Proposed Text
Part III
Other Procedures
14VAC10-10-160. Insurance.
A. Because the Virginia Birth-Related Neurological Injury
Compensation Program (Program) generally is a payer of last resort, it
each admitted claimant's parent or legal guardian must purchase private
health insurance to provide coverage for the actual medically necessary and
reasonable expenses as described in ยง 38.2-5009 A 1 of the Code of Virginia
that were, or are, incurred as a result of the admitted claimant's
birth-related neurological injury and for the admitted claimant's benefit. The
admitted claimant's parent or legal guardian may request the Program's
facilitator's assistance in obtaining a suitable health insurance policy for
the admitted claimant if he or she has no pre-existing coverage for the
admitted claimant upon the admitted claimant's admission into the Program. The
Program will reimburse, upon receipt of proof of payment, solely the portion of
the premiums that is attributable to the admitted claimant's post-admission
coverage and paid for by the admitted claimant's parent or legal guardian. The
Program must be provided with a copy of the applicable health insurance
policy, if one exists, or a complete description of applicable coverage,
before benefits are paid by the Program. It is the responsibility of the
parents or guardians to seek benefits for which an admitted claimant is
eligible by submitting requests to the Program's Third Party Administrator
or other appropriate staff person, as indicated on the Program's website.
In addition, the parents or guardians of the admitted claimant must identify a
primary care physician.
B. Claimants must utilize the primary insurer's in-network providers and facilities unless otherwise authorized by the Program. Utilizing non-network or nonparticipating providers or facilities may result in reduced payment, nonpayment, or nonreimbursement of incurred expenses.