“Managed care health insurance plan” or “MCHIP” means an arrangement for the delivery of health care in which a health carrier undertakes to provide, arrange for, pay for, or reimburse any of the costs of health care services for a covered person on a prepaid or insured basis which (i) contains one or more incentive arrangements, including any credentialing requirements intended to influence the cost or level of health care services between the health carrier and one or more providers with respect to the delivery of health care services and (ii) requires or creates benefit payment differential incentives for covered persons to use providers that are directly or indirectly managed, owned, under contract with or employed by the health carrier. Any health maintenance organization as defined in \u00a7 38.2-4300 or health carrier that offers preferred provider contracts or policies as defined in \u00a7 38.2-3407 or preferred provider subscription contracts as defined in \u00a7 38.2-4209 shall be deemed to be offering one or more MCHIPs. For the purposes of this definition, the prohibition of balance billing by a provider shall not be deemed a benefit payment differential incentive for covered persons to use providers who are directly or indirectly managed, owned, under contract with or employed by the health carrier. A single managed care health insurance plan may encompass multiple products and multiple types of benefit payment differentials; however, a single managed care health insurance plan shall encompass only one provider network or set of provider networks.\n\t\t“Medical necessity” or “medically necessary” means appropriate and necessary health care services which are rendered for any condition which, according to generally accepted principles of good medical practice, requires the diagnosis or direct care and treatment of an illness, injury, or pregnancy-related condition, and are not provided only as a convenience.\n\t\t“Network” means the set of providers directly or indirectly managed, owned, under contract with or employed directly or indirectly by a health carrier for the purpose of delivering health care services to the covered persons of an MCHIP.\n\t\t“Provider” or “health care provider” means any hospital, physician, or other person authorized by statute, licensed or certified to furnish health care services.\n\t\t“Service area” means a clearly defined geographic area in which a health carrier has directly or indirectly arranged for the provision of health care services to be generally available and readily accessible to covered persons of an MCHIP.","order_by":null,"text":{"0":{"id":277274,"text":"As used in this chapter:\n\t\t“Accident and sickness insurance company” means a person subject to licensing in accordance with provisions in Chapter 10 (\u00a7 38.2-1000 et seq.) or Chapter 41 (\u00a7 38.2-4100 et seq.) seeking or having authorization (i) to issue accident and sickness insurance as defined in \u00a7 38.2-109, (ii) to issue the benefit certificates or policies of accident and sickness insurance described in \u00a7 38.2-3801, or (iii) to provide hospital, medical and nursing benefits pursuant to \u00a7\u00a7 38.2-4116 and 38.2-4123.\n\t\t“Affiliated provider” means any provider that is employed by or has entered into a contractual agreement either directly or indirectly with a health carrier to provide health care services to members of a managed care health insurance plan for which the health carrier is responsible under this chapter.\n\t\t“Basic health care services” means emergency services, inpatient hospital and physician care, outpatient medical services, laboratory and radiological services, mental health and substance use disorder benefits, and preventive health services.\n\t\t“Copayment” means a payment required of covered persons as a condition of the receipt of specific health services.\n\t\t“Covered person” means an individual, whether a policyholder, subscriber, enrollee, or member of a managed care health insurance plan (MCHIP) who is entitled to health care services or benefits provided, arranged for, paid for or reimbursed pursuant to an MCHIP.\n\t\t“Evidence of coverage” includes any certificate, individual or group agreement or contract or related documents issued in conjunction with the certificate, agreement or contract, issued to a subscriber setting out the coverage and other rights to which a covered person is entitled.\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 carrier” means an entity subject to Title 38.2 that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including an entity providing a plan of health insurance, health benefits or health services, an accident and sickness insurance company, a health maintenance organization, or a nonstock corporation offering or administering a health services plan, a hospital services plan, or a medical or surgical services plan, or operating a plan subject to regulation under Chapter 45 (\u00a7 38.2-4500 et seq.).\n\t\t“Health maintenance organization” means a person licensed pursuant to Chapter 43 (\u00a7 38.2-4300 et seq.).\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“Managed care health insurance plan” or “MCHIP” means an arrangement for the delivery of health care in which a health carrier undertakes to provide, arrange for, pay for, or reimburse any of the costs of health care services for a covered person on a prepaid or insured basis which (i) contains one or more incentive arrangements, including any credentialing requirements intended to influence the cost or level of health care services between the health carrier and one or more providers with respect to the delivery of health care services and (ii) requires or creates benefit payment differential incentives for covered persons to use providers that are directly or indirectly managed, owned, under contract with or employed by the health carrier. Any health maintenance organization as defined in \u00a7 38.2-4300 or health carrier that offers preferred provider contracts or policies as defined in \u00a7 38.2-3407 or preferred provider subscription contracts as defined in \u00a7 38.2-4209 shall be deemed to be offering one or more MCHIPs. For the purposes of this definition, the prohibition of balance billing by a provider shall not be deemed a benefit payment differential incentive for covered persons to use providers who are directly or indirectly managed, owned, under contract with or employed by the health carrier. A single managed care health insurance plan may encompass multiple products and multiple types of benefit payment differentials; however, a single managed care health insurance plan shall encompass only one provider network or set of provider networks.\n\t\t“Medical necessity” or “medically necessary” means appropriate and necessary health care services which are rendered for any condition which, according to generally accepted principles of good medical practice, requires the diagnosis or direct care and treatment of an illness, injury, or pregnancy-related condition, and are not provided only as a convenience.\n\t\t“Network” means the set of providers directly or indirectly managed, owned, under contract with or employed directly or indirectly by a health carrier for the purpose of delivering health care services to the covered persons of an MCHIP.\n\t\t“Provider” or “health care provider” means any hospital, physician, or other person authorized by statute, licensed or certified to furnish health care services.\n\t\t“Service area” means a clearly defined geographic area in which a health carrier has directly or indirectly arranged for the provision of health care services to be generally available and readily accessible to covered persons of an MCHIP.","type":"section","prefixes":[""],"prefix":"","entire_prefix":"","prefix_anchor":"","level":1}},"ancestry":[{"id":13783,"edition_id":1,"name":"Managed Care Health Insurance Plans","identifier":"58","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:45:52","date_modified":"2026-06-26 03:45:52","permalink":{"id":217945,"object_type":"structure","relational_id":13783,"identifier":"58","token":"38.2\/58","url":"\/38.2\/58\/","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":77304,"structure_id":13783,"section_number":"38.2-5800","catch_line":"Definitions","url":"\/38.2-5800\/","token":"38.2\/58\/38.2-5800","metadata":false},{"id":64894,"structure_id":13783,"section_number":"38.2-5801","catch_line":"General provisions","url":"\/38.2-5801\/","token":"38.2\/58\/38.2-5801","metadata":false},{"id":54793,"structure_id":13783,"section_number":"38.2-5802","catch_line":"Establishment of an MCHIP","url":"\/38.2-5802\/","token":"38.2\/58\/38.2-5802","metadata":false},{"id":62075,"structure_id":13783,"section_number":"38.2-5803","catch_line":"Disclosures and representations to enrollees","url":"\/38.2-5803\/","token":"38.2\/58\/38.2-5803","metadata":false},{"id":74962,"structure_id":13783,"section_number":"38.2-5804","catch_line":"Complaint system","url":"\/38.2-5804\/","token":"38.2\/58\/38.2-5804","metadata":false},{"id":81176,"structure_id":13783,"section_number":"38.2-5805","catch_line":"Provider contracts","url":"\/38.2-5805\/","token":"38.2\/58\/38.2-5805","metadata":false},{"id":71053,"structure_id":13783,"section_number":"38.2-5806","catch_line":"Prohibited practices","url":"\/38.2-5806\/","token":"38.2\/58\/38.2-5806","metadata":false},{"id":63869,"structure_id":13783,"section_number":"38.2-5807","catch_line":"Access to care","url":"\/38.2-5807\/","token":"38.2\/58\/38.2-5807","metadata":false},{"id":60038,"structure_id":13783,"section_number":"38.2-5808","catch_line":"Examinations","url":"\/38.2-5808\/","token":"38.2\/58\/38.2-5808","metadata":false},{"id":75727,"structure_id":13783,"section_number":"38.2-5809","catch_line":"Suspension or revocation of license","url":"\/38.2-5809\/","token":"38.2\/58\/38.2-5809","metadata":false},{"id":70898,"structure_id":13783,"section_number":"38.2-5810","catch_line":"Statutory construction and relationship to other laws","url":"\/38.2-5810\/","token":"38.2\/58\/38.2-5810","metadata":false},{"id":68954,"structure_id":13783,"section_number":"38.2-5811","catch_line":"Controversies involving contracts","url":"\/38.2-5811\/","token":"38.2\/58\/38.2-5811","metadata":false}],"next_section":{"id":64894,"structure_id":13783,"section_number":"38.2-5801","catch_line":"General provisions","url":"\/38.2-5801\/","token":"38.2\/58\/38.2-5801","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-5800\/","history_text":"

This law was first created in 1998. The record of its establishment is cataloged in chapter 891<\/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 2 times. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. Those modifications are as follows: in 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":71060,"section_number":"38.2-3407.15","catch_line":"Ethics and fairness in carrier business practices","order_by":null,"url":"\/38.2-3407.15\/"},{"id":73127,"section_number":"38.2-3407.20","catch_line":"Calculation of enrollee's contribution to out-of-pocket maximum or cost-sharing requirement","order_by":null,"url":"\/38.2-3407.20\/"},{"id":85964,"section_number":"38.2-3407.22","catch_line":"Option for rebates to enrollees; protected information","order_by":null,"url":"\/38.2-3407.22\/"},{"id":86304,"section_number":"38.2-3418.10","catch_line":"Coverage for diabetes","order_by":null,"url":"\/38.2-3418.10\/"},{"id":85731,"section_number":"38.2-3418.14","catch_line":"Coverage for lymphedema","order_by":null,"url":"\/38.2-3418.14\/"},{"id":55347,"section_number":"38.2-4214","catch_line":"Application of certain provisions of law","order_by":null,"url":"\/38.2-4214\/"},{"id":64417,"section_number":"38.2-4302","catch_line":"Issuance of license; fee; minimum net worth; impairment","order_by":null,"url":"\/38.2-4302\/"},{"id":65829,"section_number":"38.2-4307","catch_line":"Annual statement","order_by":null,"url":"\/38.2-4307\/"},{"id":67952,"section_number":"38.2-4319","catch_line":"Statutory construction and relationship to other laws","order_by":null,"url":"\/38.2-4319\/"},{"id":62548,"section_number":"38.2-4509","catch_line":"Application of certain laws","order_by":null,"url":"\/38.2-4509\/"},{"id":80252,"section_number":"38.2-511","catch_line":"Failure to maintain record of complaints","order_by":null,"url":"\/38.2-511\/"},{"id":57276,"section_number":"38.2-5602.1","catch_line":"Operation of health savings accounts; high deductible health plans","order_by":null,"url":"\/38.2-5602.1\/"},{"id":70748,"section_number":"38.2-6103","catch_line":"Issuance of license; capital and surplus; impairment","order_by":null,"url":"\/38.2-6103\/"},{"id":60406,"section_number":"38.2-6113","catch_line":"Application of other laws","order_by":null,"url":"\/38.2-6113\/"},{"id":75226,"section_number":"8.01-581.17","catch_line":"Privileged communications of certain committees and entities","order_by":null,"url":"\/8.01-581.17\/"}],"refers_to":[{"id":58285,"section_number":"38.2-1000","catch_line":"Incorporation of domestic stock insurers","order_by":null,"url":"\/38.2-1000\/"},{"id":75359,"section_number":"38.2-109","catch_line":"Accident and sickness","order_by":null,"url":"\/38.2-109\/"},{"id":76321,"section_number":"38.2-3407","catch_line":"Health benefit programs","order_by":null,"url":"\/38.2-3407\/"},{"id":83921,"section_number":"38.2-3801","catch_line":"Cooperative nonprofit life benefit company defined","order_by":null,"url":"\/38.2-3801\/"},{"id":79636,"section_number":"38.2-4100","catch_line":"Fraternal benefit societies","order_by":null,"url":"\/38.2-4100\/"},{"id":64367,"section_number":"38.2-4116","catch_line":"Benefits","order_by":null,"url":"\/38.2-4116\/"},{"id":65309,"section_number":"38.2-4123","catch_line":"Exemptions","order_by":null,"url":"\/38.2-4123\/"},{"id":80669,"section_number":"38.2-4209","catch_line":"Preferred provider subscription contracts","order_by":null,"url":"\/38.2-4209\/"},{"id":72005,"section_number":"38.2-4300","catch_line":"Definitions","order_by":null,"url":"\/38.2-4300\/"},{"id":59325,"section_number":"38.2-4500","catch_line":"Applicability of chapter","order_by":null,"url":"\/38.2-4500\/"}],"permalink":{"id":217947,"object_type":"law","relational_id":77304,"identifier":"38.2-5800","token":"38.2\/58\/38.2-5800","url":"\/38.2-5800\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-5800\/","token":"38.2\/58\/38.2-5800","dublin_core":{"Title":"Definitions","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-5800","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

As used in this chapter:\n\t\t“Accident and sickness insurance company<\/span>” means a person subject to licensing in accordance with provisions in Chapter 10 (\u00a7 38.2-1000<\/a> et seq.) or Chapter 41 (\u00a7 38.2-4100<\/a> et seq.) seeking or having authorization (i) to issue<\/span> accident and sickness insurance as defined in \u00a7 38.2-109<\/a>, (ii) to issue<\/span> the benefit certificates or policies of accident and sickness insurance described in \u00a7 38.2-3801<\/a>, or (iii) to provide hospital, medical and nursing benefits pursuant to \u00a7\u00a7 38.2-4116<\/a> and 38.2-4123<\/a>.\n\t\t“Affiliated provider<\/span>” means any provider that is employed by or has entered into a contractual agreement either directly or indirectly with a health carrier<\/span> to provide health care services<\/span> to members of a managed care health insurance plan<\/span> for which the health carrier<\/span> is responsible under this chapter.\n\t\t“Basic health care services<\/span><\/span>” means emergency services, inpatient hospital and physician care, outpatient medical services, laboratory and radiological services, mental health and substance use disorder benefits, and preventive health services.\n\t\t“Copayment<\/span>” means a payment required of covered persons<\/span> as a condition of the receipt of specific health services.\n\t\t“Covered person<\/span>” means an individual, whether a policyholder, subscriber, enrollee, or member of a managed care health insurance plan<\/span> (MCHIP<\/span>) who is entitled to health care services<\/span> or benefits provided, arranged for, paid for or reimbursed pursuant to an MCHIP<\/span>.\n\t\t“Evidence of coverage<\/span>” includes any certificate, individual or group agreement or contract<\/span> or related documents issued in conjunction with the certificate, agreement or contract<\/span>, issued to a subscriber setting out the coverage and other rights to which a covered person<\/span> is entitled.\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 carrier<\/span>” means an entity subject to Title 38.2 that contracts<\/span> or offers to contract<\/span> to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services<\/span>, including an entity providing a plan of health insurance, health benefits or health services, an accident and sickness insurance company<\/span>, a health maintenance organization<\/span>, or a nonstock corporation offering or administering a health services plan<\/span>, a hospital services plan, or a medical or surgical services plan, or operating a plan subject to regulation under Chapter 45 (\u00a7 38.2-4500<\/a> et seq.).\n\t\t“Health maintenance organization<\/span>” means a person licensed pursuant to Chapter 43 (\u00a7 38.2-4300<\/a> et seq.).\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 except as such services are provided incident to the limited health care services<\/span><\/span> set forth in the preceding sentence.\n\t\t“Managed care health insurance plan<\/span>” or “MCHIP<\/span>” means an arrangement for the delivery of health care in which a health carrier<\/span> undertakes to provide, arrange for, pay for, or reimburse any of the costs of health care services<\/span> for a covered person<\/span> on a prepaid or insured basis which (i) contains one or more incentive arrangements, including any credentialing requirements intended to influence the cost or level of health care services<\/span> between the health carrier<\/span> and one or more providers<\/span> with respect to the delivery of health care services<\/span> and (ii) requires or creates benefit payment differential incentives for covered persons<\/span> to use providers<\/span> that are directly or indirectly managed, owned, under contract<\/span> with or employed by the health carrier<\/span>. Any health maintenance organization<\/span> as defined in \u00a7 38.2-4300<\/a> or health carrier<\/span> that offers preferred provider contracts<\/span> or policies as defined in \u00a7 38.2-3407<\/a> or preferred provider subscription contracts<\/span> as defined in \u00a7 38.2-4209<\/a> shall be deemed to be offering one or more MCHIPs<\/span>. For the purposes of this definition, the prohibition of balance billing by a provider shall not be deemed a benefit payment differential incentive for covered persons<\/span> to use providers<\/span> who are directly or indirectly managed, owned, under contract<\/span> with or employed by the health carrier<\/span>. A single managed care health insurance plan<\/span> may encompass multiple products and multiple types of benefit payment differentials; however, a single managed care health insurance plan<\/span> shall encompass only one provider network<\/span> or set of provider networks<\/span>.\n\t\t“Medical necessity<\/span>” or “medically necessary<\/span>” means appropriate and necessary health care services<\/span> which are rendered for any condition which, according to generally accepted principles of good medical practice, requires the diagnosis or direct care and treatment of an illness, injury, or pregnancy-related condition, and are not provided only as a convenience.\n\t\t“Network<\/span>” means the set of providers<\/span> directly or indirectly managed, owned, under contract<\/span> with or employed directly or indirectly by a health carrier<\/span> for the purpose of delivering health care services<\/span> to the covered persons<\/span> of an MCHIP<\/span>.\n\t\t“Provider” or “health care provider<\/span>” means any hospital, physician, or other person authorized by statute<\/span>, licensed or certified to furnish health care services<\/span>.\n\t\t“Service area<\/span>” means a clearly defined geographic area in which a health carrier<\/span> has directly or indirectly arranged for the provision of health care services<\/span> to be generally available and readily accessible to covered persons<\/span> of an MCHIP<\/span>.<\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nDEFINITIONS (\u00a7 38.2-5800)\n\nAs used in this chapter:\n\t\t“Accident and sickness insurance company” means a person subject\nto licensing in accordance with provisions in Chapter 10 (\u00a7 38.2-1000 et seq.)\nor Chapter 41 (\u00a7 38.2-4100 et seq.) seeking or having authorization (i) to\nissue accident and sickness insurance as defined in \u00a7 38.2-109, (ii) to issue\nthe benefit certificates or policies of accident and sickness insurance\ndescribed in \u00a7 38.2-3801, or (iii) to provide hospital, medical and nursing\nbenefits pursuant to \u00a7\u00a7 38.2-4116 and 38.2-4123.\n\t\t“Affiliated provider” means any provider that is employed by or\nhas entered into a contractual agreement either directly or indirectly with a\nhealth carrier to provide health care services to members of a managed care\nhealth insurance plan for which the health carrier is responsible under this\nchapter.\n\t\t“Basic health care services” means emergency services, inpatient\nhospital and physician care, outpatient medical services, laboratory and\nradiological services, mental health and substance use disorder benefits, and\npreventive health services.\n\t\t“Copayment” means a payment required of covered persons as a\ncondition of the receipt of specific health services.\n\t\t“Covered person” means an individual, whether a policyholder,\nsubscriber, enrollee, or member of a managed care health insurance plan (MCHIP)\nwho is entitled to health care services or benefits provided, arranged for, paid\nfor or reimbursed pursuant to an MCHIP.\n\t\t“Evidence of coverage” includes any certificate, individual or\ngroup agreement or contract or related documents issued in conjunction with the\ncertificate, agreement or contract, issued to a subscriber setting out the\ncoverage and other rights to which a covered person is entitled.\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 carrier” means an entity subject to Title 38.2 that\ncontracts or offers to contract to provide, deliver, arrange for, pay for or\nreimburse any of the costs of health care services, including an entity\nproviding a plan of health insurance, health benefits or health services, an\naccident and sickness insurance company, a health maintenance organization, or a\nnonstock corporation offering or administering a health services plan, a\nhospital services plan, or a medical or surgical services plan, or operating a\nplan subject to regulation under Chapter 45 (\u00a7 38.2-4500 et seq.).\n\t\t“Health maintenance organization” means a person licensed pursuant\nto Chapter 43 (\u00a7 38.2-4300 et seq.).\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“Managed care health insurance plan” or “MCHIP” means\nan arrangement for the delivery of health care in which a health carrier\nundertakes to provide, arrange for, pay for, or reimburse any of the costs of\nhealth care services for a covered person on a prepaid or insured basis which\n(i) contains one or more incentive arrangements, including any credentialing\nrequirements intended to influence the cost or level of health care services\nbetween the health carrier and one or more providers with respect to the\ndelivery of health care services and (ii) requires or creates benefit payment\ndifferential incentives for covered persons to use providers that are directly\nor indirectly managed, owned, under contract with or employed by the health\ncarrier. Any health maintenance organization as defined in \u00a7 38.2-4300 or\nhealth carrier that offers preferred provider contracts or policies as defined\nin \u00a7 38.2-3407 or preferred provider subscription contracts as defined in \u00a7\n38.2-4209 shall be deemed to be offering one or more MCHIPs. For the purposes of\nthis definition, the prohibition of balance billing by a provider shall not be\ndeemed a benefit payment differential incentive for covered persons to use\nproviders who are directly or indirectly managed, owned, under contract with or\nemployed by the health carrier. A single managed care health insurance plan may\nencompass multiple products and multiple types of benefit payment differentials;\nhowever, a single managed care health insurance plan shall encompass only one\nprovider network or set of provider networks.\n\t\t“Medical necessity” or “medically necessary” means\nappropriate and necessary health care services which are rendered for any\ncondition which, according to generally accepted principles of good medical\npractice, requires the diagnosis or direct care and treatment of an illness,\ninjury, or pregnancy-related condition, and are not provided only as a\nconvenience.\n\t\t“Network” means the set of providers directly or indirectly\nmanaged, owned, under contract with or employed directly or indirectly by a\nhealth carrier for the purpose of delivering health care services to the covered\npersons of an MCHIP.\n\t\t“Provider” or “health care provider” means any\nhospital, physician, or other person authorized by statute, licensed or\ncertified to furnish health care services.\n\t\t“Service area” means a clearly defined geographic area in which a\nhealth carrier has directly or indirectly arranged for the provision of health\ncare services to be generally available and readily accessible to covered\npersons of an MCHIP.\n\nHISTORY: 1998, c. 891; 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}}