{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-6500.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-6500.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-6500.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-6500.html"}],"law_id":75766,"edition_id":1,"section_id":75766,"structure_id":12800,"section_number":"38.2-6500","catch_line":"Definitions","history":"2020, cc. 916, 917.","full_text":"As used in this chapter, unless the context requires a different meaning:\n\t\t“American Health Benefit Exchange” means the program established as a component of the Exchange pursuant to this chapter that is designed to facilitate the purchase of qualified health plans or qualified dental plans by qualified individuals.\n\t\t“Bureau” means the Bureau of Insurance, a division within the Commission through which it administers insurance law.\n\t\t“Certified application counselor” means individuals certified by the Exchange to perform the duties described in 45 C.F.R. \u00a7 155.255(c).\n\t\t“Commission” means the State Corporation Commission.\n\t\t“Committee” means the Advisory Committee established pursuant to \u00a7 38.2-6503.\n\t\t“Director” means the Director of the Division appointed by the Commission pursuant to \u00a7 38.2-6502.\n\t\t“Division” means the Health Benefit Exchange Division, a division within the Commission through which it administers the Exchange.\n\t\t“Eligible employee” means an individual employed by a qualified employer who has been offered health insurance coverage by such qualified employer through the SHOP exchange.\n\t\t“Eligible entity” means the Bureau, the Department of Medical Assistance Services, or a qualified vendor that has demonstrated experience on a statewide or regional basis in individual and small group health insurance markets and in benefits coverage; however, a health carrier or an affiliate of a health carrier is not an eligible entity.\n\t\t“Essential health benefits package” means the scope of covered benefits and associated limits of a health benefit plan that (i) provides benefits pursuant to \u00a7 38.2-3451; (ii) provides the benefits in the manner described in 45 C.F.R. \u00a7 156.115; (iii) limits cost-sharing for such coverage as described in 45 C.F.R. \u00a7 156.130; and (iv) subject to offering catastrophic plans as described in \u00a7 1302(e) of the Federal Act, provides distinct levels of coverage as described in 45 C.F.R. \u00a7 156.140.\n\t\t“Exchange” means, as the context requires, either (i) the Division or (ii) the Virginia Health Benefit Exchange established pursuant to the provisions of this chapter and in accordance with \u00a7 1311(b) of the Federal Act, through which qualified health plans and qualified dental plans are made available to qualified individuals through the American Health Benefit Exchange and to qualified employers through the SHOP exchange. “Exchange,” when referring to the Virginia Health Benefit Exchange, collectively refers to both the American Health Benefit Exchange and the SHOP exchange.\n\t\t“FAMIS” means the Family Access to Medical Insurance Security Plan, including the FAMIS Plus program, established pursuant to Chapter 13 (\u00a7 32.1-351 et seq.) of Title 32.1.\n\t\t“Federal Act” means the federal Patient Protection and Affordable Care Act, P.L. 111-148, as amended by the Health Care and Education Reconciliation Act of 2010, P.L. 111-152, and as it may further be amended, and regulations issued thereunder.\n\t\t“Health benefit plan” or “plan” means a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. The term does not include coverage only for accident or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers’ compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for onsite medical clinics; or other similar insurance coverage, specified in federal regulations issued pursuant to the Federal Act, under which benefits for medical care are secondary or incidental to other insurance benefits. The term does not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; or other similar limited benefits specified in federal regulations issued pursuant to the Federal Act. The term does not include the following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance; there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor; and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor: coverage only for a specified disease or illness, for hospital indemnity, or other fixed indemnity insurance. The term does not include the following if offered as a separate policy, certificate, or contract of insurance: Medicare supplemental health insurance as defined under \u00a7 1882(g)(1) of the U.S. Social Security Act; coverage supplemental to the coverage provided under 10 U.S.C. \u00a7 1071 et seq. (TRICARE); or similar supplemental coverage provided under a group health plan.\n\t\t“Health carrier” or “carrier” means an entity subject to the insurance laws and regulations of the Commonwealth and subject to the jurisdiction of the Commission 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 insurer licensed to sell accident and sickness insurance, a health maintenance organization, a health services plan, a dental plan organization, a dental services plan, or any other entity providing a plan of health insurance, health benefits, or health care services.\n\t\t“Insurance agent” has the same meaning as provided in \u00a7 38.2-1800.\n\t\t“Minimum essential coverage” means coverage defined in 45 C.F.R. \u00a7 156.600.\n\t\t“Navigator” means an individual or entity that is registered pursuant to \u00a7 38.2-3457.\n\t\t“PHSA” means the federal Public Health Service Act, Chapter 6A of Title 42 of the United States Code, as amended.\n\t\t“Qualified dental plan” means a limited scope dental plan that has been certified in accordance with \u00a7 38.2-6506.\n\t\t“Qualified employer” means a small employer that elects to make all of its full-time employees eligible for one or more qualified health plans or qualified dental plans in the small group market offered through the SHOP exchange and, at the employer’s option, some or all of its part-time employees, provided that the employer (i) has its principal place of business in the Commonwealth and elects to provide coverage through the SHOP exchange to all of its eligible employees, wherever employed, or (ii) elects to provide coverage through the SHOP exchange to all of its eligible employees who are principally employed in the Commonwealth.\n\t\t“Qualified health plan” means a health benefit plan that has in effect a certification that the plan meets the criteria for certification described in \u00a7 1311(c) of the Federal Act and \u00a7 38.2-6506.\n\t\t“Qualified individual” means an individual, including a minor, who (i) is seeking to enroll in a qualified health plan or qualified dental plan offered to individuals through the Exchange; (ii) resides in the Commonwealth; (iii) is not incarcerated at the time of enrollment, other than incarceration pending the disposition of charges; and (iv) is, and is reasonably expected to be, for the entire period for which enrollment is sought, a citizen or a national of the United States or an alien lawfully present in the United States.\n\t\t“Secretary” means the Secretary of the U.S. Department of Health and Human Services.\n\t\t“SHOP exchange” means the Small Business Health Options Program, established as a component of the Exchange pursuant to this chapter, through which a qualified employer can provide its eligible employees and their dependents with access to one or more qualified health plans or qualified dental plans.\n\t\t“Small employer” means an employer that employed an average of not more than 50 employees during the preceding calendar year. For the purposes of this definition: (a) all persons treated as a single employer under subsection (b), (c), (m), or (o) of 26 U.S.C. \u00a7 414 shall be treated as a single employer; (b) an employer and any predecessor employer shall be treated as a single employer; and (c) all employees shall be counted, including part-time employees and employees who are not eligible for health insurance coverage through the employer. If an employer was not in existence throughout the preceding calendar year, the determination of whether the employer is a small employer shall be based on the average number of employees reasonably expected to be employed by the employer on business days in the current calendar year. An employer that makes enrollment in qualified health plans or qualified dental plans available to its eligible employees through the SHOP exchange and that no longer meets the definition of a small employer because of an increase in the number of its employees shall continue to be treated as a small employer for purposes of this chapter as long as that employer continuously makes enrollment through the SHOP exchange available to its eligible employees.\n\t\t“Small group market” means the health insurance market under which individuals obtain health insurance coverage, directly or through any arrangement, on behalf of themselves and their dependents through a group health plan maintained by a small employer.\n\t\t“State-mandated health benefit” means coverage required under this title or other laws of the Commonwealth to be provided in a policy of accident and sickness insurance, an accident and sickness subscription contract, or a health maintenance organization health care plan that includes coverage for specific health care services or benefits.\n\t\t“State Medicaid Program” means the Commonwealth’s Medicaid program under Title XIX of the Social Security Act, as amended from time to time.","order_by":null,"text":{"0":{"id":272036,"text":"As used in this chapter, unless the context requires a different meaning:\n\t\t“American Health Benefit Exchange” means the program established as a component of the Exchange pursuant to this chapter that is designed to facilitate the purchase of qualified health plans or qualified dental plans by qualified individuals.\n\t\t“Bureau” means the Bureau of Insurance, a division within the Commission through which it administers insurance law.\n\t\t“Certified application counselor” means individuals certified by the Exchange to perform the duties described in 45 C.F.R. \u00a7 155.255(c).\n\t\t“Commission” means the State Corporation Commission.\n\t\t“Committee” means the Advisory Committee established pursuant to \u00a7 38.2-6503.\n\t\t“Director” means the Director of the Division appointed by the Commission pursuant to \u00a7 38.2-6502.\n\t\t“Division” means the Health Benefit Exchange Division, a division within the Commission through which it administers the Exchange.\n\t\t“Eligible employee” means an individual employed by a qualified employer who has been offered health insurance coverage by such qualified employer through the SHOP exchange.\n\t\t“Eligible entity” means the Bureau, the Department of Medical Assistance Services, or a qualified vendor that has demonstrated experience on a statewide or regional basis in individual and small group health insurance markets and in benefits coverage; however, a health carrier or an affiliate of a health carrier is not an eligible entity.\n\t\t“Essential health benefits package” means the scope of covered benefits and associated limits of a health benefit plan that (i) provides benefits pursuant to \u00a7 38.2-3451; (ii) provides the benefits in the manner described in 45 C.F.R. \u00a7 156.115; (iii) limits cost-sharing for such coverage as described in 45 C.F.R. \u00a7 156.130; and (iv) subject to offering catastrophic plans as described in \u00a7 1302(e) of the Federal Act, provides distinct levels of coverage as described in 45 C.F.R. \u00a7 156.140.\n\t\t“Exchange” means, as the context requires, either (i) the Division or (ii) the Virginia Health Benefit Exchange established pursuant to the provisions of this chapter and in accordance with \u00a7 1311(b) of the Federal Act, through which qualified health plans and qualified dental plans are made available to qualified individuals through the American Health Benefit Exchange and to qualified employers through the SHOP exchange. “Exchange,” when referring to the Virginia Health Benefit Exchange, collectively refers to both the American Health Benefit Exchange and the SHOP exchange.\n\t\t“FAMIS” means the Family Access to Medical Insurance Security Plan, including the FAMIS Plus program, established pursuant to Chapter 13 (\u00a7 32.1-351 et seq.) of Title 32.1.\n\t\t“Federal Act” means the federal Patient Protection and Affordable Care Act, P.L. 111-148, as amended by the Health Care and Education Reconciliation Act of 2010, P.L. 111-152, and as it may further be amended, and regulations issued thereunder.\n\t\t“Health benefit plan” or “plan” means a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. The term does not include coverage only for accident or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers’ compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for onsite medical clinics; or other similar insurance coverage, specified in federal regulations issued pursuant to the Federal Act, under which benefits for medical care are secondary or incidental to other insurance benefits. The term does not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; or other similar limited benefits specified in federal regulations issued pursuant to the Federal Act. The term does not include the following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance; there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor; and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor: coverage only for a specified disease or illness, for hospital indemnity, or other fixed indemnity insurance. The term does not include the following if offered as a separate policy, certificate, or contract of insurance: Medicare supplemental health insurance as defined under \u00a7 1882(g)(1) of the U.S. Social Security Act; coverage supplemental to the coverage provided under 10 U.S.C. \u00a7 1071 et seq. (TRICARE); or similar supplemental coverage provided under a group health plan.\n\t\t“Health carrier” or “carrier” means an entity subject to the insurance laws and regulations of the Commonwealth and subject to the jurisdiction of the Commission 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 insurer licensed to sell accident and sickness insurance, a health maintenance organization, a health services plan, a dental plan organization, a dental services plan, or any other entity providing a plan of health insurance, health benefits, or health care services.\n\t\t“Insurance agent” has the same meaning as provided in \u00a7 38.2-1800.\n\t\t“Minimum essential coverage” means coverage defined in 45 C.F.R. \u00a7 156.600.\n\t\t“Navigator” means an individual or entity that is registered pursuant to \u00a7 38.2-3457.\n\t\t“PHSA” means the federal Public Health Service Act, Chapter 6A of Title 42 of the United States Code, as amended.\n\t\t“Qualified dental plan” means a limited scope dental plan that has been certified in accordance with \u00a7 38.2-6506.\n\t\t“Qualified employer” means a small employer that elects to make all of its full-time employees eligible for one or more qualified health plans or qualified dental plans in the small group market offered through the SHOP exchange and, at the employer’s option, some or all of its part-time employees, provided that the employer (i) has its principal place of business in the Commonwealth and elects to provide coverage through the SHOP exchange to all of its eligible employees, wherever employed, or (ii) elects to provide coverage through the SHOP exchange to all of its eligible employees who are principally employed in the Commonwealth.\n\t\t“Qualified health plan” means a health benefit plan that has in effect a certification that the plan meets the criteria for certification described in \u00a7 1311(c) of the Federal Act and \u00a7 38.2-6506.\n\t\t“Qualified individual” means an individual, including a minor, who (i) is seeking to enroll in a qualified health plan or qualified dental plan offered to individuals through the Exchange; (ii) resides in the Commonwealth; (iii) is not incarcerated at the time of enrollment, other than incarceration pending the disposition of charges; and (iv) is, and is reasonably expected to be, for the entire period for which enrollment is sought, a citizen or a national of the United States or an alien lawfully present in the United States.\n\t\t“Secretary” means the Secretary of the U.S. Department of Health and Human Services.\n\t\t“SHOP exchange” means the Small Business Health Options Program, established as a component of the Exchange pursuant to this chapter, through which a qualified employer can provide its eligible employees and their dependents with access to one or more qualified health plans or qualified dental plans.\n\t\t“Small employer” means an employer that employed an average of not more than 50 employees during the preceding calendar year. For the purposes of this definition: (a) all persons treated as a single employer under subsection (b), (c), (m), or (o) of 26 U.S.C. \u00a7 414 shall be treated as a single employer; (b) an employer and any predecessor employer shall be treated as a single employer; and (c) all employees shall be counted, including part-time employees and employees who are not eligible for health insurance coverage through the employer. If an employer was not in existence throughout the preceding calendar year, the determination of whether the employer is a small employer shall be based on the average number of employees reasonably expected to be employed by the employer on business days in the current calendar year. An employer that makes enrollment in qualified health plans or qualified dental plans available to its eligible employees through the SHOP exchange and that no longer meets the definition of a small employer because of an increase in the number of its employees shall continue to be treated as a small employer for purposes of this chapter as long as that employer continuously makes enrollment through the SHOP exchange available to its eligible employees.\n\t\t“Small group market” means the health insurance market under which individuals obtain health insurance coverage, directly or through any arrangement, on behalf of themselves and their dependents through a group health plan maintained by a small employer.\n\t\t“State-mandated health benefit” means coverage required under this title or other laws of the Commonwealth to be provided in a policy of accident and sickness insurance, an accident and sickness subscription contract, or a health maintenance organization health care plan that includes coverage for specific health care services or benefits.\n\t\t“State Medicaid Program” means the Commonwealth’s Medicaid program under Title XIX of the Social Security Act, as amended from time to time.","type":"section","prefixes":[""],"prefix":"","entire_prefix":"","prefix_anchor":"","level":1}},"ancestry":[{"id":12800,"edition_id":1,"name":"Virginia Health Benefit Exchange","identifier":"65","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:43:53","date_modified":"2026-06-26 03:43:53","permalink":{"id":218345,"object_type":"structure","relational_id":12800,"identifier":"65","token":"38.2\/65","url":"\/38.2\/65\/","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":75766,"structure_id":12800,"section_number":"38.2-6500","catch_line":"Definitions","url":"\/38.2-6500\/","token":"38.2\/65\/38.2-6500","metadata":false},{"id":84565,"structure_id":12800,"section_number":"38.2-6501","catch_line":"Exchange objectives","url":"\/38.2-6501\/","token":"38.2\/65\/38.2-6501","metadata":false},{"id":59610,"structure_id":12800,"section_number":"38.2-6502","catch_line":"Division established; Exchange created","url":"\/38.2-6502\/","token":"38.2\/65\/38.2-6502","metadata":false},{"id":74872,"structure_id":12800,"section_number":"38.2-6503","catch_line":"Advisory Committee","url":"\/38.2-6503\/","token":"38.2\/65\/38.2-6503","metadata":false},{"id":55843,"structure_id":12800,"section_number":"38.2-6504","catch_line":"Exchange requirements","url":"\/38.2-6504\/","token":"38.2\/65\/38.2-6504","metadata":false},{"id":76462,"structure_id":12800,"section_number":"38.2-6505","catch_line":"Duties of Exchange","url":"\/38.2-6505\/","token":"38.2\/65\/38.2-6505","metadata":false},{"id":81163,"structure_id":12800,"section_number":"38.2-6506","catch_line":"Certification of health benefit plans as qualified health plans","url":"\/38.2-6506\/","token":"38.2\/65\/38.2-6506","metadata":false},{"id":81440,"structure_id":12800,"section_number":"38.2-6507","catch_line":"Appeal of decertification or denial of certification","url":"\/38.2-6507\/","token":"38.2\/65\/38.2-6507","metadata":false},{"id":67396,"structure_id":12800,"section_number":"38.2-6508","catch_line":"Open enrollment periods","url":"\/38.2-6508\/","token":"38.2\/65\/38.2-6508","metadata":false},{"id":84381,"structure_id":12800,"section_number":"38.2-6509","catch_line":"Choice","url":"\/38.2-6509\/","token":"38.2\/65\/38.2-6509","metadata":false},{"id":67117,"structure_id":12800,"section_number":"38.2-6510","catch_line":"Health Insurance Exchange Fund; assessment","url":"\/38.2-6510\/","token":"38.2\/65\/38.2-6510","metadata":false},{"id":62589,"structure_id":12800,"section_number":"38.2-6511","catch_line":"Procurement, contracting, and personnel","url":"\/38.2-6511\/","token":"38.2\/65\/38.2-6511","metadata":false},{"id":77639,"structure_id":12800,"section_number":"38.2-6512","catch_line":"Confidentiality","url":"\/38.2-6512\/","token":"38.2\/65\/38.2-6512","metadata":false},{"id":80784,"structure_id":12800,"section_number":"38.2-6513","catch_line":"Navigators","url":"\/38.2-6513\/","token":"38.2\/65\/38.2-6513","metadata":false},{"id":85399,"structure_id":12800,"section_number":"38.2-6514","catch_line":"Certified application counselors","url":"\/38.2-6514\/","token":"38.2\/65\/38.2-6514","metadata":false},{"id":82556,"structure_id":12800,"section_number":"38.2-6515","catch_line":"Regulations","url":"\/38.2-6515\/","token":"38.2\/65\/38.2-6515","metadata":false},{"id":53968,"structure_id":12800,"section_number":"38.2-6516","catch_line":"Reports","url":"\/38.2-6516\/","token":"38.2\/65\/38.2-6516","metadata":false},{"id":58428,"structure_id":12800,"section_number":"38.2-6517","catch_line":"Relation to other laws","url":"\/38.2-6517\/","token":"38.2\/65\/38.2-6517","metadata":false}],"next_section":{"id":84565,"structure_id":12800,"section_number":"38.2-6501","catch_line":"Exchange objectives","url":"\/38.2-6501\/","token":"38.2\/65\/38.2-6501","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-6500\/","history_text":"

This law was first created in 2020. The record of its establishment is cataloged in chapters 916<\/a> and 917<\/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.<\/p>","references":[{"id":55944,"section_number":"38.2-326","catch_line":"Plan management functions","order_by":null,"url":"\/38.2-326\/"},{"id":64550,"section_number":"38.2-3455","catch_line":"Definitions","order_by":null,"url":"\/38.2-3455\/"},{"id":55347,"section_number":"38.2-4214","catch_line":"Application of certain provisions of law","order_by":null,"url":"\/38.2-4214\/"},{"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\/"}],"refers_to":[{"id":86147,"section_number":"32.1-351","catch_line":"Family Access to Medical Insurance Security Plan established","order_by":null,"url":"\/32.1-351\/"},{"id":67482,"section_number":"38.2-1800","catch_line":"Definitions","order_by":null,"url":"\/38.2-1800\/"},{"id":83154,"section_number":"38.2-3451","catch_line":"Essential health benefits","order_by":null,"url":"\/38.2-3451\/"},{"id":67193,"section_number":"38.2-3457","catch_line":"Application for registration","order_by":null,"url":"\/38.2-3457\/"},{"id":59610,"section_number":"38.2-6502","catch_line":"Division established; Exchange created","order_by":null,"url":"\/38.2-6502\/"},{"id":74872,"section_number":"38.2-6503","catch_line":"Advisory Committee","order_by":null,"url":"\/38.2-6503\/"},{"id":81163,"section_number":"38.2-6506","catch_line":"Certification of health benefit plans as qualified health plans","order_by":null,"url":"\/38.2-6506\/"}],"permalink":{"id":218347,"object_type":"law","relational_id":75766,"identifier":"38.2-6500","token":"38.2\/65\/38.2-6500","url":"\/38.2-6500\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-6500\/","token":"38.2\/65\/38.2-6500","dublin_core":{"Title":"Definitions","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-6500","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

As used in this chapter, unless the context requires a different meaning:\n\t\t“American Health Benefit Exchange<\/span>” means the program established as a component of the Exchange pursuant to this chapter that is designed to facilitate the purchase of qualified health plans<\/span> or qualified dental plans<\/span> by qualified individuals<\/span>.\n\t\t“Bureau” means the Bureau of Insurance<\/span>, a division<\/span> within the Commission<\/span> through which it administers insurance law<\/span>.\n\t\t“Certified application counselor<\/span>” means individuals certified by the Exchange to perform the duties described in 45 C.F.R. \u00a7 155.255(c).\n\t\t“Commission<\/span>” means the State Corporation Commission<\/span>.\n\t\t“Committee<\/span>” means the Advisory Committee<\/span> established pursuant to \u00a7 38.2-6503<\/a>.\n\t\t“Director<\/span>” means the Director<\/span> of the Division<\/span> appointed by the Commission<\/span> pursuant to \u00a7 38.2-6502<\/a>.\n\t\t“Division<\/span>” means the Health Benefit Exchange Division<\/span>, a division<\/span> within the Commission<\/span> through which it administers the Exchange.\n\t\t“Eligible employee<\/span>” means an individual employed by a qualified employer<\/span> who has been offered health insurance coverage by such qualified employer<\/span> through the SHOP exchange<\/span>.\n\t\t“Eligible entity<\/span>” means the Bureau, the Department of Medical Assistance Services, or a qualified vendor that has demonstrated experience on a statewide or regional basis in individual and small group health insurance markets and in benefits coverage; however, a health carrier<\/span> or an affiliate of a health carrier<\/span> is not an eligible entity<\/span>.\n\t\t“Essential health benefits package<\/span>” means the scope of covered benefits and associated limits of a health benefit plan<\/span> that (i) provides benefits pursuant to \u00a7 38.2-3451<\/a>; (ii) provides the benefits in the manner described in 45 C.F.R. \u00a7 156.115; (iii) limits cost-sharing for such coverage as described in 45 C.F.R. \u00a7 156.130; and (iv) subject to offering catastrophic plans as described in \u00a7 1302(e) of the Federal Act<\/span>, provides distinct levels of coverage as described in 45 C.F.R. \u00a7 156.140.\n\t\t“Exchange” means, as the context requires, either (i) the Division<\/span> or (ii) the Virginia Health Benefit Exchange established pursuant to the provisions of this chapter and in accordance with \u00a7 1311(b) of the Federal Act<\/span>, through which qualified health plans<\/span> and qualified dental plans<\/span> are made available to qualified individuals<\/span> through the American Health Benefit Exchange<\/span> and to qualified employers<\/span> through the SHOP exchange<\/span>. “Exchange,” when referring to the Virginia Health Benefit Exchange, collectively refers to both the American Health Benefit Exchange<\/span> and the SHOP exchange<\/span>.\n\t\t“FAMIS<\/span>” means the Family Access to Medical Insurance Security Plan, including the FAMIS<\/span> Plus program, established pursuant to Chapter 13 (\u00a7 32.1-351<\/a> et seq.) of Title 32.1.\n\t\t“Federal Act<\/span>” means the federal Patient Protection and Affordable Care Act, P.L. 111-148, as amended by the Health Care and Education Reconciliation Act of 2010, P.L. 111-152, and as it may further be amended, and regulations issued thereunder.\n\t\t“Health benefit plan<\/span>” or “plan” means a policy, contract<\/span>, certificate, or agreement offered or issued by a health carrier<\/span> to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. The term does not include coverage only for accident or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers’ compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for onsite medical clinics; or other similar insurance coverage, specified in federal regulations issued pursuant to the Federal Act<\/span>, under which benefits for medical care are secondary or incidental to other insurance benefits. The term does not include the following benefits if they are provided under a separate policy, certificate, or contract<\/span> of insurance or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; or other similar limited benefits specified in federal regulations issued pursuant to the Federal Act<\/span>. The term does not include the following benefits if the benefits are provided under a separate policy, certificate, or contract<\/span> of insurance; there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor; and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor: coverage only for a specified disease or illness, for hospital indemnity, or other fixed indemnity insurance. The term does not include the following if offered as a separate policy, certificate, or contract<\/span> of insurance: Medicare<\/span> supplemental health insurance as defined under \u00a7 1882(g)(1) of the U.S. Social Security Act; coverage supplemental to the coverage provided under 10 U.S.C. \u00a7 1071 et seq. (TRICARE); or similar supplemental coverage provided under a group health plan.\n\t\t“Health carrier<\/span>” or “carrier” means an entity subject to the insurance laws<\/span> and regulations of the Commonwealth and subject to the jurisdiction<\/span> of the Commission<\/span> 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, including an insurer<\/span> licensed to sell accident and sickness insurance, a health maintenance organization, a health services plan<\/span>, a dental plan organization, a dental services plan, or any other entity providing a plan of health insurance, health benefits, or health care services.\n\t\t“Insurance agent<\/span>” has the same meaning as provided in \u00a7 38.2-1800<\/a>.\n\t\t“Minimum essential coverage<\/span>” means coverage defined in 45 C.F.R. \u00a7 156.600.\n\t\t“Navigator<\/span>” means an individual or entity that is registered pursuant to \u00a7 38.2-3457<\/a>.\n\t\t“PHSA<\/span>” means the federal Public Health Service Act, Chapter 6A of Title 42 of the United States<\/span> Code, as amended.\n\t\t“Qualified dental plan<\/span>” means a limited scope dental plan that has been certified in accordance with \u00a7 38.2-6506<\/a>.\n\t\t“Qualified employer<\/span>” means a small employer<\/span> that elects to make all of its full-time employees eligible for one or more qualified health plans<\/span> or qualified dental plans<\/span> in the small group market<\/span> offered through the SHOP exchange<\/span> and, at the employer’s option, some or all of its part-time employees, provided that the employer (i) has its principal place of business in the Commonwealth and elects to provide coverage through the SHOP exchange<\/span> to all of its eligible employees<\/span>, wherever employed, or (ii) elects to provide coverage through the SHOP exchange<\/span> to all of its eligible employees<\/span> who are principally employed in the Commonwealth.\n\t\t“Qualified health plan<\/span>” means a health benefit plan<\/span> that has in effect a certification that the plan meets the criteria for certification described in \u00a7 1311(c) of the Federal Act<\/span> and \u00a7 38.2-6506<\/a>.\n\t\t“Qualified individual<\/span>” means an individual, including a minor<\/span>, who (i) is seeking to enroll in a qualified health plan<\/span> or qualified dental plan<\/span> offered to individuals through the Exchange; (ii) resides in the Commonwealth; (iii) is not incarcerated at the time of enrollment, other than incarceration pending the disposition<\/span> of charges; and (iv) is, and is reasonably expected to be, for the entire period for which enrollment is sought, a citizen or a national of the United States<\/span> or an alien lawfully present in the United States<\/span>.\n\t\t“Secretary<\/span>” means the Secretary<\/span> of the U.S. Department of Health and Human Services.\n\t\t“SHOP exchange<\/span>” means the Small Business Health Options Program, established as a component of the Exchange pursuant to this chapter, through which a qualified employer<\/span> can provide its eligible employees<\/span> and their dependents with access to one or more qualified health plans<\/span> or qualified dental plans<\/span>.\n\t\t“Small employer<\/span>” means an employer that employed an average of not more than 50 employees during the preceding calendar year. For the purposes of this definition: (a) all persons<\/span> treated as a single employer under subsection (b), (c), (m), or (o) of 26 U.S.C. \u00a7 414 shall be treated as a single employer; (b) an employer and any predecessor employer shall be treated as a single employer; and (c) all employees shall be counted, including part-time employees and employees who are not eligible for health insurance coverage through the employer. If an employer was not in existence throughout the preceding calendar year, the determination of whether the employer is a small employer<\/span> shall be based on the average number of employees reasonably expected to be employed by the employer on business days in the current calendar year. An employer that makes enrollment in qualified health plans<\/span> or qualified dental plans<\/span> available to its eligible employees<\/span> through the SHOP exchange<\/span> and that no longer meets the definition of a small employer<\/span> because of an increase in the number of its employees shall continue to be treated as a small employer<\/span> for purposes of this chapter as long as that employer continuously makes enrollment through the SHOP exchange<\/span> available to its eligible employees<\/span>.\n\t\t“Small group market<\/span>” means the health insurance market under which individuals obtain health insurance coverage, directly or through any arrangement, on behalf of themselves and their dependents through a group health plan maintained by a small employer<\/span>.\n\t\t“State-mandated health benefit<\/span>” means coverage required under this title or other laws<\/span> of the Commonwealth to be provided in a policy of accident and sickness insurance, an accident and sickness subscription contract<\/span>, or a health maintenance organization health care plan that includes coverage for specific health care services or benefits.\n\t\t“State Medicaid Program<\/span>” means the Commonwealth’s Medicaid program under Title XIX of the Social Security Act, as amended from time to time.<\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nDEFINITIONS (\u00a7 38.2-6500)\n\nAs used in this chapter, unless the context requires a different meaning:\n\t\t“American Health Benefit Exchange” means the program established\nas a component of the Exchange pursuant to this chapter that is designed to\nfacilitate the purchase of qualified health plans or qualified dental plans by\nqualified individuals.\n\t\t“Bureau” means the Bureau of Insurance, a division within the\nCommission through which it administers insurance law.\n\t\t“Certified application counselor” means individuals certified by\nthe Exchange to perform the duties described in 45 C.F.R. \u00a7 155.255(c).\n\t\t“Commission” means the State Corporation Commission.\n\t\t“Committee” means the Advisory Committee established pursuant to\n\u00a7 38.2-6503.\n\t\t“Director” means the Director of the Division appointed by the\nCommission pursuant to \u00a7 38.2-6502.\n\t\t“Division” means the Health Benefit Exchange Division, a division\nwithin the Commission through which it administers the Exchange.\n\t\t“Eligible employee” means an individual employed by a qualified\nemployer who has been offered health insurance coverage by such qualified\nemployer through the SHOP exchange.\n\t\t“Eligible entity” means the Bureau, the Department of Medical\nAssistance Services, or a qualified vendor that has demonstrated experience on a\nstatewide or regional basis in individual and small group health insurance\nmarkets and in benefits coverage; however, a health carrier or an affiliate of a\nhealth carrier is not an eligible entity.\n\t\t“Essential health benefits package” means the scope of covered\nbenefits and associated limits of a health benefit plan that (i) provides\nbenefits pursuant to \u00a7 38.2-3451; (ii) provides the benefits in the manner\ndescribed in 45 C.F.R. \u00a7 156.115; (iii) limits cost-sharing for such coverage\nas described in 45 C.F.R. \u00a7 156.130; and (iv) subject to offering catastrophic\nplans as described in \u00a7 1302(e) of the Federal Act, provides distinct levels of\ncoverage as described in 45 C.F.R. \u00a7 156.140.\n\t\t“Exchange” means, as the context requires, either (i) the Division\nor (ii) the Virginia Health Benefit Exchange established pursuant to the\nprovisions of this chapter and in accordance with \u00a7 1311(b) of the Federal Act,\nthrough which qualified health plans and qualified dental plans are made\navailable to qualified individuals through the American Health Benefit Exchange\nand to qualified employers through the SHOP exchange. “Exchange,”\nwhen referring to the Virginia Health Benefit Exchange, collectively refers to\nboth the American Health Benefit Exchange and the SHOP exchange.\n\t\t“FAMIS” means the Family Access to Medical Insurance Security\nPlan, including the FAMIS Plus program, established pursuant to Chapter 13 (\u00a7\n32.1-351 et seq.) of Title 32.1.\n\t\t“Federal Act” means the federal Patient Protection and Affordable\nCare Act, P.L. 111-148, as amended by the Health Care and Education\nReconciliation Act of 2010, P.L. 111-152, and as it may further be amended, and\nregulations issued thereunder.\n\t\t“Health benefit plan” or “plan” means a policy,\ncontract, certificate, or agreement offered or issued by a health carrier to\nprovide, deliver, arrange for, pay for, or reimburse any of the costs of health\ncare services. The term does not include coverage only for accident or\ndisability income insurance, or any combination thereof; coverage issued as a\nsupplement to liability insurance; liability insurance, including general\nliability insurance and automobile liability insurance; workers’\ncompensation or similar insurance; automobile medical payment insurance;\ncredit-only insurance; coverage for onsite medical clinics; or other similar\ninsurance coverage, specified in federal regulations issued pursuant to the\nFederal Act, under which benefits for medical care are secondary or incidental\nto other insurance benefits. The term does not include the following benefits if\nthey are provided under a separate policy, certificate, or contract of insurance\nor are otherwise not an integral part of the plan: limited scope dental or\nvision benefits; benefits for long-term care, nursing home care, home health\ncare, community-based care, or any combination thereof; or other similar limited\nbenefits specified in federal regulations issued pursuant to the Federal Act.\nThe term does not include the following benefits if the benefits are provided\nunder a separate policy, certificate, or contract of insurance; there is no\ncoordination between the provision of the benefits and any exclusion of benefits\nunder any group health plan maintained by the same plan sponsor; and the\nbenefits are paid with respect to an event without regard to whether benefits\nare provided with respect to such an event under any group health plan\nmaintained by the same plan sponsor: coverage only for a specified disease or\nillness, for hospital indemnity, or other fixed indemnity insurance. The term\ndoes not include the following if offered as a separate policy, certificate, or\ncontract of insurance: Medicare supplemental health insurance as defined under\n\u00a7 1882(g)(1) of the U.S. Social Security Act; coverage supplemental to the\ncoverage provided under 10 U.S.C. \u00a7 1071 et seq. (TRICARE); or similar\nsupplemental coverage provided under a group health plan.\n\t\t“Health carrier” or “carrier” means an entity subject\nto the insurance laws and regulations of the Commonwealth and subject to the\njurisdiction of the Commission that contracts or offers to contract to provide,\ndeliver, arrange for, pay for, or reimburse any of the costs of health care\nservices, including an insurer licensed to sell accident and sickness insurance,\na health maintenance organization, a health services plan, a dental plan\norganization, a dental services plan, or any other entity providing a plan of\nhealth insurance, health benefits, or health care services.\n\t\t“Insurance agent” has the same meaning as provided in \u00a7\n38.2-1800.\n\t\t“Minimum essential coverage” means coverage defined in 45 C.F.R.\n\u00a7 156.600.\n\t\t“Navigator” means an individual or entity that is registered\npursuant to \u00a7 38.2-3457.\n\t\t“PHSA” means the federal Public Health Service Act, Chapter 6A of\nTitle 42 of the United States Code, as amended.\n\t\t“Qualified dental plan” means a limited scope dental plan that has\nbeen certified in accordance with \u00a7 38.2-6506.\n\t\t“Qualified employer” means a small employer that elects to make\nall of its full-time employees eligible for one or more qualified health plans\nor qualified dental plans in the small group market offered through the SHOP\nexchange and, at the employer’s option, some or all of its part-time\nemployees, provided that the employer (i) has its principal place of business in\nthe Commonwealth and elects to provide coverage through the SHOP exchange to all\nof its eligible employees, wherever employed, or (ii) elects to provide coverage\nthrough the SHOP exchange to all of its eligible employees who are principally\nemployed in the Commonwealth.\n\t\t“Qualified health plan” means a health benefit plan that has in\neffect a certification that the plan meets the criteria for certification\ndescribed in \u00a7 1311(c) of the Federal Act and \u00a7 38.2-6506.\n\t\t“Qualified individual” means an individual, including a minor, who\n(i) is seeking to enroll in a qualified health plan or qualified dental plan\noffered to individuals through the Exchange; (ii) resides in the Commonwealth;\n(iii) is not incarcerated at the time of enrollment, other than incarceration\npending the disposition of charges; and (iv) is, and is reasonably expected to\nbe, for the entire period for which enrollment is sought, a citizen or a\nnational of the United States or an alien lawfully present in the United States.\n\t\t“Secretary” means the Secretary of the U.S. Department of Health\nand Human Services.\n\t\t“SHOP exchange” means the Small Business Health Options Program,\nestablished as a component of the Exchange pursuant to this chapter, through\nwhich a qualified employer can provide its eligible employees and their\ndependents with access to one or more qualified health plans or qualified dental\nplans.\n\t\t“Small employer” means an employer that employed an average of not\nmore than 50 employees during the preceding calendar year. For the purposes of\nthis definition: (a) all persons treated as a single employer under subsection\n(b), (c), (m), or (o) of 26 U.S.C. \u00a7 414 shall be treated as a single employer;\n(b) an employer and any predecessor employer shall be treated as a single\nemployer; and (c) all employees shall be counted, including part-time employees\nand employees who are not eligible for health insurance coverage through the\nemployer. If an employer was not in existence throughout the preceding calendar\nyear, the determination of whether the employer is a small employer shall be\nbased on the average number of employees reasonably expected to be employed by\nthe employer on business days in the current calendar year. An employer that\nmakes enrollment in qualified health plans or qualified dental plans available\nto its eligible employees through the SHOP exchange and that no longer meets the\ndefinition of a small employer because of an increase in the number of its\nemployees shall continue to be treated as a small employer for purposes of this\nchapter as long as that employer continuously makes enrollment through the SHOP\nexchange available to its eligible employees.\n\t\t“Small group market” means the health insurance market under which\nindividuals obtain health insurance coverage, directly or through any\narrangement, on behalf of themselves and their dependents through a group health\nplan maintained by a small employer.\n\t\t“State-mandated health benefit” means coverage required under this\ntitle or other laws of the Commonwealth to be provided in a policy of accident\nand sickness insurance, an accident and sickness subscription contract, or a\nhealth maintenance organization health care plan that includes coverage for\nspecific health care services or benefits.\n\t\t“State Medicaid Program” means the Commonwealth’s Medicaid\nprogram under Title XIX of the Social Security Act, as amended from time to\ntime.\n\nHISTORY: 2020, cc. 916, 917.","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}}