A. The powers of a health maintenance organization shall include, but shall not be limited to, the following, provided that the activities comply with all applicable state statutes and regulations:

Terms Used In Virginia Code 38.2-4303

  • Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
  • Basic health care services: means in and out-of-area emergency services, inpatient hospital and physician care, outpatient medical services, laboratory and radiologic services, mental health and substance use disorder benefits, and preventive health services. See Virginia Code 38.2-4300
  • Commission: means the State Corporation Commission. See Virginia Code 38.2-100
  • Contract: A legal written agreement that becomes binding when signed.
  • Copayment: means an amount an enrollee is required to pay in order to receive a specific health care service. See Virginia Code 38.2-4300
  • Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
  • Deductible: means an amount an enrollee is required to pay out-of-pocket before the health care plan begins to pay the costs associated with health care services. See Virginia Code 38.2-4300
  • Health care plan: means any arrangement in which any person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services. See Virginia Code 38.2-4300
  • Health care services: means the furnishing of services to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability. See Virginia Code 38.2-4300
  • Health maintenance organization: means any person who undertakes to provide or arrange for one or more health care plans. See Virginia Code 38.2-4300
  • 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
  • Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). Source: OCC
  • Limited health care services: means dental care services, vision care services, and such other services as may be determined by the Commission to be limited health care services. See Virginia Code 38.2-4300
  • 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
  • State: means any commonwealth, state, territory, district or insular possession of the United States. See Virginia Code 38.2-100

1. The purchase, lease, construction, renovation, operation, or maintenance of hospitals, medical or other health care facilities, and their ancillary equipment and other property reasonably required for its principal office or for other purposes necessary in the transaction of the business of the organization;

2. The making of loans to (i) health care providers under contract with it in advancement of its health care plan or (ii) any corporation under its control for the purpose of acquiring or constructing medical or other health care facilities and hospitals or in advancement of its health care plan providing health care services to enrollees;

3. The furnishing of health care services through providers that are under contract with or employed by the health maintenance organization;

4. The contracting with any person for the performance on its behalf of certain functions including, but not limited to, marketing, enrollment and administration;

5. The contracting with an insurer or with a health services plan licensed in this Commonwealth, for the provision of insurance, indemnity, or reimbursement for the cost of health care services provided by the health maintenance organization;

6. The offering, in addition to basic health care services, of:

a. Additional health care services;

b. Indemnity benefits covering out-of-area services; and

c. Indemnity benefits, in addition to those relating to out-of-area services, provided through insurers or health services plans;

7. The offering of health care plans for limited health care services; and

8. The requirement for the enrollee to pay a deductible or copayment, or both, for any health care services offered pursuant to this chapter.

B. 1. A health maintenance organization shall file notice with the Commission within 30 days after the exercise of any power granted in subdivision 1 or 2 of subsection A of this section that exceeds one percent of the admitted assets of the organization or five percent of net worth, whichever is less. A health maintenance organization shall file notice, with adequate supporting information, with the Commission prior to the exercise of any power granted in subdivision 1 or 2 of subsection A of this section that exceeds five percent of the admitted assets of the organization or 25 percent of net worth, whichever is less. Any series of transactions occurring within a 12-month period that are sufficiently similar in nature to be reasonably construed as a single transaction shall be subject to the limitations set forth in this section. The Commission shall disapprove the exercise of power if the Commission believes such exercise of power would substantially and adversely affect the financial soundness of the health maintenance organization and endanger the health maintenance organization’s ability to meet its obligations. If the Commission does not disapprove the exercise of power within 30 days of the filing, it shall be deemed approved.

2. Upon application by the health maintenance organization, the Commission may exempt from the filing requirement of subdivision 1 of subsection B of this section those activities having a minimal effect.

1980, c. 720, § 38.1-866; 1986, c. 562; 1990, c. 224; 1992, c. 481; 2003, cc. 752, 767; 2008, c. 214.

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