                                 CODE OF VIRGINIA

DEFINITIONS (§ 38.2-3461)

As used in this article, unless the context requires a different meaning:
		&#8220;Allowed amount&#8221; means the contractually agreed upon amount paid
or payable by a health carrier to a health care provider participating in the
health carrier&#8217;s network.
		&#8220;Average&#8221; means mean, median, or mode.
		&#8220;Comparable health care service&#8221; means any (i) physical and
occupational therapy service, (ii) radiology and imaging service, (iii)
laboratory service, (iv) infusion therapy service, and (v) at the discretion of
the health carrier, other health care service, provided that with respect to any
service described in clauses (i) through (v) the service (a) is a covered
non-emergency health care service or bundle of health care services provided by
a network provider and (b) is a service for which the health carrier has not
demonstrated that the allowed amount variation among participating providers is
less than $50.
		&#8220;Covered person&#8221; means a policyholder, subscriber, participant, or
other individual covered by a health benefit plan.
		&#8220;Health benefit plan&#8221; means a policy, contract, certificate, or
agreement offered by a health carrier in the small group market to provide,
deliver, arrange for, pay for, or reimburse any of the costs of health care
services. &#8220;Health benefit plan&#8221; does not include the &#8220;excepted
benefits&#8221; as defined in § 38.2-3431. &#8220;Health benefit plan&#8221;
does not include any health insurance plan administered by the Department of
Human Resource Management, including the health coverage offered to state
employees pursuant to § 2.2-2818; health insurance coverage offered to
employees of local governments, local officers, teachers, and retirees, and the
dependents of such employees, local officers, teachers and retirees pursuant to
§ 2.2-1204; or health insurance coverage provided under the Line of Duty Act
(§ 9.1-400 et seq.).
		&#8220;Health care provider&#8221; means a health care professional or
facility.
		&#8220;Health care service&#8221; means a service 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;Network&#8221; or &#8220;provider network&#8221; means the group of
participating providers providing services to a health benefit plan under which
the financing and delivery of health care services are provided, in whole or in
part, through a defined set of health care providers.
		&#8220;Network provider&#8221; means a health care provider that has
contracted with the health carrier, or with its contractor or subcontractor, to
provide health care services to covered persons as a member of a network.
		&#8220;Out-of-pocket costs&#8221; means any copayment, deductible, or
coinsurance that is the responsibility of the covered person with respect to a
covered health care service.
		&#8220;Program&#8221; means the comparable health care service incentive
program established by a health carrier pursuant to this article.
		&#8220;Small group market&#8221; means the health insurance market under which
individuals obtain health insurance coverage, directly or through any
arrangement, on behalf of themselves and their dependents through a group health
plan maintained by a small employer.

HISTORY: 2019, cc. 666, 684.