                                 CODE OF VIRGINIA

DEFINITIONS (§ 38.2-3438)

As used this article, unless the context requires a different
meaning:		&#8220;Allowed amount&#8221; means the maximum portion of a billed
charge a health carrier will pay, including any applicable cost-sharing
requirements, for a covered service or item rendered by a participating provider
or by a nonparticipating provider.		&#8220;Balance bill&#8221; means a bill sent
to an enrollee by an out-of-network provider for health care services provided
to the enrollee after the provider&#8217;s billed amount is not fully reimbursed
by the carrier, exclusive of applicable cost-sharing
requirements.		&#8220;Behavioral health crisis service provider&#8221; means a
provider licensed by the Department of Behavioral Health and Developmental
Services to provide mental health or substance abuse services as a provider of
mobile crisis response, residential crisis stabilization, or a crisis receiving
center.		&#8220;Child&#8221; means a son, daughter, stepchild, adopted child,
including a child placed for adoption, foster child, or any other child eligible
for coverage under the health benefit plan.		&#8220;Cost-sharing
requirement&#8221; means an enrollee&#8217;s deductible, copayment amount, or
coinsurance rate.		&#8220;Covered benefits&#8221; or &#8220;benefits&#8221;
means those health care services to which an individual is entitled under the
terms of a health benefit plan.		&#8220;Covered person&#8221; means a
policyholder, subscriber, enrollee, participant, or other individual covered by
a health benefit plan.		&#8220;Dependent&#8221; means the spouse or child of an
eligible employee, subject to the applicable terms of the policy, contract, or
plan covering the eligible employee.		&#8220;Emergency medical condition&#8221;
means, regardless of the final diagnosis rendered to a covered person, a medical
condition manifesting itself by acute symptoms of sufficient severity, including
severe pain, so that a prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of immediate medical
attention to result in (i) serious jeopardy to the mental or physical health of
the individual, (ii) danger of serious impairment to bodily functions, (iii)
serious dysfunction of any bodily organ or part, or (iv) in the case of a
pregnant woman, serious jeopardy to the health of the fetus.		&#8220;Emergency
services&#8221; means with respect to an emergency medical condition (i) (a) a
medical screening examination as required under § 1867 of the Social Security
Act (42 U.S.C. § 1395dd) that is within the capability of the emergency
department of a hospital, including ancillary services routinely available to
the emergency department to evaluate such emergency medical condition, and (b)
such further medical examination and treatment, to the extent they are within
the capabilities of the staff and facilities available at the hospital, as are
required under § 1867 of the Social Security Act (42 U.S.C. § 1395dd (e)(3))
to stabilize the patient and (ii) as it relates to any mental health services or
substance abuse services, as those terms are defined in § 38.2-3412.1, rendered
at a behavioral health crisis service provider (a) a behavioral health
assessment that is within the capability of a behavioral health crisis service
provider, including ancillary services routinely available to evaluate such
emergency medical condition, and (b) such further examination and treatment, to
the extent that they are within the capabilities of the staff and facilities
available at the behavioral health crisis service provider, as are required so
that the patient&#8217;s condition does not deteriorate.		&#8220;ERISA&#8221;
means the Employee Retirement Income Security Act of 1974.		&#8220;Essential
health benefits&#8221; include the following general categories and the items
and services covered within the categories in accordance with regulations issued
pursuant to the PPACA as of January 1, 2019: (i) ambulatory patient services;
(ii) emergency services; (iii) hospitalization; (iv) laboratory services; (v)
maternity and newborn care; (vi) mental health and substance abuse disorder
services, including behavioral health treatment; (vii) pediatric services,
including oral and vision care; (viii) prescription drugs; (ix) preventive and
wellness services and chronic disease management; and (x) rehabilitative and
habilitative services and devices.		&#8220;Facility&#8221; means an institution
providing health care related services or a health care setting, including
hospitals and other licensed inpatient centers; ambulatory surgical or treatment
centers; skilled nursing centers; residential treatment centers; diagnostic,
laboratory, and imaging centers; and rehabilitation and other therapeutic health
settings.		&#8220;Genetic information&#8221; means, with respect to an
individual, information about: (i) the individual&#8217;s genetic tests; (ii)
the genetic tests of the individual&#8217;s family members; (iii) the
manifestation of a disease or disorder in family members of the individual; or
(iv) any request for, or receipt of, genetic services, or participation in
clinical research that includes genetic services, by the individual or any
family member of the individual. &#8220;Genetic information&#8221; does not
include information about the sex or age of any individual. As used in this
definition, &#8220;family member&#8221; includes a first-degree, second-degree,
third-degree, or fourth-degree relative of a covered person.		&#8220;Genetic
services&#8221; means (i) a genetic test; (ii) genetic counseling, including
obtaining, interpreting, or assessing genetic information; or (iii) genetic
education.		&#8220;Genetic test&#8221; means an analysis of human DNA, RNA,
chromosomes, proteins, or metabolites, if the analysis detects genotypes,
mutations, or chromosomal changes. &#8220;Genetic test&#8221; does not include
an analysis of proteins or metabolites that is directly related to a manifested
disease, disorder, or pathological condition.		&#8220;Grandfathered plan&#8221;
means coverage provided by a health carrier to (i) a small employer on March 23,
2010, or (ii) an individual that was enrolled on March 23, 2010, including any
extension of coverage to an individual who becomes a dependent of a
grandfathered enrollee after March 23, 2010, for as long as such plan maintains
that status in accordance with federal law.		&#8220;Group health insurance
coverage&#8221; means health insurance coverage offered in connection with a
group health benefit plan.		&#8220;Group health plan&#8221; means an employee
welfare benefit plan as defined in § 3(1) of ERISA to the extent that the plan
provides medical care within the meaning of § 733(a) of ERISA to employees,
including both current and former employees, or their dependents as defined
under the terms of the plan directly or through insurance, reimbursement, or
otherwise.		&#8220;Health benefit plan&#8221; means a policy, contract,
certificate, or agreement offered by a health carrier to provide, deliver,
arrange for, pay for, or reimburse any of the costs of health care services.
&#8220;Health benefit plan&#8221; includes short-term and catastrophic health
insurance policies, and a policy that pays on a cost-incurred basis, except as
otherwise specifically exempted in this definition. &#8220;Health benefit
plan&#8221; does not include the &#8220;excepted benefits&#8221; as defined in
§ 38.2-3431.		&#8220;Health care professional&#8221; means a physician or other
health care practitioner licensed, accredited, or certified to perform specified
health care services consistent with state law.		&#8220;Health care
provider&#8221; or &#8220;provider&#8221; means a health care professional or
facility.		&#8220;Health care services&#8221; means services for the diagnosis,
prevention, treatment, cure, or relief of a health condition, illness, injury,
or disease.		&#8220;Health carrier&#8221; means an entity subject to the
insurance laws and regulations of the Commonwealth and subject to the
jurisdiction of the Commission that contracts or offers to contract to provide,
deliver, arrange for, pay for, or reimburse any of the costs of health care
services, including an insurer licensed to sell accident and sickness insurance,
a health maintenance organization, a health services plan, or any other entity
providing a plan of health insurance, health benefits, or health care
services.		&#8220;Health maintenance organization&#8221; means a person licensed
pursuant to Chapter 43 (§ 38.2-4300 et seq.).		&#8220;Health status-related
factor&#8221; means any of the following factors: health status; medical
condition, including physical and mental illnesses; claims experience; receipt
of health care services; medical history; genetic information; evidence of
insurability, including conditions arising out of acts of domestic violence;
disability; or any other health status-related factor as determined by federal
regulation.		&#8220;Individual health insurance coverage&#8221; means health
insurance coverage offered to individuals in the individual market, which
includes a health benefit plan provided to individuals through a trust
arrangement, association, or other discretionary group that is not an employer
plan, but does not include coverage defined as &#8220;excepted benefits&#8221;
in § 38.2-3431 or short-term limited duration insurance. Student health
insurance coverage shall be considered a type of individual health insurance
coverage.		&#8220;Individual market&#8221; means the market for health insurance
coverage offered to individuals other than in connection with a group health
plan.		&#8220;In-network&#8221; or &#8220;participating&#8221; means a provider
that has contracted with a carrier or a carrier&#8217;s contractor or
subcontractor to provide health care services to enrollees and be reimbursed by
the carrier at a contracted rate as payment in full for the health care
services, including applicable cost-sharing requirements.		&#8220;Managed care
plan&#8221; means a health benefit plan that either requires a covered person to
use, or creates incentives, including financial incentives, for a covered person
to use health care providers managed, owned, under contract with, or employed by
the health carrier.		&#8220;Network&#8221; means the group of participating
providers providing services to a managed care plan.		&#8220;Nonprofit data
services organization&#8221; means the nonprofit organization with which the
Commissioner of Health negotiates and enters into contracts or agreements for
the compilation, storage, analysis, and evaluation of data submitted by data
suppliers pursuant to § 32.1-276.4.		&#8220;Offer to pay&#8221; or
&#8220;payment notification&#8221; means a claim that has been adjudicated and
paid by a carrier or determined by a carrier to be payable by an enrollee to an
out-of-network provider for services described in subsection A of §
38.2-3445.01.		&#8220;Open enrollment&#8221; means, with respect to individual
health insurance coverage, the period of time during which any individual has
the opportunity to apply for coverage under a health benefit plan offered by a
health carrier and must be accepted for coverage under the plan without regard
to a preexisting condition exclusion.		&#8220;Out-of-network&#8221; or
&#8220;nonparticipating&#8221; means a provider that has not contracted with a
carrier or a carrier&#8217;s contractor or subcontractor to provide health care
services to enrollees.		&#8220;Out-of-pocket maximum&#8221; or &#8220;maximum
out-of-pocket&#8221; means the maximum amount an enrollee is required to pay in
the form of cost-sharing requirements for covered benefits in a plan year, after
which the carrier covers the entirety of the allowed amount of covered benefits
under the contract of coverage.		&#8220;Participating health care
professional&#8221; means a health care professional who, under contract with
the health carrier or with its contractor or subcontractor, has agreed to
provide health care services to covered persons with an expectation of receiving
payments, other than coinsurance, copayments, or deductibles, directly or
indirectly from the health carrier.		&#8220;PPACA&#8221; means the Patient
Protection and Affordable Care Act (P.L. 111-148), as amended by the Health Care
and Education Reconciliation Act of 2010 (P.L. 111-152), and as it may be
further amended.		&#8220;Preexisting condition exclusion&#8221; means a
limitation or exclusion of benefits, including a denial of coverage, based on
the fact that the condition was present before the effective date of coverage,
or if the coverage is denied, the date of denial, whether or not any medical
advice, diagnosis, care, or treatment was recommended or received before the
effective date of coverage. &#8220;Preexisting condition exclusion&#8221; also
includes a condition identified as a result of a pre-enrollment questionnaire or
physical examination given to an individual, or review of medical records
relating to the pre-enrollment period.		&#8220;Premium&#8221; means all moneys
paid by an employer, eligible employee, or covered person as a condition of
coverage from a health carrier, including fees and other contributions
associated with the health benefit plan.		&#8220;Preventive services&#8221;
means (i) evidence-based items or services for which a rating of A or B is in
effect in the recommendations of the U.S. Preventive Services Task Force with
respect to the individual involved; (ii) immunizations for routine use in
children, adolescents, and adults for which a recommendation of the Advisory
Committee on Immunization Practices of the Centers for Disease Control and
Prevention is in effect with respect to the individual involved; (iii)
evidence-informed preventive care and screenings provided for in comprehensive
guidelines supported by the Health Resources and Services Administration with
respect to infants, children, and adolescents; and (iv) evidence-informed
preventive care and screenings recommended in comprehensive guidelines supported
by the Health Resources and Services Administration with respect to women. For
purposes of this definition, a recommendation of the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention is
considered in effect after it has been adopted by the Director of the Centers
for Disease Control and Prevention, and a recommendation is considered to be for
routine use if it is listed on the Immunization Schedules of the Centers for
Disease Control and Prevention.		&#8220;Primary care health care
professional&#8221; means a health care professional designated by a covered
person to supervise, coordinate, or provide initial care or continuing care to
the covered person and who may be required by the health carrier to initiate a
referral for specialty care and maintain supervision of health care services
rendered to the covered person.		&#8220;Rescission&#8221; means a cancellation
or discontinuance of coverage under a health benefit plan that has a retroactive
effect. &#8220;Rescission&#8221; does not include:

1. A cancellation or discontinuance of coverage under a health benefit plan if
the cancellation or discontinuance of coverage has only a prospective effect, or
the cancellation or discontinuance of coverage is effective retroactively to the
extent it is attributable to a failure to timely pay required premiums or
contributions towards the cost of coverage; or

2. A cancellation or discontinuance of coverage when the health benefit plan
covers active employees and, if applicable, dependents and those covered under
continuation coverage provisions, if the employee pays no premiums for coverage
after termination of employment and the cancellation or discontinuance of
coverage is effective retroactively back to the date of termination of
employment due to a delay in administrative recordkeeping.
			&#8220;Stabilize&#8221; means with respect to an emergency medical condition,
to provide such medical treatment as may be necessary to assure, within
reasonable medical probability, that no material deterioration of the condition
is likely to result from or occur during the transfer of the individual from a
facility, or, with respect to a pregnant woman, that the woman has delivered,
including the placenta.			&#8220;Student health insurance coverage&#8221; means
a type of individual health insurance coverage that is provided pursuant to a
written agreement between an institution of higher education, as defined by the
Higher Education Act of 1965, and a health carrier and provided to students
enrolled in that institution of higher education and their dependents, and that
does not make health insurance coverage available other than in connection with
enrollment as a student, or as a dependent of a student, in the institution of
higher education, and does not condition eligibility for health insurance
coverage on any health status-related factor related to a student or a dependent
of the student.			&#8220;Surgical or ancillary services&#8221; means
professional services, including surgery, anesthesiology, pathology, radiology,
or hospitalist services and laboratory services.			&#8220;Wellness
program&#8221; means a program offered by an employer that is designed to
promote health or prevent disease.

HISTORY: 2011, c. 882; 2013, c. 751; 2014, c. 814; 2020, cc. 1080, 1081, 1160;
2024, cc. 199, 360.