3.1 Virginia Health Insurance Policy Requirements

Regulatory Structure

Virginia health insurance is governed by Title 38.2 of the Code of Virginia and enforced by the State Corporation Commission (SCC) Bureau of Insurance. The SCC is the umbrella regulator; the Bureau of Insurance is the operating arm that licenses producers, reviews policy forms, and approves rates. The Bureau Commissioner answers to the three-member SCC, not to the Governor.

Health coverage in Virginia is sold as accident and sickness insurance (the statutory term you will see on the exam). Self-funded employer plans escape state regulation because the federal Employee Retirement Income Security Act of 1974 (ERISA) preempts state insurance law for them.

Free Look Period

Virginia requires a 10-day free look on individual accident-and-sickness policies. The insured may return the policy to the company or to the producer within 10 days of delivery and receive a full refund of premium, no questions asked. Note the contrast with long-term care policies, which get 30 days (covered in 3.3) — a favorite exam distractor.

Essential Health Benefits

Under the Affordable Care Act (ACA), every individual and small-group plan must cover the ten Essential Health Benefit categories:

1. Ambulatory (outpatient) services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance-use disorder services
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive/wellness services and chronic-disease management
10. Pediatric services, including oral and vision care

Exam tip: A plan that excludes maternity or imposes a separate prescription-drug cap is not ACA-compliant and cannot be sold in the individual or small-group market. Preventive services (immunizations, screenings) must be covered at zero cost-sharing when delivered in-network.

Virginia Mandated Benefits

Beyond the federal floor, Virginia statute mandates specific benefits on accident-and-sickness policies. Frequently tested examples:

• Mammography screening on a defined age schedule
• Colorectal cancer screening
• Diabetes equipment, supplies, and self-management education
• Mental-health parity — benefits for mental illness and substance use must use the same deductibles, copays, coinsurance, and treatment limits as comparable medical/surgical benefits
• Newborn coverage from the moment of birth, with notice/premium typically due within 31 days
• Mandatory offer of coverage for an unmarried dependent child

Pre-Existing Conditions

The ACA bars pre-existing exclusions on medical coverage, but Medicare Supplement and LTC are governed by separate rules and can still impose a limited look-back, so do not over-generalize.

Virginia's Insurance Marketplace

Virginia ran a federal-partnership exchange for years but launched its own State-Based Marketplace (SBM) for plan year 2024, operating at vainsurancemarketplace.gov rather than HealthCare.gov. Premium tax credits and cost-sharing reductions still flow through the federal subsidy structure. Plans are sold in four metal tiers defined by actuarial value (AV) — the share of total covered costs the plan pays for a standard population.

Guaranteed Issue and Renewal

• Guaranteed issue: insurers must accept all applicants in the individual and small-group markets; coverage cannot be denied based on health status.
• Guaranteed renewal: an insurer may non-renew only for nonpayment of premium, fraud/material misrepresentation, or discontinuance of the plan with required notice.

Common trap: "guaranteed issue" governs getting a policy; "guaranteed renewable" governs keeping it. The exam tests both terms in the same question to see if you swap them.

Other Tested Distinctions

Expect questions that hinge on Virginia's specific defaults. The dependent newborn rule requires coverage from the moment of birth, with the insurer entitled to notice and any additional premium typically within 31 days; an insurer that demands earlier notice violates the statute. Coverage for an adopted child attaches from the date of placement, not the date the adoption is finalized.

Virginia also distinguishes the marketing pieces a producer may use. An outline of coverage must be delivered for many individual accident-and-sickness products so the buyer can compare benefits, exclusions, and renewal terms before purchase. Misrepresenting policy benefits, twisting (inducing a replacement through misrepresentation), and rebating (giving the buyer anything of value not stated in the contract) are all unfair trade practices the Bureau can penalize.

Finally, separate the funding models. A fully insured group plan transfers risk to the carrier and is regulated by the Bureau of Insurance, so Virginia mandates apply. A self-funded employer plan keeps the risk and is governed by ERISA, so state mandates and the state premium tax generally do not reach it. A scenario that asks which plan must cover a Virginia-mandated benefit is testing this fully-insured-versus-self-funded line.