As used in this article, unless the context requires a different meaning:

Terms Used In Virginia Code 38.2-3461

  • Accident and sickness insurance: means insurance against loss resulting from sickness, or from bodily injury or death by accident or accidental means, or from a combination of any or all of these perils. See Virginia Code 38.2-109
  • Allowed amount: means the contractually agreed upon amount paid or payable by a health carrier to a health care provider participating in the health carrier's network. See Virginia Code 38.2-3461
  • Commission: means the State Corporation Commission. See Virginia Code 38.2-100
  • Comparable health care service: means any (i) physical and occupational therapy service, (ii) radiology and imaging service, (iii) laboratory service, (iv) infusion therapy service, and (v) at the discretion of the health carrier, other health care service, provided that with respect to any service described in clauses (i) through (v) the service (a) is a covered non-emergency health care service or bundle of health care services provided by a network provider and (b) is a service for which the health carrier has not demonstrated that the allowed amount variation among participating providers is less than $50. See Virginia Code 38.2-3461
  • Contract: A legal written agreement that becomes binding when signed.
  • Health benefit plan: means a policy, contract, certificate, or agreement offered by a health carrier in the small group market to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Virginia Code 38.2-3461
  • Health care provider: means a health care professional or facility. See Virginia Code 38.2-3461
  • Health care service: means a service for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Virginia Code 38.2-3461
  • Health carrier: means an entity subject to the insurance laws and regulations of the Commonwealth and subject to the jurisdiction of the Commission that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an insurer licensed to sell accident and sickness insurance, a health maintenance organization, a health services plan, or any other entity providing a plan of health insurance, health benefits, or health care services. See Virginia Code 38.2-3461
  • Health services plan: means any arrangement for offering or administering health services or similar or related services by a corporation licensed under Chapter 42 of Title 59. See Virginia Code 38.2-100
  • Insurer: means an insurance company. See Virginia Code 38.2-100
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • Network provider: means a health care provider that has contracted with the health carrier, or with its contractor or subcontractor, to provide health care services to covered persons as a member of a network. See Virginia Code 38.2-3461
  • Person: means any association, aggregate of individuals, business, company, corporation, individual, joint-stock company, Lloyds type of organization, organization, partnership, receiver, reciprocal or interinsurance exchange, trustee or society. See Virginia Code 38.2-100
  • Program: means the comparable health care service incentive program established by a health carrier pursuant to this article. See Virginia Code 38.2-3461
  • Small group market: means the health insurance market under which individuals obtain health insurance coverage, directly or through any arrangement, on behalf of themselves and their dependents through a group health plan maintained by a small employer. See Virginia Code 38.2-3461
  • State: means any commonwealth, state, territory, district or insular possession of the United States. See Virginia Code 38.2-100
  • Subscriber: means a person obligated under a reciprocal insurance agreement. See Virginia Code 38.2-1201

“Allowed amount” means the contractually agreed upon amount paid or payable by a health carrier to a health care provider participating in the health carrier’s network.

“Average” means mean, median, or mode.

“Comparable health care service” means any (i) physical and occupational therapy service, (ii) radiology and imaging service, (iii) laboratory service, (iv) infusion therapy service, and (v) at the discretion of the health carrier, other health care service, provided that with respect to any service described in clauses (i) through (v) the service (a) is a covered non-emergency health care service or bundle of health care services provided by a network provider and (b) is a service for which the health carrier has not demonstrated that the allowed amount variation among participating providers is less than $50.

“Covered person” means a policyholder, subscriber, participant, or other individual covered by a health benefit plan.

“Health benefit plan” means a policy, contract, certificate, or agreement offered by a health carrier in the small group market to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. “Health benefit plan” does not include the “excepted benefits” as defined in § 38.2-3431. “Health benefit plan” does not include any health insurance plan administered by the Department of Human Resource Management, including the health coverage offered to state employees pursuant to § 2.2-2818; health insurance coverage offered to employees of local governments, local officers, teachers, and retirees, and the dependents of such employees, local officers, teachers and retirees pursuant to § 2.2-1204; or health insurance coverage provided under the Line of Duty Act (§ 9.1-400 et seq.).

“Health care provider” means a health care professional or facility.

“Health care service” means a service for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.

“Health carrier” means an entity subject to the insurance laws and regulations of the Commonwealth and subject to the jurisdiction of the Commission that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an insurer licensed to sell accident and sickness insurance, a health maintenance organization, a health services plan, or any other entity providing a plan of health insurance, health benefits, or health care services.

“Network” or “provider network” means the group of participating providers providing services to a health benefit plan under which the financing and delivery of health care services are provided, in whole or in part, through a defined set of health care providers.

“Network provider” means a health care provider that has contracted with the health carrier, or with its contractor or subcontractor, to provide health care services to covered persons as a member of a network.

“Out-of-pocket costs” means any copayment, deductible, or coinsurance that is the responsibility of the covered person with respect to a covered health care service.

“Program” means the comparable health care service incentive program established by a health carrier pursuant to this article.

“Small group market” means the health insurance market under which individuals obtain health insurance coverage, directly or through any arrangement, on behalf of themselves and their dependents through a group health plan maintained by a small employer.

2019, cc. 666, 684.

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