                                 CODE OF VIRGINIA

CALCULATION OF ENROLLEE&#8217;S CONTRIBUTION TO OUT-OF-POCKET MAXIMUM OR
COST-SHARING REQUIREMENT (§ 38.2-3407.20)

A. As used in this section:
			&#8220;Carrier&#8221; shall have the meaning set forth in &#xA7;
38.2-3407.10; however, &#8220;carrier&#8221; also includes any person required
to be licensed under this title that offers or operates a managed care health
insurance plan subject to Chapter 58 (&#xA7; 38.2-5800 et seq.) or that provides
or arranges for the provision of health care services, health plans, networks,
or provider panels that are subject to regulation as the business of insurance
under this title.
			&#8220;Cost sharing&#8221; means any coinsurance, copayment, or deductible.
			&#8220;Enrollee&#8221; means any person entitled to health care services from
a carrier.
			&#8220;Health care services&#8221; means items or services furnished to any
individual for the purpose of preventing, alleviating, curing, or healing human
illness, injury, or physical disability.
			&#8220;Health plan&#8221; means any individual or group health care plan,
subscription contract, evidence of coverage, certificate, health services plan,
medical or hospital services plan, accident and sickness insurance policy or
certificate, managed care health insurance plan, or other similar certificate,
policy, contract, or arrangement, and any endorsement or rider thereto, to cover
all or a portion of the cost of persons receiving covered health care services,
that is subject to state regulation and that is required to be offered,
arranged, or issued in the Commonwealth by a carrier licensed under this title.
&#8220;Health plan&#8221; does not mean (i) 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), or 10 U.S.C. &#xA7; 1071 et
seq. (TRICARE); or (ii) accident only, credit or disability insurance, long-term
care insurance, TRICARE supplement, Medicare supplement, or workers&#8217;
compensation coverages.

B. To the extent permitted by federal law and regulation and except as provided
in subsection C, when calculating an enrollee&#8217;s overall contribution to
any out-of-pocket maximum or any cost-sharing requirement under a health plan, a
carrier shall include any amounts paid by the enrollee or paid on behalf of the
enrollee by another person.

C. If the application of the provisions of subsection B would result in a health
plan&#8217;s ineligibility to qualify as a Health Savings Account-qualified High
Deductible Health Plan under 26 U.S.C. &#xA7; 223, then the requirements of
subsection B shall not apply with respect to the deductible of such health plan
until after the enrollee has satisfied the minimum deductible under 26 U.S.C
&#xA7; 223. However, with respect to items or services that are preventive care
pursuant to 26 U.S.C. &#xA7; 223 (c)(2)(C), the provisions of subsection B shall
apply regardless of whether the minimum deductible under 26 U.S.C. &#xA7; 223
has been satisfied.

D. This section shall apply with respect to health plans that are entered into,
amended, extended, or renewed on or after January 1, 2020.

E. Pursuant to the authority granted by &#xA7; 38.2-223, the Commission may
promulgate such rules and regulations as it may deem necessary to implement this
section.

HISTORY: 2019, cc. 661, 662; 2022, cc. 133, 134.