2.2-2818 - Health and related insurance for state employees.
§ 2.2-2818. Health and related insurance for state employees.
A. The Department of Human Resource Management shall establish a plan,subject to the approval of the Governor, for providing health insurancecoverage, including chiropractic treatment, hospitalization, medical,surgical and major medical coverage, for state employees and retired stateemployees with the Commonwealth paying the cost thereof to the extent of thecoverage included in such plan. The same plan shall be offered to allpart-time state employees, but the total cost shall be paid by such part-timeemployees. The Department of Human Resource Management shall administer thissection. The plan chosen shall provide means whereby coverage for thefamilies or dependents of state employees may be purchased. Except forpart-time employees, the Commonwealth may pay all or a portion of the costthereof, and for such portion as the Commonwealth does not pay, the employee,including a part-time employee, may purchase the coverage by paying theadditional cost over the cost of coverage for an employee.
Such contribution shall be financed through appropriations provided by law.
B. The plan shall:
1. Include coverage for low-dose screening mammograms for determining thepresence of occult breast cancer. Such coverage shall make available onescreening mammogram to persons age 35 through 39, one such mammogrambiennially to persons age 40 through 49, and one such mammogram annually topersons age 50 and over and may be limited to a benefit of $50 per mammogramsubject to such dollar limits, deductibles, and coinsurance factors as are noless favorable than for physical illness generally.
The term "mammogram" shall mean an X-ray examination of the breast usingequipment dedicated specifically for mammography, including but not limitedto the X-ray tube, filter, compression device, screens, film, and cassettes,with an average radiation exposure of less than one rad mid-breast, two viewsof each breast.
In order to be considered a screening mammogram for which coverage shall bemade available under this section:
a. The mammogram shall be (i) ordered by a health care practitioner actingwithin the scope of his licensure and, in the case of an enrollee of a healthmaintenance organization, by the health maintenance organization provider;(ii) performed by a registered technologist; (iii) interpreted by a qualifiedradiologist; and (iv) performed under the direction of a person licensed topractice medicine and surgery and certified by the American Board ofRadiology or an equivalent examining body. A copy of the mammogram reportshall be sent or delivered to the health care practitioner who ordered it;
b. The equipment used to perform the mammogram shall meet the standards setforth by the Virginia Department of Health in its radiation protectionregulations; and
c. The mammography film shall be retained by the radiologic facilityperforming the examination in accordance with the American College ofRadiology guidelines or state law.
2. Include coverage for postpartum services providing inpatient care and ahome visit or visits that shall be in accordance with the medical criteria,outlined in the most current version of or an official update to the"Guidelines for Perinatal Care" prepared by the American Academy ofPediatrics and the American College of Obstetricians and Gynecologists or the"Standards for Obstetric-Gynecologic Services" prepared by the AmericanCollege of Obstetricians and Gynecologists. Such coverage shall be providedincorporating any changes in such Guidelines or Standards within six monthsof the publication of such Guidelines or Standards or any official amendmentthereto.
3. Include an appeals process for resolution of written complaints concerningdenials or partial denials of claims that shall provide reasonable proceduresfor resolution of such written complaints and shall be published anddisseminated to all covered state employees. The appeals process shallinclude a separate expedited emergency appeals procedure that shall provideresolution within one business day of receipt of a complaint concerningsituations requiring immediate medical care. For appeals involving adversedecisions as defined in § 32.1-137.7, the Department shall contract with oneor more impartial health entities to review such decisions. Impartial healthentities may include medical peer review organizations and independentutilization review companies. The Department shall adopt regulations toassure that the impartial health entity conducting the reviews has adequatestandards, credentials and experience for such review. The impartial healthentity shall examine the final denial of claims to determine whether thedecision is objective, clinically valid, and compatible with establishedprinciples of health care. The decision of the impartial health entity shall(i) be in writing, (ii) contain findings of fact as to the material issues inthe case and the basis for those findings, and (iii) be final and binding ifconsistent with law and policy.
Prior to assigning an appeal to an impartial health entity, the Departmentshall verify that the impartial health entity conducting the review of adenial of claims has no relationship or association with (i) the coveredemployee; (ii) the treating health care provider, or any of its employees oraffiliates; (iii) the medical care facility at which the covered servicewould be provided, or any of its employees or affiliates; or (iv) thedevelopment or manufacture of the drug, device, procedure or other therapythat is the subject of the final denial of a claim. The impartial healthentity shall not be a subsidiary of, nor owned or controlled by, a healthplan, a trade association of health plans, or a professional association ofhealth care providers. There shall be no liability on the part of and nocause of action shall arise against any officer or employee of an impartialhealth entity for any actions taken or not taken or statements made by suchofficer or employee in good faith in the performance of his powers and duties.
4. Include coverage for early intervention services. For purposes of thissection, "early intervention services" means medically necessary speech andlanguage therapy, occupational therapy, physical therapy and assistivetechnology services and devices for dependents from birth to age three whoare certified by the Department of Behavioral Health and DevelopmentalServices as eligible for services under Part H of the Individuals withDisabilities Education Act (20 U.S.C. § 1471 et seq.). Medically necessaryearly intervention services for the population certified by the Department ofBehavioral Health and Developmental Services shall mean those servicesdesigned to help an individual attain or retain the capability to functionage-appropriately within his environment, and shall include services thatenhance functional ability without effecting a cure.
For persons previously covered under the plan, there shall be no denial ofcoverage due to the existence of a preexisting condition. The cost of earlyintervention services shall not be applied to any contractual provisionlimiting the total amount of coverage paid by the insurer to or on behalf ofthe insured during the insured's lifetime.
5. Include coverage for prescription drugs and devices approved by the UnitedStates Food and Drug Administration for use as contraceptives.
6. Not deny coverage for any drug approved by the United States Food and DrugAdministration for use in the treatment of cancer on the basis that the drughas not been approved by the United States Food and Drug Administration forthe treatment of the specific type of cancer for which the drug has beenprescribed, if the drug has been recognized as safe and effective fortreatment of that specific type of cancer in one of the standard referencecompendia.
7. Not deny coverage for any drug prescribed to treat a covered indication solong as the drug has been approved by the United States Food and DrugAdministration for at least one indication and the drug is recognized fortreatment of the covered indication in one of the standard referencecompendia or in substantially accepted peer-reviewed medical literature.
8. Include coverage for equipment, supplies and outpatient self-managementtraining and education, including medical nutrition therapy, for thetreatment of insulin-dependent diabetes, insulin-using diabetes, gestationaldiabetes and noninsulin-using diabetes if prescribed by a healthcareprofessional legally authorized to prescribe such items under law. To qualifyfor coverage under this subdivision, diabetes outpatient self-managementtraining and education shall be provided by a certified, registered orlicensed health care professional.
9. Include coverage for reconstructive breast surgery. For purposes of thissection, "reconstructive breast surgery" means surgery performed on andafter July 1, 1998, (i) coincident with a mastectomy performed for breastcancer or (ii) following a mastectomy performed for breast cancer toreestablish symmetry between the two breasts. For persons previously coveredunder the plan, there shall be no denial of coverage due to preexistingconditions.
10. Include coverage for annual pap smears, including coverage, on and afterJuly 1, 1999, for annual testing performed by any FDA-approved gynecologiccytology screening technologies.
11. Include coverage providing a minimum stay in the hospital of not lessthan 48 hours for a patient following a radical or modified radicalmastectomy and 24 hours of inpatient care following a total mastectomy or apartial mastectomy with lymph node dissection for treatment of breast cancer.Nothing in this subdivision shall be construed as requiring the provision ofinpatient coverage where the attending physician in consultation with thepatient determines that a shorter period of hospital stay is appropriate.
12. Include coverage (i) to persons age 50 and over and (ii) to persons age40 and over who are at high risk for prostate cancer, according to the mostrecent published guidelines of the American Cancer Society, for one PSA testin a 12-month period and digital rectal examinations, all in accordance withAmerican Cancer Society guidelines. For the purpose of this subdivision,"PSA testing" means the analysis of a blood sample to determine the levelof prostate specific antigen.
13. Permit any individual covered under the plan direct access to the healthcare services of a participating specialist (i) authorized to provideservices under the plan and (ii) selected by the covered individual. The planshall have a procedure by which an individual who has an ongoing specialcondition may, after consultation with the primary care physician, receive areferral to a specialist for such condition who shall be responsible for andcapable of providing and coordinating the individual's primary and specialtycare related to the initial specialty care referral. If such an individual'scare would most appropriately be coordinated by such a specialist, the planshall refer the individual to a specialist. For the purposes of thissubdivision, "special condition" means a condition or disease that is (i)life-threatening, degenerative, or disabling and (ii) requires specializedmedical care over a prolonged period of time. Within the treatment periodauthorized by the referral, such specialist shall be permitted to treat theindividual without a further referral from the individual's primary careprovider and may authorize such referrals, procedures, tests, and othermedical services related to the initial referral as the individual's primarycare provider would otherwise be permitted to provide or authorize. The planshall have a procedure by which an individual who has an ongoing specialcondition that requires ongoing care from a specialist may receive a standingreferral to such specialist for the treatment of the special condition. Ifthe primary care provider, in consultation with the plan and the specialist,if any, determines that such a standing referral is appropriate, the plan orissuer shall make such a referral to a specialist. Nothing contained hereinshall prohibit the plan from requiring a participating specialist to providewritten notification to the covered individual's primary care physician ofany visit to such specialist. Such notification may include a description ofthe health care services rendered at the time of the visit.
14. Include provisions allowing employees to continue receiving health careservices for a period of up to 90 days from the date of the primary carephysician's notice of termination from any of the plan's provider panels. Theplan shall notify any provider at least 90 days prior to the date oftermination of the provider, except when the provider is terminated for cause.
For a period of at least 90 days from the date of the notice of a provider'stermination from any of the plan's provider panels, except when a provider isterminated for cause, a provider shall be permitted by the plan to renderhealth care services to any of the covered employees who (i) were in anactive course of treatment from the provider prior to the notice oftermination and (ii) request to continue receiving health care services fromthe provider.
Notwithstanding the provisions of this subdivision, any provider shall bepermitted by the plan to continue rendering health services to any coveredemployee who has entered the second trimester of pregnancy at the time of theprovider's termination of participation, except when a provider is terminatedfor cause. Such treatment shall, at the covered employee's option, continuethrough the provision of postpartum care directly related to the delivery.
Notwithstanding the provisions of this subdivision, any provider shall bepermitted to continue rendering health services to any covered employee whois determined to be terminally ill (as defined under § 1861(dd)(3)(A) of theSocial Security Act) at the time of a provider's termination ofparticipation, except when a provider is terminated for cause. Such treatmentshall, at the covered employee's option, continue for the remainder of theemployee's life for care directly related to the treatment of the terminalillness.
A provider who continues to render health care services pursuant to thissubdivision shall be reimbursed in accordance with the carrier's agreementwith such provider existing immediately before the provider's termination ofparticipation.
15. Include coverage for patient costs incurred during participation inclinical trials for treatment studies on cancer, including ovarian cancertrials.
The reimbursement for patient costs incurred during participation in clinicaltrials for treatment studies on cancer shall be determined in the same manneras reimbursement is determined for other medical and surgical procedures.Such coverage shall have durational limits, dollar limits, deductibles,copayments and coinsurance factors that are no less favorable than forphysical illness generally.
For purposes of this subdivision:
"Cooperative group" means a formal network of facilities that collaborateon research projects and have an established NIH-approved peer review programoperating within the group. "Cooperative group" includes (i) the NationalCancer Institute Clinical Cooperative Group and (ii) the National CancerInstitute Community Clinical Oncology Program.
"FDA" means the Federal Food and Drug Administration.
"Multiple project assurance contract" means a contract between aninstitution and the federal Department of Health and Human Services thatdefines the relationship of the institution to the federal Department ofHealth and Human Services and sets out the responsibilities of theinstitution and the procedures that will be used by the institution toprotect human subjects.
"NCI" means the National Cancer Institute.
"NIH" means the National Institutes of Health.
"Patient" means a person covered under the plan established pursuant tothis section.
"Patient cost" means the cost of a medically necessary health care servicethat is incurred as a result of the treatment being provided to a patient forpurposes of a clinical trial. "Patient cost" does not include (i) the costof nonhealth care services that a patient may be required to receive as aresult of the treatment being provided for purposes of a clinical trial, (ii)costs associated with managing the research associated with the clinicaltrial, or (iii) the cost of the investigational drug or device.
Coverage for patient costs incurred during clinical trials for treatmentstudies on cancer shall be provided if the treatment is being conducted in aPhase II, Phase III, or Phase IV clinical trial. Such treatment may, however,be provided on a case-by-case basis if the treatment is being provided in aPhase I clinical trial.
The treatment described in the previous paragraph shall be provided by aclinical trial approved by:
a. The National Cancer Institute;
b. An NCI cooperative group or an NCI center;
c. The FDA in the form of an investigational new drug application;
d. The federal Department of Veterans Affairs; or
e. An institutional review board of an institution in the Commonwealth thathas a multiple project assurance contract approved by the Office ofProtection from Research Risks of the NCI.
The facility and personnel providing the treatment shall be capable of doingso by virtue of their experience, training, and expertise.
Coverage under this subdivision shall apply only if:
(1) There is no clearly superior, noninvestigational treatment alternative;
(2) The available clinical or preclinical data provide a reasonableexpectation that the treatment will be at least as effective as thenoninvestigational alternative; and
(3) The patient and the physician or health care provider who providesservices to the patient under the plan conclude that the patient'sparticipation in the clinical trial would be appropriate, pursuant toprocedures established by the plan.
16. Include coverage providing a minimum stay in the hospital of not lessthan 23 hours for a covered employee following a laparoscopy-assisted vaginalhysterectomy and 48 hours for a covered employee following a vaginalhysterectomy, as outlined in Milliman & Robertson's nationally recognizedguidelines. Nothing in this subdivision shall be construed as requiring theprovision of the total hours referenced when the attending physician, inconsultation with the covered employee, determines that a shorter hospitalstay is appropriate.
17. Include coverage for biologically based mental illness.
For purposes of this subdivision, a "biologically based mental illness" isany mental or nervous condition caused by a biological disorder of the brainthat results in a clinically significant syndrome that substantially limitsthe person's functioning; specifically, the following diagnoses are definedas biologically based mental illness as they apply to adults and children:schizophrenia, schizoaffective disorder, bipolar disorder, major depressivedisorder, panic disorder, obsessive-compulsive disorder, attention deficithyperactivity disorder, autism, and drug and alcoholism addiction.
Coverage for biologically based mental illnesses shall neither be differentnor separate from coverage for any other illness, condition or disorder forpurposes of determining deductibles, benefit year or lifetime durationallimits, benefit year or lifetime dollar limits, lifetime episodes ortreatment limits, copayment and coinsurance factors, and benefit year maximumfor deductibles and copayment and coinsurance factors.
Nothing shall preclude the undertaking of usual and customary procedures todetermine the appropriateness of, and medical necessity for, treatment ofbiologically based mental illnesses under this option, provided that all suchappropriateness and medical necessity determinations are made in the samemanner as those determinations made for the treatment of any other illness,condition or disorder covered by such policy or contract.
In no case, however, shall coverage for mental disorders provided pursuant tothis section be diminished or reduced below the coverage in effect for suchdisorders on January 1, 1999.
18. Offer and make available coverage for the treatment of morbid obesitythrough gastric bypass surgery or such other methods as may be recognized bythe National Institutes of Health as effective for the long-term reversal ofmorbid obesity. Such coverage shall have durational limits, dollar limits,deductibles, copayments and coinsurance factors that are no less favorablethan for physical illness generally. Access to surgery for morbid obesityshall not be restricted based upon dietary or any other criteria not approvedby the National Institutes of Health. For purposes of this subdivision,"morbid obesity" means (i) a weight that is at least 100 pounds over ortwice the ideal weight for frame, age, height, and gender as specified in the1983 Metropolitan Life Insurance tables, (ii) a body mass index (BMI) equalto or greater than 35 kilograms per meter squared with comorbidity orcoexisting medical conditions such as hypertension, cardiopulmonaryconditions, sleep apnea, or diabetes, or (iii) a BMI of 40 kilograms permeter squared without such comorbidity. As used herein, "BMI" equals weightin kilograms divided by height in meters squared.
19. Include coverage for colorectal cancer screening, specifically screeningwith an annual fecal occult blood test, flexible sigmoidoscopy orcolonoscopy, or in appropriate circumstances radiologic imaging, inaccordance with the most recently published recommendations established bythe American College of Gastroenterology, in consultation with the AmericanCancer Society, for the ages, family histories, and frequencies referenced insuch recommendations. The coverage for colorectal cancer screening shall notbe more restrictive than or separate from coverage provided for any otherillness, condition or disorder for purposes of determining deductibles,benefit year or lifetime durational limits, benefit year or lifetime dollarlimits, lifetime episodes or treatment limits, copayment and coinsurancefactors, and benefit year maximum for deductibles and copayments andcoinsurance factors.
20. On and after July 1, 2002, require that a prescription benefit card,health insurance benefit card, or other technology that complies with therequirements set forth in § 38.2-3407.4:2 be issued to each employee providedcoverage pursuant to this section, and shall upon any changes in the requireddata elements set forth in subsection A of § 38.2-3407.4:2, either reissuethe card or provide employees covered under the plan such correctiveinformation as may be required to electronically process a prescription claim.
21. Include coverage for infant hearing screenings and all necessaryaudiological examinations provided pursuant to § 32.1-64.1 using anytechnology approved by the United States Food and Drug Administration, and asrecommended by the national Joint Committee on Infant Hearing in its mostcurrent position statement addressing early hearing detection andintervention programs. Such coverage shall include follow-up audiologicalexaminations as recommended by a physician, physician assistant, nursepractitioner or audiologist and performed by a licensed audiologist toconfirm the existence or absence of hearing loss.
22. Notwithstanding any provision of this section to the contrary, every planestablished in accordance with this section shall comply with the provisionsof § 2.2-2818.2.
C. Claims incurred during a fiscal year but not reported during that fiscalyear shall be paid from such funds as shall be appropriated by law.Appropriations, premiums and other payments shall be deposited in theemployee health insurance fund, from which payments for claims, premiums,cost containment programs and administrative expenses shall be withdrawn fromtime to time. The funds of the health insurance fund shall be deemed separateand independent trust funds, shall be segregated from all other funds of theCommonwealth, and shall be invested and administered solely in the interestsof the employees and their beneficiaries. Neither the General Assembly norany public officer, employee, or agency shall use or authorize the use ofsuch trust funds for any purpose other than as provided in law for benefits,refunds, and administrative expenses, including but not limited tolegislative oversight of the health insurance fund.
D. For the purposes of this section:
"Part-time state employees" means classified or similarly situatedemployees in legislative, executive, judicial or independent agencies who arecompensated on a salaried basis and work at least 20 hours, but less than 32hours, per week.
"Peer-reviewed medical literature" means a scientific study published onlyafter having been critically reviewed for scientific accuracy, validity, andreliability by unbiased independent experts in a journal that has beendetermined by the International Committee of Medical Journal Editors to havemet the Uniform Requirements for Manuscripts submitted to biomedicaljournals. Peer-reviewed medical literature does not include publications orsupplements to publications that are sponsored to a significant extent by apharmaceutical manufacturing company or health carrier.
"Standard reference compendia" means:
1. American Hospital Formulary Service - Drug Information;
2. National Comprehensive Cancer Network's Drugs & Biologics Compendium; or
3. Elsevier Gold Standard's Clinical Pharmacology.
"State employee" means state employee as defined in § 51.1-124.3; employeeas defined in § 51.1-201; the Governor, Lieutenant Governor and AttorneyGeneral; judge as defined in § 51.1-301 and judges, clerks and deputy clerksof regional juvenile and domestic relations, county juvenile and domesticrelations, and district courts of the Commonwealth; and interns and residentsemployed by the School of Medicine and Hospital of the University ofVirginia, and interns, residents, and employees of the Virginia CommonwealthUniversity Health System Authority as provided in § 23-50.16:24.
E. Provisions shall be made for retired employees to obtain coverage underthe above plan, including, as an option, coverage for vision and dental care.The Commonwealth may, but shall not be obligated to, pay all or any portionof the cost thereof.
F. Any self-insured group health insurance plan established by the Departmentof Human Resource Management that utilizes a network of preferred providersshall not exclude any physician solely on the basis of a reprimand or censurefrom the Board of Medicine, so long as the physician otherwise meets the plancriteria established by the Department.
G. The plan shall include, in each planning district, at least two healthcoverage options, each sponsored by unrelated entities. No later than July 1,2006, one of the health coverage options to be available in each planningdistrict shall be a high deductible health plan that would qualify for ahealth savings account pursuant to § 223 of the Internal Revenue Code of1986, as amended.
In each planning district that does not have an available health coveragealternative, the Department shall voluntarily enter into negotiations at anytime with any health coverage provider who seeks to provide coverage underthe plan.
This subsection shall not apply to any state agency authorized by theDepartment to establish and administer its own health insurance coverage planseparate from the plan established by the Department.
H. Any self-insured group health insurance plan established by the Departmentof Human Resource Management that includes coverage for prescription drugs onan outpatient basis may apply a formulary to the prescription drug benefitsprovided by the plan if the formulary is developed, reviewed at leastannually, and updated as necessary in consultation with and with the approvalof a pharmacy and therapeutics committee, a majority of whose members areactively practicing licensed (i) pharmacists, (ii) physicians, and (iii)other health care providers.
If the plan maintains one or more drug formularies, the plan shall establisha process to allow a person to obtain, without additional cost-sharing beyondthat provided for formulary prescription drugs in the plan, a specific,medically necessary nonformulary prescription drug if, after reasonableinvestigation and consultation with the prescriber, the formulary drug isdetermined to be an inappropriate therapy for the medical condition of theperson. The plan shall act on such requests within one business day ofreceipt of the request.
Any plan established in accordance with this section shall be authorized toprovide for the selection of a single mail order pharmacy provider as theexclusive provider of pharmacy services that are delivered to the coveredperson's address by mail, common carrier, or delivery service. As used inthis subsection, "mail order pharmacy provider" means a pharmacy permittedto conduct business in the Commonwealth whose primary business is to dispensea prescription drug or device under a prescriptive drug order and to deliverthe drug or device to a patient primarily by mail, common carrier, ordelivery service.
I. Any plan established in accordance with this section requiringpreauthorization prior to rendering medical treatment shall have personnelavailable to provide authorization at all times when such preauthorization isrequired.
J. Any plan established in accordance with this section shall provide to allcovered employees written notice of any benefit reductions during thecontract period at least 30 days before such reductions become effective.
K. No contract between a provider and any plan established in accordance withthis section shall include provisions that require a health care provider orhealth care provider group to deny covered services that such provider orgroup knows to be medically necessary and appropriate that are provided withrespect to a covered employee with similar medical conditions.
L. The Department of Human Resource Management shall appoint an Ombudsman topromote and protect the interests of covered employees under any stateemployee's health plan.
The Ombudsman shall:
1. Assist covered employees in understanding their rights and the processesavailable to them according to their state health plan.
2. Answer inquiries from covered employees by telephone and electronic mail.
3. Provide to covered employees information concerning the state health plans.
4. Develop information on the types of health plans available, includingbenefits and complaint procedures and appeals.
5. Make available, either separately or through an existing Internet web siteutilized by the Department of Human Resource Management, information as setforth in subdivision 4 and such additional information as he deemsappropriate.
6. Maintain data on inquiries received, the types of assistance requested,any actions taken and the disposition of each such matter.
7. Upon request, assist covered employees in using the procedures andprocesses available to them from their health plan, including all appealprocedures. Such assistance may require the review of health care records ofa covered employee, which shall be done only with that employee's expresswritten consent. The confidentiality of any such medical records shall bemaintained in accordance with the confidentiality and disclosure laws of theCommonwealth.
8. Ensure that covered employees have access to the services provided by theOmbudsman and that the covered employees receive timely responses from theOmbudsman or his representatives to the inquiries.
9. Report annually on his activities to the standing committees of theGeneral Assembly having jurisdiction over insurance and over health and theJoint Commission on Health Care by December 1 of each year.
M. The plan established in accordance with this section shall not refuse toaccept or make reimbursement pursuant to an assignment of benefits made to adentist or oral surgeon by a covered employee.
For purposes of this subsection, "assignment of benefits" means thetransfer of dental care coverage reimbursement benefits or other rights underthe plan. The assignment of benefits shall not be effective until the coveredemployee notifies the plan in writing of the assignment.
N. Beginning July 1, 2006, any plan established pursuant to this sectionshall provide for an identification number, which shall be assigned to thecovered employee and shall not be the same as the employee's social securitynumber.
O. Any group health insurance plan established by the Department of HumanResource Management that contains a coordination of benefits provision shallprovide written notification to any eligible employee as a prominent part ofits enrollment materials that if such eligible employee is covered underanother group accident and sickness insurance policy, group accident andsickness subscription contract, or group health care plan for health careservices, that insurance policy, subscription contract or health care planmay have primary responsibility for the covered expenses of other familymembers enrolled with the eligible employee. Such written notification shalldescribe generally the conditions upon which the other coverage would beprimary for dependent children enrolled under the eligible employee'scoverage and the method by which the eligible enrollee may verify from theplan that coverage would have primary responsibility for the covered expensesof each family member.
P. Any plan established by the Department of Human Resource Managementpursuant to this section shall provide that coverage under such plan forfamily members enrolled under a participating state employee's coverage shallcontinue for a period of at least 30 days following the death of such stateemployee.
Q. The plan established in accordance with this section that follows a policyof sending its payment to the covered employee or covered family member for aclaim for services received from a nonparticipating physician or osteopathshall (i) include language in the member handbook that notifies the coveredemployee of the responsibility to apply the plan payment to the claim fromsuch nonparticipating provider, (ii) include this language with any suchpayment sent to the covered employee or covered family member, and (iii)include the name and any last known address of the nonparticipating provideron the explanation of benefits statement.
R. The Department of Human Resource Management shall report annually, byNovember 30 of each year in which a mandate is imposed under the provisionsof § 2.2-2818.2, to the Special Advisory Commission on Mandated HealthInsurance Benefits established pursuant to Article 2 (§ 2.2-2503 et seq.) ofChapter 25, on cost and utilization information for each of the mandatedbenefits set forth in subsection B, including any mandated benefit madeapplicable, pursuant to subdivision B 22, to any plan established pursuant tothis section. The report shall be in the same detail and form as required ofreports submitted pursuant to § 38.2-3419.1, with such additional informationas is required to determine the financial impact, including the costs andbenefits, of the particular mandated benefit.
(1970, c. 557, § 2.1-20.1; 1972, c. 803; 1973, cc. 69, 297; 1978, c. 70;1984, c. 430; 1988, c. 634; 1989, cc. 559, 664; 1990, c. 607; 1993, c. 138;1995, c. 353; 1996, cc. 155, 201, 905, 1046; 1997, cc. 43, 468, 521, 656;1998, cc. 35, 56, 257, 386, 631, 709, 851, 858, 875; 1999, cc. 643, 649, 921,941; 2000, cc. 66, 149, 465, 534, 657, 720, 888; 2001, cc. 334, 558, 663,844; 2004, cc. 156, 279, 855; 2005, cc. 503, 572, 640, 739; 2006, c. 396;2008, c. 420; 2009, cc. 247, 317, 813, 840; 2010, cc. 157, 357, 443.)