A. Notwithstanding any provision of § 38.2-3406.1 or 38.2-3411.1 or any other section of this title to the contrary, a health carrier shall provide coverage for preventive services and shall not impose any cost-sharing requirements such as a copayment, coinsurance, or deductible.
B. A health carrier shall provide coverage for any items or services under the most current recommendations and guidelines within the scope of preventive services as required by the PPACA as in effect on January 1, 2019.
C. 1. A health carrier may impose cost-sharing requirements with respect to an office visit if an item or service is billed separately or is tracked as individual encounter data separately from the office visit.
2. A health carrier shall not impose cost-sharing requirements with respect to an office visit if an item or service is not billed separately or is not tracked as individual encounter data separately from the office visit and the primary purpose of the office visit is the delivery of the item or service.
3. A health carrier may impose cost-sharing requirements with respect to an office visit if an item or service is not billed separately or is not tracked as individual encounter data separately from the office visit and the primary purpose of the office visit is not the delivery of the item or service.
D. Nothing in this section shall preclude a health carrier that has a network of providers from imposing cost-sharing requirements for items or services that are delivered by an out-of-network provider.
E. This section shall apply to any health carrier providing individual or group health insurance coverage, except for any grandfathered plan.
2011, c. 882; 2013, c. 751; 2020, c. 1160.
Structure Code of Virginia
Chapter 34 - Provisions Relating to Accident and Sickness Insurance
§ 38.2-3400. Application of chapter
§ 38.2-3401. Forms of insurance authorized
§ 38.2-3402. Certification to accompany application
§ 38.2-3403. Fraudulent procurement of policy
§ 38.2-3405.1. Commonwealth's right to certain accident and sickness benefits
§ 38.2-3406. Accident and sickness benefits not subject to legal process
§ 38.2-3406.2. Capped benefits under insurance policies and contracts
§ 38.2-3407. Health benefit programs
§ 38.2-3407.1. Interest on accident and sickness claim proceeds
§ 38.2-3407.2. Coverage for medical child support
§ 38.2-3407.3. Calculation of cost-sharing provisions
§ 38.2-3407.3:1. Premium payment arrearages; order of crediting payments
§ 38.2-3407.4. Explanation of benefits
§ 38.2-3407.4:2. Requirements for prescription benefit cards
§ 38.2-3407.5. Denial of benefits for certain prescription drugs prohibited
§ 38.2-3407.5:1. Coverage for prescription contraceptives
§ 38.2-3407.5:2. Reimbursements for dispensing hormonal contraceptives
§ 38.2-3407.6. Exclusion of podiatrist not permitted under certain circumstances
§ 38.2-3407.6:1. Denial of benefits for certain prescription drugs prohibited
§ 38.2-3407.7. Pharmacies; freedom of choice
§ 38.2-3407.9. Reimbursement for emergency medical services vehicle transportation services
§ 38.2-3407.9:01. Prescription drug formularies
§ 38.2-3407.9:02. Requirement for prescription drug coverage
§ 38.2-3407.9:03. Payment of clean claims to administrators of pharmacy benefits
§ 38.2-3407.9:04. Medication synchronization
§ 38.2-3407.9:05. Step therapy protocols
§ 38.2-3407.10. Health care provider panels
§ 38.2-3407.10:2. Credentialing of private mental health agencies
§ 38.2-3407.11. Access to obstetrician-gynecologists
§ 38.2-3407.11:1. Access to specialists; standing referrals
§ 38.2-3407.11:2. Standing referral for cancer patients
§ 38.2-3407.11:3. Breast cancer underwriting and preexisting condition restrictions
§ 38.2-3407.11:4. Disability arising out of childbirth; minimum benefit
§ 38.2-3407.11:5. Interhospital transfer for newborn or mother; prior authorization prohibited
§ 38.2-3407.12. Patient optional point-of-service benefit
§ 38.2-3407.13. Refusal to accept assignments prohibited; dentists and oral surgeons
§ 38.2-3407.13:1. Coordination of benefits; notice of priority of coverage
§ 38.2-3407.13:2. Claims paid to insureds for services from nonparticipating physicians
§ 38.2-3407.14. Notice of premium or deductible increases
§ 38.2-3407.15. Ethics and fairness in carrier business practices
§ 38.2-3407.15:2. Carrier contracts; required provisions regarding prior authorization
§ 38.2-3407.15:4. Limit on copayment for prescription drugs; permitted disclosures
§ 38.2-3407.15:5. Limit on cost-sharing payments for prescription insulin drugs
§ 38.2-3407.15:6. Prescription drug price transparency
§ 38.2-3407.16. Requirements for obstetrical care
§ 38.2-3407.17. Payment for services by dentists and oral surgeons
§ 38.2-3407.17:1. Payment and reimbursement practices for dental services; network access
§ 38.2-3407.18. Requirements for orally administered cancer chemotherapy drugs
§ 38.2-3407.19. Payment for services by optometrists and ophthalmologists
§ 38.2-3407.21. Short-term limited-duration medical plans
§ 38.2-3407.22. Option for rebates to enrollees; protected information
§ 38.2-3409. Coverage of dependent children
§ 38.2-3410. Construction of policy generally; words "physician" and "doctor" to include dentist
§ 38.2-3411. Coverage of newborn children required
§ 38.2-3411.1. Coverage for child health supervision services
§ 38.2-3411.2. Coverage of adopted children required
§ 38.2-3411.3. Coverage for childhood immunizations
§ 38.2-3411.4. Coverage for infant hearing screening and related diagnostics
§ 38.2-3412.1. Coverage for mental health and substance use disorders
§ 38.2-3414. Optional coverage for obstetrical services
§ 38.2-3414.1. Obstetrical benefits; coverage for postpartum services
§ 38.2-3415. Exclusion or reduction of benefits for certain causes prohibited
§ 38.2-3417. Deductibles and coinsurance options required
§ 38.2-3418. Coverage for victims of rape or incest
§ 38.2-3418.1. Coverage for mammograms
§ 38.2-3418.1:2. Coverage for pap smears
§ 38.2-3418.2. Coverage of procedures involving bones and joints
§ 38.2-3418.3. Coverage for hemophilia and congenital bleeding disorders
§ 38.2-3418.4. Coverage for reconstructive breast surgery; notice; eligibility
§ 38.2-3418.5. Coverage for early intervention services
§ 38.2-3418.6. Minimum hospital stay for mastectomy and certain lymph node dissection patients
§ 38.2-3418.7. Coverage for PSA testing
§ 38.2-3418.7:1. Coverage for colorectal cancer screening
§ 38.2-3418.8. Coverage for clinical trials for treatment studies on cancer
§ 38.2-3418.9. Minimum hospital stay for hysterectomy
§ 38.2-3418.10. Coverage for diabetes
§ 38.2-3418.11. Coverage for hospice care
§ 38.2-3418.12. Coverage for hospitalization and anesthesia for dental procedures
§ 38.2-3418.13. Coverage for the treatment of morbid obesity
§ 38.2-3418.14. Coverage for lymphedema
§ 38.2-3418.15. Coverage for prosthetic devices and components
§ 38.2-3418.15:1. Coverage for prosthetic devices and components
§ 38.2-3418.16. Coverage for telemedicine services
§ 38.2-3418.17. Coverage for autism spectrum disorder
§ 38.2-3418.18. Coverage for formula and enteral nutrition products as medicine
§ 38.2-3418.19. Coverage for organ, eye or tissue transplant
§ 38.2-3418.20. Coverage for hearing aids and related services
§ 38.2-3419. Additional mandated coverage made optional to group policy or contract holder
§ 38.2-3419.1. Report of costs and utilization of mandated benefits
§ 38.2-3420. Authority and jurisdiction of Commission; exception
§ 38.2-3421. How to show jurisdiction of other state agency or federal government
§ 38.2-3423. When subject to this title
§ 38.2-3424. Disclosure of extent and elements of coverage
§ 38.2-3430.1. Application of article
§ 38.2-3430.1:1. Health insurance coverage not required
§ 38.2-3430.4. Special rules for network plans
§ 38.2-3430.5. Application of financial capacity limits
§ 38.2-3430.6. Market requirements
§ 38.2-3430.7. Renewability of individual health insurance coverage
§ 38.2-3430.8. Certification of coverage
§ 38.2-3430.9. Regulations establishing standards
§ 38.2-3430.10. Effective date
§ 38.2-3431. Application of article; definitions
§ 38.2-3432.3. Limitation on preexisting condition exclusion period
§ 38.2-3434. Disclosure of information
§ 38.2-3436. Eligibility to enroll
§ 38.2-3437. Rules used to determine group size
§ 38.2-3439. Dependent coverage for individuals to age 26
§ 38.2-3440. Lifetime and annual limits
§ 38.2-3442. Preventive services
§ 38.2-3443. Choice of a health care professional
§ 38.2-3444. Preexisting condition exclusions
§ 38.2-3445. Patient access to emergency services
§ 38.2-3445.01. Balance billing for certain services; prohibited
§ 38.2-3445.03. Data sets for determining commercially reasonable payments
§ 38.2-3445.06. Applicability of certain sections
§ 38.2-3445.07. Rules and regulations
§ 38.2-3445.2. Out-of-network claims; reporting requirements
§ 38.2-3446. Applicability of federal law
§ 38.2-3447. Restrictions relating to premium rates
§ 38.2-3448. Guaranteed availability
§ 38.2-3449. Prohibiting discrimination based on health status
§ 38.2-3450. Genetic information and testing
§ 38.2-3451. Essential health benefits
§ 38.2-3454. Wellness programs
§ 38.2-3454.1. Renewal of health benefit plans; special exception
§ 38.2-3456. Prohibited activities
§ 38.2-3457. Application for registration
§ 38.2-3458. Power of Commission to investigate navigators
§ 38.2-3462. Comparable Health Care Service Incentive Program
§ 38.2-3463. Health care price transparency tools
§ 38.2-3464. Rules and regulations; orders
§ 38.2-3467. Prohibited conduct by carriers and pharmacy benefits managers
§ 38.2-3468. Examination of books and records; reports; access to records
§ 38.2-3469. (Effective October 1, 2020) Enforcement; regulations