                                 CODE OF VIRGINIA

EVIDENCE OF COVERAGE AND CHARGES FOR HEALTH CARE SERVICES (§ 38.2-4306)

A. 1. Each subscriber shall be entitled to evidence of coverage under a health
care plan.

   2. No evidence of coverage, or amendment to it, shall be delivered or issued
   for delivery in this Commonwealth until a copy of the form of the evidence of
   coverage, or amendment to it, has been filed with and approved by the
   Commission, subject to the provisions of subsection C of this section. Any
   evidence of coverage for enrollees in the plans administered by the Department
   of Medical Assistance Services that provide benefits pursuant to Title XIX or
   Title XXI of the Social Security Act, as amended, is excluded from the
   provisions of this section.

   3. No evidence of coverage shall contain provisions or statements which are
   unjust, unfair, untrue, inequitable, misleading, deceptive or
   misrepresentative.

   4. An evidence of coverage shall contain a clear and complete statement if a
   contract, or a reasonably complete summary if a certificate, of:
   				a. The health care services and any insurance or other benefits to which
   the enrollee is entitled under the health care plan;
   				b. Any limitations on the services, kind of services, benefits, or kind of
   benefits to be provided, including any deductible or copayment feature, or
   both;
   				c. Where and in what manner information is available as to how services
   may be obtained;
   				d. The total amount of payment for health care services and any indemnity
   or service benefits that the enrollee is obligated to pay with respect to
   individual contracts, or an indication whether the plan is contributory or
   noncontributory for group certificates;
   				e. A description of the health maintenance organization&#8217;s method for
   resolving enrollee complaints. Any subsequent change may be evidenced in a
   separate document issued to the enrollee; and
   				f. A list of providers and a description of the service area which shall
   be provided with the evidence of coverage, if such information is not given to
   the subscriber at the time of enrollment.

B. Pursuant to this subsection:

   1. No schedule of charges or amendment to the schedule of charges for enrollee
   coverage for health care services may be used in conjunction with any health
   care plan until a copy of the schedule, or its amendment, has been filed with
   the Commission. Any schedule of charges or amendment to the schedule of
   charges for enrollees in the plans administered by the Department of Medical
   Assistance Services that provide benefits pursuant to Title XIX or Title XXI
   of the Social Security Act, as amended, is excluded from the provisions of
   this subsection.

   2. The charges may be established for various categories of enrollees based
   upon sound actuarial principles, provided that charges applying to an enrollee
   in a group health plan shall not be individually determined based on the
   status of his health. A certification on the appropriateness of the charges,
   based upon reasonable assumptions, may be required by the Commission to be
   filed along with adequate supporting information. This certification shall be
   prepared by a qualified actuary or other qualified professional approved by
   the Commission.

C. The Commission shall, within a reasonable period, approve any form if the
requirements of subsection A of this section are met. It shall be unlawful to
issue a form until approved. If the Commission disapproves a filing, it shall
notify the filer. The Commission shall specify the reasons for its disapproval
in the notice. A written request for a hearing on the disapproval may be made to
the Commission within 30 days after notice of the disapproval. If the Commission
does not disapprove any form within 30 days of the filing of such form, it shall
be deemed approved unless the filer is notified in writing that the waiting
period is extended by the Commission for an additional 30 days. Filing of the
form means actual receipt by the Commission.

D. The Commission may require the submission of any relevant information it
considers necessary in determining whether to approve or disapprove a filing
made under this section.

E. The provisions of this section shall not apply in any instance in which the
provisions of this section are inconsistent or in conflict with a provision of
Article 6 (&#xA7; 38.2-3438 et seq.) of Chapter 34.

HISTORY: 1980, c. 720, § 38.1-869; 1986, c. 562; 1997, cc. 807, 913; 2003, cc.
752, 767; 2004, c. 185; 2006, c. 866; 2013, c. 751; 2014, c. 814.