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WV Code § 33-15E-7 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-7. Examinations

The commissioner may examine the business and affairs of any discount medical plan organization to protect the interests of the residents of this state based on the following reasons, including complaint indices, recent complaints or information from other states, or as he or she deems necessary. An examination shall be performed in accordance with the provisions of section nine, article two of this chapter, except that a discount medical plan organization that is the subject of the examination shall pay the expenses incurred in conducting the examination. Failure by the discount medical plan organization to pay the expenses is grounds for the refusal to renew, revoke or suspend a license to operate as a discount medical plan organization.
WV Code § 33-15E-8 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-8. Charges and Fees; Refund Requirements; Bundling of Services

(a) A discount medical plan organization may charge a periodic charge as well as a reasonable one-time processing fee for a discount medical plan.(b)(1) All discount medical plan certificates or other document demonstrating membership in the plan issued to persons in this state shall have a notice, prominently printed on the first page of the document or in a similarly conspicuous manner, stating that the member has the right to cancel his or her membership for any reason within thirty days of its receipt. If a member cancels his or her membership in the discount medical plan organization within the first thirty days after the date of receipt of the written document demonstrating membership, the member shall, upon return of the discount medical plan card to the discount medical plan organization, receive a reimbursement of all periodic charges and the amount of any one-time processing fee that exceeds $30. Notice of cancellation is deemed given when delivered by hand or deposited in a mailbox, properly addressed and postage prepaid to the mailing address of the discount medical plan organization or e-mailed to the e-mail address of the discount medical plan organization.(2) If the discount medical plan organization cancels a membership for any reason other than nonpayment of charges by the member, the discount medical plan organization shall make a pro rata reimbursement of all periodic charges to the member.(c) When a marketer or discount medical plan organization sells a discount medical plan in conjunction with any other products, the marketer or discount medical plan organization shall:(1) Provide the charges for each discount medical plan in writing to the member; or(2) Reimburse the member for all periodic charges for the discount medical plan and all periodic charges for any other product if the member cancels his or her membership in accordance with subdivision (1), subsection (b) of this section.(d) A health carrier that provides a discount medical plan product that is incidental to the insured product is not subject to this section.
WV Code § 33-15E-9 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-9. Record Filing and Retention Requirements

(a) (1) Upon demand by the commissioner, a discount medical plan organization shall file with the commissioner a list of prospective member fees and charges associated with the discount medical plan.(b) A copy of every form to be used by a discount medical plan organization, including the form for the written document demonstrating membership in the plan and all advertising, marketing materials and brochures, shall be retained by such organization and available for inspection by the commissioner for at least two years from the date on which such form was last used.
WV Code § 33-15E-10 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-10. Provider Agreements; Provider Listing Requirements

(a) (1) A discount medical plan organization shall have a written provider agreement with all providers offering medical or ancillary services to its members. The written provider agreement may be entered into directly with the provider or indirectly with a provider network to which the provider belongs.(2) A provider agreement between a discount medical plan organization and a provider shall provide the following:(A) A list of the medical or ancillary services and products to be provided at a discount;(B) The amount or amounts of the discounts or, alternatively, a fee schedule that reflects the provider's discounted rates; and(C) A written document demonstrating that the provider has agreed that it will not charge members more than the discounted rates.(3) A provider agreement between a discount medical plan organization and a provider network shall require that the provider network have written agreements with its providers that:(A) Contain the provisions described in subdivision (2) of this subsection;(B) Authorize the provider network to contract with the discount medical plan organization on behalf of the provider; and(C) Require the provider network to maintain an up-to-date list of its contracted providers and to provide the list on a monthly basis to the discount medical plan organization.(4) A provider agreement between a discount medical plan organization and an entity that contracts with a provider network shall require that the entity, in its contract with the provider network, require the provider network to have written agreements with its providers that comply with subdivision (3) of this subsection.(5) The discount medical plan organization shall maintain a copy of each of its active provider agreements; each such organization shall also retain a copy of every inactive provider agreement for at least two years after the expiration date of each such agreement.(b) Each discount medical plan organization shall maintain on its Internet website page a current list of the names and addresses of the providers with which it has contracted directly or through a provider network; the address of the website shall be prominently displayed on all of the discount medical plan organization's advertisements, marketing materials, brochures and discount medical plan cards.
WV Code § 33-15E-11 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-11. Marketing Requirements

(a) A discount medical plan organization may market directly or contract with other marketers for the distribution of its product.(b) (1) A discount medical plan organization shall have a written agreement with a marketer prior to the marketer's marketing, promoting, selling or distributing the discount medical plan.(2) The agreement between the discount medical plan organization and the marketer shall prohibit the marketer from using advertising, marketing materials, brochures and discount medical plan cards without the discount medical plan organization's approval in writing.(3) The discount medical plan organization shall be bound by and responsible for the activities of a marketer that are within the scope of the marketer's agency relationship with the organization.(c) A discount medical plan organization shall approve in writing all advertisements, marketing materials, brochures and discount cards used by marketers to market, promote, sell or distribute the discount medical plan prior to their use.
WV Code § 33-15E-12 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-12. Annual Reports

(a) If the information required in subsection (b) of this section is not provided at the time of renewal of a license under section four of this article, a discount medical plan organization shall file an annual report with the commissioner in the form prescribed by the commissioner, within three months after the end of each fiscal year.(b) The report shall include:(1) Audited financial statements prepared in accordance with generally accepted accounting principals certified by an independent certified public accountant, including the organization's balance sheet, income statement and statement of changes in cash flow for the preceding year, except that, subject to the approval of the commissioner, an organization that is an affiliate of a parent entity that is publicly traded and that prepares audited financial statements reflecting the consolidated operations of the parent entity may instead submit the audited financial statements of the parent entity and a written guaranty that the minimum capital requirements required under section five of this article will be met by the parent entity;(2) Any changes in the list of names and residence addresses of all persons responsible for the conduct of the organization's affairs, together with a disclosure of the extent and nature of any contracts or arrangements with these persons and the discount medical plan organization, including any possible conflicts of interest;(3) The number of discount medical plan members in the state; and(4) Any other information relating to the performance of the discount medical plan organization that may be required by the commissioner.(c) Any discount medical plan organization that fails to file an annual report in the form and within the time required by this section may be fined up to $500 per day for the first ten days during which the violation continues and up to $1,000 per day after the first ten days during which the violation continues. The commissioner may also suspend the organization's authority to enroll new members or to do business in this state while the violation continues.
WV Code § 33-15E-13 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-13. Discount Prescription Drug Plan Organizations

(a) A discount prescription drug plan organization shall comply with sections eight, nine, ten and eleven of this article and shall report any of the information described in section twelve of this article in the form and manner as the commissioner may require. A discount prescription drug plan organization is also subject to sections fourteen, fifteen and sixteen of this article.(b) Each discount prescription drug plan organization shall designate and provide the commissioner with the name, address and telephone number of a discount prescription drug plan compliance officer responsible for ensuring compliance with the provisions of this article that are applicable to discount prescription drug plans and discount prescription drug plan organizations.
WV Code § 33-15E-14 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-14. Administrative Enforcement Actions; Injunctions

(a) The commissioner may investigate the business affairs and conduct of every person applying for or holding a discount medical plan organization license and the operational affairs of a discount prescription drug plan organization to determine whether a violation of this article or any rule promulgated hereunder has occurred or is occurring.(b) If the commissioner has cause to believe that a violation of this article or any rule promulgated hereunder has occurred or is occurring and that an enforcement action may be warranted, he or she shall notify the discount medical plan organization or discount prescription drug plan organization in writing, specifically stating the grounds for enforcement action and informing the organization that it may pursue a hearing on the matter in accordance with the provisions of section thirteen, article two of this chapter.(c) If, after notice and hearing, a violation of this article or any legislative rule promulgated under this article is found, the Insurance Commissioner may take one or more of the following enforcement actions:(1) Place a discount medical plan organization on probation or suspend, revoke or refuse to issue or renew the organization's license;(2) Levy a civil penalty on the organization in an amount not exceeding $10,000 for each violation;(3) Issue an administrative order requiring the discount medical plan organization or discount prescription drug plan organization to cease and desist from engaging in the act or practice that constitutes the violation; or(4) Suspend the authority of the discount medical plan organization or discount prescription drug plan organization to enroll new members.(d) In addition to the penalties and other provisions of this article, the commissioner may seek both temporary and permanent injunctive relief in the circuit court of Kanawha County when a discount medical plan is being operated by a person or entity that is not licensed pursuant to this article or any person has engaged or is engaging in any activity prohibited by this article or any rule adopted pursuant to this article.
WV Code § 33-15E-15 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-15. Criminal Penalties

(a) A person that willfully operates as or aids and abets another operating as a discount medical plan organization in violation of subsection (a), section four of this article is guilty of a felony and, upon conviction thereof, shall be fined not more than $20,000 for each unauthorized act or imprisoned in the state correctional facility not less than one nor more than five years, or both fined and imprisoned.(b) No person shall collect a fee for purported membership in a discount medical plan or discount prescription drug plan and knowingly and willfully fail to provide the promised benefits of the plan.(1) Any person who violates this subsection and in doing so collects fees totaling $1,000 or more is guilty of a felony and, upon conviction thereof, shall be fined not more than $2,500 or imprisoned in a state correctional facility not less than one nor more than ten years or, in the discretion of the court, be confined in jail for not more than one year, or both fined and imprisoned or confined.(2) Any person who violates this subsection and in doing so collects fees totaling less than $1,000 is guilty of a misdemeanor and, upon conviction thereof, shall be fined not more than $2,500 or confined in jail not more than one year, or both fined and confined.
WV Code § 33-15E-16 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-16. Insurance Fraud Unit

The insurance fraud unit created pursuant to the provisions of section eight, article forty-one of this chapter may investigate suspected violations of this article.
WV Code § 33-15E-17 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act|§33-15E-17. Rules

The commissioner may propose rules for legislative approval in accordance with the provisions of article three, chapter twenty-nine-a of this code to carry out the provisions of this article. The commissioner may also promulgate emergency legislative rules to carry out the provisions of this article, including rules setting forth the requirements and prohibited practices with regard to the marketing of discount medical plans and discount prescription drug plans and for disclosures to members and prospective members of the plans.
WV Code § 33-16-1 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16. Group Accident and Sickness Insurance|§33-16-1. Scope of Article

(a) Nothing in this article shall apply to or affect any policy of liability or workers' compensation insurance, or any policy of individual accident and sickness insurance issued in accordance with article fifteen of this chapter, or any policy issued by a fraternal benefit society.(b) Nothing in this article shall apply to or in any way affect life insurance, endowment or annuity contracts or contracts supplemental thereto which contain no provisions relating to accident or sickness insurance except (a) such as provide additional benefits in case of death by accidental means and except (b) such as operate to safeguard such contracts against lapse, or to give a special surrender value or special benefit or an annuity in the event that the insured or annuitant shall become totally and permanently disabled as defined by the contract or supplemental contract.(c) No accident and sickness policy or certificate shall be delivered or issued for delivery in this state insuring more than one individual (subject to the same exceptions provided for group life insurance in section one of article fourteen of this chapter) unless to one of the groups set forth in section two of this article and unless otherwise in compliance with this article.
WV Code § 33-16-1b (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16. Group Accident and Sickness Insurance|§33-16-1b. Applicability

(a) The provisions of this article which generally require policies of group accident and sickness insurance to cover specific conditions or treatments, but which are not expressly made applicable to the following types of policies, do not apply to:(1) Coverage only for accident, or disability income insurance or any combination thereof;(2) Coverage issued as a supplement to liability insurance;(3) Liability insurance, including general liability insurance and automobile liability insurance;(4) Workers' Compensation or similar insurance;(5) Automobile medical payment insurance;(6) Credit-only insurance;(7) Coverage for on-site medical clinics; and(8) Other similar insurance coverage, which may be specified by rule, under which benefits for medical care are secondary or incidental to other insurance benefits.(b) The requirements of sections two-b, two-d, two-e and two-f, article fifteen of this chapter and the provisions of this article which generally require policies of group accident and sickness insurance to cover specific conditions or treatments, but which are not expressly made applicable to the following types of policies, do not apply to the following if provided under a separate policy, certificate, or contract of insurance:(1) Limited scope dental or vision benefits;(2) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof;(3) Coverage for only a specified disease or illness;(4) Hospital indemnity or other fixed indemnity insurance;(5) Medicare supplement insurance (as defined under section 1882(g)(1) of the Social Security Act), coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code, and similar supplemental coverage provided to coverage under group accident and sickness insurance; and(6) Any other benefits as may be specified by rule.
WV Code § 33-16-3 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16. Group Accident and Sickness Insurance|§33-16-3. Required Policy Provisions

Each such policy hereafter delivered or issued for delivery in this state shall contain in substance the following provisions:(a) A provision that the policy, the application of the policyholder, a copy of which shall be attached to such policy, and the individual applications, if any, submitted in connection with such policy by the employees or members, shall constitute the entire contract between the parties, and that all statements made by any applicant or applicants shall be deemed representations and not warranties, and that no such statement shall void the insurance or reduce benefits thereunder unless contained in a written application.(b) A provision that the insurer will furnish to the policyholder, for delivery to each employee or member of the insured group, an individual certificate setting forth in substance the essential features of the insurance coverage of such employee or member and to whom benefits thereunder are payable. If dependents are included in the coverage, only one certificate need be issued for each family unit.(c) A provision that all new employees or members, as the case may be, in the groups or classes eligible for insurance, shall from time to time be added to such groups or classes eligible to obtain such insurance in accordance with the terms of the policy.(d) No provision relative to notice or proof of loss or the time for paying benefits or the time within which suit may be brought upon the policy shall be less favorable to the insured than would be permitted in the case of an individual policy by the provisions set forth in article fifteen of this chapter.(e) A provision that all members in groups or classes eligible for insurance provided through an employee's group plan shall be permitted to pay the premiums at the same group rate and receive the same coverages for a period not to exceed eighteen months when they are involuntarily laid off from work.(f) Such further provisions establishing group accident and sickness minimum policy coverage standards as the commissioner shall promulgate by rule pursuant to chapter twenty-nine-a of this code.
WV Code § 33-16-3a (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16. Group Accident and Sickness Insurance|§33-16-3a. Same-Mental Health

[Repealed.]
WV Code § 33-16-3b (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16. Group Accident and Sickness Insurance|§33-16-3b. Home Health Care Coverage

(a) Any insurer who, on or after January 1, 1981, delivers or issues for delivery in this state group basic hospital expense or major medical expense coverage under this article shall make available to the policyholder home health care coverage consistent with the provisions of this section. For purposes of this section, "home health care" means health services provided by a home health agency certified in the state in which the home health services are delivered or under Title XVIII of the Social Security Act.(b) Home health care coverage offered shall include:(1) Services provided by a registered nurse or a licensed practical nurse;(2) Health services provided by physical, occupational, respiratory and speech therapists;(3) Health services provided by a home health aide to the extent that such services would be covered if provided to the insured on an inpatient basis;(4) Medical supplies, drugs, medicines and laboratory services to the extent that they would be covered if provided to the insured on an inpatient basis; and(5) Services provided by a licensed midwife or a licensed nurse midwife as these occupations are defined in section one, article fifteen of the code.(c) Home health care coverage may be limited to:(1) Services provided on the written order of a licensed physician, provided such order is renewed at least every sixty days;(2) Services provided, directly or through contractual agreements, by a home health agency certified in the state in which the home health services are rendered or under Title XVIII of the Social Security Act; and(3) Services as set forth in subsection (b) of this section without which the insured would have to be hospitalized.(d) Coverage under this section shall be provided for at least one hundred home visits per insured per policy year, with each home visit by a member of a home health care team to be considered as one home health care visit including up to four hours of home health care services.(e) No such policy need provide such coverage to persons eligible for Medicare.