Mandated Benefits, Offers, & Reporting
Virginia's insurance laws require that most health insurance plans, including Managed Care Health Insurance Plans (MCHIPs): 1) provide certain benefits, known as mandated benefits, in each and every individual or group contract they offer in Virginia; and 2) offer and make available to you, as an individual policyholder, or your employer, if you have group coverage, the option to purchase certain benefits known as mandated offers of coverage. Mandates apply only to Virginia-issued contracts or policies.
To read any of the specific mandated benefit or mandated offer statutes,select the code citation below.
§38.2-3408 Reimbursement for services provided by certain practitioners other than physicians
§38.2-3409 Coverage for dependent children
§38.2-3410 Terms "physician" and "doctor" to include dentist
§38.2-3411 Coverage of newborn children
§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 abuse services
§38.2-3414.1 Coverage for postpartum services
§38.2-3415 Exclusion or reduction of benefits for certain causes prohibited
§38.2-3418 Coverage for victims of rape and 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
§38.2-3418.5 Coverage for early intervention services
§38.2-3418.6 Minimal hospital stays mastectomy, certain lymph node dissection patients
§38.2-3418.7 Coverage for PSA (prostate-specific antigen) testing
§38.2-3418.7:1 Coverage for Colorectal Cancer Screenings
§38.2-3418.8 Coverage for clinical trials for treatment studies on cancer
§38.2-3418.9 Minimum hospital stays 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
§38.2-3418.14 Coverage for Lymphedema
§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
Note: This coverage requirement was to be effective January 1, 2021; however, a budget amendment required the Health Insurance Reform Commission to assess the fiscal impact of the coverage requirement, to include a determination by the Bureau of Insurance and the Joint Legislative Audit and Review Commission. Upon a finding of no fiscal impact, coverage could commence on July 1, 2021. The JLARC report of Senate Bill 423 was completed citing a fiscal impact. At its June 30, 2021 meeting, the Health Insurance Reform Commission determined that, based on the information provided, a fiscal impact does exist. Therefore, this mandate did not become effective July 1, 2021.
Mandated Offers of Coverage
§38.2-3411.1 Coverage for child health supervision services
§38.2-3414 Optional coverage for obstetrical services
§38.2-3417 Deductible and coinsurance options required
§38.2-3418.13 Coverage for Morbid Obesity
§38.2-3418.15 Coverage for prosthetic devices and components
You may contact The Office of the Managed Care Ombudsman for detailed information about these mandates or you may refer to Title 38.2 of the Code of Virginia.
By order entered February 13, 2017, in Case Number INS-2016-00223, the State Corporation Commission adopted revisions to the Rules Governing the Reporting of Cost and Utilization Data Relating to Mandated Benefits and Mandated Providers (14 VAC 5-190 of the Virginia Administrative Code) effective March 1, 2017. As specified in this order, no Form 190-A reports are required to be filed in 2017; however, health insurers required to file reports with the Bureau must do by May 1, 2018, and every other year thereafter (for example: reports for reporting years 2020 and 2021 are due until May 1, 2022).
The template for the reports is featured below. The Bureau will post a data call on the New to Review page in January of the year these reports are due. Please submit separate forms for EACH year of the reporting period.
Instructions & Forms
CPT and ICD-9-CM Codes
ICD-9 to ICD-10 Crosswalk
You can obtain copies of The Financial Impact of Mandated Health Insurance Benefits and Providers reports at: Reports to the General Assembly.
Questions regarding this change in reporting requirements may be directed to: