CODE OF VIRGINIA

PROHIBITED PRACTICES (§ 38.2-4312)

A. No health maintenance organization or its representative may cause or
knowingly permit the use of (i) advertising that is untrue or misleading, (ii)
solicitation that is untrue or misleading, or (iii) any form of evidence of
coverage that is deceptive. For the purposes of this chapter:

   1.  A statement or item of information shall be deemed to be untrue if it does
   not conform to fact in any respect that is or may be significant to an
   enrollee or person considering enrollment in a health care plan;

   2.  A statement or item of information shall be deemed to be misleading,
   whether or not it may be literally untrue, if the statement or item of
   information may be understood by a reasonable person who has no special
   knowledge of health care coverage as indicating (i) a benefit or advantage if
   that benefit or advantage does not in fact exist or (ii) the absence of any
   exclusion, limitation or disadvantage of possible significance to an enrollee
   or person considering enrollment in a health care plan if the absence of that
   exclusion, limitation, or disadvantage does not in fact exist; consideration
   shall be given to the total context in which the statement is made or the item
   of information is communicated; and

   3.  An evidence of coverage shall be deemed to be deceptive if it causes a
   reasonable person who has no special knowledge of health care plans to expect
   benefits, services, charges, or other advantages that the evidence of coverage
   does not provide or that the health care plan issuing the evidence of coverage
   does not regularly make available for enrollees covered under the evidence of
   coverage; consideration shall be given to the evidence of coverage taken as a
   whole and to the typography, format, and language.

B. The provisions of Chapter 5 (§ 38.2-500 et seq.) of this title shall apply
to health maintenance organizations, health care plans, and evidences of
coverage except to the extent that the Commission determines that the nature of
health maintenance organizations, health care plans, and evidences of coverage
render any of the provisions clearly inappropriate.

C. No health maintenance organization, unless licensed as an insurer, may use in
its name, contracts, or literature (i) any of the words “insurance,”
“casualty,” “surety,” “mutual,” or (ii) any
other words descriptive of the insurance, casualty, or surety business or
deceptively similar to the name or description of any insurance or fidelity and
surety insurer doing business in this Commonwealth.

D. No health maintenance organization shall discriminate on the basis of race,
creed, color, sex or religion in the selection of health care providers for
participation in the organization.

E. No health maintenance organization shall unreasonably discriminate against
physicians as a class or any class of providers listed in § 38.2-4221 or
pharmacists when contracting for specialty or referral practitioners or
providers, provided the plan covers services which the members of such classes
are licensed to render. Nothing contained in this section shall prevent a health
maintenance organization from selecting, in the judgment of the health
maintenance organization, the numbers of providers necessary to render the
services offered by the health maintenance organization.

F. No contract between a health maintenance organization and a provider shall
include provisions which require a health care provider or health care provider
group to deny covered services that such provider or group knows to be medically
necessary and appropriate that are provided with respect to a specific enrollee
or group of enrollees with similar medical conditions.

HISTORY: 1980, c. 720, § 38.1-876; 1985, c. 588; 1986, c. 562; 1989, c. 221;
1997, c. 297; 1998, c. 891; 1999, cc. 643, 649.