Health Insurance Benefit Coverage Law Summaries
Virginia, Health Insurance Benefit Coverage Law Summaries
Virginia's mandated health care law is located in the Code of Virginia at Title 38.2, Chapters 34 and 35.
DEFINITIONS
“Small employer” means in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least two but not more than 50 employees on business days during the preceding calendar year and who employs at least two employees on the first day of the plan year (Sec. 38.2-3431, as amended by Ch. 26 (H. 854), L. 1998, effective July 1, 1998).
“Child health supervision services” means the periodic review of a child's physical and emotional status by a licensed and qualified physician or pursuant to a physician's supervision. A review must include, but is not limited, to a history, complete physical examination, developmental assessment, anticipatory guidance, appropriate immunizations, and laboratory tests in keeping with prevailing medical standards (Sec. 38.2-3411.1, as amended by Ch. 118 (H. 574), L. 2000, effective July 1, 2000).
WHAT THE EMPLOYER MUST DO
Virginia does not require employers to provide health insurance for their employees. However, if an employer does provide insurance, it must be aware of specific coverage required to be included in health insurance policies and contracts. This coverage is summarized below.
Mental health coverage.-Inpatient services.- Each group accident and sickness insurance policy or group subscription contract providing coverage on an expense-incurred basis for a family member of the insured or the subscriber must provide coverage for inpatient and partial hospitalization mental health services as follows (Sec. 38.2-3412.1, as amended by Ch. 638, L. 2006):
Treatment for an adult as an inpatient at a hospital, inpatient unit of a mental health treatment center, alcohol or drug rehabilitation facility or intermediate care facility for a minimum period of 20 days per policy or contract year.
Treatment for a child or adolescent as an inpatient at a hospital, inpatient unit of a mental health treatment center, alcohol or drug rehabilitation facility or intermediate care facility for a minimum period of 25 days per policy or contract year.
Up to 10 days of the inpatient benefit set forth in items (1) and (2) may be converted when medically necessary at the option of the person or the parent of a child or adolescent receiving such treatment to a partial hospitalization benefit applying a formula that is no less favorable than an exchange of 1.5 days of partial hospitalization coverage for each inpatient day of coverage.
Coverage need not be provided by short-term travel, accident only, limited or specified disease policies or contracts, nor by policies or contracts designed for issuance to persons eligible for Medicare coverage or any other similar coverage under state or federal governmental plans (Sec. 38.2-3412.1, as amended by Ch. 638, L. 2006).
Outpatient services.- Each group accident and sickness insurance policy or group subscription contract providing coverage on an expense-incurred basis for a family member of the insured or the subscriber must also provide coverage for outpatient mental health services as follows (Sec. 38.2-3412.1, as amended by Ch. 638, L. 2006):
A minimum of 20 visits for outpatient treatment of an adult, child or adolescent must be provided in each policy or contract year.
The limits of the benefits must be no more restrictive than the limits of benefits applicable to physical illness; however, the coinsurance factor applicable to any outpatient visit beyond the first five of such visits covered in any policy or contract year will be at least 50 percent.
Medication management visits must be covered in the same manner as a medication management visit for the treatment of physical illness and must not be counted as an outpatient treatment visit in the calculation of the benefit.
If all covered expenses for a visit for outpatient mental health treatment apply toward any deductible required by a policy or contract, such visit must not count toward the outpatient visit benefit maximum set forth in the policy or contract.
Coverage for the outpatient services described above need not be provided by short-term travel, accident only, or limited or specified disease policies or contracts, nor by policies or contracts designed for issuance to persons eligible for Medicare or any other similar coverage under state or federal governmental plans (Sec. 38.2-3412.1, as amended by Ch. 638, L. 2006).
Biologically based mental illness.- The mental health coverage provisions described above will not be applicable to biologically based mental illnesses unless coverage for any such mental illness is not otherwise available as provided below (Sec. 38.2-3412.1, as amended by Ch. 638, L. 2006).
Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis, each corporation providing group accident and sickness subscription contracts, and each HMO providing a health care plan for health care services must provide coverage for biologically based mental illnesses (Sec. 38.2-3412.1:01(A), as amended by Ch. 156, L. 2004).
The requirements of Sec. 38.2-3412.1:01(A) above apply to all insurance policies, subscription contracts, and health care plans delivered, issued for delivery, reissued or extended on or after January 1, 2000, and to all such policies, contracts or plans to which a term is changed or any premium adjustment is made on or after such date (Sec. 38.2-3412.1:01(G), as amended by Ch. 156, L. 2004).
Dependent care coverage.- Each individual and group accident and sickness insurance policy or individual and group subscription contract providing coverage on an expense-incurred basis that provides coverage for a family member of the insured or the subscriber must, as to the family members' coverage, also provide that the accident and sickness insurance benefits applicable for children are payable with respect to a newly born child of the insured or subscriber from the moment of birth. Coverage for newly born children must be identical to coverage provided to the insured or subscriber, except that, regardless of whether such coverage would otherwise be provided under the terms and conditions of the insurance policy or subscription contract, coverage must be provided for (Sec. 38.2-3411):
necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, with coverage limits no more restrictive than for any injury or sickness covered under the insurance policy or subscription contract; and
inpatient and outpatient dental, oral surgical, and orthodontic services that are medically necessary for the treatment of medically diagnosed cleft lip, cleft palate or ectodermal dysplasia. Such coverage is subject to any deductible, cost-sharing, and policy or contract maximum provisions, provided they are no more restrictive for such services than for any injury or sickness covered under the insurance policy or subscription contract.
Disabilities.- Any group or individual accident and sickness insurance policy or subscription contract delivered or issued for delivery in Virginia which provides that coverage of a dependent child terminates upon that child's attainment of a specified age must also provide in substance that attainment of the specified age will not terminate the child's coverage during the continuance of the policy while the dependent child is and continues to be both incapable of self-sustaining employment by reason of mental retardation or physical disability and chiefly dependent upon the policyowner for support and maintenance (Sec. 38.2-3409).
Adoption.- Each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, each corporation providing individual or group accident and sickness subscription contracts, and each health maintenance organization providing a health care plan for health care services that offers coverage for a family member of the insured, subscriber, or plan enrollee, must, as to the family members' coverage, also provide that the accident and sickness insurance benefits applicable for children are payable with respect to adopted children of the insured, subscriber, or plan enrollee. The coverage applicable to family members of the insured, subscriber or enrollee must apply in the same manner and to the same but no greater extent to adopted children (Sec. 38.2-3411.2).
Once coverage is in effect, it continues according to the terms of the policy, subscription contract, or plan, unless the placement is disrupted prior to final decree of adoption, and the child is removed from placement with the insured, subscriber or plan enrollee (Sec. 38.2-3411.2).
Child health supervision services.- Every group accident and sickness insurance policy, subscription contract providing coverage under a health services plan, or evidence of coverage of a health care plan delivered or issued for delivery in Virginia or renewed, reissued, or extended if already issued, must offer and make available coverage under such policy or plan for child health supervision services to provide for the periodic examination of children covered under such policy or plan (Sec. 38.2-3411.1, as amended by Ch. 118 (H. 574), L. 2000, effective July 1, 2000).
Each policy or plan offering and making available such coverage, must, at a minimum, provide benefits for child health supervision services at approximately the following age intervals: birth, two months, four months, six months, nine months, 12 months, 15 months, 18 months, two years, three years, four years, five years, and six years (Sec. 38.2-3411.1, as amended by Ch. 118 (H. 574), L. 2000, effective July 1, 2000).
Benefits for coverage for child health supervision services are exempt from any copayment, coinsurance, deductible, or other dollar limit provision in the policy or plan (Sec. 38.2-3411.1, as amended by Ch. 118 (H. 574), L. 2000, effective July 1, 2000).
Insurers and health services plans having fewer than 1,000 covered individuals insured or covered in Virginia or less than $500,000 in premiums in Virginia as of its last annual statement need not provide coverage for child health supervision services. Also, such coverage need not be provided by short-term travel or accident only policies, short-term nonrenewable policies of not more than six months' duration, nor by specified disease, hospital indemnity and other limited benefit policies issued to provide supplemental benefits to a policy providing primary care benefits (Sec. 38.2-3411.1, as amended by Ch. 118 (H. 574), L. 2000, effective July 1, 2000).
Early intervention services.- Group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis, individual or group accident and sickness subscription contracts, and health maintenance organizations providing a health care plan for health care services must provide coverage for medically necessary early intervention services in Virginia on and after July 1, 1998 (Sec. 38.2-3418.5(A), as added by H. 1413, L. 1998, effective July 1, 1998).
Early intervention services are medically necessary speech and language therapy, occupational therapy, physical therapy and assistive technology services and devices for dependents from birth to age three who are eligible under the federal Individuals with Disabilities Education Act. The services are designed to help a child attain or retain the capability to function age-appropriately within his or her environment-this includes services that enhance functional ability without effecting a cure (Sec. 38.2-3418.5(B), as added by H. 1413, L. 1998, effective July 1, 1998).
The coverage is limited to a benefit of $5,000 per insured or member per policy or calendar year and is subject to dollar limits, deductibles and coinsurance factors that are no less favorable than for physical illness generally (Sec. 38.2-3418.5(A), as added by H. 1413, L. 1998, effective July 1, 1998). In addition, the cost of early intervention services cannot be applied to any contractual provision limiting the total amount of coverage paid under the policy or plan during the insured's or member's lifetime (Sec. 38.2-3418.5(C), as added by H. 1413, L. 1998, effective July 1, 1998).
Early intervention services do not apply to short-term travel, accident only, limited or specified disease policies, policies or contracts designed for issuance to persons eligible for coverage under Medicare, or any other similar coverage under state or governmental plans or to short-term nonrenewable policies of not more than six months duration (Sec. 38.2-3418.5, as added by H. 1413, L. 1998, effective July 1, 1998).
Immunizations.- Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing group accident and sickness subscription contracts; and each HMO providing a health care plan for health care services must provide coverage for all routine and necessary immunizations for newborn children under such policy, contract or plan delivered, issued for delivery or renewed in the state on and after July 1, 2000. The required benefits apply to immunizations administered to each newborn child from birth to 36 months of age (Sec. 38.2-3411.3, as added by Ch. 460 (S. 221) and Ch. 496 (H. 914), L. 2000, effective July 1, 2000).
Infant hearing screening.- Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing group accident and sickness subscription contracts; and each HMO providing a health care plan for health care services must provide coverage for infant hearing screenings and all necessary audiological exams provided pursuant to Sec. 32.1-64.1 and as prescribed herein for newborn children under each such policy, contract or plan delivered, issued for delivery or renewed in Virginia on and after July 1, 2001 (Sec. 38.2-3411.4, as added by Ch. 663 (S. 1200), L. 2000).
Spouses and older children.- Coverage under most group accident and sickness insurance policies may be extended (if the insured group member so elects) to insure the spouse and any child who is (1) under the age of 19 years, (2) who is a dependent and under the age of 25 years, or (3) who is a dependent and a full-time student under 25 years of age, without regard to whether the child resides in the same household as the insured group member. The amount of accident and sickness insurance for the spouse or dependent child must not exceed the amount of accident and sickness insurance for the insured group member (Sec. 38.2-3525(A) and (B), as amended and reenacted by Ch. 209 (H. 196), L. 2008).
At the insurer's option, and subject to the policyholder's election, the coverage for children may be extended beyond the ages mentioned above. Any such extension of coverage shall be as mutually agreed upon by the insurer and the group policyholder (Sec. 38.2-3525(C), as amended and reenacted by Ch. 209 (H. 196), L. 2008). Generally, one certificate may be issued for each insured group member if a statement concerning any spouse's, dependent child's, or other person's coverage is included in the certificate (Sec. 38.2-3525(D), as amended and reenacted by Ch. 209 (H. 196), L. 2008).
When a policy provides coverage for a dependent child who is enrolled based upon the child's status as a full-time student and such child is unable due to a medical condition to continue as a full-time student, coverage under the policy for such child nevertheless shall continue in force provided the child's treating physician certifies to the insurer at the time the child withdraws as a full-time student that the child's absence is medically necessary. Coverage for such child shall continue in force until the earlier of (i) the date that is 12 months from the date the child ceases to be a full-time student or (ii) the date the child no longer qualifies as a dependent child under the terms of the group policy. A child's status as a full-time student shall be determined in accordance with the criteria specified by the institution in which the child is enrolled (Sec. 38.2-3525(E), as amended and reenacted by Ch. 209 (H. 196), L. 2008).
Substance abuse coverage.-Inpatient services.- Each group accident and sickness insurance policy or group subscription contract providing coverage on an expense-incurred basis for a family member of the insured or the subscriber must provide coverage for inpatient and partial hospitalization substance abuse services as follows (Sec. 38.2-3412.1, as amended by Ch. 638, L. 2006):
Treatment for an adult as an inpatient at a hospital, inpatient unit of a mental health treatment center, alcohol or drug rehabilitation facility or intermediate care facility for a minimum period of 20 days per policy or contract year.
Treatment for a child or adolescent as an inpatient at a hospital, inpatient unit of a mental health treatment center, alcohol or drug rehabilitation facility or intermediate care facility for a minimum period of 25 days per policy or contract year.
Up to 10 days of the inpatient benefit set forth in items (1) and (2) may be converted when medically necessary at the option of the person or the parent of a child or adolescent receiving such treatment to a partial hospitalization benefit applying a formula that is no less favorable than an exchange of 1.5 days of partial hospitalization coverage for each inpatient day of coverage.
Coverage need not be provided by short-term travel, accident only, limited or specified disease policies or contracts, nor by policies or contracts designed for issuance to persons eligible for Medicare coverage or any other similar coverage under state or federal governmental plans (Sec. 38.2-3412.1, as amended by Ch. 638, L. 2006).
Outpatient services.- Each group accident and sickness insurance policy or group subscription contract providing coverage on an expense-incurred basis for a family member of the insured or the subscriber must also provide coverage for outpatient substance abuse services as follows (Sec. 38.2-3412.1, as amended by Ch. 638, L. 2006):
A minimum of 20 visits for outpatient treatment of an adult, child or adolescent must be provided in each policy or contract year.
The limits of the benefits must be no more restrictive than the limits of benefits applicable to physical illness; however, the coinsurance factor applicable to any outpatient visit beyond the first five of such visits covered in any policy or contract year will be at least 50 percent.
Medication management visits must be covered in the same manner as a medication management visit for the treatment of physical illness and must not be counted as an outpatient treatment visit in the calculation of the benefit.
If all covered expenses for a visit for outpatient substance abuse treatment apply toward any deductible required by a policy or contract, such visit must not count toward the outpatient visit benefit maximum set forth in the policy or contract.
Coverage for the outpatient services described above need not be provided by short-term travel, accident only, limited or specified disease policies or contracts, nor by policies or contracts designed for issuance to persons eligible for Medicare or any other similar coverage under state or federal governmental plans (Sec. 38.2-3412.1, as amended by Ch. 638, L. 2006).
Coordination of benefits.- An employer or the insurer, managed care plan, or third-party administrator that manages a health benefit plan for an employer may share the payment of expenses with another benefit plan sponsored by another employer, with the government through Medicare benefits, or with another type of insurance company through automobile or homeowners' insurance (subrogation). To determine which plan has primary responsibility for payment, coordination of benefits (COB) language specifies the order of benefit payments. Preserving cost management initiatives, such as deductibles and coinsurance, is known as maintenance of benefits. The National Association of Insurance Commissioners (NAIC) has established model guidelines for COB which many states apply to insurance companies, HMOs, or other health care benefit providers. Self-insured employee benefit plans are not required to adopt coordination of benefits language; however, most self-insured health plans do specify how they will coordinate benefit payments with other plans.
Any group accident and sickness insurance policy delivered in another jurisdiction may contain any provision allowed or required by the laws of that jurisdiction (Sec. 38.2-3508). No insurance contract providing hospital, medical, surgical, or similar benefits, subscription contract, or health services plan may contain any provision providing for subrogation of any person's right to recovery from a third party for person injuries (Sec. 38.2-3405).
Providers.- If an accident and sickness insurance policy provides reimbursement for any service that may be legally performed by a person licensed in Virginia as a chiropractor, optometrist, optician, professional counselor, psychologist, clinical social worker, podiatrist, physical therapist, chiropodist, clinical nurse specialist who renders mental health services, audiologist, speech pathologist, certified nurse midwife, marriage and family therapist or licensed acupuncturist, reimbursement under the policy must not be denied because the service is rendered by the licensed practitioner. This does not apply to Medicaid or any state fund (Sec. 38.2-3408, as amended by Ch. 102 (H. 1922), L. 2000, effective July 1, 2001).
Dentists.- The word “physician” or “doctor,” when used in any accident or sickness insurance policy or subscription contract, must be construed to include a dentist performing covered services within the scope of his or her professional license (Sec. 38.2-3410).
Preexisting conditions.- A “preexisting conditions provision” means a policy provision that limits, denies, or excludes coverage for charges or expenses incurred during a 12-month period following the insured's effective date of coverage, for a condition that, during a 12-month period immediately preceding the effective date of coverage, had manifested itself in such a manner as would cause an ordinarily prudent person to seek diagnosis, care, or treatment, or for which medical advice, diagnosis, care or treatment was recommended or received within 12 months immediately preceding the effective date of coverage, or as to pregnancy existing on the effective date of coverage (Sec. 38.2-3514.1, as amended by Ch. 291 (H. 2747), L. 1996, effective July 1, 1997).
In determining whether a preexisting conditions provision applies to an insured, all coverage must credit the time the person was covered under previous policies if the previous coverage was continuous to a date not more than 30 days prior to the effective date of the new coverage, exclusive of any applicable waiting period under such coverage (Sec. 38.2-3514.1, as amended by Ch. 291 (H. 2747), L. 1996, effective July 1, 1997).
Small employers.- Group health insurance plans for small employers may, with respect to a participant or beneficiary, impose a preexisting limitation only if (Sec. 38.2-3432.3(A), as amended by Ch. 136 (H. 1014), L. 2000, effective July 1, 2000):
such exclusion relates to a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date;
such exclusion extends for a period of not more than 12 months (or 12 months in the case of a late enrollee) after the enrollment date; and
the period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage, if any, applicable to the participant or beneficiary as of the enrollment date.
A preexisting condition exclusion may not be imposed in the case of an individual who, as of the last day of the 30-day period beginning with the date of birth, is covered under creditable coverage. Additionally, a preexisting condition exclusion may not be imposed in the case of a child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning on the date of the adoption or placement, is covered under creditable coverage. The previous sentence does not apply to coverage before the date of such adoption or placement (Sec. 38.2-3432.3(B)(1) and (2), as amended by Ch. 136 (H. 1014), L. 2000, effective July 1, 2000).
Section 38.2-3432.3(B)(1) and (2) (above) no longer apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage (Sec. 38.2-3432.3(B)(4), as amended by Ch. 136 (H. 1014), L. 2000, effective July 1, 2000).
A preexisting condition exclusion relating to pregnancy as a preexisting condition may not be imposed (Sec. 38.2-3432.3(B)(3), as amended by Ch. 136, L. 2000, effective July 1, 2000).
A late enrollee may be excluded from coverage for up to 12 months or may have a preexisting condition limitation apply for up to 12 months. However, in no case may a late enrollee be excluded from some or all coverage for more than 12 months. An eligible employee or dependent cannot be considered a late enrollee if all of the conditions set forth below in items (1)-(4) are met or one of the conditions set forth below in items (5) or (6) is met (Sec. 38.2-3432.3(N), as amended by Ch. 136 (H. 1014), L. 2000, effective July 1, 2000):
The individual was covered under a public or private health benefit plan at the time he or she was eligible to enroll.
The individual certified at the time of initial enrollment that coverage under another health benefit plan was the reason for declining enrollment.
The individual has lost coverage under a public or private health benefit plan as a result of termination of employment or employment status eligibility, the termination of the other plan's entire group coverage, death of a spouse or divorce.
The individual requests enrollment within 30 days after termination of coverage provided under a public or private health benefit plan.
The individual is employed by a small employer that offers multiple health benefit plans and the individual elects a different plan offered by that small employer during an open enrollment period.
A court has ordered that coverage be provided for a spouse or minor child under a covered employee's health benefit plan, the minor is eligible for coverage and is a dependent, and the request for enrollment is made within 30 days after issuance of the court order.
However, the individual may be considered a late enrollee for benefit riders or enhanced coverage levels not covered under the enrollee's prior plan (Sec. 38.2-3432.3(N), as amended by Ch. 136 (H. 1014), L. 2000, effective July 1, 2000).
Breast cancer.- No (1) insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical, major medical or cancer-only coverage on an expense-incurred basis, and policies or contracts designed for issuance to persons eligible for coverage under Medicare, or any other similar coverage under state or federal governmental plans; (2) corporation providing group accident and sickness subscription contracts; or (3) HMO providing a health care plan for health care services may deny the issuance or renewal of, or cancel, a policy, subscription contract or plan or include any exception or exclusion of benefits in such policy, subscription contract or plan for the following (Sec. 38.2-3407.11:3(A), as added by Ch. 242 (H. 2063), L. 2000):
solely because the insured has been diagnosed as having a fibrocystic condition or a nonmalignant lesion, or solely due to the family history of the insured related to breast cancer, or solely due to any combination of these factors; or
solely due to breast cancer, if the insured has been free from breast cancer for a period of five years or more prior to the date of application for coverage. In the case of coverage subject to Secs. 38.2-3432.3 (see above), 38.2-3514.1 or Sec. 38.2-3605, the provisions of those sections will be controlling as to the extent of any preexisting conditions period under such coverage.
No (1) insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, and policies or contracts designed for issuance to persons eligible for coverage under Medicare, or any other similar coverage under state or federal governmental plans; (2) corporation providing group accident and sickness subscription contracts; or (3) HMO providing a health care plan for health care services may consider routine follow-up care, used to determine whether a breast cancer has recurred in a person who has been previously determined to be free of breast cancer as evidenced by negative follow-up care for a period of at least five years following completion of local and adjuvant therapies, to constitute medical advice, diagnosis, care or treatment for purposes of determining a preexisting condition unless evidence of breast cancer is found during, or as a result of, the follow-up care (Sec. 38.2-3407.11:3(B), as added by Ch. 242 (H. 2063), L. 2000).
Reconstructive surgery.- Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing group accident and sickness subscription contracts; and each HMO providing a health care plan for health care services must provide coverage for reconstructive breast surgery under such policy, contract or plan delivered, issued for delivery or renewed in Virginia. Written notice of the availability of this coverage must be provided to subscribers upon enrollment in the policy and annually thereafter. Such notice must be prominently positioned in any literature or correspondence provided to the subscribers (Sec. 38.2-3418.4, as amended by Ch. 250 (H. 1886), L. 2002, effective July 1, 2003).
Lymphedema.- Group insurers and HMOs must provide coverage for lymphedema, including benefits for equipment, supplies, complex decongestive therapy, and outpatient self-management training and education for the treatment of lymphedema (Sec. 38.2-3418.14, as added by Ch. 243 (H. 1737), L. 2002).
Pharmaceutical services-open choice.- No insurer proposing to issue preferred provider policies or contracts may prohibit any person receiving pharmacy benefits furnished thereunder from selecting, without limitation, the pharmacy of his or her choice to furnish such benefits. No such insurer may impose upon any person receiving pharmaceutical benefits furnished under any such policy or contract (Sec. 38.2-3407.7):
any copayment, fee or condition that is not equally imposed upon all individuals in the same benefit category, class or copayment level, whether or not such benefits are furnished by pharmacists who are nonpreferred providers;
any monetary penalty that would affect or influence any such person's choice of pharmacy; or
any reduction in allowable reimbursement for pharmacy services related to utilization of pharmacists who are nonpreferred providers.
Prescription drugs.- Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, each corporation providing group accident and sickness subscription contracts, and each health maintenance organization providing a health care plan for health care services, whose policy, contract or plan includes coverage for prescription drugs, whether on an inpatient basis, outpatient basis, or both, must provide that such benefits will not be denied for any drug approved by the United States Food and Drug Administration for use in the treatment of cancer on the basis that the drug has not been approved by the FDA for the treatment of the specific type of cancer for which the drug has been prescribed, provided the drug has been recognized as safe and effective for treatment of that specific type of cancer in any standard reference compendia. Coverage includes medically necessary services associated with the administration of the drug (Sec. 38.2-3407.5, as amended by Ch. 656 (S. 1164), L. 1996, effective July 1, 1997).
Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, each corporation providing group accident and sickness subscription contracts, and each health maintenance organization providing a health care plan for health care services, whose policy, contract or plan includes coverage for prescription drugs, whether on an inpatient basis, an outpatient basis, or both, must provide that such benefits will not be denied for any drug approved by the U.S. Food and Drug Administration for use in the treatment of cancer pain on the basis that the dosage is in excess of the recommended dosage of the pain-relieving agent, if the prescription in excess of the recommended dosage has been prescribed for a patient with intractable cancer pain (Sec. 38.2-3407.6:1, as added by S. 1300, L. 1998, effective July 1, 1999).
No (1) insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis; (2) corporation providing group accident and sickness subscription contracts; or (3) HMO providing a health care plan for health care services, whose policy, contract or plan, including any certificate or evidence of coverage issued in connection with such policy, contract or plan, includes coverage for prescription drugs may exclude coverage for any prescription drug solely on the basis of the length of time since the drug obtained FDA approval (Sec. 38.2-3407.9:02, as added by Ch. 508 (S. 284), L. 2000, effective July 1, 2000).
Off-label use.- Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, each corporation providing group accident and sickness subscription contracts, and each health maintenance organization providing a health care plan for health care services, whose policy, contract or plan includes coverage for prescription drugs, whether on an inpatient basis, outpatient basis, or both, must provide that such benefits will not be denied for any drug prescribed to treat a covered indication, so long as the drug has been approved by the FDA for at least one indication and is recognized for treatment of the covered indication in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature (Sec. 38.2-3407.5, as amended by Ch. 656 (S. 1164), L. 1996, effective July 1, 1997).
Formularies.- Each (1) insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, (2) corporation providing group accident and sickness subscription contracts, and (3) HMO providing a health care plan for health care services, whose policy, contract or plan, including any certificate or evidence of coverage issued in connection with such policy, contract or plan, includes coverage for prescription drug benefits provided by the insurer, corporation, or HMO if the formulary is developed, reviewed at least annually, and updated as necessary in consultation with and with the approval of a pharmacy and therapeutics committee, a majority of whose members are actively practicing licensed pharmacists, physicians and other licensed health care providers (Sec. 38.2-3407.9:01, as added by Ch. 873 (H. 1111), L. 2000, effective July 1, 2000).
If an insurer, corporation or HMO maintains one or more closed drug formularies, it must (Sec. 38.2-3407.9:01, as added by Ch. 873 (H. 1111), L. 2000, effective July 1, 2000):
make available to participating providers and pharmacists and to any nonpreferred or nonparticipating pharmacists, the complete, current drug formulary or formularies, or any updates thereto, maintained by the insurer, corporation, or HMO;
establish a process to allow an enrollee to obtain, without additional cost-sharing beyond that provided for formulary prescription drugs in the enrollee's covered benefits, a specific, medically necessary nonformulary prescription drug if the formulary drug is determined by the insurer, corporation or HMO, after reasonable investigation and consultation with the prescribing physician, to be an inappropriate therapy for the medical condition of the enrollee;
establish a process to allow an enrollee to obtain, without additional cost-sharing beyond that provided for formulary prescription drugs in the enrollee's covered benefits, a specific, medically necessary nonformulary prescription drug when the enrollee has been receiving the specific nonformulary prescription drug for at least six months previous to the development or revision of the formulary and the prescribing physician has determined that the formulary drug is an inappropriate therapy for the specific patient or that changing drug therapy presents a significant health risk to the specific patient.
Mammograms.- Each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, each corporation providing individual or group accident and sickness subscription contracts and each health maintenance organization providing a health care plan for health care services must provide coverage for low-dose screening mammograms for determining the presence of occult breast cancer. Such coverage must make available one screening mammogram to persons age 35 through 39, one such mammogram biennially to persons age 40 through 49, one such mammogram annually to persons age 50 and over, and may be limited to a benefit of $50 per mammogram subject to such dollar limits, deductibles and coinsurance factors as are no less favorable than for physical illness generally (Sec. 38.2-3418.1, as amended by Ch. 610, L. 1996, effective July 1, 1996).
In order to be considered a screening mammogram for which coverage must be made available under this section (Sec. 38.2-3418.1, as amended by Ch. 610, L. 1996, effective July 1, 1996):
The mammogram must be ordered by a health care practitioner acting within the scope of his or her licensure and, in the case of an enrollee of a health maintenance organization, by the health maintenance organization physician; performed by a registered technologist; interpreted by a qualified radiologist; performed under the direction of a person licensed to practice medicine and surgery and certified by the American Board of Radiology or an equivalent examining body; and a copy of the mammogram report must be sent or delivered to the health care practitioner who ordered it;
The equipment used to perform the mammogram must meet the standards set forth by the Virginia Department of Health in its radiation protection regulations; and
The mammography film must be retained by the radiologic facility performing the examination in accordance with the American College of Radiology guidelines or state law.
Exceptions.- Coverage for screening mammography need not be provided by short-term travel, accident only, limited or specified disease policies, nor by short-term nonrenewable policies of not more than six months' duration (Sec. 38.2-3418.1, as amended by Ch. 610, L. 1996, effective July 1, 1996).
Contraceptives.- Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, each corporation providing group accident and sickness insurance contracts, and each HMO providing a health care plan for health care services, whose policy, contract, or plan includes coverage for prescription drugs on an outpatient basis, must offer and make available coverage for any FDA-approved prescribed drug or device for use as a contraceptive (Sec. 38.2-3407.5:1(A), as added by Ch. 748 (H. 1233), L. 1996, effective July 1, 1997).
Maternity benefits.- Each insurer proposing to issue a group hospital policy or a group major medical policy in Virginia and each corporation proposing to issue group hospital, group medical or group major medical subscription contracts must provide coverage for obstetrical services as an option available to the group policyholder or the contract holder in the case of benefits based upon treatment as an inpatient in a general hospital. The reimbursement for obstetrical services by a physician must be based on the charges for the services determined according to the same formula by which the charges are developed for other medical and surgical procedures. Such coverage must have durational limits, dollar limits, deductibles and coinsurance factors that are no less favorable than for physical illness generally (Sec. 38.2-3414).
Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, each corporation providing group accident and sickness subscription contracts, and each HMO providing a health care plan for health care services, whose policies, contracts, or plans include coverage for obstetrical services as an inpatient in a general hospital or obstetrical services by a physician must provide such benefits with durational limits, deductibles, coinsurance factors and copayments that are no less favorable than for physical illness generally (Sec. 38.2-3407.16, as added by H. 2385, L. 1998, effective March 29, 1999).
Postpartum services.- Insurers, including HMOs, that provide benefits for obstetrical services must provide coverage for postpartum services that include benefits for inpatient care and a home visit or visits in accordance with specified medical criteria (Sec. 38.2-3414.1, as added by Ch. 194, L. 1996, effective July 1, 1996).
Domestic violence victims.- No person may unfairly discriminate or permit any unfair discrimination between individuals of the same class and of essentially the same hazard (1) in the amount of premium, policy fees, or rates charged for any policy or contract of accident or health insurance; (2) in the benefits payable under such policy or contract; (3) in any of the terms or conditions of such policy or contract; or (4) in any other manner (Sec. 38.2-508, as amended by Ch. 34 (H. 1661), L. 2000).
Additionally, no person may consider the status of a victim of domestic violence as a criterion in any decision with regard to insurance underwriting, pricing, renewal, scope of coverage, or payment of claims (Sec. 38.2-508, as amended by Ch. 34 (H. 1661), L. 2000).
Morbid obesity.- Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing group accident and sickness subscription contracts; and each HMO providing a health care plan for health care services must offer and make available coverage for the treatment of morbid obesity through gastric bypass surgery or such other methods as may be recognized by the National Institutes of Health as effective for the long-term reversal of morbid obesity. Standards and criteria, including those related to diet, used by insurers to approve or restrict access to surgery for morbid obesity shall be based upon current clinical guidelines recognized by the National Institutes of Health (Sec. 38.2-3418.13, as amended by Ch. 462 (S. 1081), L. 2002, effective July 1, 2003).
Hemophilia.- Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, each corporation providing group accident and sickness subscription contracts and each HMO providing a health care plan for health care services must provide coverage for hemophilia and congenital bleeding disorders under such policy, contract or plan delivered, issued for delivery or renewed in Virginia on and after July 1, 1998 (Sec. 38.2-3418.3, as added by Ch. 43 (S. 251) and Ch. 89 (H. 673), L. 1998, effective July 1, 1998).
Diabetes.- Each insurer proposing to issue a group hospital or major medical policy in Virginia, each corporation proposing to issue a group hospital, medical or major medical subscription contract, and each HMO providing a health care plan for health care services must provide coverage for diabetes as described below (Sec. 38.2-3418.10, as amended by Ch. 1060 (H. 1376), L. 2000, effective July 1, 2000).
Such coverage must include benefits for equipment, supplies and in-person outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin using diabetes if prescribed by a health care professional legally authorized to prescribe such items under law. “Equipment” and “supplies” must not be considered durable medical equipment (Sec. 38.2-3418.10, as amended by Ch. 1060 (H. 1376), L. 2000, effective July 1, 2000).
Cervical cancer screenings.- Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, each corporation providing group accident and sickness subscription contracts and each HMO providing a health care plan for health care services must provide coverage for annual Pap smears, including coverage, on and after July 1, 1999, for annual testing performed by any FDA-approved gynelogic cytology screening technologies (Sec. 38.2-3418.1:2, as amended by H. 2354, L. 1998).
Exceptions.- Coverage for annual Pap smears need not be provided by short-term travel, accident only, limited or specified disease policies, or by short-term nonrenewable policies of not more than six months' duration (Sec. 38.2-3418.1:2, as amended by H. 2354, L. 1998).
Prostate cancer screenings.- Individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis, individual or group accident and sickness subscription contracts, and health maintenance organizations providing a health care plan for health care services must provide coverage to persons age 50 and over and to persons age 40 and over who are at high risk for prostate cancer, according to the most recent published guidelines of the American Cancer Society. The coverage is for one PSA test (blood sample analysis to determine the level of prostate specific antigen) in a 12-month period and digital rectal examinations, all in accordance with American Cancer Society guidelines under any such policy, contract or plan in Virginia on and after July 1, 1998 (Sec. 38.2-3418.7, as added by H. 915, L. 1998, effective July 1, 1998).
The prostate cancer screening requirement does not apply to short-term travel, accident only, limited or specified disease policies other than cancer policies, short-term nonrenewable policies of not more than six months' duration, or policies or contracts designed for persons eligible for Medicare (Sec. 38.2-3418.7, as added by H. 915, L. 1998, effective July 1, 1998).
Cancer pain management.- Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, each corporation providing group accident and sickness subscription contracts, and each HMO providing a health care plan for health care services must have a procedure in place to permit any covered individual who has been diagnosed with cancer to have a standing referral to a board-certified physician in pain management or oncologist who is authorized to provided services under such policy, contract or plan and has been selected by the cancer patient (Sec. 38.2-3407.11:2, as added by S. 1299, L. 1998, effective July 1, 1999).
Hospice care.- Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis, each corporation providing group accident and sickness subscription contracts, and each HMO providing a health care plan for health care services must provide coverage for hospice services under such policy, contract or plan delivered, issued for delivery or renewed in Virginia on and after July 1, 1999 (Sec. 38.2-3418.11, as added by H. 699, L. 1998).
Bone and joint disorders.- Each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, each corporation providing individual or group accident and sickness subscription contracts, and each health maintenance organization providing a health care plan for health care services that provides coverage for diagnostic and surgical treatment involving any bone or joint of the skeletal structure may not, under such policy, contract or plan delivered, issued for delivery or renewed in Virginia on and after July 1, 1995, exclude coverage for such diagnostic and surgical treatment involving any bone or joint of the head, neck, face or jaw or impose limits that are more restrictive than limits on coverage applicable to such treatment involving any bone or joint of the skeletal structure if the treatment is required because of a medical condition or injury that prevents normal function of the joint or bone and is deemed medically necessary to attain functional capacity of the affected part (Sec. 38.2-3418.2).
Exceptions.- Such coverage need not be provided by short-term travel, accident-only, limited or specified disease policies, nor to short-term nonrenewable policies of not more than six months' duration (Sec. 38.2-3418.2).
Prosthetics.- For policies, contracts and plans delivered, issued for delivery, reissued or extended in the state on and after January 1, 2010, each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing group accident and sickness subscription contracts; and each HMO providing a health care plan for health care services must provide coverage for medically necessary prosthetic devices, as well as their repair, fitting, replacement and components. An insurer may not impose any annual or lifetime dollar maximums on prosthetics coverage, other than those that apply in aggregate to all items covered under the policy. In addition, insurers, corporations and HMOs may not impose coinsurance in excess of 30 percent of the carrier's allowable charge for prosthetic devices or services when furnished by an in-network provider. Preauthorization may be required to determine medical necessity (Sec. 38.2-3418.15 as added by S. 1116, L. 2008, enacted April 8, 2009).
Dental care.- Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing group accident and sickness subscription contracts; and each HMO providing a health care plan for health care services must provide coverage for medically necessary general anesthesia and hospitalization or facility charges of a facility licensed to provide outpatient surgical procedures for dental care provided to a covered person who is determined by a licensed dentist in consultation with the covered person's treating physician to require general anesthesia and admission to a hospital or outpatient surgery facility to effectively and safely provide dental care and (1) is under the age of five; or (2) is severely disabled; or (3) has a medical condition and requires admission to a hospital or outpatient surgery facility and general anesthesia for dental care treatment (Sec. 38.2-3418.12, as added by Ch. 157 (H. 165), L. 2000).
Exceptions.- Such coverage need not be provided by short-term travel, accident-only, limited or specified disease policies, nor to policies or contracts designed for issuance to persons eligible for coverage under Medicare, or any other similar coverage under state or federal governmental plans (Sec. 38.2-3418.12, as added by Ch. 157 (H. 165), L. 2000).
Ambulance services.- No insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis, corporation providing group accident and sickness subscription contracts, or HMO providing a health care plan for health care services may (Sec. 38.2-3407.9, as amended by Ch. 630 (H. 660), L. 2000, effective July 1, 2000):
establish or promote an emergency medical response and transportation system that encourages or directs access by a person covered under such policy, contract or plan in competition with or in substitution of an emergency 911 system or other state, county or municipal emergency medical system for ambulance services.
require a covered person to obtain prior authorization before accessing an emergency 911 system or other state, county or municipal emergency medical system for ambulance services.
Small employers.- Special small employer health benefit plans are available to employers who employed an average of at least two but not more than 50 employees on business days during the preceding calendar year and who employ at least two employees on the first day of the plan year (Sec. 38.2-3431, as amended by Ch. 26 (H. 854), L. 1998, effective July 1, 1998).
See small employer preexisting condition provisions, above, for more information.
Emergency care.- HMOs must have a system to provide their members, on a 24-hour basis, access to medical care or access by telephone to a physician or licensed health care professional with appropriate medical training who can refer or direct a member for prompt medical care in cases where there is an immediate, urgent need or medical emergency (Sec. 38.2-4312.3, as added by Ch. 139 (H. 2062), L. 1996, effective July 1, 1997).
NOTICE
Local governments.- If a local employee develops a life-threatening health condition, the local employer shall provide such employee written notification of all relevant benefit options and programs available to him or her, within 10 days of the date that the employer was given notice of the serious health condition by the employee or his or her agent, unless such information is otherwise provided annually by the local employer. The employer shall provide appropriate forms to the employee so that the employee can communicate any election of benefit options to the employer in writing on the forms (Title 15.2, Subtitle II, Ch. 15, Art. 1, Sec. 15.2-1511.1, as added by Ch. 333 (H. 2764), L. 2006, enacted March 13, 2007).
<p>Local governments.— If a local employee develops a life-threatening health condition, the local employer shall provide such employee written notification of all</p>
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