A. As used in this section, a "preferred provider subscription contract" isa contract that specifies how services are to be covered when rendered byproviders participating in a plan, by nonparticipating providers, and bypreferred providers.
B. Notwithstanding the provisions of §§ 38.2-4218 and 38.2-4221, any nonstockcorporation may, as a feature of its plan, offer preferred providersubscription contracts pursuant to the requirements of this section thatlimit the numbers and types of providers of health care services eligible forpayment as preferred providers.
C. Any such nonstock corporation shall establish terms and conditions thatshall be met by a hospital, physician or other type of provider listed in §38.2-4221 in order to qualify for payment as a preferred provider under thesubscription contracts. These terms and conditions shall not discriminateunreasonably against or among health care providers. No hospital, physicianor type of provider listed in § 38.2-4221 willing to meet the terms andconditions offered to it or him shall be excluded. Differences in pricesamong hospitals or other institutional providers produced by a process ofindividual negotiations with the providers or based on market conditions, orprice differences among providers in different geographical areas shall notbe deemed unreasonable discrimination. The Commission shall have nojurisdiction to adjudicate controversies growing out of this subsection.
D. Mandated types of providers listed in § 38.2-4221 and types of providerswhose services are required to be made available and which have beenspecifically contracted for by the holder of any subscription contract shall,to the extent required by § 38.2-4221, have the same opportunity as dodoctors of medicine to qualify for payment as preferred providers.
E. Preferred provider subscription contracts shall provide for payment forservices rendered by nonpreferred providers, but the payments need not be thesame as for preferred providers.
F. No contract between a nonstock corporation and a provider shall includeprovisions which require a health care provider or health care provider groupto deny covered services that such provider or group knows to be medicallynecessary and appropriate that are provided with respect to a specificenrollee or group of enrollees with similar medical conditions.
(1983, c. 464, § 38.1-813.4; 1986, c. 562; 1999, cc. 643, 649.)
A. As used in this section, a "preferred provider subscription contract" isa contract that specifies how services are to be covered when rendered byproviders participating in a plan, by nonparticipating providers, and bypreferred providers.
B. Notwithstanding the provisions of §§ 38.2-4218 and 38.2-4221, any nonstockcorporation may, as a feature of its plan, offer preferred providersubscription contracts pursuant to the requirements of this section thatlimit the numbers and types of providers of health care services eligible forpayment as preferred providers.
C. Any such nonstock corporation shall establish terms and conditions thatshall be met by a hospital, physician or other type of provider listed in §38.2-4221 in order to qualify for payment as a preferred provider under thesubscription contracts. These terms and conditions shall not discriminateunreasonably against or among health care providers. No hospital, physicianor type of provider listed in § 38.2-4221 willing to meet the terms andconditions offered to it or him shall be excluded. Differences in pricesamong hospitals or other institutional providers produced by a process ofindividual negotiations with the providers or based on market conditions, orprice differences among providers in different geographical areas shall notbe deemed unreasonable discrimination. The Commission shall have nojurisdiction to adjudicate controversies growing out of this subsection.
D. Mandated types of providers listed in § 38.2-4221 and types of providerswhose services are required to be made available and which have beenspecifically contracted for by the holder of any subscription contract shall,to the extent required by § 38.2-4221, have the same opportunity as dodoctors of medicine to qualify for payment as preferred providers.
E. Preferred provider subscription contracts shall provide for payment forservices rendered by nonpreferred providers, but the payments need not be thesame as for preferred providers.
F. No contract between a nonstock corporation and a provider shall includeprovisions which require a health care provider or health care provider groupto deny covered services that such provider or group knows to be medicallynecessary and appropriate that are provided with respect to a specificenrollee or group of enrollees with similar medical conditions.
(1983, c. 464, § 38.1-813.4; 1986, c. 562; 1999, cc. 643, 649.)
A. As used in this section, a "preferred provider subscription contract" isa contract that specifies how services are to be covered when rendered byproviders participating in a plan, by nonparticipating providers, and bypreferred providers.
B. Notwithstanding the provisions of §§ 38.2-4218 and 38.2-4221, any nonstockcorporation may, as a feature of its plan, offer preferred providersubscription contracts pursuant to the requirements of this section thatlimit the numbers and types of providers of health care services eligible forpayment as preferred providers.
C. Any such nonstock corporation shall establish terms and conditions thatshall be met by a hospital, physician or other type of provider listed in §38.2-4221 in order to qualify for payment as a preferred provider under thesubscription contracts. These terms and conditions shall not discriminateunreasonably against or among health care providers. No hospital, physicianor type of provider listed in § 38.2-4221 willing to meet the terms andconditions offered to it or him shall be excluded. Differences in pricesamong hospitals or other institutional providers produced by a process ofindividual negotiations with the providers or based on market conditions, orprice differences among providers in different geographical areas shall notbe deemed unreasonable discrimination. The Commission shall have nojurisdiction to adjudicate controversies growing out of this subsection.
D. Mandated types of providers listed in § 38.2-4221 and types of providerswhose services are required to be made available and which have beenspecifically contracted for by the holder of any subscription contract shall,to the extent required by § 38.2-4221, have the same opportunity as dodoctors of medicine to qualify for payment as preferred providers.
E. Preferred provider subscription contracts shall provide for payment forservices rendered by nonpreferred providers, but the payments need not be thesame as for preferred providers.
F. No contract between a nonstock corporation and a provider shall includeprovisions which require a health care provider or health care provider groupto deny covered services that such provider or group knows to be medicallynecessary and appropriate that are provided with respect to a specificenrollee or group of enrollees with similar medical conditions.
(1983, c. 464, § 38.1-813.4; 1986, c. 562; 1999, cc. 643, 649.)
