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<law><site_title>Virginia Decoded</site_title><site_url>https://vacode.org</site_url><law_id>61229</law_id><section_number>32.1-137.1</section_number><catch_line>Definitions</catch_line><edition url="https://vacode.org/2025/" slug="2025" current="TRUE" last_updated="">2025</edition><referred_to_by><reference>32.1-137.16</reference><reference>38.2-5807</reference><reference>38.2-5809</reference></referred_to_by><structure><unit label="title" level="1" order_by="1" identifier="32.1">Health</unit><unit label="chapter" level="2" order_by="1" identifier="5">Regulation of Medical Care Facilities and Services</unit><unit label="article" level="3" order_by="1" identifier="1.1">Certificate of Quality Assurance of Managed Care Health Insurance Plan Licensees</unit></structure><text>
						<section><p>As used in this and the following article, unless the context indicates otherwise:
		&#x201C;<span class="dictionary">Agent</span>&#x201D; or &#x201C;insurance <span class="dictionary">agent</span>,&#x201D; when used without qualification, means an individual, partnership, limited liability company, or corporation that solicits, negotiates, procures or effects <span class="dictionary">contracts</span> of insurance or annuity in this Commonwealth.
		&#x201C;<span class="dictionary">Bureau of Insurance</span>&#x201D; means the State Corporation Commission acting pursuant to Title 38.2.
		&#x201C;<span class="dictionary">Complaint</span>&#x201D; means any written communication from a <span class="dictionary">covered person</span> primarily expressing a grievance.
		&#x201C;<span class="dictionary">Covered person</span>&#x201D; means an individual residing in the Commonwealth, whether a policyholder, subscriber, enrollee, or member of a <span class="dictionary">managed care health insurance plan</span>, who is entitled to health care services or benefits provided, arranged for, paid for or reimbursed pursuant to a <span class="dictionary">managed care health insurance plan</span> under Title 38.2.
		&#x201C;<span class="dictionary">Managed care health insurance plan</span>&#x201D; means an arrangement for the delivery of health care in which a health carrier as defined in &#xA7;&#xA0;<a class="law" title="Definitions" href="/38.2-5800/">38.2-5800</a> undertakes to provide, arrange for, pay for, or reimburse any of the costs of health care services for a <span class="dictionary">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 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 <span class="dictionary">covered persons</span> to use providers that are directly or indirectly managed, owned, under <span class="dictionary">contract</span> with or employed by the health carrier. Any health maintenance organization as defined in &#xA7;&#xA0;<a class="law" title="Definitions" href="/38.2-4300/">38.2-4300</a> or health carrier that offers preferred provider <span class="dictionary">contracts</span> or policies as defined in &#xA7;&#xA0;<a class="law" title="Health benefit programs" href="/38.2-3407/">38.2-3407</a> or preferred provider subscription <span class="dictionary">contracts</span> as defined in &#xA7;&#xA0;<a class="law" title="Preferred provider subscription contracts" href="/38.2-4209/">38.2-4209</a> shall be deemed to be offering one or more <span class="dictionary">managed care health insurance plans</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 <span class="dictionary">covered persons</span> to use providers who are directly or indirectly managed, owned, under <span class="dictionary">contract</span> with or employed by the health carrier. A single <span class="dictionary">managed care health insurance plan</span> may encompass multiple products and multiple types of benefit payment differentials; however, a single <span class="dictionary">managed care health insurance plan</span> shall encompass only one provider network or set of provider networks.
		&#x201C;<span class="dictionary"><span class="dictionary">Managed care health insurance plan</span> licensee</span>&#x201D; means a health carrier subject to licensure by the <span class="dictionary">Bureau of Insurance</span> under Title 38.2 who is responsible for a <span class="dictionary">managed care health insurance plan</span> in accordance with Chapter 58 (&#xA7;&#xA0;<a class="law" title="General provisions" href="/38.2-5801/">38.2-5801</a> et seq.) of Title 38.2.
		&#x201C;Person&#x201D; means any association, aggregate of individuals, business, company, corporation, individual, joint-stock company, Lloyds type of organization, other organization, partnership, receiver, reciprocal or inter-insurance exchange, trustee or society.</p></section></text><history>1998, c. 891.</history><metadata></metadata></law>
