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Virginia Administrative Code
Title 14. Insurance
Agency 5. State Corporation Commission, Bureau of Insurance
Chapter 405. Rules Governing Balance Billing for Out-of-Network Health Care Services
11/21/2024

14VAC5-405-80. Elective group health plans may opt-in.

A. An elective group health plan shall provide notice to the commission and to its third-party administrator of its opt-in decision on a form prescribed by the commission. The completed form must include an attestation that the elective group health plan has elected to participate in and be bound by §§ 38.2-3445 through 38.2-3445.07 of the Code of Virginia and this chapter, except as described in subsection E of this section. The form will be posted on the commission's public website for use by elective group health plans.

B. An elective group health plan shall reflect in its coverage documents its participation pursuant to subsection A of this section. The elective group health plan or plan administrator shall submit the required form electronically to the commission at least 30 days prior to the effective date. No other documents are required to be filed with the commission.

C. An elective group health plan may elect to initiate its participation on January 1 of any year or in any year on the first day of the elective group health plan's plan year.

D. An elective group health plan's election occurs on an annual basis. An elective group health plan may choose to automatically renew its election to opt in to §§ 38.2-3445 through 38.2-3445.07 of the Code of Virginia on an annual basis or it may choose to renew on an annual basis until the commission receives advance notice from the plan that it is terminating its election as of either December 31 of a calendar year or the last day of its plan year. Notices under this subsection must be submitted to the commission at least 30 days in advance of the effective date of the election to initiate participation and the effective date of the termination of participation.

E. Elective group health plan sponsors and their third-party administrators may develop their own internal processes related to member notification, member appeals, and other functions associated with any fiduciary duty to enrollees under ERISA, if applicable.

F. A list of all elective group health plans shall be posted on the commission's public website, to be updated at least each quarter. Posted information shall include relevant plan information.

G. A carrier that administers an elective group health plan shall, at the time of coverage verification through electronic and other methods of communication generally used by a provider to verify enrollee eligibility and benefits information, make information available to a provider of the elective group health plan's participation in the provisions of this chapter.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 7, eff. January 1, 2021; Errata 37:10, 37:10 VA.R. January 4, 2021.

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