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WV Code § 33-25-10 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25. Health Care Corporations|§33-25-10. Examination of Corporation; Report of Examination; Objections to Report; Access to Books, Records, etc.; Removal of Records, etc., From State

(a) The commissioner or his or her accredited examiners may at any reasonable time and shall, at least once every five years, visit each health care corporation and thoroughly examine its financial condition and methods of doing business and ascertain whether it has complied with all of the laws and rules of this state. All expenses of each such examination conducted shall be borne by such corporation. The commissioner shall make a full written report of each such examination of the corporation, certified to by the commissioner or the examiner in charge of such examinations. The commissioner shall furnish a copy of the report to the corporation examined not less than thirty days prior to filing the same in his or her office. If such corporation so requests in writing, within such thirty-day period, the commissioner shall consider the objections of such corporation to the report as proposed and shall not so file the report until after such modifications, if any, have been made therein as the commissioner deems proper. The report, when filed, shall be admissible in evidence in any action or proceeding brought by the commissioner against the corporation examined, or its officers or agents, and shall be prima facie evidence of the facts stated therein. The commissioner or his or her examiners may at any time testify and offer other proper evidence as to information secured during the course of an examination, whether or not a written report of the examination has at that time been either made, served or filed in the commissioner's office.(b) For such purposes the commissioner, his or her deputies and employees shall have free access to all books, records, papers, documents and correspondence of any such corporation and such books, records, papers, documents and records shall be and remain in the State of West Virginia. The licenses of said corporation shall be automatically revoked if such books, records, papers, documents and records are taken outside the State of West Virginia without the prior written approval of the commissioner.(c) The commissioner shall revoke the license of any such corporation which refuses to submit to such examination.
WV Code § 33-25-11 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25. Health Care Corporations|§33-25-11. Rules and Regulations

The commissioner is authorized to promulgate and adopt such rules and regulations relating to health care corporations as are necessary to discharge his duties and exercise his powers and to effectuate the provisions of this article and to protect and safeguard the interests of subscribers and the public of this state.
WV Code § 33-25-12 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25. Health Care Corporations|§33-25-12. Required Provisions in Contracts Made by Corporation With Physicians, Dentists, etc., Hospitals and Other Health Agencies

Each contract made by the corporation with any person (other than subscribers), corporation, association and institution, named or referred to in section three of this article shall contain the following provisions:(a) That the person, corporation, association or institution will render to any subscriber such service as he may be entitled to under the terms and conditions of the contract issued to the subscriber by the corporation;(b) That the person, corporation, association or institution will accept as full payment for services contracted for subscribers such compensation as is set forth in the contract between such person, corporation, association or institution and the corporation;(c) That in the event a surplus remains after an annual accounting of the financial condition of the corporation, such surplus may be used by the corporation, upon an affirmative vote of a majority of its board of directors for the following purposes, in the order of priority stated below:(1) To liquidate on a pro rata basis any obligation due any such person, corporation, association or institution in previous years;(2) To return the original contributions for working capital, or any part thereof, on a pro rata basis;(3) To reduce rates charged subscribers, or to expand the services rendered them.
WV Code § 33-25-13 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25. Health Care Corporations|§33-25-13. Contracts to Be Furnished to Subscribers; Payments for Subscribers by Others; Wage Deductions

(a) Every such corporation shall deliver to each subscriber to its health care plan a copy of the contract.(b) A corporation may accept from private agencies, corporations, associations, groups or individuals, payment for or on behalf of any subscriber of all or any part of the cost of subscriptions for direct health care services to be rendered: Provided, That no employer or sponsor may deduct the proportionate share of such payment attributable to any employee or subscriber from that employee's or subscriber's wages or salary, without the prior written consent of the employee or subscriber. It shall be unlawful for any governmental agency to pay subscriptions for or on behalf of any subscriber.
WV Code § 33-25-14 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25. Health Care Corporations|§33-25-14. Advancement of Money to Corporation

Any person may advance to such corporation any sums of money necessary for its business or to enable it to comply with any requirements of law. Such advances and such interest thereon not exceeding six percent per annum, as may be agreed upon, shall not be a liability or a claim against the corporation or any of its assets, except as provided in this section and shall be reimbursed only out of the surplus earnings of such corporation. This section does not affect the power to borrow money which any such corporation possesses under other laws. No commissions or promotion expenses shall be paid by the corporation in connection with the advance of any such money to the corporation. The amount of any such advance that has not been repaid shall be reported in each annual statement of the corporation.
WV Code § 33-25-16 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25. Health Care Corporations|§33-25-16. Disposition of Fees and Charges

All licenses or renewal fees, all auditing charges and any other income derived from this article shall be deposited with the treasurer of the State of West Virginia to the credit of the Insurance Commissioner to be used only for the cost of operation of the Insurance Commissioner's office.
WV Code § 33-25-17 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25. Health Care Corporations|§33-25-17. Bonds of Corporation Officers and Employees

Every officer or employee of any such corporation, who is entrusted with the handling of its funds, shall furnish, in such amount as may with the approval of the commissioner be fixed by the board of directors of the corporation, a bond with corporate surety, conditioned upon faithful performance of all his duties.
WV Code § 33-25-18 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25. Health Care Corporations|§33-25-18. Annual Audited Financial Report

Every health care organization organized under the laws of this state is subject to the provisions of article thirty-three of this chapter.
WV Code § 33-25-19 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25. Health Care Corporations|§33-25-19. Administrative Supervision

Every health care corporation subject to the provisions of this article is subject to the provisions of article thirty-four of this chapter.
WV Code § 33-25-20 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25. Health Care Corporations|§33-25-20. 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 § 33-25-21 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25. Health Care Corporations|§33-25-21. 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 in the rate making and solvency determination of that insurer.
WV Code § 33-25-22 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25. Health Care Corporations|§33-25-22. Assignment of Certain Benefits in Dental Care Insurance Coverage

(a) Any entity regulated under this article that provides dental care coverage to a covered person shall honor an assignment, made in writing by the person covered under the policy, of payments due under the policy to a dentist or a dental corporation for services provided to the covered person that are covered under the policy. Upon notice of the assignment, the entity shall make payments directly to the provider of the covered services. A dentist or dental corporation with a valid assignment may bill the entity and notify the entity of the assignment. Upon request of the entity, the dentist or dental corporation shall provide a copy of the assignment to the entity.(b) A covered person may revoke an assignment made pursuant to subsection (a) of this section with or without the consent of the provider. The revocation shall be in writing. The covered person shall provide notice of the revocation to the entity. The entity shall send a copy of the revocation notice to the dentist or dental corporation subject to the assignment. The revocation is effective when both the entity and the provider have received a copy of the revocation notice. The revocation is only effective for any charges incurred after both parties have received the revocation notice.(c) If, under an assignment authorized in subsection (a) of this section, a dentist or dental corporation collects payment from a covered person and subsequently receives payment from the entity, the dentist or dental corporation shall reimburse the covered person, less any applicable copayments, deductibles, or coinsurance amounts, within 45 days.(d) Nothing in this section limits an entitys ability to determine the scope of the entitys benefits, services, or any other terms of the entitys policies or to negotiate any contract with a licensed health care provider regarding reimbursement rates or any other lawful provisions.(e) Any entity providing dental care shall provide conspicuous notice to the covered person that the assignment of benefits is optional, and that additional payments may be required if the assigned benefits are not sufficient to pay for received services.
WV Code § 33-25A-1 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-1. Short Title and Purpose

(a) This article may be cited as the "Health Maintenance Organization Act of 1977."(b) Faced with the continuation of mounting costs of health care coupled with its inaccessibility to large segments of the population, the Legislature has determined that there is a need to encourage alternative methods for the delivery of health care services, with a view toward achieving greater efficiency, availability, distribution and economy in providing these services.In carrying out this intention, it is the policy of the state to eliminate legal barriers to the establishment of prepaid health care plans accountable to consumers for the health care services they provide; to provide for the financial and administrative soundness of these health care plans as it relates to their ability to provide such services, and to exempt prepaid health care plans from regulation as an insurer, the operation of insurance laws of the state and all other laws inconsistent with the purposes of this article.
WV Code § 33-25A-5 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-5. Powers of Health Maintenance Organizations

(a) Upon obtaining a certificate of authority as required under this article, a health maintenance organization may enter into health maintenance contracts in this state and engage in any activities, consistent with the purposes and provisions of this article, which are necessary to the performance of its obligations under such contracts, subject to the limitations provided in this article. A health maintenance organization may offer to its enrollees in conjunction with the benefits provided to them through their contractual arrangement for health services with the health maintenance organization a point of service option to be provided either by the health maintenance organization directly or by an insurance carrier licensed in this state with which the health maintenance organization has a contractual arrangement. Benefits for health care services within the health maintenance organization's contracted provider panel shall comply with all other provisions of this article.(b) The commissioner shall propose rules for legislative approval in accordance with the provisions of article three, chapter twenty-nine-a of this code limiting or regulating the powers of health maintenance organizations which the commissioner finds to be in the public interest. The commissioner may promulgate emergency rules pursuant to the provisions of section fifteen, article three, chapter twenty-nine-a of this code to implement standards and requirements for a point of service option.
WV Code § 33-25A-6 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-6. Governing Body

(1) The governing body of any health maintenance organization may include enrollees, providers, or other individuals.(2) Such governing body shall establish a mechanism to afford the enrollees an opportunity to participate in matters of policy and operation through the establishment of advisory panels, by the use of advisory referenda on major policy decisions, or through the use of other mechanisms as may be prescribed by the commissioner.
WV Code § 33-25A-7 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-7. Fiduciary Responsibilities of Officers; Fidelity Bond; Approval of Contracts by Commissioner

(a) Any director, officer or partner of a health maintenance organization who receives, collects, disburses or invests funds in connection with the activities of the organization is responsible for the funds in a fiduciary relationship to the enrollees.(b) A health maintenance organization shall maintain a blanket fidelity bond covering all directors, officers, managers and employees of the organization who receive, collect, disburse or invest funds in connection with the activities of the organization, issued by an insurer licensed in this state or, if the fidelity bond required by this subsection is not available from an insurer licensed in this state, a fidelity bond procured by an excess line broker licensed in this state, in an amount at least equal to the minimum amount of fidelity insurance as provided in the national association of Insurance Commissioners handbook, as amended, or as determined under a rule promulgated by the commissioner.(c) Any contracts made with providers of health care services enabling a health maintenance organization to provide health care services authorized under this article shall be filed with the commissioner. The commissioner has the power to require immediate cancellation of the contracts or the immediate renegotiation of the contract by the parties whenever he or she determines that they provide for excessive payments, or that they fail to include reasonable incentives for cost control, or that they otherwise substantially and unreasonably contribute to escalation of the costs of providing health care services to enrollees.
WV Code § 33-25A-7a (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-7a. Provider Contracts

(1) Whenever a contract exists between a health maintenance organization and a provider and the organization fails to meet its obligations to pay fees for services already rendered to a subscriber, the health maintenance organization is liable for the fee or fees rather than the subscriber; and the contract shall state that liability.(2) No subscriber of a health maintenance organization is liable to any provider of health care services for any services covered by the health maintenance organization if at any time during the provision of the services, the provider, or its agents, are aware the subscriber is a health maintenance organization enrollee.(3) If at any time during the provision of the services, a provider, or its agents, are aware that the subscriber is a health maintenance organization enrollee, that provider of services or any representative of the provider may not collect or attempt to collect from a health maintenance organization subscriber any money for services covered by a health maintenance organization and no provider or representative of the provider may maintain any action at law against a subscriber of a health maintenance organization to collect money owed to the provider by a health maintenance organization.(4) Every contract between a health maintenance organization and a provider of health care services shall be in writing and shall contain a provision that the subscriber is not liable to the provider for any services covered by the subscriber's contract with the health maintenance organization.(5) The provisions of this section shall not be construed to apply to the amount of any deductible or copayment which is not covered by the contract of the health maintenance organization.(6) When a subscriber receives covered emergency health care services from a noncontracting provider, the health maintenance organization shall be responsible for payment of the providers normal charges for those health care services, exclusive of any applicable deductibles or copayments.(7) For all provider contracts executed on or after April 15, one thousand nine hundred ninety-five, and within one hundred eighty days of that date for contracts in existence on that date:(a) The contracts must provide that the provider shall provide sixty days advance written notice to the health maintenance organization and the commissioner before canceling the contract with the health maintenance organization for any reason; and(b) The contract must also provide that nonpayment for goods or services rendered by the provider to the health maintenance organization is not a valid reason for avoiding the sixty day advance notice of cancellation.(8) Upon receipt by the health maintenance organization of a sixty day cancellation notice, the health maintenance organization may, if requested by the provider, terminate the contract in less than sixty days if the health maintenance organization is not financially impaired or insolvent.
WV Code § 33-25A-8a (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25A. Health Maintenance Organization Act|§33-25A-8a. Third Party Reimbursement for Mammography, Pap Smear or Human Papilloma Virus Testing

(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, whenever reimbursement or indemnity for laboratory or X-ray services are covered, reimbursement or indemnification shall not be denied for any of the following when performed for cancer screening or diagnostic purposes, at the direction of a person licensed to practice medicine and surgery by the Board of Medicine: (1) Mammograms when medically appropriate and consistent with the current guidelines from the United States Preventive Services Task Force or The American College of Obstetricians and Gynecologists.(2) A pap smear, either conventional or liquid-based cytology, whichever is medically appropriate and consistent with the current guidelines from the United States Preventive Services Task Force or The American College of Obstetricians and Gynecologists, for women age eighteen or over; or(3) A test for the human papilloma virus (HPV)for women age eighteen or over, when medically appropriate and consistent with the current guidelines from either the United States Preventive Services Task Force or The American College of Obstetricians and Gynecologists for women age eighteen and over.(b) A policy, provision, contract, plan or agreement may apply to mammograms, pap smears or human papilloma virus (HPV) test the same deductibles, coinsurance and other limitations as apply to other covered services.