2006 Code of Virginia § 38.2-4303 - Powers

38.2-4303. Powers.

A. The powers of a health maintenance organization shall include, but shallnot be limited to, the following, provided that the activities comply withall applicable state statutes and regulations:

1. The purchase, lease, construction, renovation, operation, or maintenanceof hospitals, medical or other health care facilities, and their ancillaryequipment and other property reasonably required for its principal office orfor other purposes necessary in the transaction of the business of theorganization;

2. The making of loans to (i) health care providers under contract with it inadvancement of its health care plan or (ii) any corporation under its controlfor the purpose of acquiring or constructing medical or other health carefacilities and hospitals or in advancement of its health care plan providinghealth care services to enrollees;

3. The furnishing of health care services through providers that are undercontract with or employed by the health maintenance organization;

4. The contracting with any person for the performance on its behalf ofcertain functions including, but not limited to, marketing, enrollment andadministration;

5. The contracting with an insurer or with a health services plan licensed inthis Commonwealth, for the provision of insurance, indemnity, orreimbursement for the cost of health care services provided by the healthmaintenance organization;

6. The offering, in addition to basic health care services, of:

a. Additional health care services;

b. Indemnity benefits covering out-of-area services; and

c. Indemnity benefits, in addition to those relating to out-of-area services,provided through insurers or health services plans;

7. The offering of health care plans for limited health care services; and

8. The requirement for the enrollee to pay a reasonable deductible orcopayment, or both, for any health care services offered pursuant to thischapter, provided that the total deductible or deductibles for basic healthcare services per calendar year or contract year shall not exceed the maximumannual deductibles permissible for health plans offered in conjunction withplans made available pursuant to 26 U.S.C. 220 or any successor thereto. Ifthe federal program for these plans is terminated, the health care plan mayoffer plans with deductibles that do not exceed those permitted for the lastyear in which the federal program was in effect plus $50 per calendar yearthereafter. In determining whether a health care plan's deductibles areunreasonable, the Commission may consider at least the following criteria:

a. Whether the deductibles will adversely affect accessibility to health careservices among the health care plan's enrollees in the Commonwealth;

b. Whether the health care plan has demonstrated its ability to monitor andimplement the deductible plans; and

c. Whether the health care plan's level of capitalization and financialcondition are adequate to support the deductible plans.

B. 1. A health maintenance organization shall file notice with the Commissionwithin 30 days after the exercise of any power granted in subdivision 1 or 2of subsection A of this section that exceeds one percent of the admittedassets of the organization or five percent of net worth, whichever is less. Ahealth maintenance organization shall file notice, with adequate supportinginformation, with the Commission prior to the exercise of any power grantedin subdivision 1 or 2 of subsection A of this section that exceeds fivepercent of the admitted assets of the organization or 25 percent of networth, whichever is less. Any series of transactions occurring within a12-month period that are sufficiently similar in nature to be reasonablyconstrued as a single transaction shall be subject to the limitations setforth in this section. The Commission shall disapprove the exercise of powerif the Commission believes such exercise of power would substantially andadversely affect the financial soundness of the health maintenanceorganization and endanger the health maintenance organization's ability tomeet its obligations. If the Commission does not disapprove the exercise ofpower within 30 days of the filing, it shall be deemed approved.

2. Upon application by the health maintenance organization, the Commissionmay exempt from the filing requirement of subdivision 1 of subsection B ofthis section those activities having a minimal effect.

(1980, c. 720, 38.1-866; 1986, c. 562; 1990, c. 224; 1992, c. 481; 2003,cc. 752, 767.)