Federal & State Regulations | Health plans - Virginia | J. J. Keller® Compliance Network

State Info

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. State laws include the following provisions:

The plan may not refuse to enroll a child under a parent's coverage because the child was born out of wedlock; the child is not claimed as a dependent on the parent's federal income tax return; or the child does not reside with the parent or in the insurer's, health services plan's, or health maintenance organization's service area. (§38.2-3407.2)
If the plan requires participants to pay a specified percentage of the cost of covered services, it must calculate such amount payable based upon an amount not to exceed the total amount actually paid or payable to the provider of such services. (§38.2-3407.3)
If the plan covers prescription drugs on an outpatient basis, it must offer and make available coverage for any prescribed drug or device approved by the United States Food and Drug Administration for use as a contraceptive. (§38.2-3407.5:1)
No podiatrist shall be excluded from participating in any preferred provider plan. (§38.2-3407.6)
If the plan covers prescription drugs, whether on an inpatient basis, an outpatient basis, or both, it must not denied any drug approved by the United States Food and Drug Administration for use in the treatment of cancer pain on the basis that the dosage is in excess of the recommended dosage of the pain-relieving agent, if the prescription in excess of the recommended dosage has been prescribed. (§38.2-3407.6:1)
The plan must not prohibit any person receiving pharmacy benefits from selecting, without limitation, the pharmacy of his choice to furnish such benefits. (§38.2-3407.7)
If the plan covers ambulance services, any person providing such services to a plan participant must receive reimbursement for such services directly from the issuer of such policy, when the issuer of such policy is presented with an assignment of benefits by the person providing such services. (§38.2-3407.9)
If the plan covers prescription drugs on an outpatient basis, it may apply a formulary to the prescription drug benefits provided if the formulary is developed, reviewed at least annually, and updated as necessary. (§38.2-3407.9:01)
If the plan covers prescription drugs, it must not exclude coverage for any prescription drug solely on the basis of the length of time since the drug obtained FDA approval. (§38.2-3407.9:01)
The plan must permit standing referrals to the health care services of a participating specialist authorized to provide services under the plan and selected by such individual for a condition or disease that is life-threatening, degenerative, or disabling; and requires specialized medical care over a prolonged period of time. (§38.2-3407.11:1)
The plan must have a procedure in place to permit participants who have been diagnosed with cancer to have a standing referral to a board-certified physician in pain management or oncologist who is authorized to provide services under the plan and has been selected by the cancer patient. (§38.2-3407.11:2)
The plan cannot deny coverage solely because the enrollee or participant has been diagnosed as having a fibrocystic condition or a nonmalignant lesion, or solely due to the family history of the insured related to breast cancer; or solely due to breast cancer if the insured has been free from breast cancer for a period of five years or more prior to the date of application for coverage. (§38.2-3407.11:3)
If the plan is an HMO, it must provide a point-of-service benefit to be provided or offered in conjunction with the health maintenance organization's health care plan as an additional benefit for the enrollee, at the enrollee's option. (§38.2-3407.12)
Prepaid dental plans must not refuse to accept or make reimbursement pursuant to an assignment of benefits made to a dentist or oral surgeon. (§38.2-3407.13)
If the plan provides for reimbursement for any service that may be performed by a chiropractor, optometrist, optician, professional counselor, psychologist, clinical social worker, podiatrist, physical therapist, chiropodist, clinical nurse specialist who renders mental health services, audiologist, speech pathologist, certified nurse midwife, marriage and family therapist, or licensed acupuncturist, reimbursement must not be denied because the service is rendered by the licensed practitioner. (§38.2-3408)
Dependent coverage must not be terminated while the dependent is and continues to be both incapable of self-sustaining employment by reason of mental retardation or physical handicap, and chiefly dependent upon the policy owner for support and maintenance. (§38.2-3409)
If the plan covers family members, it must cover newly born children from the moment of birth, and include coverage for necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, as well as inpatient and outpatient dental, oral surgical, and orthodontic services which are medically necessary for the treatment of medically diagnosed cleft lip, cleft palate or ectodermal dysplasia. (§38.2-3411)
The plan must offer and make available coverage under such policy or plan for child health supervision services for children up to age six. (§38.2-3411.1)
If the plan covers dependents, it must cover adopted children from the date of placement. (§38.2-3411.2)
The plan must cover all routine and necessary immunizations for newborn children from birth to thirty-six months of age. (§38.2-3411.3)
The plan must cover infant hearing screenings and all necessary audiological examinations for newborns. (§38.2-3411.4)
If the plan provides coverage on an expense-incurred basis for family members, it must cover inpatient and partial hospitalization for mental health and substance abuse services. (§38.2-3412.1)
The plan must include benefits for pregnancy following an act of rape of an insured or subscriber which was reported to the police within seven days following its occurrence, to the same extent as any other covered accident. The 7-day requirement shall be extended to 180 days in the case of an act of rape or incest of a female under 13 years of age. (§38.2-3418)
If the plan covers diagnostic and surgical treatment involving any bone or joint of the skeletal structure, it must not exclude coverage for such diagnostic and surgical treatment involving any bone or joint of the head, neck, face or jaw or impose limits that are more restrictive than limits on coverage applicable to such treatment involving any bone or joint of the skeletal structure if the treatment is required because of a medical condition or injury which prevents normal function of the joint or bone and is deemed medically necessary to attain functional capacity of the affected part. (§38.2-3418.2)
The plan must cover hemophilia and congenital bleeding disorders. (§38.2-3418.3)
The plan must cover medically necessary early intervention services, limited to a benefit of $5,000 per insured or member per policy or calendar year, and must be subject to such dollar limits, deductibles and coinsurance factors as are no less favorable than for physical illness generally. (§38.2-3418.5)
Plans must cover one PSA test in a 12-month period, for persons age 50 and over, and persons age forty and over who are at high risk for prostate cancer. (§38.2-3418.7)
The plan must cover colorectal cancer screening. (§38.2-3418.7:1)
The plan must cover patient costs incurred during participation in clinical trials for treatment studies on cancer, including ovarian cancer trials. (§38.2-3418.8)
The plan must cover equipment, supplies and in-person outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin-using diabetes if prescribed. (§38.2-3418.10)
The plan must cover hospice services. (§38.2-3418.11)
The plan must cover medically necessary general anesthesia and hospitalization or facility charges of a facility licensed to provide outpatient surgical procedures for dental care provided to a covered person who is determined by a licensed dentist in consultation with the covered person's treating physician to require general anesthesia and admission to a hospital or outpatient surgery facility to effectively and safely provide dental care and is under the age of five, is severely disabled, or has a medical condition and requires admission to a hospital or outpatient surgery facility and general anesthesia for dental care treatment. (§38.2-3418.12)
The plan must offer and make available optional coverage for the treatment of morbid obesity through gastric bypass surgery or such other methods as may be recognized by the National Institutes of Health as effective for the long-term reversal of morbid obesity. (§38.2-3418.13)