38.2-4306 - Evidence of coverage and charges for health care services.
§ 38.2-4306. Evidence of coverage and charges for health care services.
A. 1. Each subscriber shall be entitled to evidence of coverage under ahealth care plan.
2. No evidence of coverage, or amendment to it, shall be delivered or issuedfor delivery in this Commonwealth until a copy of the form of the evidence ofcoverage, or amendment to it, has been filed with and approved by theCommission, subject to the provisions of subsection C of this section. Anyevidence of coverage for enrollees in the plans administered by theDepartment of Medical Assistance Services that provide benefits pursuant toTitle XIX or Title XXI of the Social Security Act, as amended, is excludedfrom the provisions of this section.
3. No evidence of coverage shall contain provisions or statements which areunjust, unfair, untrue, inequitable, misleading, deceptive ormisrepresentative.
4. An evidence of coverage shall contain a clear and complete statement if acontract, or a reasonably complete summary if a certificate, of:
a. The health care services and any insurance or other benefits to which theenrollee is entitled under the health care plan;
b. Any limitations on the services, kind of services, benefits, or kind ofbenefits to be provided, including any deductible or copayment feature, orboth;
c. Where and in what manner information is available as to how services maybe obtained;
d. The total amount of payment for health care services and any indemnity orservice benefits that the enrollee is obligated to pay with respect toindividual contracts, or an indication whether the plan is contributory ornoncontributory for group certificates;
e. A description of the health maintenance organization's method forresolving enrollee complaints. Any subsequent change may be evidenced in aseparate document issued to the enrollee;
f. A list of providers and a description of the service area which shall beprovided with the evidence of coverage, if such information is not given tothe subscriber at the time of enrollment; and
g. Any right of subscribers covered under a group contract to convert theircoverages to an individual contract issued by the health maintenanceorganization.
B. Pursuant to this subsection:
1. No schedule of charges or amendment to the schedule of charges forenrollee coverage for health care services may be used in conjunction withany health care plan until a copy of the schedule, or its amendment, has beenfiled with the Commission. Any schedule of charges or amendment to theschedule of charges for enrollees in the plans administered by the Departmentof Medical Assistance Services that provide benefits pursuant to Title XIX orTitle XXI of the Social Security Act, as amended, is excluded from theprovisions of this subsection.
2. The charges may be established for various categories of enrollees basedupon sound actuarial principles, provided that charges applying to anenrollee in a group health plan shall not be individually determined based onthe status of his health. A certification on the appropriateness of thecharges, based upon reasonable assumptions, may be required by the Commissionto be filed along with adequate supporting information. This certificationshall be prepared by a qualified actuary or other qualified professionalapproved by the Commission.
C. The Commission shall, within a reasonable period, approve any form if therequirements of subsection A of this section are met. It shall be unlawful toissue a form until approved. If the Commission disapproves a filing, it shallnotify the filer. The Commission shall specify the reasons for itsdisapproval in the notice. A written request for a hearing on the disapprovalmay 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 filingof such form, it shall be deemed approved unless the filer is notified inwriting that the waiting period is extended by the Commission for anadditional 30 days. Filing of the form means actual receipt by the Commission.
D. The Commission may require the submission of any relevant information itconsiders necessary in determining whether to approve or disapprove a filingmade under this section.
(1980, c. 720, § 38.1-869; 1986, c. 562; 1997, cc. 807, 913; 2003, cc. 752,767; 2004, c. 185; 2006, c. 866.)