2006 Code of Virginia § 32.1-137.1 - Definitions

32.1-137.1. Definitions.

As used in this and the following article, unless the context indicatesotherwise:

"Agent" or "insurance agent," when used without qualification, means anindividual, partnership, limited liability company, or corporation thatsolicits, negotiates, procures or effects contracts of insurance or annuityin this Commonwealth.

"Bureau of Insurance" means the State Corporation Commission actingpursuant to Title 38.2.

"Complaint" means any written communication from a covered person primarilyexpressing a grievance.

"Covered person" means an individual residing in the Commonwealth, whethera policyholder, subscriber, enrollee, or member of a managed care healthinsurance plan, who is entitled to health care services or benefits provided,arranged for, paid for or reimbursed pursuant to a managed care healthinsurance plan under Title 38.2.

"Managed care health insurance plan" means an arrangement for the deliveryof health care in which a health carrier as defined in 38.2-5800 undertakesto provide, arrange for, pay for, or reimburse any of the costs of healthcare services for a covered person on a prepaid or insured basis which (i)contains one or more incentive arrangements, including any credentialingrequirements intended to influence the cost or level of health care servicesbetween the health carrier and one or more providers with respect to thedelivery of health care services; and (ii) requires or creates benefitpayment differential incentives for covered persons to use providers that aredirectly or indirectly managed, owned, under contract with or employed by thehealth carrier. Any health maintenance organization as defined in 38.2-4300or health carrier that offers preferred provider contracts or policies asdefined in 38.2-3407 or preferred provider subscription contracts asdefined in 38.2-4209 shall be deemed to be offering one or more managedcare health insurance plans. For the purposes of this definition, theprohibition of balance billing by a provider shall not be deemed a benefitpayment differential incentive for covered persons to use providers who aredirectly or indirectly managed, owned, under contract with or employed by thehealth carrier. A single managed care health insurance plan may encompassmultiple products and multiple types of benefit payment differentials;however, a single managed care health insurance plan shall encompass only oneprovider network or set of provider networks.

"Managed care health insurance plan licensee" means a health carriersubject to licensure by the Bureau of Insurance under Title 38.2 who isresponsible for a managed care health insurance plan in accordance withChapter 58 ( 38.2-5801 et seq.) of Title 38.2.

"Person" means any association, aggregate of individuals, business,company, corporation, individual, joint-stock company, Lloyds type oforganization, other organization, partnership, receiver, reciprocal orinter-insurance exchange, trustee or society.

(1998, c. 891.)