A. No health maintenance organization or its representative may cause orknowingly permit the use of (i) advertising that is untrue or misleading,(ii) solicitation that is untrue or misleading, or (iii) any form of evidenceof coverage that is deceptive. For the purposes of this chapter:
1. A statement or item of information shall be deemed to be untrue if it doesnot conform to fact in any respect that is or may be significant to anenrollee or person considering enrollment in a health care plan;
2. A statement or item of information shall be deemed to be misleading,whether or not it may be literally untrue, if the statement or item ofinformation may be understood by a reasonable person who has no specialknowledge of health care coverage as indicating (i) a benefit or advantage ifthat benefit or advantage does not in fact exist or (ii) the absence of anyexclusion, limitation or disadvantage of possible significance to an enrolleeor person considering enrollment in a health care plan if the absence of thatexclusion, limitation, or disadvantage does not in fact exist; considerationshall be given to the total context in which the statement is made or theitem of information is communicated; and
3. An evidence of coverage shall be deemed to be deceptive if it causes areasonable person who has no special knowledge of health care plans to expectbenefits, services, charges, or other advantages that the evidence ofcoverage does not provide or that the health care plan issuing the evidenceof coverage does not regularly make available for enrollees covered under theevidence of coverage; consideration shall be given to the evidence ofcoverage taken as a whole and to the typography, format, and language.
B. The provisions of Chapter 5 (§ 38.2-500 et seq.) of this title shall applyto health maintenance organizations, health care plans, and evidences ofcoverage except to the extent that the Commission determines that the natureof health maintenance organizations, health care plans, and evidences ofcoverage render any of the provisions clearly inappropriate.
C. No health maintenance organization, unless licensed as an insurer, may usein its name, contracts, or literature (i) any of the words "insurance,""casualty," "surety," "mutual," or (ii) any other words descriptive ofthe insurance, casualty, or surety business or deceptively similar to thename or description of any insurance or fidelity and surety insurer doingbusiness in this Commonwealth.
D. No health maintenance organization shall discriminate on the basis ofrace, creed, color, sex or religion in the selection of health care providersfor participation in the organization.
E. No health maintenance organization shall unreasonably discriminate againstphysicians as a class or any class of providers listed in § 38.2-4221 orpharmacists when contracting for specialty or referral practitioners orproviders, provided the plan covers services which the members of suchclasses are licensed to render. Nothing contained in this section shallprevent a health maintenance organization from selecting, in the judgment ofthe health maintenance organization, the numbers of providers necessary torender the services offered by the health maintenance organization.
F. No contract between a health maintenance organization and a provider shallinclude provisions which require a health care provider or health careprovider group to deny covered services that such provider or group knows tobe medically necessary and appropriate that are provided with respect to aspecific enrollee or group of enrollees with similar medical conditions.
(1980, c. 720, § 38.1-876; 1985, c. 588; 1986, c. 562; 1989, c. 221; 1997, c.297; 1998, c. 891; 1999, cc. 643, 649.)
A. No health maintenance organization or its representative may cause orknowingly permit the use of (i) advertising that is untrue or misleading,(ii) solicitation that is untrue or misleading, or (iii) any form of evidenceof coverage that is deceptive. For the purposes of this chapter:
1. A statement or item of information shall be deemed to be untrue if it doesnot conform to fact in any respect that is or may be significant to anenrollee or person considering enrollment in a health care plan;
2. A statement or item of information shall be deemed to be misleading,whether or not it may be literally untrue, if the statement or item ofinformation may be understood by a reasonable person who has no specialknowledge of health care coverage as indicating (i) a benefit or advantage ifthat benefit or advantage does not in fact exist or (ii) the absence of anyexclusion, limitation or disadvantage of possible significance to an enrolleeor person considering enrollment in a health care plan if the absence of thatexclusion, limitation, or disadvantage does not in fact exist; considerationshall be given to the total context in which the statement is made or theitem of information is communicated; and
3. An evidence of coverage shall be deemed to be deceptive if it causes areasonable person who has no special knowledge of health care plans to expectbenefits, services, charges, or other advantages that the evidence ofcoverage does not provide or that the health care plan issuing the evidenceof coverage does not regularly make available for enrollees covered under theevidence of coverage; consideration shall be given to the evidence ofcoverage taken as a whole and to the typography, format, and language.
B. The provisions of Chapter 5 (§ 38.2-500 et seq.) of this title shall applyto health maintenance organizations, health care plans, and evidences ofcoverage except to the extent that the Commission determines that the natureof health maintenance organizations, health care plans, and evidences ofcoverage render any of the provisions clearly inappropriate.
C. No health maintenance organization, unless licensed as an insurer, may usein its name, contracts, or literature (i) any of the words "insurance,""casualty," "surety," "mutual," or (ii) any other words descriptive ofthe insurance, casualty, or surety business or deceptively similar to thename or description of any insurance or fidelity and surety insurer doingbusiness in this Commonwealth.
D. No health maintenance organization shall discriminate on the basis ofrace, creed, color, sex or religion in the selection of health care providersfor participation in the organization.
E. No health maintenance organization shall unreasonably discriminate againstphysicians as a class or any class of providers listed in § 38.2-4221 orpharmacists when contracting for specialty or referral practitioners orproviders, provided the plan covers services which the members of suchclasses are licensed to render. Nothing contained in this section shallprevent a health maintenance organization from selecting, in the judgment ofthe health maintenance organization, the numbers of providers necessary torender the services offered by the health maintenance organization.
F. No contract between a health maintenance organization and a provider shallinclude provisions which require a health care provider or health careprovider group to deny covered services that such provider or group knows tobe medically necessary and appropriate that are provided with respect to aspecific enrollee or group of enrollees with similar medical conditions.
(1980, c. 720, § 38.1-876; 1985, c. 588; 1986, c. 562; 1989, c. 221; 1997, c.297; 1998, c. 891; 1999, cc. 643, 649.)
A. No health maintenance organization or its representative may cause orknowingly permit the use of (i) advertising that is untrue or misleading,(ii) solicitation that is untrue or misleading, or (iii) any form of evidenceof coverage that is deceptive. For the purposes of this chapter:
1. A statement or item of information shall be deemed to be untrue if it doesnot conform to fact in any respect that is or may be significant to anenrollee or person considering enrollment in a health care plan;
2. A statement or item of information shall be deemed to be misleading,whether or not it may be literally untrue, if the statement or item ofinformation may be understood by a reasonable person who has no specialknowledge of health care coverage as indicating (i) a benefit or advantage ifthat benefit or advantage does not in fact exist or (ii) the absence of anyexclusion, limitation or disadvantage of possible significance to an enrolleeor person considering enrollment in a health care plan if the absence of thatexclusion, limitation, or disadvantage does not in fact exist; considerationshall be given to the total context in which the statement is made or theitem of information is communicated; and
3. An evidence of coverage shall be deemed to be deceptive if it causes areasonable person who has no special knowledge of health care plans to expectbenefits, services, charges, or other advantages that the evidence ofcoverage does not provide or that the health care plan issuing the evidenceof coverage does not regularly make available for enrollees covered under theevidence of coverage; consideration shall be given to the evidence ofcoverage taken as a whole and to the typography, format, and language.
B. The provisions of Chapter 5 (§ 38.2-500 et seq.) of this title shall applyto health maintenance organizations, health care plans, and evidences ofcoverage except to the extent that the Commission determines that the natureof health maintenance organizations, health care plans, and evidences ofcoverage render any of the provisions clearly inappropriate.
C. No health maintenance organization, unless licensed as an insurer, may usein its name, contracts, or literature (i) any of the words "insurance,""casualty," "surety," "mutual," or (ii) any other words descriptive ofthe insurance, casualty, or surety business or deceptively similar to thename or description of any insurance or fidelity and surety insurer doingbusiness in this Commonwealth.
D. No health maintenance organization shall discriminate on the basis ofrace, creed, color, sex or religion in the selection of health care providersfor participation in the organization.
E. No health maintenance organization shall unreasonably discriminate againstphysicians as a class or any class of providers listed in § 38.2-4221 orpharmacists when contracting for specialty or referral practitioners orproviders, provided the plan covers services which the members of suchclasses are licensed to render. Nothing contained in this section shallprevent a health maintenance organization from selecting, in the judgment ofthe health maintenance organization, the numbers of providers necessary torender the services offered by the health maintenance organization.
F. No contract between a health maintenance organization and a provider shallinclude provisions which require a health care provider or health careprovider group to deny covered services that such provider or group knows tobe medically necessary and appropriate that are provided with respect to aspecific enrollee or group of enrollees with similar medical conditions.
(1980, c. 720, § 38.1-876; 1985, c. 588; 1986, c. 562; 1989, c. 221; 1997, c.297; 1998, c. 891; 1999, cc. 643, 649.)
