                                 CODE OF VIRGINIA

DEFINITIONS (§ 38.2-4300)

As used in this chapter:
		&#8220;Acceptable securities&#8221; means securities that (i) are legal
investments under the laws of the Commonwealth for public sinking funds or for
other public funds, (ii) are not in default as to principal or interest, (iii)
have a current market value of not less than $50,000 nor more than $500,000, and
(iv) are issued pursuant to a system of book-entry evidencing ownership
interests of the securities with transfers of ownership effected on the records
of the depository and its participants pursuant to rules and procedures
established by the depository.
		&#8220;Basic health care services&#8221; means in and out-of-area emergency
services, inpatient hospital and physician care, outpatient medical services,
laboratory and radiologic services, mental health and substance use disorder
benefits, and preventive health services. In the case of a health maintenance
organization that has contracted with the Commonwealth to furnish basic health
services to recipients of medical assistance under Title XIX of the United
States Social Security Act pursuant to § 38.2-4320, the basic health services
to be provided by the health maintenance organization to program recipients may
differ from the basic health services required by this section to the extent
necessary to meet the benefit standards prescribed by the state plan for medical
assistance services authorized pursuant to § 32.1-325.
		&#8220;Copayment&#8221; means an amount an enrollee is required to pay in
order to receive a specific health care service.
		&#8220;Deductible&#8221; means an amount an enrollee is required to pay
out-of-pocket before the health care plan begins to pay the costs associated
with health care services.
		&#8220;Emergency services&#8221; means those health care services that are
rendered by affiliated or nonaffiliated providers after the sudden onset of a
medical condition that manifests itself by symptoms of sufficient severity,
including severe pain, that the absence of immediate medical attention could
reasonably be expected by a prudent layperson who possesses an average knowledge
of health and medicine to result in (i) serious jeopardy to the mental or
physical health of the individual, (ii) danger of serious impairment of the
individual&#8217;s bodily functions, (iii) serious dysfunction of any of the
individual&#8217;s bodily organs, or (iv) in the case of a pregnant woman,
serious jeopardy to the health of the fetus. Emergency services provided within
the plan&#8217;s service area shall include covered health care services from
nonaffiliated providers only when delay in receiving care from a provider
affiliated with the health maintenance organization could reasonably be expected
to cause the enrollee&#8217;s condition to worsen if left unattended.
		&#8220;Enrollee&#8221; or &#8220;member&#8221; means an individual who is
enrolled in a health care plan.
		&#8220;Evidence of coverage&#8221; means any certificate or individual or
group agreement or contract issued in conjunction with the certificate,
agreement or contract, issued to a subscriber setting out the coverage and other
rights to which an enrollee is entitled.
		&#8220;Excess insurance&#8221; or &#8220;stop loss insurance&#8221; means
insurance issued to a health maintenance organization by an insurer licensed in
the Commonwealth, on a form approved by the Commission, or a risk assumption
transaction acceptable to the Commission, providing indemnity or reimbursement
against the cost of health care services provided by the health maintenance
organization.
		&#8220;Health care plan&#8221; means any arrangement in which any person
undertakes to provide, arrange for, pay for, or reimburse any part of the cost
of any health care services. A significant part of the arrangement shall consist
of arranging for or providing health care services, including emergency services
and services rendered by nonparticipating referral providers, as distinguished
from mere indemnification against the cost of the services, on a prepaid basis.
For purposes of this section, a significant part shall mean at least 90 percent
of total costs of health care services.
		&#8220;Health care services&#8221; means the furnishing of services to any
individual for the purpose of preventing, alleviating, curing, or healing human
illness, injury, or physical disability.
		&#8220;Health maintenance organization&#8221; means any person who undertakes
to provide or arrange for one or more health care plans.
		&#8220;Limited health care services&#8221; means dental care services, vision
care services, and such other services as may be determined by the Commission to
be limited health care services. Limited health care services shall not include
hospital, medical, surgical, or emergency services except as such services are
provided incident to the limited health care services set forth in the preceding
sentence.
		&#8220;Net worth&#8221; or &#8220;capital and surplus&#8221; means the excess
of total admitted assets over the total liabilities of the health maintenance
organization, provided that surplus notes shall be reported and accounted for in
accordance with guidance set forth in the National Association of Insurance
Commissioners (NAIC) accounting practice and procedures manuals.
		&#8220;Nonparticipating referral provider&#8221; means a provider who is not a
participating provider but with whom a health maintenance organization has
arranged, through referral by its participating providers, to provide health
care services to enrollees. Payment or reimbursement by a health maintenance
organization for health care services provided by nonparticipating referral
providers may exceed five percent of total costs of health care services, only
to the extent that any such excess payment or reimbursement over five percent
shall be combined with the costs for services which represent mere
indemnification, with the combined amount subject to the combination of
limitations set forth in this definition and in this section&#8217;s definition
of health care plan.
		&#8220;Participating provider&#8221; means a provider who has agreed to
provide health care services to enrollees and to hold those enrollees harmless
from payment with an expectation of receiving payment, other than copayments or
deductibles, directly or indirectly from the health maintenance organization.
		&#8220;Provider&#8221; or &#8220;health care provider&#8221; means any
physician, hospital, or other person that is licensed or otherwise authorized in
the Commonwealth to furnish health care services.
		&#8220;Subscriber&#8221; means a contract holder, an individual enrollee, or
the enrollee in an enrolled family who is responsible for payment to the health
maintenance organization or on whose behalf such payment is made.

HISTORY: 1980, c. 720, § 38.1-863; 1986, cc. 76, 528, 562; 1990, c. 224; 1992,
cc. 241, 481; 1993, c. 305; 1995, cc. 182, 345; 2000, c. 503; 2003, cc. 752,
767; 2004, c. 175; 2006, c. 448; 2015, c. 649.