Sections
Article 1 General Provisions 38.2-3400 – 38.2-3407.22
Article 2 Mandated Benefits 38.2-3408 – 38.2-3419.1
Article 3 Jurisdiction over Providers of Health Care Services 38.2-3420 – 38.2-3424.1
Article 4 1. Individual Health Insurance Coverage 38.2-3430.1 – 38.2-3430.10
Article 5 Group Market Reforms and Individual Coverage Offered to Employees of Small Employers 38.2-3431 – 38.2-3437
Article 6 Federal Market Reforms 38.2-3438 – 38.2-3454.1
Article 7 Navigators 38.2-3455 – 38.2-3460
Article 8 Health Care Shared Savings 38.2-3461 – 38.2-3464
Article 9 Pharmacy Benefits Managers 38.2-3465 – 38.2-3470

Terms Used In Virginia Code > Title 38.2 > Chapter 34 - Provisions Relating to Accident and Sickness Insurance

  • 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
  • Adult: means a person 18 years of age or more. See Virginia Code 1-203
  • 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
  • Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
  • Annuities: means all agreements to make periodic payments in specified or calculable sums pursuant to the terms of a contract for a stated period of time or for the life of the person or persons specified in the contract. See Virginia Code 38.2-106
  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Articles of trust: includes the original articles of trust, the original certificate of trust issued by the Commission, and all amendments to the articles of trust. See Virginia Code 13.1-1201
  • Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
  • Attachment: A procedure by which a person's property is seized to pay judgments levied by the court.
  • Attorney: means the person designated and authorized by subscribers as the attorney-in-fact having authority to obligate them on reciprocal insurance contracts. See Virginia Code 38.2-1201
  • Authority: means an authority created under the provisions of § 15. See Virginia Code 15.2-5101
  • Average: means mean, median, or mode. See Virginia Code 38.2-3461
  • Bankruptcy: Refers to statutes and judicial proceedings involving persons or businesses that cannot pay their debts and seek the assistance of the court in getting a fresh start. Under the protection of the bankruptcy court, debtors may discharge their debts, perhaps by paying a portion of each debt. Bankruptcy judges preside over these proceedings.
  • Beneficial owner: means any owner of a beneficial interest in a business trust, the fact of ownership to be determined and evidenced, whether by means of registration, the issuance of certificates or otherwise, in conformity to the applicable provisions of the governing instrument of the business trust. See Virginia Code 13.1-1201
  • Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
  • Bonds: means any bonds, interim certificates, notes, debentures, or other obligations of the authority issued pursuant to this chapter. See Virginia Code 15.2-5301
  • Bureau of Insurance: means the division of the Commission established to administer the insurance laws of the Commonwealth. See Virginia Code 38.2-100
  • business of insurance: include solicitation, negotiations preliminary to execution, execution of an insurance contract, and the transaction of matters subsequent to execution of the contract and arising out of it. See Virginia Code 38.2-100
  • Business trust: includes , without limitation, any of the following entities that conform with subdivisions 1 and 2 of this definition:

    (1) A trust of the type known at common law as a "business trust" or "Massachusetts trust";

    (2) A trust qualifying as a real estate mortgage investment conduit under § 860 D of the United States Internal Revenue Code of 1986, as amended, or under any successor provision;

    (3) A trust qualifying as a real estate investment trust under §§ 856 through 859 of the United States Internal Revenue Code of 1986, as amended, or under any successor provision; or

    (4) A "real estate investment trust" or "trust" created under former Chapter 9 of Title 6 or former Chapter 9 of Title 6. See Virginia Code 13.1-1201

  • City: means both cities and counties, and city-specific terms such as "mayor" shall be deemed to also include the equivalent county term. See Virginia Code 15.2-5301
  • Claim: means a request from a pharmacy or pharmacist to be reimbursed for the cost of administering, filling, or refilling a prescription for a drug or for providing a medical supply or device. See Virginia Code 38.2-3465
  • Claims processing services: means the administrative services performed in connection with the processing and adjudicating of claims relating to pharmacist services that include (i) receiving payments for pharmacist services, (ii) making payments to pharmacists or pharmacies for pharmacist services, or (iii) both receiving and making payments. See Virginia Code 38.2-3465
  • Commission: means the State Corporation Commission of Virginia. See Virginia Code 13.1-1201
  • Commission: means the State Corporation Commission. See Virginia Code 38.2-100
  • Commissioner: means one of the members of an authority appointed in accordance with the provisions of this chapter. See Virginia Code 15.2-5301
  • Commissioner of Insurance: means the administrative or executive officer of the Bureau. See Virginia Code 38.2-100
  • Company: means any association, aggregate of individuals, business, 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
  • 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
  • Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
  • Continuance: Putting off of a hearing ot trial until a later time.
  • Contract: A legal written agreement that becomes binding when signed.
  • Contract pharmacy: means a pharmacy operating under contract with a 340B-covered entity to provide dispensing services to the 340B-covered entity, as described in 75 Fed. See Virginia Code 38.2-3465
  • Conviction: A judgement of guilt against a criminal defendant.
  • 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.
  • Council: means the governing body of a city or town. See Virginia Code 15.2-102
  • County: means any existing county or such unit hereafter created. See Virginia Code 15.2-102
  • Covered entity: means an entity described in § 340B(a)(4) of the federal Public Health Service Act, 42 U. See Virginia Code 38.2-3465
  • Covered individual: means an individual receiving prescription medication coverage or reimbursement provided by a pharmacy benefits manager or a carrier under a health benefit plan. See Virginia Code 38.2-3465
  • Covered person: means a policyholder, subscriber, participant, or other individual covered by a health benefit plan. See Virginia Code 38.2-3461
  • Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
  • Dependent: A person dependent for support upon another.
  • Electronic funds transfer: The transfer of money between accounts by consumer electronic systems-such as automated teller machines (ATMs) and electronic payment of bills-rather than by check or cash. (Wire transfers, checks, drafts, and paper instruments do not fall into this category.) Source: OCC
  • Eligible individual: means an individual:

    1. See Virginia Code 38.2-3430.2

  • employer contribution rule: means a requirement relating to the minimum level or amount of employer contribution toward the premium for enrollment of eligible individuals and the term "group participation rule" means a requirement relating to the minimum number of eligible employees that must be enrolled in relation to a specified percentage or number of eligible employees. See Virginia Code 38.2-3432.2
  • Entity: includes any domestic or foreign business trust or other business entity, any estate or trust, and any state, the United States, and any foreign government. See Virginia Code 13.1-1201
  • Equitable: Pertaining to civil suits in "equity" rather than in "law." In English legal history, the courts of "law" could order the payment of damages and could afford no other remedy. See damages. A separate court of "equity" could order someone to do something or to cease to do something. See, e.g., injunction. In American jurisprudence, the federal courts have both legal and equitable power, but the distinction is still an important one. For example, a trial by jury is normally available in "law" cases but not in "equity" cases. Source: U.S. Courts
  • Exchange: means either a (i) federal health benefit exchange established by the Secretary of the U. See Virginia Code 38.2-3455
  • Federal government: means the United States of America or any agency or instrumentality, corporate or otherwise, of the United States of America. See Virginia Code 15.2-5301
  • Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
  • Foreign business trust: means a trust formed under the law of a jurisdiction other than the Commonwealth that would be a business trust if formed under the law of the Commonwealth. See Virginia Code 13.1-1201
  • Fraud: Intentional deception resulting in injury to another.
  • Garnishment: Generally, garnishment is a court proceeding in which a creditor asks a court to order a third party who owes money to the debtor or otherwise holds assets belonging to the debtor to turn over to the creditor any of the debtor
  • Gift: A voluntary transfer or conveyance of property without consideration, or for less than full and adequate consideration based on fair market value.
  • Governing body: means the board of supervisors of a county, council of a city, or council of a town, as the context may require. See Virginia Code 15.2-102
  • Governing instrument: means a trust instrument that creates a business trust and provides for the governance of the affairs of the business trust and the conduct of its business, including, without limitation, a declaration of trust. See Virginia Code 13.1-1201
  • Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
  • 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
  • hospital authority: means a body corporate organized in accordance with the provisions of this chapter for the purposes, with the powers and subject to the restrictions hereinafter set forth. See Virginia Code 15.2-5301
  • Includes: means includes, but not limited to. See Virginia Code 1-218
  • inhabitants: means with reference to any county, city, town, political subdivision of the Commonwealth or any combination thereof, the natural persons in such county, city, town, political subdivision or combination as shown by the unadjusted United States decennial census last preceding the time at which any provision dependent upon population is being applied or the time as of which it is being construed. See Virginia Code 1-235
  • insurance policies: shall include contracts of fidelity, indemnity, guaranty and suretyship. See Virginia Code 38.2-100
  • Insurer: means an insurance company. See Virginia Code 38.2-100
  • Joint committee: Committees including membership from both houses of teh legislature. Joint committees are usually established with narrow jurisdictions and normally lack authority to report legislation.
  • 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.
  • Jurisdiction of formation: means the state or country the law of which includes the organic law governing a domestic or foreign business trust or other business entity. See Virginia Code 13.1-1201
  • 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
  • Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity.
  • Lien: A claim against real or personal property in satisfaction of a debt.
  • Life insurance: includes policies that also provide (i) endowment benefits; (ii) additional benefits incidental to a loss in the event of death, dismemberment, or loss by accident or accidental means; (iii) additional benefits to safeguard the contract from lapse or to provide a special surrender value, a special benefit or an annuity, in the event of total and permanent disability of the insured; and (iv) optional modes of settlement of proceeds. See Virginia Code 38.2-102
  • Litigation: A case, controversy, or lawsuit. Participants (plaintiffs and defendants) in lawsuits are called litigants.
  • Locality: means a county, city, or town as the context may require. See Virginia Code 1-221
  • Mail order pharmacy: means a pharmacy whose primary business is to receive prescriptions by mail or through electronic submissions and to dispense medication to covered individuals through the use of the United States mail or other common or contract carrier services and that provides any consultation with covered individuals electronically rather than face-to-face. See Virginia Code 38.2-3465
  • mayor: shall be deemed to also include the equivalent county term. See Virginia Code 15.2-5301
  • Medicare: means the "Health Insurance for the Aged Act" Title XVIII of the Social Security Amendment of 1965, as amended. See Virginia Code 38.2-100
  • Month: means a calendar month and "year" means a calendar year. See Virginia Code 1-223
  • Mortgage: The written agreement pledging property to a creditor as collateral for a loan.
  • Navigator: means an individual or entity described in 42 U. See Virginia Code 38.2-3455
  • 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
  • Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
  • obligee: includes any bondholder, trustee or trustees for any bondholders, any lessor demising property to the authority used in connection with a hospital project or any assignee or assignees of such lessor's interest or any part thereof, and the United States of America when it is a party to any contract with the authority. See Virginia Code 15.2-5301
  • 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. See Virginia Code 38.2-3461
  • Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
  • PBM: means an entity that performs pharmacy benefits management. See Virginia Code 38.2-3465
  • 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
  • Pharmacy benefits management: means the administration or management of prescription drug benefits provided by a carrier for the benefit of covered individuals. See Virginia Code 38.2-3465
  • Pharmacy benefits manager: includes an entity acting for a PBM in a contractual relationship in the performance of pharmacy benefits management for a carrier, nonprofit hospital, or third-party payor under a health program administered by the Commonwealth. See Virginia Code 38.2-3465
  • Pharmacy benefits manager affiliate: means a business, pharmacy, or pharmacist that directly or indirectly, through one or more intermediaries, owns or controls, is owned or controlled by, or is under common ownership interest or control with a pharmacy benefits manager. See Virginia Code 38.2-3465
  • Probation: A sentencing alternative to imprisonment in which the court releases convicted defendants under supervision as long as certain conditions are observed.
  • Program: means the comparable health care service incentive program established by a health carrier pursuant to this article. See Virginia Code 38.2-3461
  • project: means any and all medical facilities and approaches thereto and appurtenances thereof. See Virginia Code 15.2-5301
  • 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. See Virginia Code 38.2-3461
  • Qualified dental plan: means a limited scope dental plan that has in effect a certification that the plan meets the criteria for certification described in § 1311(d)(2)(B)(ii) of the Patient Protection and Affordable Care Act, P. See Virginia Code 38.2-3455
  • Qualified health plan: means a health benefit plan that has in effect a certification that the plan meets the criteria for certification described in § 1311(c) of the Patient Protection and Affordable Care Act, P. See Virginia Code 38.2-3455
  • Quorum: The number of legislators that must be present to do business.
  • rates: means any rate of premium, policy fee, membership fee or any other charge made by an insurer for or in connection with a contract or policy of insurance. See Virginia Code 38.2-100
  • Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
  • Rescission: The cancellation of budget authority previously provided by Congress. The Impoundment Control Act of 1974 specifies that the President may propose to Congress that funds be rescinded. If both Houses have not approved a rescission proposal (by passing legislation) within 45 days of continuous session, any funds being withheld must be made available for obligation.
  • Restitution: The court-ordered payment of money by the defendant to the victim for damages caused by the criminal action.
  • Secretary: means the Secretary of the U. See Virginia Code 38.2-3455
  • Service of process: The service of writs or summonses to the appropriate party.
  • 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
  • Spread pricing: means the model of prescription drug pricing in which the pharmacy benefits manager charges a health benefit plan a contracted price for prescription drugs, and the contracted price for the prescription drugs differs from the amount the pharmacy benefits manager directly or indirectly pays the pharmacist or pharmacy for pharmacist services. See Virginia Code 38.2-3465
  • State: means any commonwealth, state, territory, district or insular possession of the United States. See Virginia Code 38.2-100
  • state agency: means the same as that term is defined in § 2. See Virginia Code 1-206
  • Statute: A law passed by a legislature.
  • Subscriber: means a person obligated under a reciprocal insurance agreement. See Virginia Code 38.2-1201
  • Supreme Court: means the Supreme Court of Virginia. See Virginia Code 1-249
  • Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
  • Trust: includes a common law trust, business trust, and foreign business trust. See Virginia Code 13.1-1201
  • Trust indenture: includes instruments pledging the revenues of real or personal properties but not conveying such properties or conferring a right to foreclose and cause a sale thereof. See Virginia Code 15.2-5301
  • Trustee: means a person appointed as a trustee in accordance with the governing instrument of a business trust. See Virginia Code 13.1-1201
  • Trustee: A person or institution holding and administering property in trust.
  • Veto: The procedure established under the Constitution by which the President/Governor refuses to approve a bill or joint resolution and thus prevents its enactment into law. A regular veto occurs when the President/Governor returns the legislation to the house in which it originated. The President/Governor usually returns a vetoed bill with a message indicating his reasons for rejecting the measure. In Congress, the veto can be overridden only by a two-thirds vote in both the Senate and the House.
  • Writ: A formal written command, issued from the court, requiring the performance of a specific act.