§ 38.2-3406.1. Application of requirements that policies offered by smallemployers include state-mandated health benefits.
A. As used in this section:
"Eligible individual" means an individual who is employed by a smallemployer and has satisfied applicable waiting period requirements.
"Health insurance coverage" means benefits consisting of coverage for costsof medical care, whether directly, through insurance or reimbursement, orotherwise, and including items and services paid for as medical care under agroup policy of accident and sickness insurance, hospital or medical servicepolicy or certificate, hospital or medical service plan contract, or healthmaintenance organization contract, which coverage is subject to this title oris provided under a plan regulated under the Employee Retirement IncomeSecurity Act of 1974.
"Health insurer" means any insurance company that issues accident andsickness insurance policies providing hospital, medical and surgical, ormajor medical coverage on an expense-incurred basis, a corporation thatprovides accident and sickness subscription contracts, or any healthmaintenance organization that provides a health care plan that provides,arranges for, pays for, or reimburses any part of the cost of any health careservices, that is licensed to engage in such business in the Commonwealth,and that is subject to the laws of the Commonwealth that regulate insurancewithin the meaning of § 514(b)(2) of the Employee Retirement Income SecurityAct of 1974 (29 U.S.C. § 1144(b)(2)).
"Small employer" means, with respect to a calendar year and a plan year, anemployer located in the Commonwealth that employed at least two but not morethan 50 eligible individuals on business days during the preceding calendaryear and who employs at least two eligible individuals on the date a policyunder this section becomes effective.
"State-mandated health benefit" means coverage required under this title orother laws of the Commonwealth to be provided in a policy of accident andsickness insurance or a contract for a health-related condition that (i)includes coverage for specific health care services or benefits; (ii) placeslimitations or restrictions on deductibles, coinsurance, copayments, or anyannual or lifetime maximum benefit amounts; or (iii) includes a specificcategory of licensed health care practitioners from whom an insured isentitled to receive care. "State-mandated health benefit" includes, withoutlimitation, any coverage, or the offering of coverage, of a benefit orprovider pursuant to §§ 38.2-3407.5 through 38.2-3407.6:1, 38.2-3407.9:01,38.2-3407.9:02, 38.2-3407.11 through 38.2-3407.11:3, 38.2-3407.16, 38.2-3408,38.2-3411 through 38.2-3414.1, 38.2-3418 through 38.2-3418.14, or §38.2-4221. For purposes of this article, "state-mandated health benefit"does not include a benefit that is mandated by federal law.
B. Notwithstanding any statute, rule, or regulation to the contrary, and forthe purposes of this section, a group accident and sickness insurance policyproviding hospital, medical and surgical, or major medical coverage on anexpense-incurred basis; a group accident and sickness subscription contractproviding health insurance coverage for eligible individuals; and a healthcare plan that provides, arranges for, pays for, or reimburses any part ofthe cost of any health care services that is offered, sold, or issued by ahealth insurer to a small employer:
1. Shall not be required to include coverage, or the offer of coverage, forany state-mandated health benefit, except for:
a. Coverage for mammograms pursuant to § 38.2-3418.1;
b. Coverage for pap smears pursuant to § 38.2-3418.1:2;
c. Coverage for PSA testing pursuant to § 38.2-3418.7; and
d. Coverage for colorectal cancer screening pursuant to § 38.2-3418.7:1.
2. May include any, or none, of the state-mandated health benefits nototherwise noted in subdivision B 1 as the health insurer and the smallemployer shall agree.
Notwithstanding any provision of this section to the contrary, if any planauthorized by this section includes and offers health care services coveredby the plan that may be legally rendered by a health care provider listed in§ 38.2-3408, that plan shall allow for the reimbursement of such coveredservices when rendered by such provider. Unless otherwise provided in thissection, this provision shall not require any benefit be provided as acovered service.
C. Any application and any enrollment form used in connection with coverageunder this section shall prominently disclose that the policy, contract, orevidence of coverage is not required to provide state-mandated healthbenefits, shall prominently disclose any and all state-mandated healthbenefits that the policy, subscription contract, or evidence of coverage doesnot provide, and shall clearly describe all eligibility requirements.
D. A policy form, subscription contract, or evidence of coverage issued underthis section to a small employer shall prominently disclose any and allstate-mandated health benefits that the policy, subscription contract, orevidence of coverage does not provide. Such disclosure shall also be includedin certificate forms or other evidences of coverage furnished to eachparticipant. Health insurers proposing to issue forms providing coverageunder this section shall clearly disclose the intended purposes for suchpolicies, contracts, or evidences of coverage when submitting the forms tothe Commission for approval in accordance with § 38.2-316.
E. The Commission shall adopt any regulations necessary to implement thissection.
§ 38.2-3406.1. Application of requirements that policies offered by smallemployers include state-mandated health benefits.
A. As used in this section:
"Eligible individual" means an individual who is employed by a smallemployer and has satisfied applicable waiting period requirements.
"Health insurance coverage" means benefits consisting of coverage for costsof medical care, whether directly, through insurance or reimbursement, orotherwise, and including items and services paid for as medical care under agroup policy of accident and sickness insurance, hospital or medical servicepolicy or certificate, hospital or medical service plan contract, or healthmaintenance organization contract, which coverage is subject to this title oris provided under a plan regulated under the Employee Retirement IncomeSecurity Act of 1974.
"Health insurer" means any insurance company that issues accident andsickness insurance policies providing hospital, medical and surgical, ormajor medical coverage on an expense-incurred basis, a corporation thatprovides accident and sickness subscription contracts, or any healthmaintenance organization that provides a health care plan that provides,arranges for, pays for, or reimburses any part of the cost of any health careservices, that is licensed to engage in such business in the Commonwealth,and that is subject to the laws of the Commonwealth that regulate insurancewithin the meaning of § 514(b)(2) of the Employee Retirement Income SecurityAct of 1974 (29 U.S.C. § 1144(b)(2)).
"Small employer" means, with respect to a calendar year and a plan year, anemployer located in the Commonwealth that employed at least two but not morethan 50 eligible individuals on business days during the preceding calendaryear and who employs at least two eligible individuals on the date a policyunder this section becomes effective.
"State-mandated health benefit" means coverage required under this title orother laws of the Commonwealth to be provided in a policy of accident andsickness insurance or a contract for a health-related condition that (i)includes coverage for specific health care services or benefits; (ii) placeslimitations or restrictions on deductibles, coinsurance, copayments, or anyannual or lifetime maximum benefit amounts; or (iii) includes a specificcategory of licensed health care practitioners from whom an insured isentitled to receive care. "State-mandated health benefit" includes, withoutlimitation, any coverage, or the offering of coverage, of a benefit orprovider pursuant to §§ 38.2-3407.5 through 38.2-3407.6:1, 38.2-3407.9:01,38.2-3407.9:02, 38.2-3407.11 through 38.2-3407.11:3, 38.2-3407.16, 38.2-3408,38.2-3411 through 38.2-3414.1, 38.2-3418 through 38.2-3418.14, or §38.2-4221. For purposes of this article, "state-mandated health benefit"does not include a benefit that is mandated by federal law.
B. Notwithstanding any statute, rule, or regulation to the contrary, and forthe purposes of this section, a group accident and sickness insurance policyproviding hospital, medical and surgical, or major medical coverage on anexpense-incurred basis; a group accident and sickness subscription contractproviding health insurance coverage for eligible individuals; and a healthcare plan that provides, arranges for, pays for, or reimburses any part ofthe cost of any health care services that is offered, sold, or issued by ahealth insurer to a small employer:
1. Shall not be required to include coverage, or the offer of coverage, forany state-mandated health benefit, except for:
a. Coverage for mammograms pursuant to § 38.2-3418.1;
b. Coverage for pap smears pursuant to § 38.2-3418.1:2;
c. Coverage for PSA testing pursuant to § 38.2-3418.7; and
d. Coverage for colorectal cancer screening pursuant to § 38.2-3418.7:1.
2. May include any, or none, of the state-mandated health benefits nototherwise noted in subdivision B 1 as the health insurer and the smallemployer shall agree.
Notwithstanding any provision of this section to the contrary, if any planauthorized by this section includes and offers health care services coveredby the plan that may be legally rendered by a health care provider listed in§ 38.2-3408, that plan shall allow for the reimbursement of such coveredservices when rendered by such provider. Unless otherwise provided in thissection, this provision shall not require any benefit be provided as acovered service.
C. Any application and any enrollment form used in connection with coverageunder this section shall prominently disclose that the policy, contract, orevidence of coverage is not required to provide state-mandated healthbenefits, shall prominently disclose any and all state-mandated healthbenefits that the policy, subscription contract, or evidence of coverage doesnot provide, and shall clearly describe all eligibility requirements.
D. A policy form, subscription contract, or evidence of coverage issued underthis section to a small employer shall prominently disclose any and allstate-mandated health benefits that the policy, subscription contract, orevidence of coverage does not provide. Such disclosure shall also be includedin certificate forms or other evidences of coverage furnished to eachparticipant. Health insurers proposing to issue forms providing coverageunder this section shall clearly disclose the intended purposes for suchpolicies, contracts, or evidences of coverage when submitting the forms tothe Commission for approval in accordance with § 38.2-316.
E. The Commission shall adopt any regulations necessary to implement thissection.
§ 38.2-3406.1. Application of requirements that policies offered by smallemployers include state-mandated health benefits.
A. As used in this section:
"Eligible individual" means an individual who is employed by a smallemployer and has satisfied applicable waiting period requirements.
"Health insurance coverage" means benefits consisting of coverage for costsof medical care, whether directly, through insurance or reimbursement, orotherwise, and including items and services paid for as medical care under agroup policy of accident and sickness insurance, hospital or medical servicepolicy or certificate, hospital or medical service plan contract, or healthmaintenance organization contract, which coverage is subject to this title oris provided under a plan regulated under the Employee Retirement IncomeSecurity Act of 1974.
"Health insurer" means any insurance company that issues accident andsickness insurance policies providing hospital, medical and surgical, ormajor medical coverage on an expense-incurred basis, a corporation thatprovides accident and sickness subscription contracts, or any healthmaintenance organization that provides a health care plan that provides,arranges for, pays for, or reimburses any part of the cost of any health careservices, that is licensed to engage in such business in the Commonwealth,and that is subject to the laws of the Commonwealth that regulate insurancewithin the meaning of § 514(b)(2) of the Employee Retirement Income SecurityAct of 1974 (29 U.S.C. § 1144(b)(2)).
"Small employer" means, with respect to a calendar year and a plan year, anemployer located in the Commonwealth that employed at least two but not morethan 50 eligible individuals on business days during the preceding calendaryear and who employs at least two eligible individuals on the date a policyunder this section becomes effective.
"State-mandated health benefit" means coverage required under this title orother laws of the Commonwealth to be provided in a policy of accident andsickness insurance or a contract for a health-related condition that (i)includes coverage for specific health care services or benefits; (ii) placeslimitations or restrictions on deductibles, coinsurance, copayments, or anyannual or lifetime maximum benefit amounts; or (iii) includes a specificcategory of licensed health care practitioners from whom an insured isentitled to receive care. "State-mandated health benefit" includes, withoutlimitation, any coverage, or the offering of coverage, of a benefit orprovider pursuant to §§ 38.2-3407.5 through 38.2-3407.6:1, 38.2-3407.9:01,38.2-3407.9:02, 38.2-3407.11 through 38.2-3407.11:3, 38.2-3407.16, 38.2-3408,38.2-3411 through 38.2-3414.1, 38.2-3418 through 38.2-3418.14, or §38.2-4221. For purposes of this article, "state-mandated health benefit"does not include a benefit that is mandated by federal law.
B. Notwithstanding any statute, rule, or regulation to the contrary, and forthe purposes of this section, a group accident and sickness insurance policyproviding hospital, medical and surgical, or major medical coverage on anexpense-incurred basis; a group accident and sickness subscription contractproviding health insurance coverage for eligible individuals; and a healthcare plan that provides, arranges for, pays for, or reimburses any part ofthe cost of any health care services that is offered, sold, or issued by ahealth insurer to a small employer:
1. Shall not be required to include coverage, or the offer of coverage, forany state-mandated health benefit, except for:
a. Coverage for mammograms pursuant to § 38.2-3418.1;
b. Coverage for pap smears pursuant to § 38.2-3418.1:2;
c. Coverage for PSA testing pursuant to § 38.2-3418.7; and
d. Coverage for colorectal cancer screening pursuant to § 38.2-3418.7:1.
2. May include any, or none, of the state-mandated health benefits nototherwise noted in subdivision B 1 as the health insurer and the smallemployer shall agree.
Notwithstanding any provision of this section to the contrary, if any planauthorized by this section includes and offers health care services coveredby the plan that may be legally rendered by a health care provider listed in§ 38.2-3408, that plan shall allow for the reimbursement of such coveredservices when rendered by such provider. Unless otherwise provided in thissection, this provision shall not require any benefit be provided as acovered service.
C. Any application and any enrollment form used in connection with coverageunder this section shall prominently disclose that the policy, contract, orevidence of coverage is not required to provide state-mandated healthbenefits, shall prominently disclose any and all state-mandated healthbenefits that the policy, subscription contract, or evidence of coverage doesnot provide, and shall clearly describe all eligibility requirements.
D. A policy form, subscription contract, or evidence of coverage issued underthis section to a small employer shall prominently disclose any and allstate-mandated health benefits that the policy, subscription contract, orevidence of coverage does not provide. Such disclosure shall also be includedin certificate forms or other evidences of coverage furnished to eachparticipant. Health insurers proposing to issue forms providing coverageunder this section shall clearly disclose the intended purposes for suchpolicies, contracts, or evidences of coverage when submitting the forms tothe Commission for approval in accordance with § 38.2-316.
E. The Commission shall adopt any regulations necessary to implement thissection.
