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WV Code § 33-15-16 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15. Accident and Sickness Insurance|§33-15-16. Policies Not to Exclude Insured's Children From Coverage; Required Services; Coordination With Other Insurance

(a) An insurer issuing accident and sickness policies in this state shall provide coverage for the child or children of the insured without regard to the amount of child support ordered to be paid or actually paid by the insured, if any, and without regard to the fact that the insured may not have legal custody of the child or children or that the child or children may not be residing in the home of the insured.(b) An insurer issuing accident and sickness policies in this state shall provide benefits to dependent children placed with participants or beneficiaries for adoption under the same terms and conditions as apply to natural, dependent children of participants and beneficiaries, irrespective of whether the adoption has become final.(c) An insurer shall not deny enrollment of a child under the health plan of the child's parent on the grounds that:(1) The child was born out of wedlock;(2) The child is not claimed as a dependent on the parent's federal tax return; or(3) The child does not reside with the parent or in the insurer's service area.(d) Where a child has health coverage through an insurer of a noncustodial parent the insurer shall:(1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through that coverage;(2) Permit the custodial parent, or the provider, with the custodial parent's approval, to submit claims for covered services without the approval of the noncustodial parent; and(3) Make payments on claims submitted in accordance with subdivision (2) of this subsection directly to the custodial parent, the provider or the state Medicaid agency: Provided, That upon payment to the custodial parent, the provider or the state Medicaid agency, the insurer's obligation to the noncustodial parent under the policy with respect to the covered child's claims shall be fully satisfied.(e) Where a parent is required by a court or administrative order to provide health coverage for a child, and the parent is eligible for family health coverage, the insurer shall:(1) Permit the parent to enroll, under the family coverage, a child who is otherwise eligible for the coverage without regard to any enrollment season restrictions;(2) If the parent is enrolled but fails to make application to obtain coverage for the child, enroll the child under family coverage upon application of the child's other parent, the state agency administering the Medicaid program or the state agency administering 42 U.S.C. §651 through §669, the child support enforcement program; and(3) Not disenroll or eliminate coverage of the child unless the insurer is provided satisfactory written evidence that:(A) The court or administrative order is no longer in effect; or(B) The child is or will be enrolled in comparable health coverage through another insurer which will take effect not later than the effective date of disenrollment.
WV Code § 33-15-17 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15. Accident and Sickness Insurance|§33-15-17. Child Immunization Services Coverage

All policies issued pursuant to this article shall cover the cost of child immunization services as described in section five, article three, chapter sixteen of this code, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration. These services shall be exempt from any deductible, per-visit charge and/or copayment provisions which may be in force in these policies or contracts. This section does not require that other health care services provided at the time of immunization be exempt from any deductible and/or copayment provisions.
WV Code § 33-15-18 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15. Accident and Sickness Insurance|§33-15-18. Equal Treatment of State Agency

An insurer may not impose requirements on a state agency, which has been assigned the rights of an individual eligible for medical assistance under Medicaid and covered for health benefits from the insurer, that are different from requirements applicable to an agent or assignee of any other individual so covered.
WV Code § 33-15-19 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15. Accident and Sickness Insurance|§33-15-19. Coordination of Benefits With Medicaid

Any health insurer, health maintenance organization as defined in article twenty-five-a of this chapter, prepaid limited health service organization as defined in article twenty-five-d of this chapter or hospital and medical service corporations as defined in article twenty-four of this chapter is prohibited from considering the availability or eligibility for medical assistance in this or any other state under 42 U.S.C. §1396a, Section 1902 of the Social Security Act, referred to in this article as Medicaid, when considering eligibility for coverage or making payments under its plan for eligible enrollees, subscribers, policyholders or certificateholders.
WV Code § 33-15-22 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15. Accident and Sickness Insurance|§33-15-22. 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 § 33-15A-1 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15A. West Virginia Long-Term Care Insurance Act|§33-15A-1. Short Title

This article may be known and cited as the West Virginia Long-Term Care Insurance Act.
WV Code § 33-15A-2 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15A. West Virginia Long-Term Care Insurance Act|§33-15A-2. Declaration of Policy and Purpose

The purpose of this act is to promote the public interest, to promote the availability of long-term care insurance policies, to protect applicants for long-term care insurance, as defined, from unfair or deceptive sales or enrollment practices, to establish standards for long-term care insurance, to facilitate public understanding and comparison of long-term care insurance policies, and to facilitate flexibility and innovation in the development of long-term care insurance coverage.
WV Code § 33-15A-3 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15A. West Virginia Long-Term Care Insurance Act|§33-15A-3. Applicability

The requirements of this act shall apply to policies delivered or issued for delivery in this state on or after the effective date of this act. This act is not intended to supersede the obligations of entities subject to this act to comply with the substance of other applicable insurance laws insofar as they do not conflict with this act, except that laws and regulations designed and intended to apply to Medicare supplement insurance policies shall not be applied to long-term care insurance.
WV Code § 33-15A-5 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15A. West Virginia Long-Term Care Insurance Act|§33-15A-5. Extraterritorial Jurisdiction - Group Long-Term Care Insurance

No group long-term care insurance coverage may be offered to a resident of this state under a group policy issued in another state to a group described in subdivision (4), subsection (e), section four of this article unless this state or another state having statutory and regulatory long-term care insurance requirements substantially similar to those adopted in this state has made a determination that such requirements have been met.
WV Code § 33-15A-7 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15A. West Virginia Long-Term Care Insurance Act|§33-15A-7. Severability

If any provision of this act or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the act and application of such provision to other persons or circumstances shall not be affected thereby.
WV Code § 33-15A-8 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15A. West Virginia Long-Term Care Insurance Act|§33-15A-8. Incontestability Period

(a) For a policy or certificate that has been in force for less than six months an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is material to the acceptance for coverage.(b) For a policy or certificate that has been in force for at least six months but less than two years, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is both material to the acceptance for coverage and which pertains to the condition for which benefits are sought.(c) After a policy or certificate has been in force for two years it is not contestable upon the grounds of misrepresentation alone. The policy or certificate may be contested only upon a showing that the insured knowingly and intentionally misrepresented relevant facts relating to the insured's health.(d) No long-term care insurance policy or certificate may be field issued based on medical or health status. For purposes of this subsection, "field issued" means a policy or certificate issued by an agent or a third-party administrator pursuant to the underwriting authority granted to the agent or third-party administrator by an insurer.(e) If an insurer has paid benefits under the long-term care insurance policy or certificate, the benefit payments may not be recovered by the insurer in the event that the policy or certificate is rescinded.(f) In the event of the death of the insured, this section shall not apply to the remaining death benefit of a life insurance policy that accelerates benefits for long-term care. In this situation, the remaining death benefits under these policies shall be governed by section four, article thirteen of this chapter. In all other situations, this section shall apply to life insurance policies that accelerate benefits for long-term care.
WV Code § 33-15A-9 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15A. West Virginia Long-Term Care Insurance Act|§33-15A-9. Nonforfeiture Benefits

(a) Except as provided in subsection (b) of this section, a long-term care insurance policy may not be delivered or issued for delivery in this state unless the policyholder or certificate holder has been offered the option of purchasing a policy or certificate including a nonforfeiture benefit. The offer of a nonforfeiture benefit may be in the form of a rider that is attached to the policy. In the event the policyholder or certificate holder declines the nonforfeiture benefit, the insurer shall provide a contingent benefit upon lapse that shall be available for a specified period of time following a substantial increase in premium rates.(b) When a group long-term care insurance policy is issued, the offer required in subsection (a) of this section shall be made to the group policyholder. However, if the policy is issued as group long-term care insurance as defined in subdivision (4), subsection (e), section four of this article, other than to a continuing care retirement community or other similar entity, the offering shall be made to each proposed certificate holder.(c) The commissioner may promulgate rules pursuant to chapter twenty-nine-a of this code specifying the type or types of nonforfeiture benefits to be offered as part of long-term care insurance policies and certificates, the standards for nonforfeiture benefits and the rules regarding contingent benefit upon lapse, including a determination of the specified period of time during which a contingent benefit upon lapse will be available and the substantial premium rate increase that triggers a contingent benefit upon lapse as described in subsection (a) of this section.
WV Code § 33-15A-10 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15A. West Virginia Long-Term Care Insurance Act|§33-15A-10. Authority to Promulgate Rules

 The commissioner may issue reasonable rules pursuant to chapter twenty-nine-a of this code to promote premium adequacy and to protect the policyholder in the event of substantial rate increases and to establish minimum standards for marketing practices, agent compensation, agent testing, penalties and reporting practices for long-term care insurance.
WV Code § 33-15A-11 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15A. West Virginia Long-Term Care Insurance Act|§33-15A-11. Penalties

 In addition to any other penalties provided by the laws of this state, any insurer and any agent found to have violated any requirement of this state relating to the regulation of long-term care insurance or the marketing of such insurance shall be subject to a fine of up to three times the amount of any commissions paid for each policy involved in the violation or up to $10,000, whichever is greater.
WV Code § 33-15B-1 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15B. Uniform Health Care Administration Act|§33-15B-1. Legislative Findings; Purpose

The Legislature hereby finds that there is a need to provide guidelines regarding uniform health care administration in order to best serve consumers, health care providers and insurers and to organize and streamline the claims process. The purpose of this article is to authorize the insurance commissioner to develop standard forms and procedures regarding health care claims and to require that all insurers, third party payers, and health care providers implement and use such standards in a uniform manner.
WV Code § 33-15B-2 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15B. Uniform Health Care Administration Act|§33-15B-2. Scope of Article

The provisions of this article apply to all health care providers in the state; all health insurers writing or issuing accident and sickness policies, including hospital service corporations, health service corporations, medical service corporations, dental service corporations and HMOs; all third party payers; all state agencies and departments, including, but not limited to, the public employees insurance agency and providers of services under Medicare and Medicaid; and all entities involved in the payment of health care claims.
WV Code § 33-15B-3 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15B. Uniform Health Care Administration Act|§33-15B-3. Insurance Commissioner to Propose Rules; Use of Standardized Forms and Classifications; Advisory Group

(a) The commissioner shall propose rules for legislative approval, in accordance with the provisions of chapter twenty-nine-a of this code, regarding the implementation and use of uniform health care administrative forms. Such rules shall establish, where practicable, the acceptance and use throughout the health care system of standard administrative forms, terms or procedures, including, but not limited to, the following:(1) The standard CMS 1500 health insurance claim form, as amended, or other similar forms, terms, and definitions to be used which are consistent with health care and insurance industry standards.(2) International classification of disease, ninth clinical modifications (ICD-9-CM) and common procedural terminology (CPT) codes, as amended, or other similar forms, terms, and definitions to be used which are consistent with health care and insurance industry standards.(3) National uniform billing data element specifications (UB-04), as amended, and as supplemented by the West Virginia uniform billing committee, or other similar forms, terms, and definitions to be used which are consistent with health care and insurance industry standards.(4) Consideration of current practices involving reimbursement of claims and explanation of benefits, and the implementation of standards and guidelines regarding explanation of benefits, including, but not limited to, consideration of line item explanations of payments or denial of payments.(b) The legislative rules required herein shall be developed with the advice of an advisory group to be appointed by the commissioner. Such advisory group shall consist of representatives of consumers, providers, payors, and regulatory agencies, including representatives from the following: The department of health and human resources; the West Virginia health care authority; West Virginia dental association; West Virginia pharmacists association; the West Virginia hospital association; commercial health insurers; third party administrators; the West Virginia state medical association; the West Virginia nurses association; public employees insurance agency; and consumers.(c) The commissioner and the advisory group shall review the legislative rules to be proposed pursuant to this section as necessary and update the same in a timely manner in order to conform to current legislation and health care and insurance industry standards and trends.
WV Code § 33-15B-5 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15B. Uniform Health Care Administration Act|§33-15B-5. Penalties for Violation

Any person, partnership, corporation, limited liability company, professional corporation, health care provider, insurer or other payer, or other entity violating any provision of this article shall be subject to a fine imposed by the commissioner of not more than $1000 for each violation and, in addition to or in lieu of any fine imposed, the West Virginia health care authority is empowered to withhold rate approval or a certificate of need for any health care provider violating any provision of this article.
WV Code § 33-15B-6 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15B. Uniform Health Care Administration Act|§33-15B-6. Citation of Article

This article may be known as the "Uniform Health Care Administration Act."
WV Code § 33-15C-1 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15C. Diabetes Insurance|§33-15C-1. Insurance for Diabetics

[Repealed.]
WV Code § 33-15E-1 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-1. Short Title

This article shall be cited as the "Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act."
WV Code § 33-15E-2 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-2. Purpose

The purpose of this article is to establish standards for discount medical plan organizations and discount prescription drug plan organizations in order to better protect consumers from unfair or deceptive marketing, sales and enrollment practices and to facilitate consumer understanding of the role and function of the organizations in providing access to medical or ancillary services.
WV Code § 33-15E-4 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-4. Licensing Requirements

(a) A person is required to obtain a license prior to doing business in this state as a discount medical plan organization.(b) The commissioner shall propose rules for legislative approval in accordance with the provisions of article three, chapter twenty-nine-a of this code, as well as emergency rules in accordance with section fifteen of said article, setting forth the licensing requirements. These rules shall include, at a minimum:(1) All necessary forms and other information considered necessary and required by the commissioner for processing the license application;(2) Applicable fees;(3) Reciprocity requirements;(4) Time frames for the application and approval process;(5) Conditions of approval of the license application or denial of the license;(6) Renewal process;(7) Notice requirements; and(8) Any other provisions considered necessary by the commissioner to effectuate the provisions of this article.
WV Code § 33-15E-5 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-5. Minimum Capital Requirements

(a) Before the commissioner issues a license to any person required to obtain a license under section four of this article, the person seeking to operate a discount medical plan organization shall demonstrate that it has a positive net worth of at least $150,000.(b) Each discount medical plan organization shall at all times maintain a positive net worth of at least $150,000.
WV Code § 33-15E-6 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-6. Surety Bond Requirements

Each licensed discount medical plan organization shall maintain in force a surety bond in its own name, in an amount not less than $35,000, in favor of the commissioner for the benefit of any person who is damaged by any violation of this article. The bond shall cover any violation occurring during the time period during which the bond is in effect and shall be issued by an insurance company licensed to do business in this state. A copy of the bond or a statement identifying the depository, trustee, and account number of the surety account, and thereafter proof of annual renewal of the bond or maintenance of the surety account, shall be filed with the commissioner.