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WV Code § 33-16A-5 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16A. Group Health Insurance Conversion|§33-16A-5. Persons for Whom Coverage Not Required

The insurer shall not be required to issue a converted policy covering any person if such person is or could be covered by Medicare (Title XVIII of the United State Social Security Act as supplemented by the Social Security Amendments of 1965 or as later amended or superseded). Furthermore, the insurer shall not be required to issue a converted policy covering any person if:(a) (1) Such person is covered for similar benefits by another hospital, surgical, medical or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program; or(2) Similar benefits are provided to such person, pursuant to or in accordance with the requirements of any state or federal law; and(b) The benefits provided under the sources referred to in (1) above for such person or benefits provided under the sources referred to in (2) above for such person, together with the benefits provided by the converted policy, would result in overinsurance according to the insurer's standards. The insurer's standards must bear some reasonable relationship to actual health care costs in the area in which the insured lives at the time of conversion and must be filed with the commissioner prior to their use in denying coverage.
WV Code § 33-16A-6 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16A. Group Health Insurance Conversion|§33-16A-6. Inquiries by Insurer

A converted policy may include a provision whereby the insurer may request information in advance of any premium due date of such policy of any person covered thereunder as to whether (i) he is covered for similar benefits by another hospital, surgical, medical or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program, (ii) he is covered for similar benefits under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis, or (iii) similar benefits are provided for or available to such person, pursuant to or in accordance with the requirements of any state or federal law. The converted policy may provide that the insurer may refuse to renew the policy or the coverage of any person insured thereunder for the following reasons only:(a) Either the benefits provided under the sources referred to in (i) and (ii) above for such person or benefits provided or available under the sources referred to in (iii) above for such person, together with the benefits provided by the converted policy, would result in overinsurance according to the insurer's standards on file with the commissioner or the converted policyholder fails to provide the requested information;(b) Fraud or material misrepresentation in applying for any benefits under the converted policy;(c) Eligibility of the insured person for coverage under Medicare (Title XVIII of the United States Social Security Act as supplemented by the Social Security Amendments of 1965 or as later amended or superseded) or under any other state or federal law providing for benefits similar to those provided by the converted policy;(d) Other reasons approved by the commissioner.
WV Code § 33-16A-7 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16A. Group Health Insurance Conversion|§33-16A-7. Limits of Coverage

An insurer shall not be required to issue a converted policy which provides benefits in excess of those provided under the group policy from which conversion is made.
WV Code § 33-16A-8 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16A. Group Health Insurance Conversion|§33-16A-8. Preexisting Conditions; Reduction of Benefits

The converted policy shall not exclude a preexisting condition not excluded by the group policy. However, the converted policy may provide that any hospital, surgical or medical benefits payable thereunder may be reduced by the amount of any such benefits payable under the group policy after the termination of the individual's insurance thereunder. The converted policy may also include provisions so that during the first policy year the benefits payable under the converted policy, together with the benefits payable under the group policy, shall not exceed those that would have been payable had the individual's insurance under the group policy remained in force and effect.
WV Code § 33-16A-9 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16A. Group Health Insurance Conversion|§33-16A-9. Alternate Plans of Conversion Coverage

If the group insurance policy from which conversion is made insures the employee or member for basic hospital or surgical expense insurance, the employee or member shall be entitled to obtain a converted policy providing, at his option, coverage on an expense incurred basis under any one of the plans meeting the following requirements:Plan A(a) Hospital room and board daily expense benefits in a maximum dollar amount approximating the average semiprivate rate charged in metropolitan areas of this state, for a maximum duration of seventy days;(b) Miscellaneous hospital expense benefits of a maximum amount of ten times the hospital room and board daily expense benefits; and(c) Surgical operation expense benefits according to a surgical schedule consistent with those customarily offered by the insurer under group or individual health insurance policies and providing a maximum benefit of $800; orPlan B(a) Hospital room and board daily expense benefits in a maximum dollar amount equal to seventy-five percent of the maximum dollar amount determined for Plan A, for a maximum duration of seventy days;(b) Miscellaneous hospital expense benefits of a maximum amount of ten times the hospital room and board daily expense benefits; and(c) Surgical operation expense benefits according to a surgical schedule consistent with those customarily offered by the insurer under group or individual health insurance policies and providing a maximum benefit of $600; orPlan C(a) Hospital room and board daily expense benefits in a maximum dollar amount equal to fifty percent of the maximum dollar amount determined for Plan A, for a maximum duration of seventy days;(b) Miscellaneous hospital benefits of a maximum amount of ten times the hospital room and board daily expense benefits; and(c) Surgical operation expense benefits according to a surgical schedule consistent with those customarily offered by the insurer under group or individual health insurance policies and providing a maximum benefit of $400.The maximum dollar amounts in Plan A shall be determined by the commissioner and may be redetermined by him from time to time as to converted policies issued subsequent to such redetermination. Such redetermination shall not be made more often than once in three years. The maximum dollar amounts in Plans A, B and C shall be rounded to the nearest multiple of $10.
WV Code § 33-16A-10a (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16A. Group Health Insurance Conversion|§33-16A-10a. Continuum of Care Services

If the group insurance policy from which conversion is made insures the employee or member for continuum of care services pursuant to article five-d, chapter sixteen of this code, the employee or member shall be entitled to obtain a converted policy providing benefits for continuum of care services to the same extent such benefits are provided in the group insurance policy: Provided, That any insurance carrier required to provide supplemental insurance coverage for continuum of care services hereunder shall not be required to expend funds for underwriting such supplemental coverage until the continuum of care board, in cooperation with the West Virginia state Insurance Commissioner, shall have completed a written master plan related to insurance coverage as set forth in section five, article five-d, chapter sixteen of the Code of West Virginia, 1931, as amended, including, but not limited to, the specific standards and coverages to be provided in such supplemental coverage: Provided, however, That a public hearing shall be held pursuant to the provisions of chapter twenty-nine-a of this code applicable to such proceedings prior to the considerations of the aforesaid plan by said board. The rates for continuum of care coverage shall accurately reflect the cost of such coverage and shall not be subsidized by the rate structure for any other coverage.
WV Code § 33-16A-11 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16A. Group Health Insurance Conversion|§33-16A-11. Combined Policy Coverage

The conversion privilege required by this article shall, if the group insurance policy insures the employee or member for basic hospital or surgical expense insurance as well as major medical expense insurance, make available the plans of benefits set forth in sections nine and ten of this article. At the option of the insurer, such plans or benefits may be provided under one policy.The insurer may also, in lieu of the plans of benefits set forth in sections nine and ten of this article, provide a policy of comprehensive medical expense benefits without first dollar coverage. Said policy shall conform to the requirements of section ten of this article: Provided, That an insurer electing to provide such a policy shall make available a low deductible option, not to exceed $100, a high deductible option between 500 and $1,000, and a third deductible option midway between the high and low deductible options.The insurer may, at its option, also offer alternative plans for group health conversion in addition to those required by this article.
WV Code § 33-16A-12 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16A. Group Health Insurance Conversion|§33-16A-12. Coverage Following Retirement

In the event coverage would be continued under the group policy on an employee following his retirement, but prior to the time he is or could be covered by Medicare, he may elect, in lieu of such continuation of group insurance, to have the same conversion rights as would apply had his insurance terminated at retirement by reason of termination of employment or membership.The converted policy may provide for reduction of coverage on any person upon his eligibility for coverage under Medicare or under any other state or federal law providing for benefits similar to those provided by the converted policy.
WV Code § 33-16A-13 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16A. Group Health Insurance Conversion|§33-16A-13. Other Conversion Privileges

Subject to the conditions set forth in the previous sections of this article, the conversion privilege shall also be available (a) to the surviving spouse, if any, at the death of the employee or member, with respect to the spouse and such children whose coverage under the group policy terminates by reason of such death, otherwise to each surviving child whose coverage under the group policy terminates by reason of such death, or, if the group policy provides for continuation of dependents coverage following the employee's or member's death, at the end of such continuation, (b) to the spouse of the employee or member upon termination of coverage of the spouse, while the employee or member remains insured under the group policy, by reason of ceasing to be a qualified family member under the group policy, with respect to the spouse and such children whose coverage under the group policy terminates at the same time, or (c) to a child solely with respect to himself upon termination of his coverage by reason of ceasing to be a qualified family member under the group policy, if a conversion privilege is not otherwise provided above with respect to such termination.
WV Code § 33-16A-14 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16A. Group Health Insurance Conversion|§33-16A-14. Benefit Levels; Election to Provide Group Coverage; Notification of Conversion Privilege; Policy Delivered Outside State

(a) If the benefit levels required in section nine of this article exceed the benefit levels provided under the group policy, the conversion policy may offer benefits which are substantially similar to those provided under the group policy in lieu of those required in section nine.(b) The insurer may elect to provide group insurance coverage in lieu of the issuance of a converted individual policy.(c) The insurer, prior to terminating the policy for any reason, shall notify each employee or member, or such employee's or member's spouse, child or dependent entitled to the conversion privilege under this article, at least sixty days in advance of the termination, in writing, of the pending termination. The notice shall inform the employee or member of the conversion privilege provided in this article.(d) A notification of the conversion privilege shall also be included in each certificate of coverage.(e) A converted policy which is delivered outside this state must be on a form which could be delivered in such other jurisdiction as a converted policy had the group policy been issued in that jurisdiction.
WV Code § 33-16A-15 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16A. Group Health Insurance Conversion|§33-16A-15. 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 § 33-16B-1 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16B. Accident and Sickness Rates|§33-16B-1. Filing and Approval of Accident and Sickness Rates

Premium rate charges for any individual or group accident and sickness insurance policy, certificate or other evidence of insurance issued, endorsed or delivered in this state shall be filed with the Commissioner for a waiting period of sixty days before the charges become effective. At the expiration of sixty days the premium rate charges filed are deemed approved unless prior thereto the charges have been affirmatively approved or disapproved by the Commissioner.The Commissioner shall disapprove accident and health insurance premium rates which are not in compliance with the requirements of this chapter or any rule promulgated by the Commissioner pursuant to section two of this article. The Commissioner shall send written notice of the disapproval to the insurer. The Commissioner may approve the premium rates before the sixty-day period expires by giving written notice of approval.
WV Code § 33-16B-2 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16B. Accident and Sickness Rates|§33-16B-2. Ratemaking Standards

Premium rates charged for any individual accident and health insurance policy or for any group accident and health insurance policy issued pursuant to this chapter shall be reasonable in relation to the benefits available under the policy. The commissioner shall promulgate rules pursuant to chapter twenty-nine-a to establish minimum ratemaking standards in accordance with accepted actuarial principles and practices.
WV Code § 33-16B-3 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16B. Accident and Sickness Rates|§33-16B-3. Exceptions

This article does not apply to policies issued to group accident and health insurance plans upon which premiums are negotiated with the group policyholder and are experienced rated.
WV Code § 33-16B-4 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16B. Accident and Sickness Rates|§33-16B-4. Authority of Commissioner to Promulgate Rules and Regulations Regarding Affiliate and Subsidiary Operating Results

The commissioner may as he deems necessary after notice and hearing promulgate rules and regulations in accordance with chapter twenty-nine-a of this code to define the commissioner's authority to consider the operating results of an insurer's affiliates and subsidiaries in the rate making and solvency determination of that insurer.
WV Code § 33-16C-1 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16C. Employer Group Accident and Sickness Insurance Policies|§33-16C-1. To 33-16c-10

Repealed.Acts, 1997 Reg. Sess., Ch. 109.
WV Code § 33-16D-1 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16D. Marketing and Rate Practices for Small Employer Accident and Sickness Insurance Policies|§33-16D-1. Purpose of Article

The purpose of this article is to promote the availability of health insurance coverage to small employers, to prevent abusive rating practices, to require disclosure of rating practices to purchasers, to establish rules for continuity of coverage for employers and covered individuals, and to improve the efficiency and fairness of the small group health insurance marketplace.
WV Code § 33-16D-3 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16D. Marketing and Rate Practices for Small Employer Accident and Sickness Insurance Policies|§33-16D-3. Health Insurance Plans Subject to This Article

The provisions of this article apply to any health benefit plan which provides coverage to one or more eligible employees of a small employer situate in the State of West Virginia: Provided, That the provisions of this article shall not apply to individual health insurance policies which are subject to policy form and premium rate approval as required by article sixteen-b of this chapter.
WV Code § 33-16D-4 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16D. Marketing and Rate Practices for Small Employer Accident and Sickness Insurance Policies|§33-16D-4. Discrimination Prohibited; Guaranteed Issue; Filing With Commissioner; Violations and Penalties

(a) All carriers subject to this article are strictly prohibited from marketing their product to a specific group, legal occupation, locale, zip code, neighborhood, race, religion, or any discriminatory group.(b) For plan years beginning after June 30, 1997, in which the plan has, on the first day of the plan year, at least two enrollees who are current employees, each carrier shall accept every small employer that applies for coverage under a health benefit plan, unless such health benefit plan is made available only through a bona fide association, and consistent with public law 104-191 (Public Health Service Act section 2711 (a) (1) (B)), shall accept for enrollment in the plan every employee of the small employer, including dependents, when an employee or dependent first becomes eligible to enroll under terms of the plan and under the rules of the carrier that are uniformly applicable to small employers. This subsection shall not apply to:(1) A network plan if the carrier:(A) Limits coverage to a small employer's employees and dependents who reside, live or work in the carrier's service area; or(B) Obtains the commissioner's approval to deny coverage in its service area due to the carrier's lack of capacity for additional enrollees, but only if the carrier denies coverage uniformly to all small employers without regard to their claims experience or that of their employees and dependents or to any health status-related factor relating to employees and their dependents. A carrier may not offer small group coverage in the same service area for one hundred eighty days after the date coverage is denied under this paragraph; or(2) A carrier that obtains the commissioner's approval to deny coverage due to the carrier's insufficient financial reserves for additional coverage, but only if the carrier denies coverage uniformly to all small employers, consistent with all requirements of this chapter and without regard to the claims experience of the small employers and their employees and dependents or to any health status-related factor relating to employees and their dependents. A carrier may not offer small group coverage for one hundred eighty days after the date coverage is denied under this subdivision or until the carrier has obtained the commissioner's approval of the level of its reserves for additional coverage, whichever is later.(c) All carriers subject to this article shall file any marketing information upon request of the commissioner. The commissioner shall review said information and shall have the authority to take appropriate action to eliminate discriminatory marketing practices, including imposing fines on violators of this section of not more than $10,000. Upon a second violation of this section, the commissioner shall have the authority to revoke the violator's license to transact insurance.
WV Code § 33-16D-6 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16D. Marketing and Rate Practices for Small Employer Accident and Sickness Insurance Policies|§33-16D-6. Insurance Commissioner to Promulgate Rules

Pursuant to chapter twenty-nine-a of this code, the Insurance Commissioner may promulgate rules necessary to implement the provisions of this article.
WV Code § 33-16D-8 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16D. Marketing and Rate Practices for Small Employer Accident and Sickness Insurance Policies|§33-16D-8. Disclosure of Rating Practices, Renewability Provisions and Availability of Health Benefit Plans

(a) Each small employer carrier shall make reasonable disclosure in solicitation and sales materials provided to small employers of the following:(1) The extent to which premium rates for a specific small employer are established or adjusted due to the claim experience, health status or duration of coverage of the employees of the small employer;(2) The provisions concerning the carrier's right to change premium rates and the factors, including case characteristics, which affect changes in premium rates;(3) A description of the class of business in which the small employer is or will be included, including the applicable grouping of plans and the benefits and premiums available under all health benefit plans for which the small employer is qualified;(4) The provisions relating to renewability of coverage;(5) The provisions relating to any preexisting conditions limitations; and(6) An explanation, if applicable, that the small employer is purchasing a minimum benefits plan issued pursuant to article sixteen-c of this chapter.(b) All disclosure statements shall be presented in clear and understandable form and format and shall be separate from any policy, certificate or evidence of coverage otherwise provided. No carrier may be required under this section to disclose proprietary or trade secret information to a small employer.
WV Code § 33-16D-9 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 16D. Marketing and Rate Practices for Small Employer Accident and Sickness Insurance Policies|§33-16D-9. Maintenance of Records

(a) Each small employer carrier shall maintain at its principal place of business a complete and detailed description of its rating practices and renewal underwriting practices, including information and documentation which demonstrate that its rating methods and practices are based upon commonly accepted actuarial principles.(b) Each small employer carrier shall file each first day of March with the commissioner an actuarial certification that the carrier is in compliance with the provisions of section five of this article and that the rating methods of the carrier are actuarially sound. A copy of such certification shall be retained by the carrier at its principal place of business.(c) A small employer carrier shall make the information and documentation described in subsection (a) of this section available to the commissioner upon request.