A. One or more insurers may offer or administer a health benefit programunder which the insurer or insurers may offer preferred provider policies orcontracts that limit the numbers and types of providers of health careservices eligible for payment as preferred providers.
B. Any such insurer shall establish terms and conditions that shall be met bya hospital, physician or type of provider listed in § 38.2-3408 in order toqualify for payment as a preferred provider under the policies or contracts.These terms and conditions shall not discriminate unreasonably against oramong such health care providers. No hospital, physician or type of providerlisted in § 38.2-3408 willing to meet the terms and conditions offered to itor him shall be excluded. Neither differences in prices among hospitals orother institutional providers produced by a process of individualnegotiations with providers or based on market conditions, or pricedifferences among providers in different geographical areas, shall be deemedunreasonable discrimination. The Commission shall have no jurisdiction toadjudicate controversies growing out of this subsection.
C. Mandated types of providers set forth in § 38.2-3408, and types ofproviders whose services are required to be made available and that have beenspecifically contracted for by the holder of any such policy or contractshall, to the extent required by § 38.2-3408, have the same opportunity toqualify for payment as a preferred provider as do doctors of medicine.
D. Preferred provider policies or contracts shall provide for payment forservices rendered by nonpreferred providers, but the payments need not be thesame as for preferred providers.
E. An insurer may offer individual or group exclusive provider policies orcontracts if:
1. The insurer provides or includes a benefit for preferred and nonpreferredproviders in accordance with the provisions of subsection D to a groupcontract holder to be provided or offered as a benefit for the enrollee, atthe enrollee's option, individually to accept or reject. In connection withits group enrollment application, every insurer shall, at no additional costto the group contract holder, make available or arrange with a carrier tomake available to the prospective group contract holder and to allprospective enrollees, in advance of initial enrollment and in advance ofeach reenrollment, a notice in form and substance approved by the Commissionas required under § 38.2-316, that accurately and completely explains to thegroup contract holder and prospective enrollee the benefit for preferred andnonpreferred providers and permits each enrollee to make his election. Theform of notice provided in connection with any reenrollment may be the sameas the approved form of notice filed under § 38.2-316 used in connection withinitial enrollment and may be made available to the group contract holder andprospective enrollee by the carrier in any reasonable manner; and
2. The insurer provides out-of-network emergency services at the minimumlevel required by the preferred provider policy or contract.
F. For the purposes of this section, "exclusive provider policies orcontracts" are insurance policies or contracts that condition the payment ofbenefits on the use of preferred providers, and "preferred provider policiesor contracts" are insurance policies or contracts that specify how servicesare to be covered when rendered by preferred and nonpreferred classificationsof providers.
(1983, c. 464, § 38.1-347.2; 1986, c. 562; 2008, c. 215.)
A. One or more insurers may offer or administer a health benefit programunder which the insurer or insurers may offer preferred provider policies orcontracts that limit the numbers and types of providers of health careservices eligible for payment as preferred providers.
B. Any such insurer shall establish terms and conditions that shall be met bya hospital, physician or type of provider listed in § 38.2-3408 in order toqualify for payment as a preferred provider under the policies or contracts.These terms and conditions shall not discriminate unreasonably against oramong such health care providers. No hospital, physician or type of providerlisted in § 38.2-3408 willing to meet the terms and conditions offered to itor him shall be excluded. Neither differences in prices among hospitals orother institutional providers produced by a process of individualnegotiations with providers or based on market conditions, or pricedifferences among providers in different geographical areas, shall be deemedunreasonable discrimination. The Commission shall have no jurisdiction toadjudicate controversies growing out of this subsection.
C. Mandated types of providers set forth in § 38.2-3408, and types ofproviders whose services are required to be made available and that have beenspecifically contracted for by the holder of any such policy or contractshall, to the extent required by § 38.2-3408, have the same opportunity toqualify for payment as a preferred provider as do doctors of medicine.
D. Preferred provider policies or contracts shall provide for payment forservices rendered by nonpreferred providers, but the payments need not be thesame as for preferred providers.
E. An insurer may offer individual or group exclusive provider policies orcontracts if:
1. The insurer provides or includes a benefit for preferred and nonpreferredproviders in accordance with the provisions of subsection D to a groupcontract holder to be provided or offered as a benefit for the enrollee, atthe enrollee's option, individually to accept or reject. In connection withits group enrollment application, every insurer shall, at no additional costto the group contract holder, make available or arrange with a carrier tomake available to the prospective group contract holder and to allprospective enrollees, in advance of initial enrollment and in advance ofeach reenrollment, a notice in form and substance approved by the Commissionas required under § 38.2-316, that accurately and completely explains to thegroup contract holder and prospective enrollee the benefit for preferred andnonpreferred providers and permits each enrollee to make his election. Theform of notice provided in connection with any reenrollment may be the sameas the approved form of notice filed under § 38.2-316 used in connection withinitial enrollment and may be made available to the group contract holder andprospective enrollee by the carrier in any reasonable manner; and
2. The insurer provides out-of-network emergency services at the minimumlevel required by the preferred provider policy or contract.
F. For the purposes of this section, "exclusive provider policies orcontracts" are insurance policies or contracts that condition the payment ofbenefits on the use of preferred providers, and "preferred provider policiesor contracts" are insurance policies or contracts that specify how servicesare to be covered when rendered by preferred and nonpreferred classificationsof providers.
(1983, c. 464, § 38.1-347.2; 1986, c. 562; 2008, c. 215.)
A. One or more insurers may offer or administer a health benefit programunder which the insurer or insurers may offer preferred provider policies orcontracts that limit the numbers and types of providers of health careservices eligible for payment as preferred providers.
B. Any such insurer shall establish terms and conditions that shall be met bya hospital, physician or type of provider listed in § 38.2-3408 in order toqualify for payment as a preferred provider under the policies or contracts.These terms and conditions shall not discriminate unreasonably against oramong such health care providers. No hospital, physician or type of providerlisted in § 38.2-3408 willing to meet the terms and conditions offered to itor him shall be excluded. Neither differences in prices among hospitals orother institutional providers produced by a process of individualnegotiations with providers or based on market conditions, or pricedifferences among providers in different geographical areas, shall be deemedunreasonable discrimination. The Commission shall have no jurisdiction toadjudicate controversies growing out of this subsection.
C. Mandated types of providers set forth in § 38.2-3408, and types ofproviders whose services are required to be made available and that have beenspecifically contracted for by the holder of any such policy or contractshall, to the extent required by § 38.2-3408, have the same opportunity toqualify for payment as a preferred provider as do doctors of medicine.
D. Preferred provider policies or contracts shall provide for payment forservices rendered by nonpreferred providers, but the payments need not be thesame as for preferred providers.
E. An insurer may offer individual or group exclusive provider policies orcontracts if:
1. The insurer provides or includes a benefit for preferred and nonpreferredproviders in accordance with the provisions of subsection D to a groupcontract holder to be provided or offered as a benefit for the enrollee, atthe enrollee's option, individually to accept or reject. In connection withits group enrollment application, every insurer shall, at no additional costto the group contract holder, make available or arrange with a carrier tomake available to the prospective group contract holder and to allprospective enrollees, in advance of initial enrollment and in advance ofeach reenrollment, a notice in form and substance approved by the Commissionas required under § 38.2-316, that accurately and completely explains to thegroup contract holder and prospective enrollee the benefit for preferred andnonpreferred providers and permits each enrollee to make his election. Theform of notice provided in connection with any reenrollment may be the sameas the approved form of notice filed under § 38.2-316 used in connection withinitial enrollment and may be made available to the group contract holder andprospective enrollee by the carrier in any reasonable manner; and
2. The insurer provides out-of-network emergency services at the minimumlevel required by the preferred provider policy or contract.
F. For the purposes of this section, "exclusive provider policies orcontracts" are insurance policies or contracts that condition the payment ofbenefits on the use of preferred providers, and "preferred provider policiesor contracts" are insurance policies or contracts that specify how servicesare to be covered when rendered by preferred and nonpreferred classificationsof providers.
(1983, c. 464, § 38.1-347.2; 1986, c. 562; 2008, c. 215.)
