                                 CODE OF VIRGINIA

PATIENT OPTIONAL POINT-OF-SERVICE BENEFIT (§ 38.2-3407.12)

A. As used in this section:
			&#8220;Affiliate&#8221; shall have the meaning set forth in § 38.2-1322.
			&#8220;Allowable charge&#8221; means the amount from which the
carrier&#8217;s payment to a provider for any covered item or service is
determined before taking into account any cost-sharing arrangement.
			&#8220;Carrier&#8221; means:

   1. Any insurer licensed under this title proposing to offer or issue accident
   and sickness insurance policies which are subject to Chapter 34 (&#xA7;
   38.2-3400 et seq.) or 39 (&#xA7; 38.2-3900 et seq.) of this title;

   2. Any nonstock corporation licensed under this title proposing to issue or
   deliver subscription contracts for one or more health services plans, medical
   or surgical services plans or hospital services plans which are subject to
   Chapter 42 (&#xA7; 38.2-4200 et seq.) of this title;

   3. Any health maintenance organization licensed under this title which
   provides or arranges for the provision of one or more health care plans which
   are subject to Chapter 43 (&#xA7; 38.2-4300 et seq.) of this title;

   4. Any nonstock corporation licensed under this title proposing to issue or
   deliver subscription contracts for one or more dental or optometric services
   plans which are subject to Chapter 45 (&#xA7; 38.2-4500 et seq.) of this
   title; and

   5. Any other person licensed under this title which provides or arranges for
   the provision of health care coverage or benefits or health care plans or
   provider panels which are subject to regulation as the business of insurance
   under this title.
   				&#8220;Co-insurance&#8221; means the portion of the carrier&#8217;s
   allowable charge for the covered item or service which is not paid by the
   carrier and for which the enrollee is responsible.
   				&#8220;Co-payment&#8221; means the out-of-pocket charge other than
   co-insurance or a deductible for an item or service to be paid by the enrollee
   to the provider towards the allowable charge as a condition of the receipt of
   specific health care items and services.
   				&#8220;Cost sharing arrangement&#8221; means any co-insurance, co-payment,
   deductible or similar arrangement imposed by the carrier on the enrollee as a
   condition to or consequence of the receipt of covered items or services.
   				&#8220;Deductible&#8221; means the dollar amount of a covered item or
   service which the enrollee is obligated to pay before benefits are payable
   under the carrier&#8217;s policy or contract with the group contract holder.
   				&#8220;Enrollee&#8221; or &#8220;member&#8221; means any individual who is
   enrolled in a group health benefit plan provided or arranged by a health
   maintenance organization or other carrier. If a health maintenance
   organization arranges or contracts for the point-of-service benefit required
   under this section through another carrier, any enrollee selecting the
   point-of-service benefit shall be treated as an enrollee of that other carrier
   when receiving covered items or services under the point-of-service benefit.
   				&#8220;Group contract holder&#8221; means any contract holder of a group
   health benefit plan offered or arranged by a health maintenance organization
   or other carrier. For purposes of this section, the group contract holder
   shall be the person to which the group agreement or contract for the group
   health benefit plan is issued.
   				&#8220;Group health benefit plan&#8221; shall mean any health care plan,
   subscription contract, evidence of coverage, certificate, health services
   plan, medical or hospital services plan, accident and sickness insurance
   policy or certificate, or other similar certificate, policy, contract or
   arrangement, and any endorsement or rider thereto, offered, arranged or issued
   by a carrier to a group contract holder to cover all or a portion of the cost
   of enrollees (or their eligible dependents) receiving covered health care
   items or services. Group health benefit plan does not mean (i) health care
   plans, contracts or policies issued in the individual market; (ii) coverages
   issued pursuant to Title XVIII of the Social Security Act, 42 U.S.C. &#xA7;
   1395 et seq. (Medicare), Title XIX of the Social Security Act, 42 U.S.C.
   &#xA7; 1396 et seq. (Medicaid) or Title XXI of the Social Security Act, 42
   U.S.C. &#xA7; 1397aa et seq. (CHIP), 5 U.S.C. &#xA7; 8901 et seq. (federal
   employees), 10 U.S.C. &#xA7; 1071 et seq. (TRICARE) or Chapter 28 (&#xA7;
   2.2-2800 et seq.) of Title 2.2 (state employees); (iii) accident only, credit
   or disability insurance, or long-term care insurance, plans providing only
   limited health care services under &#xA7; 38.2-4300 (unless offered by
   endorsement or rider to a group health benefit plan), TRICARE supplement,
   Medicare supplement, or workers&#8217; compensation coverages; or (iv) an
   employee welfare benefit plan (as defined in section 3 (1) of the Employee
   Retirement Income Security Act of 1974, 29 U.S.C. &#xA7; 1002 (1)), which is
   self-insured or self-funded.
   				&#8220;Group specific administrative cost&#8221; means the direct
   administrative cost incurred by a carrier related to the offer of the
   point-of-service benefit to a particular group contract holder.
   				&#8220;Health care plan&#8221; shall have the meaning set forth in &#xA7;
   38.2-4300.
   				&#8220;Person&#8221; means any individual, corporation, trust,
   association, partnership, limited liability company, organization or other
   entity.
   				&#8220;Point-of-service benefit&#8221; means a health maintenance
   organization&#8217;s delivery system or covered benefits, or the delivery
   system or covered benefits of another carrier under contract or arrangement
   with the health maintenance organization, which permit an enrollee (and
   eligible dependents) to receive covered items and services outside of the
   provider panel, including optometrists and clinical psychologists, of the
   health maintenance organization under the terms and conditions of the group
   contract holder&#8217;s group health benefit plan with the health maintenance
   organization or with another carrier arranged by or under contract with the
   health maintenance organization and which otherwise complies with this
   section. Without limiting the foregoing, the benefits offered or arranged by a
   carrier&#8217;s indemnity group accident and sickness policy under Chapter 34
   (&#xA7; 38.2-3400 et seq.) of this title, health services plan under Chapter
   42 (&#xA7; 38.2-4200 et seq.) of this title or preferred provider organization
   plan under Chapter 34 (&#xA7; 38.2-3400 et seq.) or 42 (&#xA7; 38.2-4200 et
   seq.) of this title which permit an enrollee (and eligible dependents) to
   receive the full range of covered items and services outside of a provider
   panel, including optometrists and clinical psychologists, and which are
   otherwise in compliance with applicable law and this section shall constitute
   a point-of-service benefit.
   				&#8220;Preferred provider organization plan&#8221; means a health benefit
   program offered pursuant to a preferred provider policy or contract under
   &#xA7; 38.2-3407 or covered services offered under a preferred provider
   subscription contract under &#xA7; 38.2-4209.
   				&#8220;Provider&#8221; means any physician, hospital or other person,
   including optometrists and clinical psychologists, that is licensed or
   otherwise authorized in the Commonwealth to deliver or furnish health care
   items or services.
   				&#8220;Provider panel&#8221; means the participating providers or referral
   providers who have a contract, agreement or arrangement with a health
   maintenance organization or other carrier, either directly or through an
   intermediary, and who have agreed to provide items or services to enrollees of
   the health maintenance organization or other carrier.

B. To the maximum extent permitted by applicable law, every health care plan
offered or proposed to be offered in the large group market in the Commonwealth
by a health maintenance organization licensed under this title to a group
contract holder shall provide or include, or the health maintenance organization
shall arrange for or contract with another carrier to provide or include, a
point-of-service benefit to be provided or offered in conjunction with the
health maintenance organization&#8217;s health care plan as an additional
benefit for the enrollee, at the enrollee&#8217;s option, individually to accept
or reject. In connection with its group enrollment application, every health
maintenance organization shall, at no additional cost to the group contract
holder, make available or arrange with a carrier to make available to the
prospective group contract holder and to all prospective enrollees, in advance
of initial enrollment and in advance of each reenrollment, a notice in form and
substance acceptable to the Commission which accurately and completely explains
to the group contract holder and prospective enrollee the point-of-service
benefit and permits each enrollee to make his or her election. The form of
notice provided in connection with any reenrollment may be the same as the
approved form of notice used in connection with initial enrollment and may be
made available to the group contract holder and prospective enrollee by the
carrier in any reasonable manner.

C. To the extent permitted under applicable law, a health maintenance
organization providing or arranging, or contracting with another carrier to
provide, the point-of-service benefit under this section and a carrier providing
the point-of-service benefit required under this section under arrangement or
contract with a health maintenance organization:

   1. May not impose, or permit to be imposed, a minimum enrollee participation
   level on the point-of-service benefit alone;

   2. May not refuse to reimburse a provider of the type listed or referred to in
   &#xA7; 38.2-3408 or 38.2-4221 for items or services provided under the
   point-of-service benefit required under this section solely on the basis of
   the license or certification of the provider to provide such items or services
   if the carrier otherwise covers the items or services provided and the
   provision of the items or services is within the provider&#8217;s lawful scope
   of practice or authority; and

   3. Shall rate and underwrite all prospective enrollees of the group contract
   holder as a single group prior to any enrollee electing to accept or reject
   the point-of-service benefit.

D. The premium imposed by a carrier with respect to enrollees who select the
point-of-service benefit may be different from that imposed by the health
maintenance organization with respect to enrollees who do not select the
point-of-service benefit. Unless a group contract holder determines otherwise,
any enrollee who accepts the point-of-service benefit shall be responsible for
the payment of any premium over the amount of the premium applicable to an
enrollee who selects the coverage offered by the health maintenance organization
without the point-of-service benefit and for any identifiable group specific
administrative cost incurred directly by the carrier or any administrative cost
incurred by the group contract holder in offering the point-of-service benefit
to the enrollee. If a carrier offers the point-of-service benefit to a group
contract holder where no enrollees of the group contract holder elect to accept
the point-of-service benefit and incurs an identifiable group specific
administrative cost directly as a consequence of the offering to that group
contract holder, the carrier may reflect that group specific administrative cost
in the premium charged to other enrollees selecting the point-of-service benefit
under this section. Unless the group contract holder otherwise directs or
authorizes the carrier in writing, the carrier shall make reasonable efforts to
ensure that no portion of the cost of offering or arranging the point-of-service
benefit shall be reflected in the premium charged by the carrier to the group
contract holder for a group health benefit plan without the point-of-service
benefit. Any premium differential and any group specific administrative cost
imposed by a carrier relating to the cost of offering or arranging the
point-of-service benefit must be actuarially sound and supported by a sworn
certification of an officer of each carrier offering or arranging the
point-of-service benefit filed with the Commission certifying that the premiums
are based on sound actuarial principles and otherwise comply with this section.
The certifications shall be in a form, and shall be accompanied by such
supporting information in a form acceptable to the Commission.

E. Any carrier may impose different co-insurance, co-payments, deductibles and
other cost-sharing arrangements for the point-of-service benefit required under
this section based on whether or not the item or service is provided through the
provider panel of the health maintenance organization; provided that, except to
the extent otherwise prohibited by applicable law, any such cost-sharing
arrangement:

   1. Shall not impose on the enrollee (or his or her eligible dependents, as
   appropriate) any co-insurance percentage obligation which is payable by the
   enrollee which exceeds the greater of: (i) thirty percent of the
   carrier&#8217;s allowable charge for the items or services provided by the
   provider under the point-of-service benefit or (ii) the co-insurance amount
   which would have been required had the covered items or services been received
   through the provider panel;

   2. Shall not impose on an enrollee (or his or her eligible dependents, as
   appropriate) a co-payment or deductible which exceeds the greatest co-payment
   or deductible, respectively, imposed by the carrier or its affiliate under one
   or more other group health benefit plans providing a point-of-service benefit
   which are currently offered and actively marketed by the carrier or its
   affiliate in the Commonwealth and are subject to regulation under this title;
   and

   3. Shall not result in annual aggregate cost-sharing payments to the enrollee
   (or his or her eligible dependents, as appropriate) which exceed the greatest
   annual aggregate cost-sharing payments which would apply had the covered items
   or services been received under another group health benefit plan providing a
   point-of-service benefit which is currently offered and actively marketed by
   the carrier or its affiliate in the Commonwealth and which is subject to
   regulation under this title.

F. Except to the extent otherwise required under applicable law, any carrier
providing the point-of-service benefit required under this section may not
utilize an allowable charge or basis for determining the amount to be reimbursed
or paid to any provider from which covered items or services are received under
the point-of-service benefit which is not at least as favorable to the provider
as that used:

   1. By the carrier or its affiliate in calculating the reimbursement or payment
   to be made to similarly situated providers under another group health benefit
   plan providing a point-of-service benefit which is subject to regulation under
   this title and which is currently offered or arranged by the carrier or its
   affiliate and actively marketed in the Commonwealth, if the carrier or its
   affiliate offers or arranges another such group health benefit plan providing
   a point-of-service benefit in the Commonwealth; or

   2. By the health maintenance organization in calculating the reimbursement or
   payment to be made to similarly situated providers on its provider panel.

G. Except as expressly permitted in this section or required under applicable
law, no carrier shall impose on any person receiving or providing health care
items or services under the point-of-service benefit any condition or penalty
designed to discourage the enrollee&#8217;s selection or use of the
point-of-service benefit, which is not otherwise similarly imposed either: (i)
on enrollees in another group health benefit plan, if any, currently offered or
arranged and actively marketed by the carrier or its affiliate in the
Commonwealth or (ii) on enrollees who receive the covered items or services from
the health maintenance organization&#8217;s provider panel. Nothing in this
section shall preclude a carrier offering or arranging a point-of-service
benefit from imposing on enrollees selecting the point-of-service benefit
reasonable utilization review, preadmission certification or precertification
requirements or other utilization or cost control measures which are similarly
imposed on enrollees participating in one or more other group health benefit
plans which are subject to regulation under this title and are currently offered
and actively marketed by the carrier or its affiliates in the Commonwealth or
which are otherwise required under applicable law.

H. Except as expressly otherwise permitted in this section or as otherwise
required under applicable law, the scope of the health care items and services
which are covered under the point-of-service benefit required under this section
shall at least include the same health care items and services which would be
covered if provided under the health maintenance organization&#8217;s health
care plan, including without limitation any items or services covered under a
rider or endorsement to the applicable health care plan. Carriers shall be
required to disclose prominently in all group health benefit plans and in all
marketing materials utilized with respect to such group health benefit plans
that the scope of the benefits provided under the point-of-service option are at
least as great as those provided through the HMO&#8217;s health care plan for
that group. Filings of point-of-service benefits submitted to the Commission
shall be accompanied by a certification signed by an officer of the filing
carrier certifying that the scope of the point-of-service benefits includes at a
minimum the same health care items and services as are provided under the
HMO&#8217;s group health care plan for that group.

I. Nothing in this section shall prohibit a health maintenance organization from
offering or arranging the point-of-service benefit (i) as a separate group
health benefit plan or under a different name than the health maintenance
organization&#8217;s group health benefit plan which does not contain the
point-of-service benefit or (ii) from managing a group health benefit plan under
which the point-of-service benefit is offered in a manner which separates or
otherwise differentiates it from the group health benefit plan which does not
contain the point-of-service benefit.

J. Notwithstanding anything in this section to the contrary, to the extent
permitted under applicable law, no health maintenance organization shall be
required to offer or arrange a point-of-service benefit under this section with
respect to any group health benefit plan offered to a group contract holder if
the health maintenance organization determines in good faith that the group
contract holder will be concurrently offering another group health benefit plan
or a self-insured or self-funded health benefit plan which allows the enrollees
to access care from their provider of choice whether or not the provider is a
member of the health maintenance organization&#8217;s panel.

K. This section shall apply only to group health benefit plans issued in the
Commonwealth in the commercial large group market by carriers regulated by this
title and shall not apply to (i) health care plans, contracts or policies issued
in the individual or small group market; (ii) coverages issued pursuant to Title
XVIII of the Social Security Act, 42 U.S.C. &#xA7; 1395 et seq. (Medicare),
Title XIX of the Social Security Act, 42 U.S.C. &#xA7; 1396 et seq. (Medicaid)
or Title XXI of the Social Security Act, 42 U.S.C. &#xA7; 1397aa et seq. (CHIP),
5 U.S.C. &#xA7; 8901 et seq. (federal employees), 10 U.S.C. &#xA7; 1071 et seq.
(TRICARE) or Chapter 28 (&#xA7; 2.2-2800 et seq.) of Title 2.2 (state
employees); (iii) accident only, credit or disability insurance, or long-term
care insurance, plans providing only limited health care services under &#xA7;
38.2-4300 (unless offered by endorsement or rider to a group health benefit
plan), TRICARE supplement, Medicare supplement, or workers&#8217; compensation
coverages; (iv) an employee welfare benefit plan (as defined in section 3 (1) of
the Employee Retirement Income Security Act of 1974, 29 U.S.C. &#xA7; 1002 (1)),
which is self-insured or self-funded; or (v) a qualified health plan when the
plan is offered in the Commonwealth by a health carrier through a health benefit
exchange established under &#xA7; 1311 of the federal Patient Protection and
Affordable Care Act (P.L. 111-148).

L. Nothing in this section shall operate to limit any rights or obligations
arising under &#xA7; 38.2-3407, 38.2-3407.7, 38.2-3407.10, 38.2-3407.11,
38.2-4209, 38.2-4209.1, 38.2-4312, or 38.2-4312.1.

HISTORY: 1998, c. 908; 2013, c. 751; 2014, cc. 157, 417, 814; 2015, c. 709.