                                 CODE OF VIRGINIA

EXPLANATION OF BENEFITS (§ 38.2-3407.4)

A. Each insurer issuing an accident and sickness insurance policy, a corporation
issuing subscription contracts, and each health maintenance organization shall
file for approval explanation of benefits forms. These explanation of benefit
forms shall be subject to the requirements of &#xA7; 38.2-316 or &#xA7;
38.2-4306 as applicable.

B. The explanation of benefits shall accurately and clearly set forth the
benefits payable under the contract.

C. The Commission may issue regulations to establish (i) standards for the
accuracy and clarity of the information presented in an explanation of benefits
and (ii) alternative methods of delivery of the explanation of benefits that
permit (a) a subscriber who is legally authorized to consent to care for a
covered person or recipient, (b) a covered person or recipient who is legally
authorized to consent to that covered person&#8217;s or recipient&#8217;s own
care, or (c) another party who has the exclusive legal authorization to consent
to care for the covered person or recipient to receive the explanation of
benefits by an alternative method, provided that each such alternative method is
in compliance with the provisions of 45 C.F.R. &#xA7; 164.522 regarding the
right to request privacy protection for protected health information.

D. The term &#8220;explanation of benefits&#8221; as used in this section shall
include any form provided by an insurer, health services plan, or health
maintenance organization which explains the amounts covered under a policy or
plan or shows the amounts payable by a covered person to a health care provider.

HISTORY: 1994, c. 320; 2020, cc. 715, 716.