reglab/housing_qa huggingface dataset:
WV Code § 33-25C-4 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25C. Health Maintenance Organization Patient Bill of Rights|§33-25C-4. Access to Appropriate Health Services

(a) Each managed care plan must allow an enrollee to choose a primary care provider who is accepting new enrollees from a list of participating providers. Enrollees also must be permitted to change primary care providers after six months with the change becoming effective no later than the beginning of the month next following the enrollee's request for the change.(b) The enrollee's managed care plan may not provide to any provider or any primary care physician an incentive or disincentive plan that includes specific payment made directly or indirectly, in any form, to the provider or primary care physician as an inducement to deny, release, limit, or delay specific, medically necessary and appropriate services provided with respect to a specific enrollee or groups of enrollees with similar medical conditions.(c) A managed care plan shall have a procedure by which an enrollee, upon diagnosis with a life-threatening, degenerative or disabling condition or disease, either of which requires specialized health care over a prolonged period of time, may receive a standing referral to a specialist with expertise in that condition or disease who will be responsible for and capable of providing and coordinating the member's specialty care. When a standing referral is made, the managed care plan shall periodically review the referral for continued necessity.(d) Each managed care plan must provide for appropriate and timely referral of enrollees to a choice of specialists within the plan if specialty care is warranted. The referral shall be first to a specialist located in the geographic area of the plan in which the enrollee resides and if an appropriate specialist is not available in the area, then to a specialist located elsewhere within the plan. If the type of medical specialist who is appropriate for a specific condition is not represented on the specialty panel, enrollees must have access to nonparticipating specialty health care providers in a manner consistent with their managed care contract.(e) Each managed care plan must, upon the request of an enrollee, provide access by the enrollee to a second opinion regarding a diagnosis or treatment plan requiring a serious or complex procedure, from a qualified participating provider.(f) Each managed care plan must, at the option of the enrollee, continue to cover services of a primary care provider whose contract with the plan or whose contract with a subcontractor is being terminated by the plan or subcontractor without cause under the terms of that contract for at least sixty days following notice of termination to the enrollees. The plan's obligation to continue to cover the primary care physician's services is contingent upon the primary care physician's acceptance and compliance with the same terms and conditions as those of the contract the plan or subcontractor is terminating, except for any provision requiring that the managed care plan assign new enrollees to the terminated provider.
WV Code § 33-25C-8 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25C. Health Maintenance Organization Patient Bill of Rights|§33-25C-8. Delegation of Duties

Each managed care plan is accountable for and must oversee any activities required by this article that it delegates to any subcontractor. No contract with a subcontractor executed by the managed care plan or the subcontractor may relieve the managed care plan of its obligations to any enrollee for the provision of health care services or of its responsibility for compliance with statutes or rules.
WV Code § 33-25C-10 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25C. Health Maintenance Organization Patient Bill of Rights|§33-25C-10. Construction

To the extent permitted by law, if any provision of this article conflict with other state or federal law, then the provision must be construed in a manner most favorable to the enrollee.
WV Code § 33-25D-1 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-1. Short Title

This article may be cited as the "Prepaid Limited Health Service Organization Act."
WV Code § 33-25D-6 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-6. Minimum Capital

(a) Each prepaid limited health service organization shall have and maintain fully paid-in capital stock, if a for-profit stock corporation, or statutory surplus funds, if a nonprofit corporation, totaling at least:(1) The greater of $250,000 or ten percent of its expenses for the previous twelve-month period as reported in its most recent financial statement filed pursuant to subsection (a), section twelve of this article, with respect to each limited health service for which the organization will not offer inpatient services up to a maximum total for all limited health services of the required capital and surplus for an insurer under article three, section five-b of this chapter; and(2) The greater of $1 million or ten percent of its expenses for the previous twelve-month period as reported in its most recent financial statement filed pursuant to subsection (a), section twelve of this article, with respect to each limited health service for which the organization will offer inpatient services up to a maximum total for all limited health services of the required capital and surplus for an insurer under article three, section five-b of this chapter.(b) For purposes of this section, "expenses" means those costs set forth by the national association of Insurance Commissioners (NAIC) in the statement of revenues, expenses and net worth contained in the annual statement instruction--limited health service organization and the official NAIC annual statement blanks--limited health service organization.
WV Code § 33-25D-7 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-7. Powers of Organization

(a) Upon obtaining a certificate of authority as required under this article, a prepaid limited health service organization may enter into limited health service 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 for in this article: Provided, That nothing in this article authorizes any prepaid limited health service organization to transact any insurance other than that for which the organization is granted a certificate of authority under this article.(b) The commissioner may 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 prepaid limited health service organizations which he or she finds to be in the public interest.
WV Code § 33-25D-8 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-8. Governing Body; Enrollee Participation

(a) The governing body of any prepaid limited health service organization may include enrollees, providers, or other individuals.(b) The 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 § 33-25D-9 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-9. Fiduciary Responsibilities of Managers; Fidelity Bond

(a) Any director, officer or other manager of a prepaid limited health service 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 prepaid limited health service 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 subdivision 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 the commissioner may by rule, propose for legislative approval in accordance with the provisions of article three, chapter twenty-nine-a of this code, require.
WV Code § 33-25D-12 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-12. Annual and Quarterly Reports

(a) Every prepaid limited health service organization shall comply with and is subject to the provisions of section fourteen, article four of this chapter relating to filing of financial statements with the commissioner and the national association of Insurance Commissioners. The annual financial statement required by that section shall include, but not be limited to, the following: (1) A statutory financial statement of the organization, including its balance sheet and receipts and disbursements for the preceding year certified by an independent certified public accountant, reflecting at least: (A) All prepayment and other payments received for limited health services rendered; (B) Expenditures to all providers, by classes or groups of providers, and insurance companies or nonprofit health service plan corporations engaged to fulfill obligations arising out of the limited health service contract; (C) Expenditures for capital improvements, or additions thereto, including, but not limited to, construction, renovation or purchase of facilities and capital equipment; and (D) The organization's fidelity bond;(2) The number of new enrollees enrolled during the year, the number of enrollees as of the end of the year and the number of enrollees terminated during the year on a form prescribed by the commissioner;(3) A summary of information compiled pursuant to subdivision (3), subsection (a), section five of this article in such form as the commissioner requires;(4) A report of the names and residence addresses of all persons set forth in subdivision (3), subsection (d), section three of this article who were associated with the prepaid limited health service organization during the preceding year, and the amount of wages, expense reimbursements, or other payments to those individuals for services to the prepaid limited health service organization, including a full disclosure of all financial arrangements during the preceding year required to be disclosed pursuant to subdivision (3), subsection (d), section three of this article; and(5) Other information relating to the performance of the prepaid limited health service organization as is reasonably necessary to enable the commissioner to carry out his or her duties under this article.
WV Code § 33-25D-13 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-13. Annual Report to Enrollees

Every prepaid limited health service organization or its representative shall annually, before April 1, provide to each enrollee a summary of: Its most recent annual financial statement, including a balance sheet and statement of receipts and disbursements; a description of the prepaid limited health service organization, each limited health service offered, its facilities and personnel for each limited health service offered, any material changes therein since the last report, the current evidence of coverage for each limited health service for which the enrollee is enrolled, and a clear and understandable description of the prepaid limited health service organization's method for resolving enrollee complaints: Provided, That with respect to enrollees who have been enrolled through contracts between a prepaid limited health service organization and an employer, the prepaid limited health service organization satisfies the requirement of this section by providing the requisite summary to each enrolled employee: Provided, however, That with respect to Medicaid recipients enrolled under a group contract between a prepaid limited health service organization and the governmental agency responsible for administering the Medicaid program, the prepaid limited health service organization satisfies the requirement of this section by providing the requisite summary to each local office of the governmental agency responsible for administering the Medicaid program for inspection by enrollees of the prepaid limited health service organization.
WV Code § 33-25D-17 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-17. Powers of Insurers, Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations, Health Service Corporations and Health Maintenance Organizations

(a) An insurance company licensed in this state, a hospital, medical, dental or health service corporation authorized to do business in this state or a health maintenance organization holding a certificate of authority under article twenty-five-a of this chapter, after applying for and receiving a certificate of authority as a prepaid limited health service organization, may through a subsidiary or affiliate organize and operate a prepaid limited health service organization under the provisions of this article. Notwithstanding any other law to the contrary, any two or more insurance companies, hospital, medical, dental or health service corporations, health maintenance organizations or subsidiaries or affiliates thereof, may jointly organize and operate a prepaid limited health service organization. The business of insurance is considered to include the providing of health care by a prepaid limited health service organization owned or operated by an insurer or a subsidiary of the insurer.(b) Notwithstanding any provision of insurance, hospital, medical, dental or health service corporation or health maintenance organization laws, an insurer, a hospital, medical, dental or health service corporation or a health maintenance organization may contract with a prepaid limited health service organization to provide insurance or similar protection against the cost of care provided through prepaid limited health service organizations and to provide coverage in the event of the failure of the prepaid limited health service organization to meet its obligations. The enrollees of a prepaid limited health service organization constitute a permissible group under those laws. Under the contracts, the insurer or hospital, medical, dental or health service corporation or health maintenance organization may make benefit payments to prepaid limited health service organizations for limited health services rendered by providers.(c) Notwithstanding any provision of insurance, hospital, medical, dental or health service corporation or health maintenance organization laws, an insurer, a hospital, medical, dental or health service corporation or a health maintenance organization may exclude in any contract or policy issued to a group, any coverage which would duplicate the coverage of a prepaid limited health service organization, whether for services, supplies or reimbursement, to the extent that the coverage or service is provided in accordance with this chapter pursuant to a contract or policy issued to the same group or to a part of that group by a prepaid limited health service organization.
WV Code § 33-25D-18 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-18. Examinations

(a) The commissioner may make an examination of the affairs of any prepaid limited health service 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 prepaid limited health service organization and providers with whom the organization has contracts, agreements or other arrangements, or any such 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 five years: Provided, That in making the examination, the Department of Health and Human Resources or the accredited entity shall utilize the services of persons or organizations with demonstrable expertise in assessing quality of health care.(c) Every prepaid limited health service 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 prepaid limited health service organization and the principals of the providers concerning their business.(d) The prepaid limited health service organization is subject to the provisions of section 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 another state.(f) The expenses of an examination assessing quality of health care under subsection (b) of this section and section nineteen of this article shall be reimbursed pursuant to subdivision (5), subsection (i), section nine, article two of this chapter.
WV Code § 33-25D-19 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-19. Quality Assurance

(a) Each prepaid limited health service organization shall have in writing a quality assurance program approved by the commissioner which 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 prepaid limited health service organization;(4) A written policy that addresses enrollees' rights and responsibilities;(5) The adoption of practice guidelines for the use of preventive health services; and(6) Any other criteria considered necessary by the commissioner.(c) This section becomes effective on May 1, 1999.
WV Code § 33-25D-21 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-21. Rehabilitation, Liquidation or Conservation of Prepaid Limited Health Service Organization

Any rehabilitation, liquidation or conservation of a prepaid limited health service organization is considered to be the rehabilitation, liquidation or conservation of an insurance company, is the exclusive remedy for rehabilitation, liquidation and conservation of a prepaid limited health service organization 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 prepaid limited health service 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 prepaid limited health service organization would be hazardous either to the enrollees or to the people of this state.
WV Code § 33-25D-22 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-22. Rules

The commissioner may propose rules for legislative approval in accordance with the provisions of article three, chapter twenty-nine-a of this code:(1) To effectuate the purposes of this article and to prevent circumvention and evasion thereof; and(2) To define the commissioner's authority to consider the operating results of a prepaid limited health service organization's affiliates and subsidiaries in the rate making and solvency determination of that prepaid limited health service organization.
WV Code § 33-25D-23 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-23. Administrative Procedures

(a) 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 or she shall notify the prepaid limited health service 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.(b) After the hearing, or upon the failure of the prepaid limited health service organization to appear at the hearing, the commissioner shall take action as is considered advisable on written findings which shall be mailed to the prepaid limited health service organization. The action of the commissioner is subject to review. The court may modify, affirm or reverse the order of the commissioner, in whole or in part.(c) Proceedings under this article are governed by the provisions of section thirteen, article two of this chapter.
WV Code § 33-25D-24 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-24. Fees

Every prepaid limited health service organization subject to this article shall pay to the commissioner the following fees: (1) For filing an application for a certificate of authority or amendment thereto, $200; (2) For each renewal of a certificate of authority, the annual fee as provided in section thirteen, article three of this chapter; (3) For each form filing and for each rate filing, the fee as provided in section thirty-four, article six of this chapter; and (4) For filing each annual report, $25. Fees charged under this section are for the purposes set forth in section thirteen, article three of this chapter.
WV Code § 33-25D-27 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 25D. Prepaid Limited Health Service Organization Act|§33-25D-27. Filings and Reports as Public Documents

All applications, filings and reports required under this article are public documents: Provided, That where the provisions of other articles in this chapter are applicable to prepaid limited health service organizations, all applications, filings and reports required under those articles shall be afforded the level of confidentiality as provided in those articles.