Managed Care E&O & ACO Liability Insurance in Virginia

Virginia at a glance

Primary regulator

Virginia State Corporation Commission — Bureau of Insurance

Licenses managed care health insurance plans and enforces network-adequacy and prompt-pay rules in Virginia.

Governing statute

Managed Care Health Insurance Plan Act, Code of Virginia Title 38.2

Sets network-adequacy, utilization-review, and grievance requirements for Virginia-licensed MCHIPs.

Medicaid managed care program

Cardinal Care

Delivers physical and behavioral health Medicaid benefits through contracted MCOs statewide.

External review statute

Code of Virginia §38.2-3556

Provides for external review of adverse utilization-review decisions once internal grievance procedures are exhausted.

The Managed Care Health Insurance Plan Act

Virginia regulates managed care organizations under the Managed Care Health Insurance Plan Act, codified in Title 38.2 of the Code of Virginia, which requires MCHIPs to maintain adequate provider networks, follow specific utilization-review procedures, and provide a defined internal grievance process before a member can pursue further appeal. The Bureau of Insurance, part of the State Corporation Commission, licenses these plans and reviews complaints, giving Virginia a somewhat different regulatory posture than states where a standalone insurance department handles the function.

Cardinal Care and Medicaid managed care delegation

Virginia consolidated its Medicaid managed care programs into Cardinal Care, which delivers both physical and behavioral health benefits through contracted managed care organizations statewide. These MCOs typically delegate credentialing and utilization-review functions to participating provider networks, and an error at that delegated level — a lapsed credential, a missed grievance deadline — can still generate a claim against the delegating organization.

External review and prompt-pay under Title 38.2

Virginia law provides for external review of adverse utilization-review decisions under Code of Virginia §38.2-3556 once internal grievance procedures are exhausted, and separately sets prompt-payment obligations under §38.2-3407.15 that the Bureau of Insurance monitors through complaint review and market-conduct examinations. Chronic delays in claims payment can draw regulatory scrutiny that runs alongside, or ahead of, an individual member's E&O claim.

Coordinating E&O with cyber and fiduciary coverage

A managed-care E&O policy in Virginia is designed to respond to utilization-review, credentialing, network-adequacy, and claims-handling disputes, while a breach of member health data is better addressed through a cyber policy and ERISA fiduciary duties through a separate fiduciary liability form. Cardinal Care MCOs delegating across physical and behavioral health networks should confirm all three lines are coordinated rather than relying on one broad E&O form.

Who we write this for in Virginia

Managed care E&O FAQs for Virginia