                                 CODE OF VIRGINIA

CALCULATION OF COST-SHARING PROVISIONS (§ 38.2-3407.3)

A. An insurer, health services plan, or health maintenance organization that
issues an accident and sickness insurance policy or contract pursuant to which
the insured, subscriber or enrollee is required to pay a specified percentage of
the cost of covered services, shall calculate such amount payable based upon an
amount not to exceed the total amount actually paid or payable to the provider
of such services for the services provided to the insured, subscriber, or
enrollee. When there is no amount actually paid or payable to the provider by
the insurer, health services plan, or health maintenance organization for the
services provided, the insurer, health services plan, or health maintenance
organization shall use such insurer&#8217;s, health services plan&#8217;s, or
health maintenance organization&#8217;s pre-established allowed amount to
calculate the amount payable by the insured for such services. When an insured,
subscriber, or enrollee receives covered services outside the insurer&#8217;s,
health services plan&#8217;s, or health maintenance organization&#8217;s
provider network, and such entity utilizes another insurer&#8217;s, health
services plan&#8217;s, or health maintenance organization&#8217;s provider
network located outside the Commonwealth, such entity may satisfy the obligation
of this section by using the cost of services as reported by the out-of-state
insurer, health services plan, or health maintenance organization when
calculating the insured&#8217;s, subscriber&#8217;s, or enrollee&#8217;s
percentage of the cost of covered services.

B. Any insurer, health services plan, or health maintenance organization failing
to administer its contracts as set forth herein shall be deemed to have
committed a knowing and willful violation of this section, and shall be punished
as set forth in subsection A of &#xA7; 38.2-218. Each claim payment found to
have been calculated in noncompliance with this section shall be deemed a
separate and distinct violation, and shall further be deemed a violation subject
to subdivision D 1 c of &#xA7; 38.2-218, permitting the Commission to require
restitution in addition to any other penalties.

HISTORY: 1994, c. 320; 1997, c. 56; 1998, c. 49; 2017, c. 588.