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Virginia Administrative Code
Title 14. Insurance
Agency 5. State Corporation Commission, Bureau of Insurance
Chapter 135. Rules Governing Individual and Small Group Market Health Benefit Plans
11/24/2024

14VAC5-135-50. Prohibitions, limitations, and disclosures.

A. A health carrier shall not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, gender expression, sexual orientation, or status as a transgender individual. Nothing in this section shall be construed to prevent a health carrier from appropriately utilizing reasonable medical management techniques including medical necessity.

B. If a health carrier offers an optional benefit to a health benefit plan, the health carrier may file a separate schedule that includes the additional benefit and identify the health benefit plan to which the schedule applies. A different plan identification is necessary to distinguish the health benefit plan with the additional benefit.

C. A health carrier may offer a health benefit plan that does not include pediatric oral health benefits if:

1. The health carrier is reasonably assured that pediatric oral health benefits are available to the purchaser of the health benefit plan in accordance with § 38.2-3451 B of the Code of Virginia, and

2. The plan contains the following statement on the first page of the policy and bold:

"This policy does not provide the ACA-required pediatric oral health benefits."

D. If an individual policy contains a military service exclusion or a provision that suspends coverage during military service, the policy shall provide for a refund of unearned premium upon receipt of written notice of the military service.

E. A policy application shall not contain questions about any health-status related factors other than age and tobacco use.

F. A policy shall only be rated on age, tobacco use, geographic location, plan category, and whether the policy covers dependents in accordance with § 38.2-3447 of the Code of Virginia.

G. No policy shall contain a provision that allows for increase in premium or change in deductible except during renewal.

H. A health benefit plan shall not impose any preexisting condition exclusion.

I. Policy exclusions may be no more restrictive than allowed by the state-selected essential health benefits benchmark plan.

Statutory Authority

§ 38.2-223 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 39, Issue 10, eff. January 1, 2023.

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