2006 Code of Virginia § 38.2-5800 - Definitions

38.2-5800. Definitions.

As used in this chapter:

"Accident and sickness insurance company" means a person subject tolicensing in accordance with provisions in Chapter 10 ( 38.2-1000 et seq.)or Chapter 41 ( 38.2-4100 et seq.) of this title seeking or havingauthorization (i) to issue accident and sickness insurance as defined in 38.2-109, (ii) to issue the benefit certificates or policies of accident andsickness insurance described in 38.2-3801, or (iii) to provide hospital,medical and nursing benefits pursuant to 38.2-4116 and 38.2-4123.

"Affiliated provider" means any provider that is employed by or has enteredinto a contractual agreement either directly or indirectly with a healthcarrier to provide health care services to members of a managed care healthinsurance plan for which the health carrier is responsible under this chapter.

"Basic health care services" means emergency services, inpatient hospitaland physician care, outpatient medical services, laboratory and radiologicalservices, and preventive health services. "Basic health care services"shall also mean limited treatment of mental illness and substance abuse asset forth in 38.2-3412.1 or in the case of a health maintenanceorganization shall be in accordance with such minimum standards set by theCommission which shall not exceed the level of services mandated forinsurance carriers pursuant to Chapter 34 ( 38.2-3400 et seq.) of this title.

"Copayment" means a payment required of covered persons as a condition ofthe receipt of specific health services.

"Covered person" means an individual, whether a policyholder, subscriber,enrollee, or member of a managed care health insurance plan (MCHIP) who isentitled to health care services or benefits provided, arranged for, paid foror reimbursed pursuant to an MCHIP.

"Evidence of coverage" includes any certificate, individual or groupagreement or contract or related documents issued in conjunction with thecertificate, agreement or contract, issued to a subscriber setting out thecoverage and other rights to which a covered person is entitled.

"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 carrier" means an entity subject to Title 38.2 that contracts oroffers to contract to provide, deliver, arrange for, pay for or reimburse anyof the costs of health care services, including an entity providing a plan ofhealth insurance, health benefits or health services, an accident andsickness insurance company, a health maintenance organization, or a nonstockcorporation offering or administering a health services plan, a hospitalservices plan, or a medical or surgical services plan, or operating a plansubject to regulation under Chapter 45 ( 38.2-4500 et seq.) of this title.

"Health maintenance organization" means a person licensed pursuant toChapter 43 ( 38.2-4300 et seq.) of this title.

"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.

"Managed care health insurance plan" or "MCHIP" means an arrangement forthe delivery of health care in which a health carrier undertakes to provide,arrange for, pay for, or reimburse any of the costs of health care servicesfor a covered person on a prepaid or insured basis which (i) contains one ormore incentive arrangements, including any credentialing requirementsintended to influence the cost or level of health care services between thehealth carrier and one or more providers with respect to the delivery ofhealth care services and (ii) requires or creates benefit paymentdifferential 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 MCHIPs. Forthe purposes of this definition, the prohibition of balance billing by aprovider shall not be deemed a benefit payment differential incentive forcovered persons to use providers who are directly or indirectly managed,owned, under contract with or employed by the health carrier. A singlemanaged care health insurance plan may encompass multiple products andmultiple types of benefit payment differentials; however, a single managedcare health insurance plan shall encompass only one provider network or setof provider networks.

"Medical necessity" or "medically necessary" means appropriate andnecessary health care services which are rendered for any condition which,according to generally accepted principles of good medical practice, requiresthe diagnosis or direct care and treatment of an illness, injury, orpregnancy-related condition, and are not provided only as a convenience.

"Network" means the set of providers directly or indirectly managed, owned,under contract with or employed directly or indirectly by a health carrierfor the purpose of delivering health care services to the covered persons ofan MCHIP.

"Provider" or "health care provider" means any hospital, physician, orother person authorized by statute, licensed or certified to furnish healthcare services.

"Service area" means a clearly defined geographic area in which a healthcarrier has directly or indirectly arranged for the provision of health careservices to be generally available and readily accessible to covered personsof an MCHIP.

(1998, c. 891; 2006, c. 448.)