Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 408. Certificate of Quality Assurance of Managed Care Health Insurance Plan Licensees

12VAC5-408-120. Changes to geographic service areas.

A. No MCHIP shall operate in a manner that varies in a material manner with the geographic service area information submitted pursuant to this chapter. Any changes in such information which would result in operational changes that vary in a material manner with the information currently on file with the department shall be subject to the department's prior approval.

B. The request for a material change in a geographic service area shall include:

1. A description of the current geographic service area including a map of the current service area, a list of current primary care and specialty physicians and other providers, and the number of covered persons by service area.

2. An explanation as to whether the MCHIP is requesting an expansion or a reduction in its service area.

3. Notification that the MCHIP licensee has inquired of the Bureau of Insurance as to whether or not the service area request constitutes a material change and the bureau's determination, if available.

4. If a service area expansion is proposed, then the following is required:

a. A description of the service area that includes a map of the geographic service area expansion, projections of new enrollment, a listing of new primary care and specialty providers and other providers and their locations, and physician capacity to accept the anticipated enrollment;

b. Information necessary to determine if the MCHIP licensee will be capable of conforming to the access, availability, and travel requirements of 12VAC5-408-260 and 12VAC5-408-270; and

c. The methodology used to determine that the current health care system in the proposed service area can support the expansion.

5. If an MCHIP is reducing or eliminating a service area, the following information is required:

a. A description of the service area being reduced or eliminated;

b. The reason for the reduction or elimination of the service area and the effective date on which health care services will no longer be available through the MCHIP; and

c. Any information required by the department to determine that MCHIP covered persons are ensured continuity of care during the transition.

C. If the department fails to act on a notice of material change within 30 days of receipt of filing all necessary information, the proposed changes shall be deemed approved. The department, at its discretion, may extend the period of time within which to approve or disapprove the proposed changes for up to an additional 30 days. Licensees shall be notified in writing of any such extensions.

Statutory Authority

§ 32.1-137.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 16, Issue 7, eff. January 20, 2000; amended, Virginia Register Volume 18, Issue 8, eff. January 30, 2002.

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