Virginia Code 38.2-3407.3: Calculation of cost-sharing provisions.
A. An insurer, health services plan, or health maintenance organization that issues an accident and sickness insurance policy or contract pursuant to which the insured, subscriber or enrollee is required to pay a specified percentage of the cost of covered services, shall calculate such amount payable based upon an amount not to exceed the total amount actually paid or payable to the provider of such services for the services provided to the insured, subscriber, or enrollee. When there is no amount actually paid or payable to the provider by the insurer, health services plan, or health maintenance organization for the services provided, the insurer, health services plan, or health maintenance organization shall use such insurer’s, health services plan’s, or health maintenance organization’s pre-established allowed amount to calculate the amount payable by the insured for such services. When an insured, subscriber, or enrollee receives covered services outside the insurer’s, health services plan’s, or health maintenance organization’s provider network, and such entity utilizes another insurer’s, health services plan’s, or health maintenance organization’s provider network located outside the Commonwealth, such entity may satisfy the obligation of this section by using the cost of services as reported by the out-of-state insurer, health services plan, or health maintenance organization when calculating the insured’s, subscriber’s, or enrollee’s percentage of the cost of covered services.
Terms Used In Virginia Code 38.2-3407.3
- Accident and sickness insurance: means insurance against loss resulting from sickness, or from bodily injury or death by accident or accidental means, or from a combination of any or all of these perils. See Virginia Code 38.2-109
- Commission: means the State Corporation Commission. See Virginia Code 38.2-100
- Contract: A legal written agreement that becomes binding when signed.
- Health services plan: means any arrangement for offering or administering health services or similar or related services by a corporation licensed under Virginia Code 38.2-100
- Insurer: means an insurance company. See Virginia Code 38.2-100
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Restitution: The court-ordered payment of money by the defendant to the victim for damages caused by the criminal action.
- Subscriber: means a person obligated under a reciprocal insurance agreement. See Virginia Code 38.2-1201
B. Any insurer, health services plan, or health maintenance organization failing to administer its contracts as set forth herein shall be deemed to have committed a knowing and willful violation of this section, and shall be punished as set forth in subsection A of § 38.2-218. Each claim payment found to have been calculated in noncompliance with this section shall be deemed a separate and distinct violation, and shall further be deemed a violation subject to subdivision D 1 c of § 38.2-218, permitting the Commission to require restitution in addition to any other penalties.