                                 CODE OF VIRGINIA

HEALTH AND RELATED INSURANCE FOR STATE EMPLOYEES (§ 2.2-2818)

A. The Department of Human Resource Management shall establish a plan, subject
to the approval of the Governor, for providing health insurance coverage,
including chiropractic treatment, hospitalization, medical, surgical, and major
medical coverage, for state employees and retired state employees with the
Commonwealth paying the cost thereof to the extent of the coverage included in
such plan. The same plan shall be offered to all part-time state employees, but
the total cost shall be paid by such part-time employees. The Department of
Human Resource Management shall administer this section. The plan chosen shall
provide means whereby coverage for the families or dependents of state employees
may be purchased. Except for part-time employees, the Commonwealth may pay all
or a portion of the cost thereof, and for such portion as the Commonwealth does
not pay, the employee, including a part-time employee, may purchase the coverage
by paying the additional cost over the cost of coverage for an employee.
			Such contribution shall be financed through appropriations provided by law.

B. The plan shall:

   1. Include coverage for low-dose screening mammograms for determining the
   presence of occult breast cancer. Such coverage shall make available one
   screening mammogram to persons age 35 through 39, one such mammogram
   biennially to persons age 40 through 49, and one such mammogram annually to
   persons age 50 and over and may be limited to a benefit of $50 per mammogram
   subject to such dollar limits, deductibles, and coinsurance factors as are no
   less favorable than for physical illness generally.
   				The term &#8220;mammogram&#8221; shall mean an X-ray examination of the
   breast using equipment dedicated specifically for mammography, including but
   not limited to the X-ray tube, filter, compression device, screens, film, and
   cassettes, with an average radiation exposure of less than one rad mid-breast,
   two views of each breast.
   				In order to be considered a screening mammogram for which coverage shall
   be made available under this section:
   				a. The mammogram shall be (i) ordered by a health care practitioner acting
   within the scope of his licensure and, in the case of an enrollee of a health
   maintenance organization, by the health maintenance organization provider;
   (ii) performed by a registered technologist; (iii) interpreted by a qualified
   radiologist; and (iv) performed under the direction of a person licensed to
   practice medicine and surgery and certified by the American Board of Radiology
   or an equivalent examining body. A copy of the mammogram report shall be sent
   or delivered to the health care practitioner who ordered it;
   				b. The equipment used to perform the mammogram shall meet the standards
   set forth by the Virginia Department of Health in its radiation protection
   regulations; and
   				c. The mammography film shall be retained by the radiologic facility
   performing the examination in accordance with the American College of
   Radiology guidelines or state law.

   2. Include coverage for postpartum services providing inpatient care and a
   home visit or visits that shall be in accordance with the medical criteria,
   outlined in the most current version of or an official update to the
   &#8220;Guidelines for Perinatal Care&#8221; prepared by the American Academy
   of Pediatrics and the American College of Obstetricians and Gynecologists or
   the &#8220;Standards for Obstetric-Gynecologic Services&#8221; prepared by the
   American College of Obstetricians and Gynecologists. Such coverage shall be
   provided incorporating any changes in such Guidelines or Standards within six
   months of the publication of such Guidelines or Standards or any official
   amendment thereto.

   3. Include an appeals process for resolution of complaints that shall provide
   reasonable procedures for the resolution of such complaints and shall be
   published and disseminated to all covered state employees. The appeals process
   shall be compliant with federal rules and regulations governing nonfederal,
   self-insured governmental health plans. The appeals process shall include a
   separate expedited emergency appeals procedure that shall provide resolution
   within time frames established by federal law. For appeals involving adverse
   decisions as defined in &#xA7; 32.1-137.7, the Department shall contract with
   one or more independent review organizations to review such decisions.
   Independent review organizations are entities that conduct independent
   external review of adverse benefit determinations. The Department shall adopt
   regulations to assure that the independent review organization conducting the
   reviews has adequate standards, credentials and experience for such review.
   The independent review organization shall examine the final denial of claims
   to determine whether the decision is objective, clinically valid, and
   compatible with established principles of health care. The decision of the
   independent review organization shall (i) be in writing, (ii) contain findings
   of fact as to the material issues in the case and the basis for those
   findings, and (iii) be final and binding if consistent with law and policy.
   				Prior to assigning an appeal to an independent review organization, the
   Department shall verify that the independent review organization conducting
   the review of a denial of claims has no relationship or association with (i)
   the covered person or the covered person&#8217;s authorized representative;
   (ii) the treating health care provider, or any of its employees or affiliates;
   (iii) the medical care facility at which the covered service would be
   provided, or any of its employees or affiliates; or (iv) the development or
   manufacture of the drug, device, procedure, or other therapy that is the
   subject of the final denial of a claim. The independent review organization
   shall not be a subsidiary of, nor owned or controlled by, a health plan, a
   trade association of health plans, or a professional association of health
   care providers. There shall be no liability on the part of and no cause of
   action shall arise against any officer or employee of an independent review
   organization for any actions taken or not taken or statements made by such
   officer or employee in good faith in the performance of his powers and duties.

   4. Include coverage for early intervention services. For purposes of this
   section, &#8220;early intervention services&#8221; means medically necessary
   speech and language therapy, occupational therapy, physical therapy and
   assistive technology services and devices for dependents from birth to age
   three who are certified by the Department of Behavioral Health and
   Developmental Services as eligible for services under Part H of the
   Individuals with Disabilities Education Act (20 U.S.C. &#xA7; 1471 et seq.).
   Medically necessary early intervention services for the population certified
   by the Department of Behavioral Health and Developmental Services shall mean
   those services designed to help an individual attain or retain the capability
   to function age-appropriately within his environment, and shall include
   services that enhance functional ability without effecting a cure.
   				For persons previously covered under the plan, there shall be no denial of
   coverage due to the existence of a preexisting condition. The cost of early
   intervention services shall not be applied to any contractual provision
   limiting the total amount of coverage paid by the insurer to or on behalf of
   the insured during the insured&#8217;s lifetime.

   5. Include coverage for prescription drugs and devices approved by the United
   States Food and Drug Administration for use as contraceptives.

   6. Not deny coverage for any drug approved by the United States Food and Drug
   Administration for use in the treatment of cancer on the basis that the drug
   has not been approved by the United States Food and Drug Administration for
   the treatment of the specific type of cancer for which the drug has been
   prescribed, if the drug has been recognized as safe and effective for
   treatment of that specific type of cancer in one of the standard reference
   compendia.

   7. Not deny coverage for any drug prescribed to treat a covered indication so
   long as the drug has been approved by the United States Food and Drug
   Administration for at least one indication and the drug is recognized for
   treatment of the covered indication in one of the standard reference compendia
   or in substantially accepted peer-reviewed medical literature.

   8. Include coverage for equipment, supplies, and outpatient self-management
   training and education, including medical nutrition therapy, for the treatment
   of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes,
   and noninsulin-using diabetes if prescribed by a health care professional
   legally authorized to prescribe such items under law. To qualify for coverage
   under this subdivision, diabetes outpatient self-management training and
   education shall be provided by a certified, registered, or licensed health
   care professional.

   9. Include coverage for reconstructive breast surgery. For purposes of this
   section, &#8220;reconstructive breast surgery&#8221; means surgery performed
   on and after July 1, 1998, (i) coincident with a mastectomy performed for
   breast cancer or (ii) following a mastectomy performed for breast cancer to
   reestablish symmetry between the two breasts. For persons previously covered
   under the plan, there shall be no denial of coverage due to preexisting
   conditions.

   10. Include coverage for annual pap smears, including coverage, on and after
   July 1, 1999, for annual testing performed by any FDA-approved gynecologic
   cytology screening technologies.

   11. Include coverage providing a minimum stay in the hospital of not less than
   48 hours for a patient following a radical or modified radical mastectomy and
   24 hours of inpatient care following a total mastectomy or a partial
   mastectomy with lymph node dissection for treatment of breast cancer. Nothing
   in this subdivision shall be construed as requiring the provision of inpatient
   coverage where the attending physician in consultation with the patient
   determines that a shorter period of hospital stay is appropriate.

   12. Include coverage (i) to persons age 50 and over and (ii) to persons age 40
   and over who are at high risk for prostate cancer, according to the most
   recent published guidelines of the American Cancer Society, for one
   prostate-specific antigen test in a 12-month period and digital rectal
   examinations.

   13. Permit any individual covered under the plan direct access to the health
   care services of a participating specialist (i) authorized to provide services
   under the plan and (ii) selected by the covered individual. The plan shall
   have a procedure by which an individual who has an ongoing special condition
   may, after consultation with the primary care physician, receive a referral to
   a specialist for such condition who shall be responsible for and capable of
   providing and coordinating the individual&#8217;s primary and specialty care
   related to the initial specialty care referral. If such an individual&#8217;s
   care would most appropriately be coordinated by such a specialist, the plan
   shall refer the individual to a specialist. For the purposes of this
   subdivision, &#8220;special condition&#8221; means a condition or disease that
   is (i) life-threatening, degenerative, or disabling and (ii) requires
   specialized medical care over a prolonged period of time. Within the treatment
   period authorized by the referral, such specialist shall be permitted to treat
   the individual without a further referral from the individual&#8217;s primary
   care provider and may authorize such referrals, procedures, tests, and other
   medical services related to the initial referral as the individual&#8217;s
   primary care provider would otherwise be permitted to provide or authorize.
   The plan shall have a procedure by which an individual who has an ongoing
   special condition that requires ongoing care from a specialist may receive a
   standing referral to such specialist for the treatment of the special
   condition. If the primary care provider, in consultation with the plan and the
   specialist, if any, determines that such a standing referral is appropriate,
   the plan or issuer shall make such a referral to a specialist. Nothing
   contained herein shall prohibit the plan from requiring a participating
   specialist to provide written notification to the covered individual&#8217;s
   primary care physician of any visit to such specialist. Such notification may
   include a description of the health care services rendered at the time of the
   visit.

   14. Include provisions allowing employees to continue receiving health care
   services for a period of up to 90 days from the date of the primary care
   physician&#8217;s notice of termination from any of the plan&#8217;s provider
   panels. The plan shall notify any provider at least 90 days prior to the date
   of termination of the provider, except when the provider is terminated for
   cause.
   				For a period of at least 90 days from the date of the notice of a
   provider&#8217;s termination from any of the plan&#8217;s provider panels,
   except when a provider is terminated for cause, a provider shall be permitted
   by the plan to render health care services to any of the covered employees who
   (i) were in an active course of treatment from the provider prior to the
   notice of termination and (ii) request to continue receiving health care
   services from the provider.
   				Notwithstanding the provisions of this subdivision, any provider shall be
   permitted by the plan to continue rendering health services to any covered
   employee who has entered the second trimester of pregnancy at the time of the
   provider&#8217;s termination of participation, except when a provider is
   terminated for cause. Such treatment shall, at the covered employee&#8217;s
   option, continue through the provision of postpartum care directly related to
   the delivery.
   				Notwithstanding the provisions of this subdivision, any provider shall be
   permitted to continue rendering health services to any covered employee who is
   determined to be terminally ill (as defined under &#xA7; 1861(dd)(3)(A) of the
   Social Security Act) at the time of a provider&#8217;s termination of
   participation, except when a provider is terminated for cause. Such treatment
   shall, at the covered employee&#8217;s option, continue for the remainder of
   the employee&#8217;s life for care directly related to the treatment of the
   terminal illness.
   				A provider who continues to render health care services pursuant to this
   subdivision shall be reimbursed in accordance with the carrier&#8217;s
   agreement with such provider existing immediately before the provider&#8217;s
   termination of participation.

   15. Include coverage for patient costs incurred during participation in
   clinical trials for treatment studies on cancer, including ovarian cancer
   trials.
   				The reimbursement for patient costs incurred during participation in
   clinical trials for treatment studies on cancer shall be determined in the
   same manner as reimbursement is determined for other medical and surgical
   procedures. Such coverage shall have durational limits, dollar limits,
   deductibles, copayments, and coinsurance factors that are no less favorable
   than for physical illness generally.
   				For purposes of this subdivision:
   				&#8220;Cooperative group&#8221; means a formal network of facilities that
   collaborate on research projects and have an established NIH-approved peer
   review program operating within the group. &#8220;Cooperative group&#8221;
   includes (i) the National Cancer Institute Clinical Cooperative Group and (ii)
   the National Cancer Institute Community Clinical Oncology Program.
   				&#8220;FDA&#8221; means the Federal Food and Drug Administration.
   				&#8220;Multiple project assurance contract&#8221; means a contract between
   an institution and the federal Department of Health and Human Services that
   defines the relationship of the institution to the federal Department of
   Health and Human Services and sets out the responsibilities of the institution
   and the procedures that will be used by the institution to protect human
   subjects.
   				&#8220;NCI&#8221; means the National Cancer Institute.
   				&#8220;NIH&#8221; means the National Institutes of Health.
   				&#8220;Patient&#8221; means a person covered under the plan established
   pursuant to this section.
   				&#8220;Patient cost&#8221; means the cost of a medically necessary health
   care service that is incurred as a result of the treatment being provided to a
   patient for purposes of a clinical trial. &#8220;Patient cost&#8221; does not
   include (i) the cost of nonhealth care services that a patient may be required
   to receive as a result of the treatment being provided for purposes of a
   clinical trial, (ii) costs associated with managing the research associated
   with the clinical trial, or (iii) the cost of the investigational drug or
   device.
   				Coverage for patient costs incurred during clinical trials for treatment
   studies on cancer shall be provided if the treatment is being conducted in a
   Phase II, Phase III, or Phase IV clinical trial. Such treatment may, however,
   be provided on a case-by-case basis if the treatment is being provided in a
   Phase I clinical trial.
   				The treatment described in the previous paragraph shall be provided by a
   clinical trial approved by:
   				a. The National Cancer Institute;
   				b. An NCI cooperative group or an NCI center;
   				c. The FDA in the form of an investigational new drug application;
   				d. The federal Department of Veterans Affairs; or
   				e. An institutional review board of an institution in the Commonwealth
   that has a multiple project assurance contract approved by the Office of
   Protection from Research Risks of the NCI.
   				The facility and personnel providing the treatment shall be capable of
   doing so by virtue of their experience, training, and expertise.
   				Coverage under this subdivision shall apply only if:

      1. There is no clearly superior, noninvestigational treatment alternative;

      2. The available clinical or preclinical data provide a reasonable
      expectation that the treatment will be at least as effective as the
      noninvestigational alternative; and

      3. The patient and the physician or health care provider who provides
      services to the patient under the plan conclude that the patient&#8217;s
      participation in the clinical trial would be appropriate, pursuant to
      procedures established by the plan.

   16. Include coverage providing a minimum stay in the hospital of not less than
   23 hours for a covered employee following a laparoscopy-assisted vaginal
   hysterectomy and 48 hours for a covered employee following a vaginal
   hysterectomy, as outlined in Milliman &amp; Robertson&#8217;s nationally
   recognized guidelines. Nothing in this subdivision shall be construed as
   requiring the provision of the total hours referenced when the attending
   physician, in consultation with the covered employee, determines that a
   shorter hospital stay is appropriate.

   17. Include coverage for biologically based mental illness.
   				For purposes of this subdivision, a &#8220;biologically based mental
   illness&#8221; is any mental or nervous condition caused by a biological
   disorder of the brain that results in a clinically significant syndrome that
   substantially limits the person&#8217;s functioning; specifically, the
   following diagnoses are defined as biologically based mental illness as they
   apply to adults and children: schizophrenia, schizoaffective disorder, bipolar
   disorder, major depressive disorder, panic disorder, obsessive-compulsive
   disorder, attention deficit hyperactivity disorder, autism, and drug and
   alcoholism addiction.
   				Coverage for biologically based mental illnesses shall neither be
   different nor separate from coverage for any other illness, condition, or
   disorder for purposes of determining deductibles, benefit year or lifetime
   durational limits, benefit year or lifetime dollar limits, lifetime episodes
   or treatment limits, copayment and coinsurance factors, and benefit year
   maximum for deductibles and copayment and coinsurance factors.
   				Nothing shall preclude the undertaking of usual and customary procedures
   to determine the appropriateness of, and medical necessity for, treatment of
   biologically based mental illnesses under this option, provided that all such
   appropriateness and medical necessity determinations are made in the same
   manner as those determinations made for the treatment of any other illness,
   condition, or disorder covered by such policy or contract.

   18. Offer and make available coverage for the treatment of morbid obesity
   through gastric bypass surgery or such other methods as may be recognized by
   the National Institutes of Health as effective for the long-term reversal of
   morbid obesity. Such coverage shall have durational limits, dollar limits,
   deductibles, copayments, and coinsurance factors that are no less favorable
   than for physical illness generally. Access to surgery for morbid obesity
   shall not be restricted based upon dietary or any other criteria not approved
   by the National Institutes of Health. For purposes of this subdivision,
   &#8220;morbid obesity&#8221; means (i) a weight that is at least 100 pounds
   over or twice the ideal weight for frame, age, height, and gender as specified
   in the 1983 Metropolitan Life Insurance tables, (ii) a body mass index (BMI)
   equal to or greater than 35 kilograms per meter squared with comorbidity or
   coexisting medical conditions such as hypertension, cardiopulmonary
   conditions, sleep apnea, or diabetes, or (iii) a BMI of 40 kilograms per meter
   squared without such comorbidity. As used herein, &#8220;BMI&#8221; equals
   weight in kilograms divided by height in meters squared.

   19. Include coverage for colorectal cancer screening, specifically screening
   with an annual fecal occult blood test, flexible sigmoidoscopy or colonoscopy,
   or in appropriate circumstances radiologic imaging, in accordance with the
   most recently published recommendations established by the American College of
   Gastroenterology, in consultation with the American Cancer Society, for the
   ages, family histories, and frequencies referenced in such recommendations.
   The coverage for colorectal cancer screening shall not be more restrictive
   than or separate from coverage provided for any other illness, condition, or
   disorder for purposes of determining deductibles, benefit year or lifetime
   durational limits, benefit year or lifetime dollar limits, lifetime episodes
   or treatment limits, copayment and coinsurance factors, and benefit year
   maximum for deductibles and copayments and coinsurance factors.

   20. On and after July 1, 2002, require that a prescription benefit card,
   health insurance benefit card, or other technology that complies with the
   requirements set forth in &#xA7; 38.2-3407.4:2 be issued to each employee
   provided coverage pursuant to this section, and shall upon any changes in the
   required data elements set forth in subsection A of &#xA7; 38.2-3407.4:2,
   either reissue the card or provide employees covered under the plan such
   corrective information as may be required to electronically process a
   prescription claim.

   21. Include coverage for infant hearing screenings and all necessary
   audiological examinations provided pursuant to &#xA7; 32.1-64.1 using any
   technology approved by the United States Food and Drug Administration, and as
   recommended by the national Joint Committee on Infant Hearing in its most
   current position statement addressing early hearing detection and intervention
   programs. Such coverage shall include follow-up audiological examinations as
   recommended by a physician, a physician assistant, an advanced practice
   registered nurse, or an audiologist and performed by a licensed audiologist to
   confirm the existence or absence of hearing loss.

   22. Notwithstanding any provision of this section to the contrary, every plan
   established in accordance with this section shall comply with the provisions
   of &#xA7; 2.2-2818.2.

C. Claims incurred during a fiscal year but not reported during that fiscal year
shall be paid from such funds as shall be appropriated by law. Appropriations,
premiums, and other payments shall be deposited in the employee health insurance
fund, from which payments for claims, premiums, cost containment programs, and
administrative expenses shall be withdrawn from time to time. The funds of the
health insurance fund shall be deemed separate and independent trust funds,
shall be segregated from all other funds of the Commonwealth, and shall be
invested and administered solely in the interests of the employees and their
beneficiaries. Neither the General Assembly nor any public officer, employee, or
agency shall use or authorize the use of such trust funds for any purpose other
than as provided in law for benefits, refunds, and administrative expenses,
including but not limited to legislative oversight of the health insurance fund.

D. For the purposes of this section:
			&#8220;Peer-reviewed medical literature&#8221; means a scientific study
published only after having been critically reviewed for scientific accuracy,
validity, and reliability by unbiased independent experts in a journal that has
been determined by the International Committee of Medical Journal Editors to
have met the Uniform Requirements for Manuscripts submitted to biomedical
journals. &#8220;Peer-reviewed medical literature&#8221; does not include
publications or supplements to publications that are sponsored to a significant
extent by a pharmaceutical manufacturing company or health carrier.
			&#8220;Standard reference compendia&#8221; means:

   1. American Hospital Formulary Service Drug Information;

   2. National Comprehensive Cancer Network&#8217;s Drugs &amp; Biologics
   Compendium; or

   3. Elsevier Gold Standard&#8217;s Clinical Pharmacology.
   				&#8220;State employee&#8221; means state employee as defined in &#xA7;
   51.1-124.3; employee as defined in &#xA7; 51.1-201; the Governor, Lieutenant
   Governor and Attorney General; judge as defined in &#xA7; 51.1-301 and judges,
   clerks, and deputy clerks of regional juvenile and domestic relations, county
   juvenile and domestic relations, and district courts of the Commonwealth;
   interns and residents employed by the School of Medicine and Hospital of the
   University of Virginia, and interns, residents, and employees of the Virginia
   Commonwealth University Health System Authority as provided in &#xA7;
   23.1-2415; and employees of the Virginia Alcoholic Beverage Control Authority
   as provided in &#xA7; 4.1-101.05.

E. Provisions shall be made for retired employees to obtain coverage under the
above plan, including, as an option, coverage for vision and dental care. The
Commonwealth may, but shall not be obligated to, pay all or any portion of the
cost thereof.

F. Any self-insured group health insurance plan established by the Department of
Human Resource Management that utilizes a network of preferred providers shall
not exclude any physician solely on the basis of a reprimand or censure from the
Board of Medicine, so long as the physician otherwise meets the plan criteria
established by the Department.

G. The plan shall include, in each planning district, at least two health
coverage options, each sponsored by unrelated entities. No later than July 1,
2006, one of the health coverage options to be available in each planning
district shall be a high deductible health plan that would qualify for a health
savings account pursuant to &#xA7; 223 of the Internal Revenue Code of 1986, as
amended.
			In each planning district that does not have an available health coverage
alternative, the Department shall voluntarily enter into negotiations at any
time with any health coverage provider who seeks to provide coverage under the
plan.
			This subsection shall not apply to any state agency authorized by the
Department to establish and administer its own health insurance coverage plan
separate from the plan established by the Department.

H. Any self-insured group health insurance plan established by the Department of
Human Resource Management that includes coverage for prescription drugs on an
outpatient basis may apply a formulary to the prescription drug benefits
provided by the plan if the formulary is developed, reviewed at least annually,
and updated as necessary in consultation with and with the approval of a
pharmacy and therapeutics committee, a majority of whose members are actively
practicing licensed (i) pharmacists, (ii) physicians, and (iii) other health
care providers.
			If the plan maintains one or more drug formularies, the plan shall establish
a process to allow a person to obtain, without additional cost-sharing beyond
that provided for formulary prescription drugs in the plan, a specific,
medically necessary nonformulary prescription drug if, after reasonable
investigation and consultation with the prescriber, the formulary drug is
determined to be an inappropriate therapy for the medical condition of the
person. The plan shall act on such requests within one business day of receipt
of the request.
			Any plan established in accordance with this section shall be authorized to
provide for the selection of a single mail order pharmacy provider as the
exclusive provider of pharmacy services that are delivered to the covered
person&#8217;s address by mail, common carrier, or delivery service. As used in
this subsection, &#8220;mail order pharmacy provider&#8221; means a pharmacy
permitted to conduct business in the Commonwealth whose primary business is to
dispense a prescription drug or device under a prescriptive drug order and to
deliver the drug or device to a patient primarily by mail, common carrier, or
delivery service.

I. Any plan established in accordance with this section requiring
preauthorization prior to rendering medical treatment shall have personnel
available to provide authorization at all times when such preauthorization is
required.

J. Any plan established in accordance with this section shall provide to all
covered employees written notice of any benefit reductions during the contract
period at least 30 days before such reductions become effective.

K. No contract between a provider and any plan established in accordance with
this section shall include provisions that 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 covered employee with similar medical conditions.

L. The Department of Human Resource Management shall appoint an Ombudsman to
promote and protect the interests of covered employees under any state
employee&#8217;s health plan.
			The Ombudsman shall:

   1. Assist covered employees in understanding their rights and the processes
   available to them according to their state health plan.

   2. Answer inquiries from covered employees by telephone and electronic mail.

   3. Provide to covered employees information concerning the state health plans.

   4. Develop information on the types of health plans available, including
   benefits and complaint procedures and appeals.

   5. Make available, either separately or through an existing Internet web site
   utilized by the Department of Human Resource Management, information as set
   forth in subdivision 4 and such additional information as he deems
   appropriate.

   6. Maintain data on inquiries received, the types of assistance requested, any
   actions taken and the disposition of each such matter.

   7. Upon request, assist covered employees in using the procedures and
   processes available to them from their health plan, including all appeal
   procedures. Such assistance may require the review of health care records of a
   covered employee, which shall be done only in accordance with the federal
   Health Insurance Portability and Accountability Act privacy rules. The
   confidentiality of any such medical records shall be maintained in accordance
   with the confidentiality and disclosure laws of the Commonwealth.

   8. Ensure that covered employees have access to the services provided by the
   Ombudsman and that the covered employees receive timely responses from the
   Ombudsman or his representatives to the inquiries.

   9. Report annually on his activities to the standing committees of the General
   Assembly having jurisdiction over insurance and over health and the Joint
   Commission on Health Care by December 1 of each year.

M. The plan established in accordance with this section shall not refuse to
accept or make reimbursement pursuant to an assignment of benefits made to a
dentist or oral surgeon by a covered employee.
			For purposes of this subsection, &#8220;assignment of benefits&#8221; means
the transfer of dental care coverage reimbursement benefits or other rights
under the plan. The assignment of benefits shall not be effective until the
covered employee notifies the plan in writing of the assignment.

N. Beginning July 1, 2006, any plan established pursuant to this section shall
provide for an identification number, which shall be assigned to the covered
employee and shall not be the same as the employee&#8217;s social security
number.

O. Any group health insurance plan established by the Department of Human
Resource Management that contains a coordination of benefits provision shall
provide written notification to any eligible employee as a prominent part of its
enrollment materials that if such eligible employee is covered under another
group accident and sickness insurance policy, group accident and sickness
subscription contract, or group health care plan for health care services, that
insurance policy, subscription contract, or health care plan may have primary
responsibility for the covered expenses of other family members enrolled with
the eligible employee. Such written notification shall describe generally the
conditions upon which the other coverage would be primary for dependent children
enrolled under the eligible employee&#8217;s coverage and the method by which
the eligible enrollee may verify from the plan that coverage would have primary
responsibility for the covered expenses of each family member.

P. Any plan established by the Department of Human Resource Management pursuant
to this section shall provide that coverage under such plan for family members
enrolled under a participating state employee&#8217;s coverage shall continue
for a period of at least 30 days following the death of such state employee.

Q. The plan established in accordance with this section that follows a policy of
sending its payment to the covered employee or covered family member for a claim
for services received from a nonparticipating physician or osteopath shall (i)
include language in the member handbook that notifies the covered employee of
the responsibility to apply the plan payment to the claim from such
nonparticipating provider, (ii) include this language with any such payment sent
to the covered employee or covered family member, and (iii) include the name and
any last known address of the nonparticipating provider on the explanation of
benefits statement.

R. The plan established by the Department of Human Resource Management pursuant
to this section shall provide that coverage under such plan for an incapacitated
child enrolled under a participating state employee&#8217;s coverage shall be
valid without regard to whether such child lives with the covered employee as a
member of the employee&#8217;s household so long as the child is dependent upon
the employee for more than half of the child&#8217;s financial support and the
child is receiving residential support services.
			For purposes of this subsection, &#8220;incapacitated child&#8221; means an
adult child who is incapacitated due to a physical or mental health condition
that existed prior to the termination of coverage due to such child attaining
the limiting age under the plan for eligible children dependents.

S. The Department of Human Resource Management shall report annually, by
November 30 of each year, on cost and utilization information for each of the
mandated benefits set forth in subsection B, including any mandated benefit made
applicable, pursuant to subdivision B 22, to any plan established pursuant to
this section. The report shall be in the same detail and form as required of
reports submitted pursuant to &#xA7; 38.2-3419.1, with such additional
information as is required to determine the financial impact, including the
costs and benefits, of the particular mandated benefit.

HISTORY: 1970, c. 557, § 2.1-20.1; 1972, c. 803; 1973, cc. 69, 297; 1978, c.
70; 1984, c. 430; 1988, c. 634; 1989, cc. 559, 664; 1990, c. 607; 1993, c. 138;
1995, c. 353; 1996, cc. 155, 201, 905, 1046; 1997, cc. 43, 468, 521, 656; 1998,
cc. 35, 56, 257, 386, 631, 709, 851, 858, 875; 1999, cc. 643, 649, 921, 941;
2000, cc. 66, 149, 465, 534, 657, 720, 888; 2001, cc. 334, 558, 663, 844; 2004,
cc. 156, 279, 855; 2005, cc. 503, 572, 640, 739; 2006, c. 396; 2008, c. 420;
2009, cc. 247, 317, 813, 840; 2010, cc. 157, 357, 443; 2012, cc. 60, 201; 2013,
c. 709; 2014, c. 631; 2015, cc. 38, 730; 2023, cc. 182, 183; 2025, cc. 237, 246.