                                 CODE OF VIRGINIA

DEFINITIONS (§ 38.2-3438)

As used this article, unless the context requires a different meaning:
		&#8220;Allowed amount&#8221; means the maximum portion of a billed charge a
health carrier will pay, including any applicable cost-sharing requirements, for
a covered service or item rendered by a participating provider or by a
nonparticipating provider.
		&#8220;Balance bill&#8221; means a bill sent to an enrollee by an
out-of-network provider for health care services provided to the enrollee after
the provider&#8217;s billed amount is not fully reimbursed by the carrier,
exclusive of applicable cost-sharing requirements.
		&#8220;Behavioral health crisis service provider&#8221; means a provider
licensed by the Department of Behavioral Health and Developmental Services to
provide mental health or substance abuse services as a provider of mobile crisis
response, residential crisis stabilization, or a crisis receiving center.
		&#8220;Child&#8221; means a son, daughter, stepchild, adopted child, including
a child placed for adoption, foster child, or any other child eligible for
coverage under the health benefit plan.
		&#8220;Cost-sharing requirement&#8221; means an enrollee&#8217;s deductible,
copayment amount, or coinsurance rate.
		&#8220;Covered benefits&#8221; or &#8220;benefits&#8221; means those health
care services to which an individual is entitled under the terms of a health
benefit plan.
		&#8220;Covered person&#8221; means a policyholder, subscriber, enrollee,
participant, or other individual covered by a health benefit plan.
		&#8220;Dependent&#8221; means the spouse or child of an eligible employee,
subject to the applicable terms of the policy, contract, or plan covering the
eligible employee.
		&#8220;Emergency medical condition&#8221; means, regardless of the final
diagnosis rendered to a covered person, a medical condition manifesting itself
by acute symptoms of sufficient severity, including severe pain, so that a
prudent layperson, who possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical attention to result in
(i) serious jeopardy to the mental or physical health of the individual, (ii)
danger of serious impairment to bodily functions, (iii) serious dysfunction of
any bodily organ or part, or (iv) in the case of a pregnant woman, serious
jeopardy to the health of the fetus.
		&#8220;Emergency services&#8221; means with respect to an emergency medical
condition (i) (a) a medical screening examination as required under § 1867 of
the Social Security Act (42 U.S.C. § 1395dd) that is within the capability of
the emergency department of a hospital, including ancillary services routinely
available to the emergency department to evaluate such emergency medical
condition, and (b) such further medical examination and treatment, to the extent
they are within the capabilities of the staff and facilities available at the
hospital, as are required under § 1867 of the Social Security Act (42 U.S.C. §
1395dd (e)(3)) to stabilize the patient and (ii) as it relates to any mental
health services or substance abuse services, as those terms are defined in §
38.2-3412.1, rendered at a behavioral health crisis service provider (a) a
behavioral health assessment that is within the capability of a behavioral
health crisis service provider, including ancillary services routinely available
to evaluate such emergency medical condition, and (b) such further examination
and treatment, to the extent that they are within the capabilities of the staff
and facilities available at the behavioral health crisis service provider, as
are required so that the patient&#8217;s condition does not deteriorate.
		&#8220;ERISA&#8221; means the Employee Retirement Income Security Act of 1974.
		&#8220;Essential health benefits&#8221; include the following general
categories and the items and services covered within the categories in
accordance with regulations issued pursuant to the PPACA as of January 1, 2019:
(i) ambulatory patient services; (ii) emergency services; (iii) hospitalization;
(iv) laboratory services; (v) maternity and newborn care; (vi) mental health and
substance abuse disorder services, including behavioral health treatment; (vii)
pediatric services, including oral and vision care; (viii) prescription drugs;
(ix) preventive and wellness services and chronic disease management; and (x)
rehabilitative and habilitative services and devices.
		&#8220;Facility&#8221; means an institution providing health care related
services or a health care setting, including hospitals and other licensed
inpatient centers; ambulatory surgical or treatment centers; skilled nursing
centers; residential treatment centers; diagnostic, laboratory, and imaging
centers; and rehabilitation and other therapeutic health settings.
		&#8220;Genetic information&#8221; means, with respect to an individual,
information about: (i) the individual&#8217;s genetic tests; (ii) the genetic
tests of the individual&#8217;s family members; (iii) the manifestation of a
disease or disorder in family members of the individual; or (iv) any request
for, or receipt of, genetic services, or participation in clinical research that
includes genetic services, by the individual or any family member of the
individual. &#8220;Genetic information&#8221; does not include information about
the sex or age of any individual. As used in this definition, &#8220;family
member&#8221; includes a first-degree, second-degree, third-degree, or
fourth-degree relative of a covered person.
		&#8220;Genetic services&#8221; means (i) a genetic test; (ii) genetic
counseling, including obtaining, interpreting, or assessing genetic information;
or (iii) genetic education.
		&#8220;Genetic test&#8221; means an analysis of human DNA, RNA, chromosomes,
proteins, or metabolites, if the analysis detects genotypes, mutations, or
chromosomal changes. &#8220;Genetic test&#8221; does not include an analysis of
proteins or metabolites that is directly related to a manifested disease,
disorder, or pathological condition.
		&#8220;Grandfathered plan&#8221; means coverage provided by a health carrier
to (i) a small employer on March 23, 2010, or (ii) an individual that was
enrolled on March 23, 2010, including any extension of coverage to an individual
who becomes a dependent of a grandfathered enrollee after March 23, 2010, for as
long as such plan maintains that status in accordance with federal law.
		&#8220;Group health insurance coverage&#8221; means health insurance coverage
offered in connection with a group health benefit plan.
		&#8220;Group health plan&#8221; means an employee welfare benefit plan as
defined in § 3(1) of ERISA to the extent that the plan provides medical care
within the meaning of § 733(a) of ERISA to employees, including both current
and former employees, or their dependents as defined under the terms of the plan
directly or through insurance, reimbursement, or otherwise.
		&#8220;Health benefit plan&#8221; means a policy, contract, certificate, or
agreement offered by a health carrier to provide, deliver, arrange for, pay for,
or reimburse any of the costs of health care services. &#8220;Health benefit
plan&#8221; includes short-term and catastrophic health insurance policies, and
a policy that pays on a cost-incurred basis, except as otherwise specifically
exempted in this definition. &#8220;Health benefit plan&#8221; does not include
the &#8220;excepted benefits&#8221; as defined in § 38.2-3431.
		&#8220;Health care professional&#8221; means a physician or other health care
practitioner licensed, accredited, or certified to perform specified health care
services consistent with state law.
		&#8220;Health care provider&#8221; or &#8220;provider&#8221; means a health
care professional or facility.
		&#8220;Health care services&#8221; means services for the diagnosis,
prevention, treatment, cure, or relief of a health condition, illness, injury,
or disease.
		&#8220;Health carrier&#8221; means an entity subject to the insurance laws and
regulations of the Commonwealth and subject to the jurisdiction of the
Commission that contracts or offers to contract to provide, deliver, arrange
for, pay for, or reimburse any of the costs of health care services, including
an insurer licensed to sell accident and sickness insurance, a health
maintenance organization, a health services plan, or any other entity providing
a plan of health insurance, health benefits, or health care services.
		&#8220;Health maintenance organization&#8221; means a person licensed pursuant
to Chapter 43 (§ 38.2-4300 et seq.).
		&#8220;Health status-related factor&#8221; means any of the following factors:
health status; medical condition, including physical and mental illnesses;
claims experience; receipt of health care services; medical history; genetic
information; evidence of insurability, including conditions arising out of acts
of domestic violence; disability; or any other health status-related factor as
determined by federal regulation.
		&#8220;Individual health insurance coverage&#8221; means health insurance
coverage offered to individuals in the individual market, which includes a
health benefit plan provided to individuals through a trust arrangement,
association, or other discretionary group that is not an employer plan, but does
not include coverage defined as &#8220;excepted benefits&#8221; in § 38.2-3431
or short-term limited duration insurance. Student health insurance coverage
shall be considered a type of individual health insurance coverage.
		&#8220;Individual market&#8221; means the market for health insurance coverage
offered to individuals other than in connection with a group health plan.
		&#8220;In-network&#8221; or &#8220;participating&#8221; means a provider that
has contracted with a carrier or a carrier&#8217;s contractor or subcontractor
to provide health care services to enrollees and be reimbursed by the carrier at
a contracted rate as payment in full for the health care services, including
applicable cost-sharing requirements.
		&#8220;Managed care plan&#8221; means a health benefit plan that either
requires a covered person to use, or creates incentives, including financial
incentives, for a covered person to use health care providers managed, owned,
under contract with, or employed by the health carrier.
		&#8220;Network&#8221; means the group of participating providers providing
services to a managed care plan.
		&#8220;Nonprofit data services organization&#8221; means the nonprofit
organization with which the Commissioner of Health negotiates and enters into
contracts or agreements for the compilation, storage, analysis, and evaluation
of data submitted by data suppliers pursuant to § 32.1-276.4.
		&#8220;Offer to pay&#8221; or &#8220;payment notification&#8221; means a claim
that has been adjudicated and paid by a carrier or determined by a carrier to be
payable by an enrollee to an out-of-network provider for services described in
subsection A of § 38.2-3445.01.
		&#8220;Open enrollment&#8221; means, with respect to individual health
insurance coverage, the period of time during which any individual has the
opportunity to apply for coverage under a health benefit plan offered by a
health carrier and must be accepted for coverage under the plan without regard
to a preexisting condition exclusion.
		&#8220;Out-of-network&#8221; or &#8220;nonparticipating&#8221; means a
provider that has not contracted with a carrier or a carrier&#8217;s contractor
or subcontractor to provide health care services to enrollees.
		&#8220;Out-of-pocket maximum&#8221; or &#8220;maximum out-of-pocket&#8221;
means the maximum amount an enrollee is required to pay in the form of
cost-sharing requirements for covered benefits in a plan year, after which the
carrier covers the entirety of the allowed amount of covered benefits under the
contract of coverage.
		&#8220;Participating health care professional&#8221; means a health care
professional who, under contract with the health carrier or with its contractor
or subcontractor, has agreed to provide health care services to covered persons
with an expectation of receiving payments, other than coinsurance, copayments,
or deductibles, directly or indirectly from the health carrier.
		&#8220;PPACA&#8221; means the Patient Protection and Affordable Care Act (P.L.
111-148), as amended by the Health Care and Education Reconciliation Act of 2010
(P.L. 111-152), and as it may be further amended.
		&#8220;Preexisting condition exclusion&#8221; means a limitation or exclusion
of benefits, including a denial of coverage, based on the fact that the
condition was present before the effective date of coverage, or if the coverage
is denied, the date of denial, whether or not any medical advice, diagnosis,
care, or treatment was recommended or received before the effective date of
coverage. &#8220;Preexisting condition exclusion&#8221; also includes a
condition identified as a result of a pre-enrollment questionnaire or physical
examination given to an individual, or review of medical records relating to the
pre-enrollment period.
		&#8220;Premium&#8221; means all moneys paid by an employer, eligible employee,
or covered person as a condition of coverage from a health carrier, including
fees and other contributions associated with the health benefit plan.
		&#8220;Preventive services&#8221; means (i) evidence-based items or services
for which a rating of A or B is in effect in the recommendations of the U.S.
Preventive Services Task Force with respect to the individual involved; (ii)
immunizations for routine use in children, adolescents, and adults for which a
recommendation of the Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention is in effect with respect to the
individual involved; (iii) evidence-informed preventive care and screenings
provided for in comprehensive guidelines supported by the Health Resources and
Services Administration with respect to infants, children, and adolescents; and
(iv) evidence-informed preventive care and screenings recommended in
comprehensive guidelines supported by the Health Resources and Services
Administration with respect to women. For purposes of this definition, a
recommendation of the Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention is considered in effect after it has
been adopted by the Director of the Centers for Disease Control and Prevention,
and a recommendation is considered to be for routine use if it is listed on the
Immunization Schedules of the Centers for Disease Control and Prevention.
		&#8220;Primary care health care professional&#8221; means a health care
professional designated by a covered person to supervise, coordinate, or provide
initial care or continuing care to the covered person and who may be required by
the health carrier to initiate a referral for specialty care and maintain
supervision of health care services rendered to the covered person.
		&#8220;Rescission&#8221; means a cancellation or discontinuance of coverage
under a health benefit plan that has a retroactive effect.
&#8220;Rescission&#8221; does not include:

1. A cancellation or discontinuance of coverage under a health benefit plan if
the cancellation or discontinuance of coverage has only a prospective effect, or
the cancellation or discontinuance of coverage is effective retroactively to the
extent it is attributable to a failure to timely pay required premiums or
contributions towards the cost of coverage; or

2. A cancellation or discontinuance of coverage when the health benefit plan
covers active employees and, if applicable, dependents and those covered under
continuation coverage provisions, if the employee pays no premiums for coverage
after termination of employment and the cancellation or discontinuance of
coverage is effective retroactively back to the date of termination of
employment due to a delay in administrative recordkeeping.
			&#8220;Stabilize&#8221; means with respect to an emergency medical condition,
to provide such medical treatment as may be necessary to assure, within
reasonable medical probability, that no material deterioration of the condition
is likely to result from or occur during the transfer of the individual from a
facility, or, with respect to a pregnant woman, that the woman has delivered,
including the placenta.
			&#8220;Student health insurance coverage&#8221; means a type of individual
health insurance coverage that is provided pursuant to a written agreement
between an institution of higher education, as defined by the Higher Education
Act of 1965, and a health carrier and provided to students enrolled in that
institution of higher education and their dependents, and that does not make
health insurance coverage available other than in connection with enrollment as
a student, or as a dependent of a student, in the institution of higher
education, and does not condition eligibility for health insurance coverage on
any health status-related factor related to a student or a dependent of the
student.
			&#8220;Surgical or ancillary services&#8221; means professional services,
including surgery, anesthesiology, pathology, radiology, or hospitalist services
and laboratory services.
			&#8220;Wellness program&#8221; means a program offered by an employer that is
designed to promote health or prevent disease.

HISTORY: 2011, c. 882; 2013, c. 751; 2014, c. 814; 2020, cc. 1080, 1081, 1160;
2024, cc. 199, 360.