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WV Code § 33-25A-11 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-11. Open Enrollment Period

(1) Once a health maintenance organization has been in operation at least five years, or has enrollment of not less than fifty thousand persons, the health maintenance organization shall, in any year following a year in which the health maintenance organization has achieved an operating surplus, maintain an open enrollment period of at least thirty days during which time the health maintenance organization shall, within the limits of its capacity, accept individuals in the order in which they apply without regard to preexisting illness, medical conditions or degree of disability except for individuals who are confined to an institution because of chronic illness or permanent injury: Provided, That no health maintenance organization shall be required to continue an open enrollment period after such time as enrollment pursuant to the open enrollment period is equal to three percent of the health maintenance organization's net increase in enrollment during the previous year.(2) Where a health maintenance organization demonstrates to the satisfaction of the commissioner that it has a disproportionate share of high-risk enrollees and that, by maintaining open enrollment, it would be required to enroll so disproportionate a share of high-risk enrollees as to jeopardize its economic viability, the commissioner may:(a) Waive the requirement for open enrollment for a period of not more than three years; or(b) Authorize the organization to impose any underwriting restrictions upon open enrollment as are necessary: (i) To preserve its financial stability; (ii) to prevent excessive adverse selection by prospective enrollees; or (iii) to avoid unreasonably high or unmarketable charges for enrollee coverage of health services. A health maintenance organization may receive more than one waiver or authorization.
WV Code § 33-25A-13 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-13. Investments

With the exception of investments otherwise made in accordance with this article, the investable funds of a health maintenance organization shall be invested only in securities or other investments permitted by the laws of this state for the investment of assets constituting the legal reserves of life insurance companies or such other securities or investments as the commissioner may permit.
WV Code § 33-25A-14a (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-14a. Other Prohibited Practices

(a) No health maintenance organization may cancel or fail to renew the coverage of an enrollee except for: (1) Failure to pay the charge for health care coverage; (2) termination of the health maintenance organization; (3) termination of the group plan; (4) enrollee moving out of the area served; (5) enrollee moving out of an eligible group; or (6) other reasons established in rules promulgated by the Commissioner. No health maintenance organization shall use any technique of rating or grouping to cancel or fail to renew the coverage of an enrollee. An enrollee shall be given thirty days' notice of any cancellation or nonrenewal and the notice shall include the reasons for the cancellation or nonrenewal: Provided, That each enrollee moving out of an eligible group shall be granted the opportunity to enroll in the health maintenance organization on an individual basis. A health maintenance organization may not disenroll an enrollee for nonpayment of copayments unless the enrollee has failed to make payment in at least three instances over any twelve-month period: Provided, however, That the enrollee may not be disenrolled if the disenrollment would constitute abandonment of a patient. Any enrollee wrongfully disenrolled shall be reenrolled.(b) The providers of a health maintenance organization who provide health care services and the health maintenance organization shall not have recourse against enrollees for amounts above those specified in the evidence of coverage as the periodic prepayment or copayment for health care services.(c) No health maintenance organization shall enroll more than three hundred thousand persons in this state: Provided, That a health maintenance organization may petition the Commissioner to exceed an enrollment of three hundred thousand persons and, upon notice and hearing, good cause being shown and a determination made that an increase would be beneficial to the subscribers, creditors and stockholders of the organization or would otherwise increase the availability of coverage to consumers within the state, the Commissioner may, by written order only, allow the petitioning organization to exceed an enrollment of three hundred thousand persons.(d) No health maintenance organization shall discriminate in enrollment policies or quality of services against any person on the basis of race, sex, age, religion, place of residence, source of payment or, with respect to enrollment in group policies, health status: Provided, That differences in rates based on valid actuarial distinctions, including distinctions relating to age and sex, shall not be considered discrimination in enrollment policies.(e) Any person who, in connection with an enrollment, violates any provision of this section may be held liable for an amount equivalent to one year's subscription rate, plus costs and a reasonable attorney's fee.
WV Code § 33-25A-16 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-16. Powers of Insurers and Hospital and Medical Service Corporations

(1) An insurance company licensed in this state or a hospital or medical service corporation authorized to do business in this state, after applying for and receiving a certificate of authority as a health maintenance organization, may through a subsidiary or affiliate organize and operate a health maintenance organization under the provisions of this article. Notwithstanding any other law to the contrary, any two or more insurance companies, hospital or medical service corporations, or subsidiaries or affiliates thereof, may jointly organize and operate a health maintenance organization. The business of insurance is considered to include the providing of health care by a health maintenance organization owned or operated by an insurer or a subsidiary thereof.(2) Notwithstanding any provision of insurance and hospital or medical service corporation laws, an insurer or a hospital or medical service corporation may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of the failure of the health maintenance organization to meet its obligations. The enrollees of a health maintenance organization constitute a permissible group under such laws. Among other things, under the contracts, the insurer or hospital or medical service corporation may make benefit payments to health maintenance organizations for health care services rendered by providers.
WV Code § 33-25A-17 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-17. Examinations

(a) The Commissioner may make an examination of the affairs of any health maintenance organization and providers with whom the organization has contracts, agreements or other arrangements as often as he or she considers it necessary for the protection of the interests of the people of this state but not less frequently than once every five years.(b) The Commissioner may contract with the Department of Health and Human Resources, any entity which has been accredited by a nationally recognized accrediting organization and has been approved by the Commissioner to make examinations concerning the quality of health care services of any health maintenance organization and providers with whom the organization has contracts, agreements or other arrangements, or any entity contracted with by the Department of Health and Human Resources, as often as it considers necessary for the protection of the interests of the people of this state, but not less frequently than once every three years: Provided, That in making the examination, the Department of Health and Human Resources or the accredited entity shall use the services of persons or organizations with demonstrable expertise in assessing quality of health care.(c) Every health maintenance organization and affiliated provider shall submit its books and records to the examinations and in every way facilitate them. For the purpose of examinations, the Commissioner and the Department of Health and Human Resources have all powers necessary to conduct the examinations, including, but not limited to, the power to issue subpoenas, the power to administer oaths to and examine the officers and agents of the health maintenance organization and the principals of the providers concerning their business.(d) The health maintenance organization and any other entity subject to examination pursuant to this article are subject to the provisions of sections four, five, six, seven, eight and nine, article two of this chapter in regard to the expense and conduct of examinations.(e) In lieu of the examination, the Commissioner may accept the report of an examination made by other states.(f) The expenses of an examination assessing quality of health care under subsection (b) of this section and section seventeen-a of this article shall be reimbursed pursuant to subsection (n), section nine, article two of this chapter.
WV Code § 33-25A-17a (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-17a. Quality Assurance

(a) Each health maintenance organization shall have in writing a quality assurance program that describes the program's objectives, organization and problem solving activities.(b) The scope of the quality assurance program shall include, at a minimum:(1) Organizational arrangements and responsibilities for quality management and improvement processes;(2) A documented utilization management program;(3) Written policies and procedures for credentialing and recredentialing physicians and other licensed providers who fall under the scope of authority of the health maintenance organization;(4) A written policy that addresses enrollee's rights and responsibilities;(5) The adoption of practice guidelines for the use of preventive health services; and(6) Any other criteria deemed necessary by the commissioner.(c) As a condition of doing business in this state, each health maintenance organization which has been in existence for at least three years shall apply for and submit to an accreditation examination to be performed by a nationally recognized accreditation and review organization approved by the commissioner. The accreditation and review organization must be experienced in health maintenance organization activities and in the appraisal of medical practice and quality assurance in a health maintenance organization setting: Provided, That in those instances where a health maintenance organization has timely applied for and reasonably pursued an accreditation examination, but the examination has not been completed, the health maintenance organization may, upon compliance with all other provisions of this article, engage in business in this state upon submission of proof to the commissioner of its application for review.(d) Within thirty days of receipt of the written report of the accreditation and review organization by the health maintenance organization, the health maintenance organization shall submit a copy of this report to the commissioner.(e) This section shall become effective on May 1, 1998.
WV Code § 33-25A-19 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-19. Rehabilitation, Liquidation or Conservation of Health Maintenance Organization

Any rehabilitation, liquidation or conservation of a health maintenance organization shall be considered to be the rehabilitation, liquidation or conservation of an insurance company, shall be the exclusive remedy for rehabilitation, liquidation and conservation of an HMO as provided by this article and shall be conducted under the supervision of the commissioner pursuant to the law governing the rehabilitation, liquidation or conservation of insurance companies. The commissioner may apply for an order directing him or her to rehabilitate, liquidate or conserve a health maintenance organization upon any one or more grounds set out in the rehabilitation statutes or when, in his or her opinion, the continued operation of the health maintenance organization would be hazardous either to the enrollees or to the people of this state.
WV Code § 33-25A-20 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-20. Regulations

The commissioner may after notice and hearing promulgate reasonable rules and regulations in accordance with chapter twenty-nine-a of this code, as are necessary or proper to effectuate the purposes of this article and to prevent circumvention and evasion thereof.
WV Code § 33-25A-21 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-21. Administrative Procedures

(1) When the commissioner has cause to believe that grounds for the denial of an application for a certificate of authority exist, or that grounds for the suspension or revocation of a certificate of authority exist, he shall notify the health maintenance organization in writing specifically stating the grounds for denial, suspension or revocation and fixing a time of at least twenty days thereafter for a hearing on the matter.(2) After such hearing, or upon the failure of the health maintenance organization to appear at such hearing, the commissioner shall take action as is deemed advisable on written findings which shall be mailed to the health maintenance organization. The action of the commissioner shall be subject to review. The court may modify, affirm or reverse the order of the commissioner in whole or in part.(3) The provisions of the administrative procedures act, chapter twenty-nine-a of this code, shall apply to proceedings under this article to the extent that they are not in conflict with subsections (1) and (2) of this section.
WV Code § 33-25A-22 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-22. Fees

Every health maintenance organization subject to this article shall pay to the Commissioner the following fees: For filing an application for a certificate of authority or amendment to the application, $200; for each renewal of a certificate of authority, the annual fee as provided in section thirteen, article three of this chapter; for each form filing and for each rate filing, the fee, as provided in section thirty-four, article six of this chapter; and for filing each annual report, $100. Fees charged under this section shall be for the purposes set forth in section thirteen, article three of this chapter.
WV Code § 33-25A-23a (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-23a. Civil Penalty Imposed by Commissioner

No provider shall collect or attempt to collect from a health maintenance organization enrollee any money for services covered by the health maintenance organization. If a provider collects or attempts to collect from a health maintenance organization enrollee any money for services covered by the health maintenance organization, then the provider may be subjected to a civil money penalty to be imposed by the commissioner. Upon a determination that there is probable cause to believe that there has been a violation of this section, the commissioner may provide written notice to the alleged violator, stating the nature of the alleged violation and that failure to refund the amount of any improper billing within thirty days may result in imposition of a civil penalty pursuant to the provisions of this section. If the alleged violator fails to make a refund within thirty days, the commissioner shall issue a written notice of hearing stating the nature of the alleged violation and the time and place at which the alleged violator shall appear to show good cause why a civil penalty should not be imposed: Provided, That if the commissioner has previously found on three occasions that probable cause existed to support a violation, the alleged violator shall not be afforded the opportunity to make a refund before issuance of the notice of hearing for any subsequent violation.If, after notice and hearing, the commissioner determines that a violation of this section has occurred, the commissioner may assess a civil penalty of not less than the amount charged the subscriber but not more than $1,000. Subsequent violations of this section result in fines of not more than $2,000. Any provider so assessed shall be notified of the assessment in writing and the notice shall specify the reasons for the assessment. Any provider may waive the right to a hearing and receive a reduction in penalties of twenty-five percent.
WV Code § 33-25A-25 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-25. Filings and Reports as Public Documents

All applications, filings and reports required under this article shall be treated as public documents: Provided, That where the provisions of other articles in this chapter are applicable to health maintenance organizations, all applications, filings and reports required under those articles shall be afforded the level of confidentiality as provided in those articles.
WV Code § 33-25A-26 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-26. Confidentiality of Medical Information

Any data or information pertaining to the diagnosis, treatment or health of any enrollee or applicant obtained from that person or from any provider by any health maintenance organization shall be held in confidence and shall not be disclosed to any person except: (1) To the extent that it may be necessary to facilitate an assessment of the quality of care delivered pursuant to section seventeen of this article or to review the grievance procedure pursuant to section twelve of this article; (2) upon the express written consent of the enrollee or his or her legally authorized representative; (3) pursuant to statute or court order for the production of evidence or the discovery thereof; (4) in the event of claim or litigation between that person and the health maintenance organization wherein the data or information is pertinent; or (5) to a department or division of the state pursuant to the terms of a group contract for the provision of health care services between the HMO and the department or division of the state. A health maintenance organization is entitled to claim any statutory privileges against the disclosure which the provider who furnished the information to the health maintenance organization is entitled to claim.
WV Code § 33-25A-27 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-27. Authority to Contract With Health Maintenance Organizations Under Medicaid

The department of welfare is hereby authorized to enter into contracts with health maintenance organizations certified and permitted to market under the laws of this state, and to furnish to recipients of medical assistance under Title XIX of the Social Security Act, 42 U.S.C. Section 1396, et. seq., health care services offered to such recipients under the medical assistance plan of West Virginia.
WV Code § 33-25A-28 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-28. Required Health Maintenance Organization Option

(1) Each employer shall offer no less than once every year to every employee and dependent entitled to receive health care under an existing health benefit plan supported in whole or in part by such employer the opportunity to become enrollees in certified health maintenance organizations which have the capacity to provide basic health services in health maintenance organization service areas in which at least twenty-five such employees reside: Provided, That nothing herein shall require an employer to contribute more on behalf of an employee seeking to enroll in a health maintenance organization than would be contributed on the employee's behalf to the existing health plan.(2) If any employees of an employer are represented by a collective bargaining representative or other employee representative designated or selected under any law of this state, the offer described in subsection (1) of this section should be made to such collective bargaining representatives or other employee representative, and only if such representative approves the offer should it be made to employees represented by such representatives.(3) If there is more than one certified health maintenance organization which meets the requirements of subsection (1) of this section and such health maintenance organizations have service areas contemporaneously covering the same twenty-five or more employees, the employer shall offer such employees at least one health maintenance organization which provides health services primarily through staff physicians, or medical groups, or a combination of both; and one health maintenance organization which provides health services through other means.(4) Any employer who knowingly fails to comply with any of the requirements of this section shall be subject to a fine of not more than $10,000 for every thirty-day period that such violation continues.(5) The commissioner is authorized, in addition to the remedy provided in subsection (4) of this section, to seek an injunction in a court of competent jurisdiction to compel compliance with the provisions of this section.
WV Code § 33-25A-31 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-31. Policies Discriminating Among Health Care Providers

Notwithstanding any other provisions of law, when any health insurance policy, health care services plan or other contract provides for the payment of medical expenses, benefits or procedures, such policy, plan or contract shall be construed to include payment to all health care providers including medical physicians, osteopathic physicians, podiatric physicians, chiropractic physicians, midwives and nurse practitioners who provide medical services, benefits or procedures which are within the scope of each respective provider's license. Any limitation or condition placed upon services, diagnoses or treatment by, or payment to any particular type of licensed provider shall apply equally to all types of licensed providers without unfair discrimination as to the usual and customary treatment procedures of any of the aforesaid providers.
WV Code § 33-25A-32 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-32. Authority of Commissioner to Promulgate Rules and Regulations Regarding Affiliate and Subsidiary Operating Results

The commissioner may as he deems necessary after notice and hearing promulgate rules and regulations in accordance with chapter twenty-nine-a of this code to define the commissioner's authority to consider the operating results of an insurer's affiliates and subsidiaries in the rate making and solvency determination of that insurer.
WV Code § 33-25A-33 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-33. Guaranty Fund

On or before January 15, 1996, the commissioner shall submit a report to the Legislature setting forth a plan to establish a guaranty fund for health maintenance organizations operating in West Virginia.