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2023 West Virginia Code › Chapter 33. Insurance › Article 25A. Health Maintenance Organization Act › §33-25A-22. Fees

Every health maintenance organization subject to this article shall pay to the Commissioner the following fees: For filing an application for a certificate of authority or amendment to the application, $200; for each renewal of a certificate of authority, the annual fee as provided in section thirteen, article three of this chapter; for each form filing and for each rate filing, the fee, as provided in section thirty-four, article six of this chapter; and for filing each annual report, $100. Fees charged under this section shall be for the purposes set forth in section thirteen, article three of this chapter.
2023 West Virginia Code › Chapter 33. Insurance › Article 25A. Health Maintenance Organization Act › §33-25A-23a. Civil Penalty Imposed by Commissioner

No provider shall collect or attempt to collect from a health maintenance organization enrollee any money for services covered by the health maintenance organization. If a provider collects or attempts to collect from a health maintenance organization enrollee any money for services covered by the health maintenance organization, then the provider may be subjected to a civil money penalty to be imposed by the commissioner. Upon a determination that there is probable cause to believe that there has been a violation of this section, the commissioner may provide written notice to the alleged violator, stating the nature of the alleged violation and that failure to refund the amount of any improper billing within thirty days may result in imposition of a civil penalty pursuant to the provisions of this section. If the alleged violator fails to make a refund within thirty days, the commissioner shall issue a written notice of hearing stating the nature of the alleged violation and the time and place at which the alleged violator shall appear to show good cause why a civil penalty should not be imposed: Provided, That if the commissioner has previously found on three occasions that probable cause existed to support a violation, the alleged violator shall not be afforded the opportunity to make a refund before issuance of the notice of hearing for any subsequent violation.
If, after notice and hearing, the commissioner determines that a violation of this section has occurred, the commissioner may assess a civil penalty of not less than the amount charged the subscriber but not more than $1,000. Subsequent violations of this section result in fines of not more than $2,000. Any provider so assessed shall be notified of the assessment in writing and the notice shall specify the reasons for the assessment. Any provider may waive the right to a hearing and receive a reduction in penalties of twenty-five percent.
2023 West Virginia Code › Chapter 33. Insurance › Article 25A. Health Maintenance Organization Act › §33-25A-25. Filings and Reports as Public Documents

All applications, filings and reports required under this article shall be treated as public documents: Provided, That where the provisions of other articles in this chapter are applicable to health maintenance organizations, all applications, filings and reports required under those articles shall be afforded the level of confidentiality as provided in those articles.
2023 West Virginia Code › Chapter 33. Insurance › Article 25A. Health Maintenance Organization Act › §33-25A-26. Confidentiality of Medical Information

Any data or information pertaining to the diagnosis, treatment or health of any enrollee or applicant obtained from that person or from any provider by any health maintenance organization shall be held in confidence and shall not be disclosed to any person except: (1) To the extent that it may be necessary to facilitate an assessment of the quality of care delivered pursuant to section seventeen of this article or to review the grievance procedure pursuant to section twelve of this article; (2) upon the express written consent of the enrollee or his or her legally authorized representative; (3) pursuant to statute or court order for the production of evidence or the discovery thereof; (4) in the event of claim or litigation between that person and the health maintenance organization wherein the data or information is pertinent; or (5) to a department or division of the state pursuant to the terms of a group contract for the provision of health care services between the HMO and the department or division of the state. A health maintenance organization is entitled to claim any statutory privileges against the disclosure which the provider who furnished the information to the health maintenance organization is entitled to claim.
2023 West Virginia Code › Chapter 33. Insurance › Article 25A. Health Maintenance Organization Act › §33-25A-27. Authority to Contract With Health Maintenance Organizations Under Medicaid

The department of welfare is hereby authorized to enter into contracts with health maintenance organizations certified and permitted to market under the laws of this state, and to furnish to recipients of medical assistance under Title XIX of the Social Security Act, 42 U.S.C. Section 1396, et. seq., health care services offered to such recipients under the medical assistance plan of West Virginia.
2023 West Virginia Code › Chapter 33. Insurance › Article 25A. Health Maintenance Organization Act › §33-25A-28. Required Health Maintenance Organization Option

(1) Each employer shall offer no less than once every year to every employee and dependent entitled to receive health care under an existing health benefit plan supported in whole or in part by such employer the opportunity to become enrollees in certified health maintenance organizations which have the capacity to provide basic health services in health maintenance organization service areas in which at least twenty-five such employees reside: Provided, That nothing herein shall require an employer to contribute more on behalf of an employee seeking to enroll in a health maintenance organization than would be contributed on the employee's behalf to the existing health plan.
(2) If any employees of an employer are represented by a collective bargaining representative or other employee representative designated or selected under any law of this state, the offer described in subsection (1) of this section should be made to such collective bargaining representatives or other employee representative, and only if such representative approves the offer should it be made to employees represented by such representatives.
(3) If there is more than one certified health maintenance organization which meets the requirements of subsection (1) of this section and such health maintenance organizations have service areas contemporaneously covering the same twenty-five or more employees, the employer shall offer such employees at least one health maintenance organization which provides health services primarily through staff physicians, or medical groups, or a combination of both; and one health maintenance organization which provides health services through other means.
(4) Any employer who knowingly fails to comply with any of the requirements of this section shall be subject to a fine of not more than $10,000 for every thirty-day period that such violation continues.
(5) The commissioner is authorized, in addition to the remedy provided in subsection (4) of this section, to seek an injunction in a court of competent jurisdiction to compel compliance with the provisions of this section.
2023 West Virginia Code › Chapter 33. Insurance › Article 25A. Health Maintenance Organization Act › §33-25A-31. Policies Discriminating Among Health Care Providers

Notwithstanding any other provisions of law, when any health insurance policy, health care services plan or other contract provides for the payment of medical expenses, benefits or procedures, such policy, plan or contract shall be construed to include payment to all health care providers including medical physicians, osteopathic physicians, podiatric physicians, chiropractic physicians, midwives and nurse practitioners who provide medical services, benefits or procedures which are within the scope of each respective provider's license. Any limitation or condition placed upon services, diagnoses or treatment by, or payment to any particular type of licensed provider shall apply equally to all types of licensed providers without unfair discrimination as to the usual and customary treatment procedures of any of the aforesaid providers.
2023 West Virginia Code › Chapter 33. Insurance › Article 25A. Health Maintenance Organization Act › §33-25A-32. 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.
2023 West Virginia Code › Chapter 33. Insurance › Article 25A. Health Maintenance Organization Act › §33-25A-34. Ambulance Services

The Legislature finds that ambulance services in this state are performed by various volunteer emergency service squads, county operations and small businesses, which may lack the sophistication and expertise required to negotiate a contract with a health maintenance organization for the provision of ambulance services, and that the best interests of the citizens of the state require the continued development and preservation of an emergency medical system to serve all the citizens of the state, including those citizens who do not receive health care services through a health maintenance organization. Therefore, the commissioner shall promulgate legislative rules, pursuant to the provisions of article twenty-nine-a of this code, to regulate contracting for emergency medical services. The rules shall be promulgated as expeditiously as possible in order to be considered by the Legislature in the regular session in the year one thousand nine hundred ninety-seven. The rules shall consider the following: Reimbursement for nonemergency transportation by nonparticipating providers and the appropriate use of 911 or community dispatching, as well as other items the commissioner may deem necessary.
2023 West Virginia Code › Chapter 33. Insurance › Article 25A. Health Maintenance Organization Act › §33-25A-36. 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.
(f) The provisions of this section shall not apply to insurers or managed care organizations with respect to their Medicaid or CHIP plans or contracts which are reviewed and approved by the Department of Health and Human Resources Bureau for Medical Services.
2023 West Virginia Code › Chapter 33. Insurance › Article 25B. Federal Insurance Subsidy for Children's Health › §33-25B-1. Definitions

The following words, as used in this article, have the meanings set forth below, unless the context clearly requires otherwise:
(a) "Applicant aide" means an individual licensed by the state to care for the physical or emotional needs of children or an employee authorized by his employer where the employer is an institution licensed by the state to care for the physical or emotional needs of children and who has received an applicant aide certificate. Individuals include, but are not limited to, licensed teachers, child care workers, social workers, guidance counselors, psychologists, nurses and physicians. Licensed institutions include, but are not limited to, hospitals, schools, local human services offices, child care centers and medical clinics;
(b) "Approved providers" means any accident and health insurer licensed by the state or any health services organization licensed by the state or any other entity approved by the Insurance Commissioner for provision of health care coverage for children;
(c) "Corporation" means a nonprofit corporation organized under the laws of West Virginia which has undertaken to implement a federal insurance subsidy for children's health insurance created by this article; and
(d) "Insurance subsidy fund" or "fund" means a fund or account established by the corporation for the deposit of moneys to implement the insurance subsidy program.
2023 West Virginia Code › Chapter 33. Insurance › Article 25B. Federal Insurance Subsidy for Children's Health › §33-25B-2. Purpose

The purpose of this article is to:
(a) Assist, promote, encourage, develop and advance the knowledge of lower to moderate income families with dependent children of the earned income credit available for money spent on health insurance;
(b) Cooperate and act in conjunction with other organizations, public and private, the objects of which are the promotion and education of lower to moderate income families with dependent children of the earned income credit available for money spent on health insurance;
(c) Establish a system of qualified applicant aides who shall be trained by the department of health and human services and, who, for a modest dollar incentive, will on a volunteer basis make knowledge of this program available to the targeted families; and
(d) Establish a mechanism by which to provide counseling and assistance to families and aid them in filing for the insurance voucher, selecting an appropriate health insurance policy and completing the required federal income tax return.
2023 West Virginia Code › Chapter 33. Insurance › Article 25B. Federal Insurance Subsidy for Children's Health › §33-25B-3. General Powers

In order for a nonprofit corporation to participate in the program provided pursuant to this article, the nonprofit corporation must be organized and incorporated as a nonprofit corporation pursuant to the provisions of article one, section thirty-one of this code. The nonprofit corporation, in addition to all other lawful powers, shall have the power to provide counseling services to West Virginia families on the purchase of federally subsidized health insurance and to accept gifts, grants, or loans from and enter into contracts or other transactions with any federal or state agency, any municipality, any private organization or any other source as may be authorized by law.
2023 West Virginia Code › Chapter 33. Insurance › Article 25B. Federal Insurance Subsidy for Children's Health › §33-25B-4. Voucher Applications; Contents

A guardian or applicant aide may file with a nonprofit corporation, organized for the purposes of this article, a sworn voucher application signed by the guardian asserting:
(a) That the guardian meets the requirements for the federal earned income credit for child health insurance for the current or next calendar year;
(b) The good-faith estimate value of the health insurance earned income credit for the year in question;
(c) That the guardian will use the voucher to purchase health insurance covering dependent children;
(d) That the guardian will prepare a federal tax return for the year in question; and
(e) That the guardian agrees to assign the value of any federal tax refund, in the amount of the voucher issued by the corporation to the corporation when filing the guardian's federal tax return.
2023 West Virginia Code › Chapter 33. Insurance › Article 25B. Federal Insurance Subsidy for Children's Health › §33-25B-5. Duties and Responsibilities of Corporation

Upon presentation of a valid voucher application, the corporation shall issue from its insurance subsidy fund a voucher to the guardian or applicant aide, made out in behalf of the guardian and redeemable for the face amount by any approved provider. The corporation shall retain in the fund all moneys received from refundable tax credits of guardians. These moneys shall be used to extend additional vouchers. The corporation may solicit and receive donations of moneys for the fund. No corporation may require that vouchers be presented to a specific approved provider in order to be eligible to participate in the program.
2023 West Virginia Code › Chapter 33. Insurance › Article 25B. Federal Insurance Subsidy for Children's Health › §33-25B-6. Duties and Responsibilities of Department of Health and Human Resources to Provide Training and Other Services

(a) The Department of Health and Human Resources shall design and provide the vouchers to any corporation wishing to participate in the program at a cost not to exceed the actual cost of the voucher.
(b) No later than ninety days after a request is made by a corporation wishing to participate in the insurance subsidy program, the Department of Health and Human Resources in cooperation with the corporations participating in the program, shall begin to conduct regional training and information sessions in all regions of the state. The purpose of these sessions is to train guardians and potential applicant aides in the necessary rules to qualify under the federal guidelines for earned income credits and the requirements of this section. These sessions shall be open to the public and potential applicant aides, at a charge not to exceed $10 which shall be used solely to defray the costs of conducting the training sessions. Sessions shall be available in at least the first and fourth quarter of the calendar year in all regions of the state after a request has been made by a corporation to commence such training sessions. The Department of Health and Human Resources may waive the fee for guardians.
(c) Potential applicant aides shall be tested by the Department of Health and Human Resources. Potential applicant aides who successfully complete the test shall be awarded a certificate entitling them to work as an applicant aide. The Department of Health and Human Resources shall propose legislative rules for promulgation in accordance with the provisions of article three, chapter twenty-nine-a of this code.
2023 West Virginia Code › Chapter 33. Insurance › Article 25B. Federal Insurance Subsidy for Children's Health › §33-25B-7. Allowable Commission for Applicant Aides; Prohibited Practices

(a) Applicant aides may receive a commission not to exceed five percent of the voucher, from an approved provider. No commission may be paid until the fund is fully reimbursed for the voucher. Applicant aides may not solicit or accept any compensation from guardians or potential guardians.
(b) An applicant aide shall be prohibited from entering into any agreement with an approved provider, whether such agreement is for profit or not for profit, to recommend a specific approved provider, to the exclusion of all other approved providers, in the course of counseling guardians or applicants.
(c) Applicant aides who engage in deceptive practices or who aid or encourage deception or fraud may, upon hearing by the corporation, have their certificate as an applicant aide revoked for a period of not less than five years. This action shall be in addition to any other penalties available at law.
(d) The corporation may pursue triple damages in civil court for any losses to the fund attributable to actions or the conduct of applicant aides or guardians.
2023 West Virginia Code › Chapter 33. Insurance › Article 25B. Federal Insurance Subsidy for Children's Health › §33-25B-8. Activities Not Deemed the Sale of Insurance; Exemptions From Benefits and Taxation

(a) Assisting individuals in the preparation of applications to the fund and selection of the providers does not constitute the sale of insurance and shall not be subject to regulation by the Insurance Commissioner.
(b) Insurance coverage bought by the guardian through the use of a voucher provided pursuant to the provisions of this article will be exempt from state law and regulations requiring certain mandatory state insurance coverages or benefits.
(c) Insurance coverage bought by guardians through the use of a voucher provided pursuant to the provisions of this article shall not be subject to state premium taxes.
2023 West Virginia Code › Chapter 33. Insurance › Article 25B. Federal Insurance Subsidy for Children's Health › §33-25B-9. Annual Report and Audits

On January 1, of each year the corporation shall report on its operations for the preceding fiscal year to the Governor and the State Legislature. The report shall include a summary of the activities of the corporation and a complete operating and financial statement. A corporation shall cause an annual audit to be made by a resident certified public accountant or a registered public accountant of its books, accounts and records, with respect to its receipts, disbursements and all other matters related to the operation of the insurance subsidy program. The person performing such audit shall also furnish copies of the audit report to the Joint Committee on Government and Finance and the Legislative Auditor.
2023 West Virginia Code › Chapter 33. Insurance › Article 25C. Health Maintenance Organization Patient Bill of Rights › §33-25C-1. Short Title and Purpose

This article may be referred to as the "Patients' Bill of Rights." It is the intent of the Legislature that enrollees covered by health care plans receive quality, cost-effective health care designed to maintain and improve their health. The purpose of this article is to ensure that health plan enrollees:
(a) Have improved access to information regarding their health plans;
(b) Have sufficient and timely access to appropriate health care services, and choice among health care providers;
(c) Are assured that health care decisions are made by appropriate medical personnel;
(d) Have access to a quick and impartial process for appealing plan decisions;
(e) Are protected from unnecessary invasions of health care privacy; and
(f) Are assured that personal health care information will be used only as necessary to obtain and pay for health care or to improve the quality of care.
2023 West Virginia Code › Chapter 33. Insurance › Article 25C. Health Maintenance Organization Patient Bill of Rights › §33-25C-2. Definitions

For purposes of this article:
(a) "Commissioner" means the commissioner of insurance.
(b) "Credentials" means medical training, education, specialties, and board certifications of the provider.
(c) "Enrollee" is a natural person who has entered into an agreement with a health maintenance organization or prepaid limited health service organization for the provision of managed health care.
(d) "External review" means a process, independent of all affected parties, to determine if a health care service is medically necessary, or experimental.
(e) "Health care plan" means a plan that establishes, operates, or maintains a network of health care providers that have entered into agreements with the plan to provide health care services to enrollees to whom the plan has the ultimate obligation to arrange for the provision of or payment for services through organizational arrangements for ongoing quality assurance, utilization review programs, or dispute resolution.
For purposes of this definition, "health care plan" shall not include indemnity health insurance policies including those using a contracted provider network;
(f) "Managed care plan" or "plan" means any health maintenance organization or prepaid limited health service organization: Provided, That this article only applies to prepaid limited health service organizations to the extent of coverage and services these organizations offer;
(g) "Provider" means any physician, hospital or other person or organization which is licensed or otherwise authorized in this state to provide health care services or supplies.
2023 West Virginia Code › Chapter 33. Insurance › Article 25C. Health Maintenance Organization Patient Bill of Rights › §33-25C-3. Notice of Certain Enrollee Rights

All managed care plans must on or after July 1, 2002, provide to enrollees a notice of certain enrollee rights. The notice shall be provided to enrollees on a yearly basis on a form prescribed by the commissioner and shall include, but not be limited to:
(a) The enrollee's rights to a description of his or her rights and responsibilities, plan benefits, benefit limitations, premiums, and individual cost-sharing requirements;
(b) The enrollee's right to a description of the plan's grievance procedure and the right to pursue grievance and hearing procedures without reprisal from the managed care plan;
(c) A description of the method in which an enrollee can obtain a listing of the plan's provider network, including the names and credentials of all participating providers, and the method in which an enrollee may choose providers within the plan;
(d) The enrollee's right to privacy and confidentiality;
(e) The right to full disclosure from the enrollee's health care provider of any information relating to his or her medical condition or treatment plan, and the ability to examine and offer corrections to the enrollee's medical records;
(f) The enrollee's right to be informed of plan policies and any charges for which the enrollee will be responsible;
(g) The right of enrollees to have coverage denials involving medical necessity or experimental treatment reviewed by appropriate medical professionals who are knowledgeable about the recommended or requested health service, as part of an external review as provided in this article;
(h) A description of the method in which an enrollee can obtain access to a summary of the plan's accreditation report;
(i) The right of an enrollee to have medical advice or options communicated to him or her without any limitations or restrictions being placed upon the provider or primary care physician by the managed care plan;
(j) A list of all other legally mandated benefits to which the enrollee is entitled, including coverage for services provided pursuant to sections eight-a, eight-b, eight-c, eight-d, eight-e, article twenty-five-a of this chapter, article twenty-five-e of this chapter, and article forty-two of this chapter, and all rules promulgated pursuant to this chapter regulating managed care plans.
(k) Any other areas the commissioner may propose in accordance with section nine of this article.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.