                                 CODE OF VIRGINIA

DEFINITIONS (§ 32.1-137.1)

As used in this and the following article, unless the context indicates
otherwise:
		&#8220;Agent&#8221; or &#8220;insurance agent,&#8221; when used without
qualification, means an individual, partnership, limited liability company, or
corporation that solicits, negotiates, procures or effects contracts of
insurance or annuity in this Commonwealth.
		&#8220;Bureau of Insurance&#8221; means the State Corporation Commission
acting pursuant to Title 38.2.
		&#8220;Complaint&#8221; means any written communication from a covered person
primarily expressing a grievance.
		&#8220;Covered person&#8221; means an individual residing in the Commonwealth,
whether a policyholder, subscriber, enrollee, or member of a managed care health
insurance plan, who is entitled to health care services or benefits provided,
arranged for, paid for or reimbursed pursuant to a managed care health insurance
plan under Title 38.2.
		&#8220;Managed care health insurance plan&#8221; means an arrangement for the
delivery of health care in which a health carrier as defined in § 38.2-5800
undertakes to provide, arrange for, pay for, or reimburse any of the costs of
health care services for a covered person on a prepaid or insured basis which
(i) contains one or more incentive arrangements, including any credentialing
requirements intended to influence the cost or level of health care services
between the health carrier and one or more providers with respect to the
delivery of health care services; and (ii) requires or creates benefit payment
differential incentives for covered persons to use providers that are directly
or indirectly managed, owned, under contract with or employed by the health
carrier. Any health maintenance organization as defined in § 38.2-4300 or
health carrier that offers preferred provider contracts or policies as defined
in § 38.2-3407 or preferred provider subscription contracts as defined in §
38.2-4209 shall be deemed to be offering one or more managed care health
insurance plans. For the purposes of this definition, the prohibition of balance
billing by a provider shall not be deemed a benefit payment differential
incentive for covered persons to use providers who are directly or indirectly
managed, owned, under contract with or employed by the health carrier. A single
managed care health insurance plan may encompass multiple products and multiple
types of benefit payment differentials; however, a single managed care health
insurance plan shall encompass only one provider network or set of provider
networks.
		&#8220;Managed care health insurance plan licensee&#8221; means a health
carrier subject to licensure by the Bureau of Insurance under Title 38.2 who is
responsible for a managed care health insurance plan in accordance with Chapter
58 (§ 38.2-5801 et seq.) of Title 38.2.
		&#8220;Person&#8221; 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.

HISTORY: 1998, c. 891.