                                 CODE OF VIRGINIA

CERTIFICATION OF HEALTH BENEFIT PLANS AS QUALIFIED HEALTH PLANS (§ 38.2-6506)

A. The Exchange, in consultation with the Bureau, shall certify a health benefit
plan as a qualified health plan, unless the Exchange determines that making the
plan available through the Exchange is not in the interest of qualified
individuals and qualified employers in the Commonwealth, if:

   1. The plan provides health benefits in the essential health benefits package.
   The plan may provide any state-mandated health benefit that is not provided in
   the essential health benefits package. The plan is not required to provide
   benefits that duplicate the minimum benefits of qualified dental plans, as set
   forth in subsection F, if (i) the Exchange has determined that at least one
   qualified dental plan is available to supplement the plan&#8217;s coverage and
   (ii) the health carrier makes prominent disclosure at the time it offers the
   plan, in a form approved by the Bureau, that such plan does not provide the
   full range of pediatric dental benefits included in the essential health
   benefits package and that qualified dental plans providing those benefits and
   other dental benefits not covered by such plan are offered through the
   Exchange;

   2. The premium rates and policy forms have been approved by or filed with the
   Commission, in accordance with &#xA7;&#xA7; 38.2-316 and 38.2-316.1;

   3. The plan provides at least a bronze level of coverage unless the plan is
   certified as a qualified catastrophic plan, meets the requirements of the
   Federal Act for catastrophic plans, and will only be offered to individuals
   eligible for catastrophic coverage;

   4. The plan&#8217;s cost-sharing requirements do not exceed the limits
   established under &#xA7; 1302(c)(1) of the Federal Act;

   5. The health carrier offering the plan:
   				a. Is licensed and in good standing to offer health insurance coverage in
   the Commonwealth;
   				b. Offers (i) at least one qualified health plan in the silver level of
   coverage and one qualified health plan at a gold level of coverage throughout
   each service area in which it offers coverage through the Exchange and (ii) a
   child-only plan at the same level of coverage as any qualified health plan
   offered through the Exchange to individuals who, as of the beginning of the
   plan year, are less than 21 years of age;
   				c. Charges the same premium rate for each qualified health plan without
   regard to whether the plan is offered through the Exchange or directly by the
   health carrier or through an agent;
   				d. Does not charge any cancellation fees or penalties in violation of
   subsection D of &#xA7; 38.2-6504; and
   				e. Complies with the regulations developed by the Secretary under &#xA7;
   1311(d) of the Federal Act and such other requirements as the Exchange may
   establish; and

   6. The plan meets the requirements of certification as adopted by regulation
   pursuant to &#xA7; 38.2-6514 or promulgated by the Secretary under &#xA7;
   1311(c) of the Federal Act, which include minimum standards in the areas of
   marketing practices, network adequacy, essential community providers in
   underserved areas, accreditation, quality improvement, uniform enrollment
   forms, and descriptions of coverage and information on quality measures for
   health benefit plan performance.

B. The Exchange shall not refuse to certify a health benefit plan as a qualified
health plan (i) on the basis that the plan is a fee-for-service plan, (ii)
through the imposition of premium price controls by the Exchange, or (iii) on
the basis that the health benefit plan provides treatments necessary to prevent
patients&#8217; deaths in circumstances that the Exchange determines are
inappropriate or too costly.

C. In order to foster a competitive marketplace and consumer choice, the
Exchange shall certify all health benefit plans recommended by the Bureau
meeting the requirements of &#xA7; 1311(c) of the Federal Act for participation
in the Exchange unless it is not in the interest of qualified individuals and
qualified employers. The Exchange shall establish and publish a transparent,
objective process for decertifying qualified health plans if it is determined
that it is not in the public interest to permit such plans to be offered through
the Exchange.

D. The Exchange shall require each health carrier seeking certification of a
health benefit plan as a qualified health plan to permit individuals to learn,
in a timely manner upon the request of the individual, the amount of
cost-sharing, including deductibles, copayments, and coinsurance, under the
individual&#8217;s plan or coverage that such individual would be responsible
for paying with respect to the furnishing of a specific item or service by a
participating provider. At a minimum, this information shall be made available
to the individual through the Exchange&#8217;s website and through other means
for individuals without access to the Internet.

E. The Exchange shall apply the criteria of this section in a manner that
assures a level playing field between or among health carriers participating in
the Exchange.

F. The provisions of this chapter that are applicable to qualified health plans
shall also apply to the extent applicable to qualified dental plans, except as
modified (i) by regulations adopted by the Commission or (ii) in accordance with
the following:

   1. A health carrier seeking certification of a dental benefit plan as a
   qualified dental plan shall be licensed in the Commonwealth to offer dental
   coverage but need not be licensed to offer other health benefits;

   2. Qualified dental plans shall be limited to dental and oral health benefits,
   without substantial duplication of the benefits typically offered by health
   benefit plans without dental coverage, and shall include, at a minimum, the
   pediatric dental benefits prescribed by the Secretary pursuant to &#xA7;
   1302(b)(1)(J) of the Federal Act and such other dental benefits as the
   Exchange may specify or the Secretary may specify by regulation; and

   3. Participants in the Exchange shall have the option to purchase at least the
   pediatric dental benefit component of the essential health benefits package
   either through a separate qualified dental plan or as a part of a combined
   offer by a qualified health plan, provided that, with respect to a combined
   offer, the health and dental benefits are priced separately and also made
   available for purchase separately at the same price.

HISTORY: 2020, cc. 916, 917; 2022, cc. 556, 560.