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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
11/5/2024

12VAC5-408-50. Compliance provisions appropriate for type of plan.

A. Managed care health insurance plan licensees that offer one or more PPO plans as defined in this chapter must require their PPO plans to only comply with the following sections:

1. Parts I (12VAC5-408-10 et seq.) and II (12VAC5-408-160 et seq.) of this chapter;

2. Part III (12VAC5-408-220 et seq.) of this chapter except for subdivision 1 of 12VAC5-408-220 and subdivisions 2 and 10 of 12VAC5-408-240;

3. 12VAC5-408-260 through 12VAC5-408-280 of this chapter except subsection E of 12VAC5-408-260, subsections D and E of 12VAC5-408-270 and subsection G of 12VAC5-408-280; and

4. Parts VI (12VAC5-408-320 et seq.) and VII (12VAC5-408-360) of this chapter.

The MCHIP licensee may comply with 12VAC5-408-170, 12VAC5-408-200, as well as subdivisions A 2 through A 4 of this section, by demonstrating it operates a PPO plan in conformity with the standards of a nationally recognized accrediting body applicable to preferred provider organizations and acceptable to the department. While such demonstration shall be considered reasonable and adequate compliance for purposes of initial and renewal MCHIP certification, the department may employ a checklist to identify and determine compliance with specific statutory or regulatory requirements that are more stringent than the nationally recognized accrediting body standards.

B. Managed care health insurance plan licensees other than PPO plans, including health maintenance organizations, must comply with this entire chapter. The MCHIP licensee may comply with 12VAC5-408-170, 12VAC5-408-200, 12VAC5-408-210, as well as Parts III through VII (12VAC5-408-220 through 12VAC5-408-360) of this chapter by demonstrating that the MCHIP licensee operates in conformity with the standards of a nationally recognized accrediting body that are appropriate for the type of MCHIP corresponding to the licensee and acceptable to the department. Such demonstration shall be considered reasonable and adequate compliance for purposes of initial and renewal MCHIP certification. Nothing in the preceding sentences shall preclude the department from imposing further requirements if the regulatory requirements are more stringent than the nationally recognized accrediting body's standards.

C. Accreditation by a nationally recognized accrediting body shall satisfy the department in demonstrating that the MCHIP licensee operates in conformity with the standards of a nationally recognized accrediting body as permitted under subsection A or B of this section, provided the MCHIP licensee follows the provisions of 12VAC5-408-100 to be eligible for exemption from examination. Otherwise, an MCHIP that is not accredited shall be subject to the triennial comprehensive onsite examination requirements of 12VAC5-408-90. Nothing in the preceding sentences shall preclude the department from imposing further requirements if the regulatory requirements are more stringent than the nationally recognized accrediting body's standards.

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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