Administrative Code

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Virginia Administrative Code
Title 14. Insurance
Agency 5. State Corporation Commission, Bureau of Insurance
Chapter 211. Rules Governing Health Maintenance Organizations

14VAC5-211-30. Covered and uncovered expenses.

A. Health maintenance organizations licensed in this Commonwealth shall report to the commission on a form prescribed by the commission all uncovered expenses for the three-month periods ending on December 31, March 31, June 30, and September 30 on or before March 1, May 15, August 15, and November 15, respectively, of each year. This statement of covered and uncovered expenses shall be filed with each annual and quarterly financial statement pursuant to § 38.2-4307.1 C of the Code of Virginia.

B. Each expense of a health maintenance organization that is owed or paid to a health care provider under contract with a health maintenance organization shall be considered a covered health care expense by that health maintenance organization if (i) the contract between the health maintenance organization and the health care provider contains the hold harmless clause required by § 38.2-5805 C 9 of the Code of Virginia and (ii) the expense falls within the scope of the hold harmless clause.

C. If there is an intermediary organization between the health maintenance organization and the health care providers, the hold harmless clause shall be amended to include nonpayment by either the health maintenance organization or the intermediary organization. The hold harmless clause shall be included in any contract between the intermediary organization and health care providers and in any contract between the health maintenance organization and the intermediary organization before health care expenses owed or paid to the intermediary organization shall be considered covered expenses.

D. A health maintenance organization may request permission from the commission to treat other types of expenses as covered expenses. The request shall be in writing and state the health maintenance organization's justification for the requested treatment. In no case shall a health maintenance organization treat an expense, other than those set forth in subsections B and C of this section, as a covered expense without the prior approval of the commission.

E. Each expense that is not a covered expense under this section shall be considered an uncovered expense.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. July 1, 2005.

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