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Virginia Administrative Code
Title 14. Insurance
Agency 5. State Corporation Commission, Bureau of Insurance
Chapter 190. Rules Governing the Reporting of Cost and Utilization Data Relating to Mandated Benefits and Mandated Providers
12/23/2024

14VAC5-190-30. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Applicable policy" or "contract" means any accident and sickness insurance policy providing hospital, medical and surgical, or major medical coverage on an expense incurred basis or any accident and sickness subscription contract or evidence of coverage or any health care plan provided by a health maintenance organization issued or issued for delivery in the Commonwealth of Virginia.

"Covered lives" means the total number of covered lives reported by a health insurance issuer on the National Association of Insurance Commissioners (NAIC) Supplemental Health Care Exhibit for Individual Comprehensive Health Coverage, Small Group Employer Comprehensive Health Coverage, and Large Group Employer Comprehensive Health Coverage combined as defined in the NAIC Annual Statement Instructions, or equivalents in a successor form.

"Health insurance issuer" means an insurance company or insurance organization (including a health maintenance organization) that is licensed to engage in the business of insurance in the Commonwealth and is subject to the laws of the Commonwealth that regulate insurance within the meaning of § 514(b)(2) of the Employee Retirement Income Security Act of 1974 (29 USC § 1144 (b)(2)). Such term does not include a group health plan.

"Incurred claims" means the total losses sustained whether paid or unpaid.

"Mandated benefits" means those benefits that must be included or offered in policies delivered or issued for delivery in the Commonwealth as required by §§ 38.2-3409 through 38.2-3419 of the Code of Virginia.

"Mandated providers" means those practitioners that are listed in §§ 38.2-3408 and 38.2-4221 of the Code of Virginia.

"Paid claims" means the aggregate of loss payments, less deductions for all credits, except that no deduction is made for reinsurance recoveries, during a given period.

"Reporting period" means the two individual calendar years immediately preceding the May 1 reporting date, reported separately.

Statutory Authority

§§ 12.1-13 and 38.2-223 of the Code of Virginia.

Historical Notes

Derived from Regulation 38, Case No. INS910044, § 3, eff. October 1, 1991; amended, Case No. INS940147, Virginia Register Volume 11, Issue 8, eff. December 7, 1994; Volume 33, Issue 14, eff. March 1, 2017.

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