38.2-3407.3 - Calculation of cost-sharing provisions. - Virginia Statutes

§ 38.2-3407.3. Calculation of cost-sharing provisions.

A. An insurer, health services plan or health maintenance organization thatissues an accident and sickness insurance policy or contract pursuant towhich the insured, subscriber or enrollee is required to pay a specifiedpercentage of the cost of covered services, shall calculate such amountpayable based upon an amount not to exceed the total amount actually paid orpayable to the provider of such services for the services provided to theinsured, subscriber or enrollee. When an insured, subscriber or enrolleereceives covered services outside the insurer's, health services plan's orhealth maintenance organization's provider network, and such entity utilizesanother insurer's, health services plan's or health maintenanceorganization's provider network located outside the Commonwealth, such entitymay satisfy the obligation of this section by using the cost of services asreported by the out-of-state insurer, health services plan or healthmaintenance organization when calculating the insured's, subscriber's orenrollee's percentage of the cost of covered services.

B. Any insurer, health services plan or health maintenance organizationfailing to administer its contracts as set forth herein shall be deemed tohave committed a knowing and willful violation of this section, and shall bepunished as set forth in subsection A of § 38.2-218. Each claim payment foundto have been calculated in noncompliance with this section shall be deemed aseparate and distinct violation, and shall further be deemed a violationsubject to subdivision D 1 c of § 38.2-218, permitting the Commission torequire restitution in addition to any other penalties.

(1994, c. 320; 1997, c. 56; 1998, c. 49.)