"Acceptable securities" means securities that (i) are legal investmentsunder the laws of the Commonwealth for public sinking funds or for otherpublic funds, (ii) are not in default as to principal or interest, (iii) havea current market value of not less than $50,000 nor more than $500,000, and(iv) are issued pursuant to a system of book-entry evidencing ownershipinterests of the securities with transfers of ownership effected on therecords of the depository and its participants pursuant to rules andprocedures established by the depository.
"Basic health care services" means in and out-of-area emergency services,inpatient hospital and physician care, outpatient medical services,laboratory and radiologic services, and preventive health services. "Basichealth care services" shall also mean limited treatment of mental illnessand substance abuse in accordance with such minimum standards as may beprescribed by the Commission which shall not exceed the level of servicesmandated for insurance carriers pursuant to Chapter 34 (§ 38.2-3400 et seq.)of this title. In the case of a health maintenance organization that hascontracted with the Commonwealth to furnish basic health services torecipients of medical assistance under Title XIX of the United States SocialSecurity Act pursuant to § 38.2-4320, the basic health services to beprovided by the health maintenance organization to program recipients maydiffer from the basic health services required by this section to the extentnecessary to meet the benefit standards prescribed by the state plan formedical assistance services authorized pursuant to § 32.1-325.
"Copayment" means an amount an enrollee is required to pay in order toreceive a specific health care service.
"Deductible" means an amount an enrollee is required to pay out-of-pocketbefore the health care plan begins to pay the costs associated with healthcare services.
"Emergency services" means those health care services that are rendered byaffiliated or nonaffiliated providers after the sudden onset of a medicalcondition that manifests itself by symptoms of sufficient severity, includingsevere pain, that the absence of immediate medical attention could reasonablybe expected by a prudent layperson who possesses an average knowledge ofhealth and medicine to result in (i) serious jeopardy to the mental orphysical health of the individual, (ii) danger of serious impairment of theindividual's bodily functions, (iii) serious dysfunction of any of theindividual's bodily organs, or (iv) in the case of a pregnant woman, seriousjeopardy to the health of the fetus. Emergency services provided within theplan's service area shall include covered health care services fromnonaffiliated providers only when delay in receiving care from a provideraffiliated with the health maintenance organization could reasonably beexpected to cause the enrollee's condition to worsen if left unattended.
"Enrollee" or "member" means an individual who is enrolled in a healthcare plan.
"Evidence of coverage" means any certificate or individual or groupagreement or contract issued in conjunction with the certificate, agreementor contract, issued to a subscriber setting out the coverage and other rightsto which an enrollee is entitled.
"Excess insurance" or "stop loss insurance" means insurance issued to ahealth maintenance organization by an insurer licensed in the Commonwealth,on a form approved by the Commission, or a risk assumption transactionacceptable to the Commission, providing indemnity or reimbursement againstthe cost of health care services provided by the health maintenanceorganization.
"Health care plan" means any arrangement in which any person undertakes toprovide, arrange for, pay for, or reimburse any part of the cost of anyhealth care services. A significant part of the arrangement shall consist ofarranging for or providing health care services, including emergency servicesand services rendered by nonparticipating referral providers, asdistinguished from mere indemnification against the cost of the services, ona prepaid basis. For purposes of this section, a significant part shall meanat least 90 percent of total costs of health care services.
"Health care services" means the furnishing of services to any individualfor the purpose of preventing, alleviating, curing, or healing human illness,injury, or physical disability.
"Health maintenance organization" means any person who undertakes toprovide or arrange for one or more health care plans.
"Limited health care services" means dental care services, vision careservices, mental health services, substance abuse services, pharmaceuticalservices, and such other services as may be determined by the Commission tobe limited health care services. Limited health care services shall notinclude hospital, medical, surgical, or emergency services except as suchservices are provided incident to the limited health care services set forthin the preceding sentence.
"Net worth" or "capital and surplus" means the excess of total admittedassets over the total liabilities of the health maintenance organization,provided that surplus notes shall be reported and accounted for in accordancewith guidance set forth in the National Association of InsuranceCommissioners (NAIC) accounting practice and procedures manuals.
"Nonparticipating referral provider" means a provider who is not aparticipating provider but with whom a health maintenance organization hasarranged, through referral by its participating providers, to provide healthcare services to enrollees. Payment or reimbursement by a health maintenanceorganization for health care services provided by nonparticipating referralproviders may exceed five percent of total costs of health care services,only to the extent that any such excess payment or reimbursement over fivepercent shall be combined with the costs for services which represent mereindemnification, with the combined amount subject to the combination oflimitations set forth in this definition and in this section's definition ofhealth care plan.
"Participating provider" means a provider who has agreed to provide healthcare services to enrollees and to hold those enrollees harmless from paymentwith an expectation of receiving payment, other than copayments ordeductibles, directly or indirectly from the health maintenance organization.
"Provider" or "health care provider" means any physician, hospital, orother person that is licensed or otherwise authorized in the Commonwealth tofurnish health care services.
"Subscriber" means a contract holder, an individual enrollee, or theenrollee in an enrolled family who is responsible for payment to the healthmaintenance organization or on whose behalf such payment is made.
(1980, c. 720, § 38.1-863; 1986, cc. 76, 528, 562; 1990, c. 224; 1992, cc.241, 481; 1993, c. 305; 1995, cc. 182, 345; 2000, c. 503; 2003, cc. 752, 767;2004, c. 175; 2006, c. 448.)
"Acceptable securities" means securities that (i) are legal investmentsunder the laws of the Commonwealth for public sinking funds or for otherpublic funds, (ii) are not in default as to principal or interest, (iii) havea current market value of not less than $50,000 nor more than $500,000, and(iv) are issued pursuant to a system of book-entry evidencing ownershipinterests of the securities with transfers of ownership effected on therecords of the depository and its participants pursuant to rules andprocedures established by the depository.
"Basic health care services" means in and out-of-area emergency services,inpatient hospital and physician care, outpatient medical services,laboratory and radiologic services, and preventive health services. "Basichealth care services" shall also mean limited treatment of mental illnessand substance abuse in accordance with such minimum standards as may beprescribed by the Commission which shall not exceed the level of servicesmandated for insurance carriers pursuant to Chapter 34 (§ 38.2-3400 et seq.)of this title. In the case of a health maintenance organization that hascontracted with the Commonwealth to furnish basic health services torecipients of medical assistance under Title XIX of the United States SocialSecurity Act pursuant to § 38.2-4320, the basic health services to beprovided by the health maintenance organization to program recipients maydiffer from the basic health services required by this section to the extentnecessary to meet the benefit standards prescribed by the state plan formedical assistance services authorized pursuant to § 32.1-325.
"Copayment" means an amount an enrollee is required to pay in order toreceive a specific health care service.
"Deductible" means an amount an enrollee is required to pay out-of-pocketbefore the health care plan begins to pay the costs associated with healthcare services.
"Emergency services" means those health care services that are rendered byaffiliated or nonaffiliated providers after the sudden onset of a medicalcondition that manifests itself by symptoms of sufficient severity, includingsevere pain, that the absence of immediate medical attention could reasonablybe expected by a prudent layperson who possesses an average knowledge ofhealth and medicine to result in (i) serious jeopardy to the mental orphysical health of the individual, (ii) danger of serious impairment of theindividual's bodily functions, (iii) serious dysfunction of any of theindividual's bodily organs, or (iv) in the case of a pregnant woman, seriousjeopardy to the health of the fetus. Emergency services provided within theplan's service area shall include covered health care services fromnonaffiliated providers only when delay in receiving care from a provideraffiliated with the health maintenance organization could reasonably beexpected to cause the enrollee's condition to worsen if left unattended.
"Enrollee" or "member" means an individual who is enrolled in a healthcare plan.
"Evidence of coverage" means any certificate or individual or groupagreement or contract issued in conjunction with the certificate, agreementor contract, issued to a subscriber setting out the coverage and other rightsto which an enrollee is entitled.
"Excess insurance" or "stop loss insurance" means insurance issued to ahealth maintenance organization by an insurer licensed in the Commonwealth,on a form approved by the Commission, or a risk assumption transactionacceptable to the Commission, providing indemnity or reimbursement againstthe cost of health care services provided by the health maintenanceorganization.
"Health care plan" means any arrangement in which any person undertakes toprovide, arrange for, pay for, or reimburse any part of the cost of anyhealth care services. A significant part of the arrangement shall consist ofarranging for or providing health care services, including emergency servicesand services rendered by nonparticipating referral providers, asdistinguished from mere indemnification against the cost of the services, ona prepaid basis. For purposes of this section, a significant part shall meanat least 90 percent of total costs of health care services.
"Health care services" means the furnishing of services to any individualfor the purpose of preventing, alleviating, curing, or healing human illness,injury, or physical disability.
"Health maintenance organization" means any person who undertakes toprovide or arrange for one or more health care plans.
"Limited health care services" means dental care services, vision careservices, mental health services, substance abuse services, pharmaceuticalservices, and such other services as may be determined by the Commission tobe limited health care services. Limited health care services shall notinclude hospital, medical, surgical, or emergency services except as suchservices are provided incident to the limited health care services set forthin the preceding sentence.
"Net worth" or "capital and surplus" means the excess of total admittedassets over the total liabilities of the health maintenance organization,provided that surplus notes shall be reported and accounted for in accordancewith guidance set forth in the National Association of InsuranceCommissioners (NAIC) accounting practice and procedures manuals.
"Nonparticipating referral provider" means a provider who is not aparticipating provider but with whom a health maintenance organization hasarranged, through referral by its participating providers, to provide healthcare services to enrollees. Payment or reimbursement by a health maintenanceorganization for health care services provided by nonparticipating referralproviders may exceed five percent of total costs of health care services,only to the extent that any such excess payment or reimbursement over fivepercent shall be combined with the costs for services which represent mereindemnification, with the combined amount subject to the combination oflimitations set forth in this definition and in this section's definition ofhealth care plan.
"Participating provider" means a provider who has agreed to provide healthcare services to enrollees and to hold those enrollees harmless from paymentwith an expectation of receiving payment, other than copayments ordeductibles, directly or indirectly from the health maintenance organization.
"Provider" or "health care provider" means any physician, hospital, orother person that is licensed or otherwise authorized in the Commonwealth tofurnish health care services.
"Subscriber" means a contract holder, an individual enrollee, or theenrollee in an enrolled family who is responsible for payment to the healthmaintenance organization or on whose behalf such payment is made.
(1980, c. 720, § 38.1-863; 1986, cc. 76, 528, 562; 1990, c. 224; 1992, cc.241, 481; 1993, c. 305; 1995, cc. 182, 345; 2000, c. 503; 2003, cc. 752, 767;2004, c. 175; 2006, c. 448.)
"Acceptable securities" means securities that (i) are legal investmentsunder the laws of the Commonwealth for public sinking funds or for otherpublic funds, (ii) are not in default as to principal or interest, (iii) havea current market value of not less than $50,000 nor more than $500,000, and(iv) are issued pursuant to a system of book-entry evidencing ownershipinterests of the securities with transfers of ownership effected on therecords of the depository and its participants pursuant to rules andprocedures established by the depository.
"Basic health care services" means in and out-of-area emergency services,inpatient hospital and physician care, outpatient medical services,laboratory and radiologic services, and preventive health services. "Basichealth care services" shall also mean limited treatment of mental illnessand substance abuse in accordance with such minimum standards as may beprescribed by the Commission which shall not exceed the level of servicesmandated for insurance carriers pursuant to Chapter 34 (§ 38.2-3400 et seq.)of this title. In the case of a health maintenance organization that hascontracted with the Commonwealth to furnish basic health services torecipients of medical assistance under Title XIX of the United States SocialSecurity Act pursuant to § 38.2-4320, the basic health services to beprovided by the health maintenance organization to program recipients maydiffer from the basic health services required by this section to the extentnecessary to meet the benefit standards prescribed by the state plan formedical assistance services authorized pursuant to § 32.1-325.
"Copayment" means an amount an enrollee is required to pay in order toreceive a specific health care service.
"Deductible" means an amount an enrollee is required to pay out-of-pocketbefore the health care plan begins to pay the costs associated with healthcare services.
"Emergency services" means those health care services that are rendered byaffiliated or nonaffiliated providers after the sudden onset of a medicalcondition that manifests itself by symptoms of sufficient severity, includingsevere pain, that the absence of immediate medical attention could reasonablybe expected by a prudent layperson who possesses an average knowledge ofhealth and medicine to result in (i) serious jeopardy to the mental orphysical health of the individual, (ii) danger of serious impairment of theindividual's bodily functions, (iii) serious dysfunction of any of theindividual's bodily organs, or (iv) in the case of a pregnant woman, seriousjeopardy to the health of the fetus. Emergency services provided within theplan's service area shall include covered health care services fromnonaffiliated providers only when delay in receiving care from a provideraffiliated with the health maintenance organization could reasonably beexpected to cause the enrollee's condition to worsen if left unattended.
"Enrollee" or "member" means an individual who is enrolled in a healthcare plan.
"Evidence of coverage" means any certificate or individual or groupagreement or contract issued in conjunction with the certificate, agreementor contract, issued to a subscriber setting out the coverage and other rightsto which an enrollee is entitled.
"Excess insurance" or "stop loss insurance" means insurance issued to ahealth maintenance organization by an insurer licensed in the Commonwealth,on a form approved by the Commission, or a risk assumption transactionacceptable to the Commission, providing indemnity or reimbursement againstthe cost of health care services provided by the health maintenanceorganization.
"Health care plan" means any arrangement in which any person undertakes toprovide, arrange for, pay for, or reimburse any part of the cost of anyhealth care services. A significant part of the arrangement shall consist ofarranging for or providing health care services, including emergency servicesand services rendered by nonparticipating referral providers, asdistinguished from mere indemnification against the cost of the services, ona prepaid basis. For purposes of this section, a significant part shall meanat least 90 percent of total costs of health care services.
"Health care services" means the furnishing of services to any individualfor the purpose of preventing, alleviating, curing, or healing human illness,injury, or physical disability.
"Health maintenance organization" means any person who undertakes toprovide or arrange for one or more health care plans.
"Limited health care services" means dental care services, vision careservices, mental health services, substance abuse services, pharmaceuticalservices, and such other services as may be determined by the Commission tobe limited health care services. Limited health care services shall notinclude hospital, medical, surgical, or emergency services except as suchservices are provided incident to the limited health care services set forthin the preceding sentence.
"Net worth" or "capital and surplus" means the excess of total admittedassets over the total liabilities of the health maintenance organization,provided that surplus notes shall be reported and accounted for in accordancewith guidance set forth in the National Association of InsuranceCommissioners (NAIC) accounting practice and procedures manuals.
"Nonparticipating referral provider" means a provider who is not aparticipating provider but with whom a health maintenance organization hasarranged, through referral by its participating providers, to provide healthcare services to enrollees. Payment or reimbursement by a health maintenanceorganization for health care services provided by nonparticipating referralproviders may exceed five percent of total costs of health care services,only to the extent that any such excess payment or reimbursement over fivepercent shall be combined with the costs for services which represent mereindemnification, with the combined amount subject to the combination oflimitations set forth in this definition and in this section's definition ofhealth care plan.
"Participating provider" means a provider who has agreed to provide healthcare services to enrollees and to hold those enrollees harmless from paymentwith an expectation of receiving payment, other than copayments ordeductibles, directly or indirectly from the health maintenance organization.
"Provider" or "health care provider" means any physician, hospital, orother person that is licensed or otherwise authorized in the Commonwealth tofurnish health care services.
"Subscriber" means a contract holder, an individual enrollee, or theenrollee in an enrolled family who is responsible for payment to the healthmaintenance organization or on whose behalf such payment is made.
(1980, c. 720, § 38.1-863; 1986, cc. 76, 528, 562; 1990, c. 224; 1992, cc.241, 481; 1993, c. 305; 1995, cc. 182, 345; 2000, c. 503; 2003, cc. 752, 767;2004, c. 175; 2006, c. 448.)
