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
3/1/2024

12VAC5-408-190. Covered person education and communication.

A. The MCHIP licensee shall make available to each covered person at the time of enrollment or at the time the contract or evidence of coverage is issued, as required by law and upon request thereafter, policies and procedures applicable to the covered person including, but not limited to:

1. A statement of covered person's rights and responsibilities;

2. Procedures for obtaining care including:

a. Referral and authorization requirements;

b. Primary care services;

c. Specialty care and hospital services;

d. Behavioral services, when the complexity of the covered person's condition requires the knowledge base and expertise beyond those of the primary care provider;

e. Emergency services and after-hours coverage, including access to emergency care, and any requirements for prior authorization and payment for out-of-service areas;

f. Care and coverage when out of the service area;

g. Out-of-network services; and

h. Pharmacy services;

3. Procedures concerning the complaint process and the process for appealing adverse decisions affecting covered person coverage benefits;

4. To the extent there are coverage restrictions for changing primary care providers, procedures for changing primary care and specialty care providers including any restrictions on changing providers;

5. All necessary mailing addresses and telephone numbers for seeking information or authorization;

6. The toll-free number for the complaint unit of the center; and

7. Notice of the right to obtain information on types of provider payment arrangements used to compensate providers for health care services rendered to covered persons, including, but not limited to, withholds, bonus payments, capitation, processing fees, and fee-for-service discounts.

B. Lists of all network providers shall be made available to covered persons as required in subsection G of § 38.2-3407.10 of the Code of Virginia.

C. There shall be a mechanism for providing covered person information in plain language that is clearly understood and in the languages of the major population groups served.

D. Covered persons shall be provided an opportunity for input regarding the service provided by the MCHIP and any mechanism for input shall be disclosed to them.

E. There shall be a mechanism for assisting covered persons affected by changes in the MCHIP licensee's service areas or network providers. Such mechanisms may include access to information through an internet website, a toll-free telephone number, an electronic copy of the MCHIP's current provider directory, newsletters or any combination thereof.

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.

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

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