Administrative Code

Virginia Administrative Code
Title 14. Insurance
Agency 5. State Corporation Commission, Bureau of Insurance
1/23/2020

Chapter 190. Rules Governing the Reporting of Cost and Utilization Data Relating to Mandated Benefits and Mandated Providers

14VAC5-190-10. Purpose.

The purpose of this regulation is to implement § 38.2-3419.1 of the Code of Virginia with respect to mandated health insurance benefits and providers. This regulation is designed to:

1. Provide the format for the reporting of costs and utilization associated with mandated benefits and providers;

2. Define the information that is required to be reported; and

3. Describe general data reporting elements related to costs and utilization associated with mandated benefits and mandated providers.

Statutory Authority

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

Historical Notes

Derived from Regulation 38, Case No. INS910044, § 1, 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.

14VAC5-190-20. Scope.

This regulation shall apply to every health insurance issuer licensed to issue policies of accident and sickness insurance, subscription contracts, or evidences of coverage in this Commonwealth.

Statutory Authority

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

Historical Notes

Derived from Regulation 38, Case No. INS910044, § 2, 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.

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.

14VAC5-190-40. (Repealed.)

Historical Notes

Derived from Regulation 38, Case No. INS910044, § 4, eff. October 1, 1991; amended, Case No. INS940147, Virginia Register Volume 11, Issue 8, eff. December 7, 1994; repealed, Virginia Register Volume 33, Issue 14, eff. March 1, 2017.

14VAC5-190-50. Reporting and filing requirements.

A. Beginning May 1, 2018, and every other year thereafter, any health insurance issuer licensed to issue an applicable policy or contract in the Commonwealth of Virginia who reported greater than 5,000 covered lives in Virginia during either of the individual calendar years comprising the reporting period shall file with the Bureau of Insurance a separate Form 190-A report for each calendar year in the reporting period.

B. The Form 190-A report may be obtained on the Bureau of Insurance's webpage at http://www.scc.virginia.gov/boi/co/health/mandben.aspx, and shall be filed electronically in accordance with the instructions that appear on the Bureau of Insurance's webpage.

Statutory Authority

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

Historical Notes

Derived from Regulation 38, Case No. INS910044, § 5, 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.

14VAC5-190-60. Annual notification and modification of reporting form.

The Bureau of Insurance shall be permitted to modify the data requirements of the Form 190-A report and data reporting instructions on an annual basis. Any such modifications, including the addition of new benefit or provider categories as necessitated by the addition of new mandated benefit or provider requirements to the Code of Virginia, as well as instructions related to tracking and compiling data through medical procedure and diagnostic codes, shall be provided to the health insurance issuers described in 14VAC5-190-50 A via letter or on the Bureau of Insurance's webpage. Failure by an entity to receive or review such annual notification shall not be grounds for noncompliance with the reporting requirements set forth in this chapter.

Statutory Authority

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

Historical Notes

Derived from Regulation 38, Case No. INS910044, § 6, 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.

14VAC5-190-70. Penalties.

The failure by a health insurance issuer to file a substantially complete and accurate report as required by this chapter by the required date may be considered a willful violation and is subject to an appropriate penalty in accordance with §§ 38.2-218 and 38.2-219 of the Code of Virginia.

Statutory Authority

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

Historical Notes

Derived from Regulation 38, Case No. INS910044, § 7, 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.

14VAC5-190-80. Severability.

If any provision of these rules or the application thereof to any person or circumstances is for any reason held to be invalid, the remainder of these rules and the application of such provision to other persons or circumstances shall not be affected thereby.

Statutory Authority

§§ 12.1-13, 38.2-223 and 38.2-3419.1 of the Code of Virginia.

Historical Notes

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

APPENDIX A. (Repealed.)

APPENDIX B. (Repealed.)

Forms (14VAC5-190)

Form 190-A, Mandated Benefits Reporting Form for Virginia (undated), http://www.scc.virginia.gov/boi/co/health/mandben.aspx



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