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2023 West Virginia Code › Chapter 33. Insurance › Article 23. Fraternal Benefit Societies › §33-23-26. Reinsurance

A domestic society may, by an authorized reinsurance agreement, cede any individual risk or risks in whole or in part to an insurer (other than another fraternal benefit society) having the power to make such reinsurance; but no such society may reinsure substantially all of its insurance in force without the written permission of the commissioner.
2023 West Virginia Code › Chapter 33. Insurance › Article 23. Fraternal Benefit Societies › §33-23-27. Licensing of Foreign and Alien Societies

(a) No foreign or alien society shall transact business in this state without a license issued by the commissioner. Any such society may be licensed to transact business in this state upon filing with the commissioner:
(1) A duly certified copy of its charter or articles of incorporation;
(2) A copy of its Constitution and laws, certified by its secretary or corresponding officer;
(3) A statement of its business under oath of its president and secretary or corresponding officers in a form prescribed by the commissioner, duly verified by an examination made by the supervising insurance official of its home state or other state, territory, province or country, satisfactory to the commissioner;
(4) A certificate from the proper official of its home state, territory, province or country that the society is legally incorporated and licensed to transact business therein;
(5) Copies of its certificate forms; and
(6) Such other information as he may deem necessary; and upon a showing that its assets are invested in accordance with the provisions of this article.
(b) No license shall be issued to a foreign or alien society desiring admission to this state unless such society has the qualifications required of domestic societies organized under this article.
2023 West Virginia Code › Chapter 33. Insurance › Article 23. Fraternal Benefit Societies › §33-23-28. Term of License; Renewal, Refusal, Revocation or Suspension; Penalty in Lieu Thereof; Reissuance

The term of license, renewal thereof, refusal to license, revocation or suspension of license or penalty in lieu thereof, and reissuance of license of all societies shall be governed by the provisions of sections eight, nine, ten, and eleven of article three of this chapter, to the same extent that such sections are applicable to other insurers.
2023 West Virginia Code › Chapter 33. Insurance › Article 23. Fraternal Benefit Societies › §33-23-29. Fees; Exemption of Funds and Assets From Taxation

(a) Each society shall pay to the commissioner an annual license fee of $50 and a fee of $25 for filing the annual statement of the society, all fees so collected to be used for the purposes specified in section thirteen, article three of this chapter.
(b) Every society licensed under this article is hereby declared to be a charitable and benevolent institution, and all of its funds and assets shall be exempt from all state, county, district and municipal taxes except taxes on real property and office equipment.
2023 West Virginia Code › Chapter 33. Insurance › Article 23. Fraternal Benefit Societies › §33-23-30. Use of Funds

(a) All assets shall be held, invested and disbursed for the use and benefit of the society and no member or beneficiary shall have or acquire individual rights therein or become entitled to any apportionment or the surrender of any part thereof, except as provided in the contract.
(b) A society may create, maintain, invest, disburse and apply any special funds or funds necessary to carry out any purpose permitted by the laws of such society.
(c) Every society, the admitted assets of which are less than the sum of its accrued liabilities and reserves under all of its certificates when valued according to standards required for certificates issued after one year from the effective date of this article, shall, in every provision of the laws of the society for payments by members of such society, in whatever form made, distinctly state the purpose of the same and the proportion thereof which may be used for expenses, and no part of the money collected for mortuary or disability purposes or the net accretions thereto shall be used for expenses.
2023 West Virginia Code › Chapter 33. Insurance › Article 23. Fraternal Benefit Societies › §33-23-31. Investments

(a) A domestic society shall invest its funds only in the investments that are authorized by sections ten through twenty, inclusive, article eight of this chapter for the investment of the assets of domestic insurers.
(b) Foreign and alien societies shall have investments of the same general quality as required of domestic societies, except that other investments authorized by the laws of the foreign or alien society's state or country of domicile may be recognized as assets in the discretion of the commissioner.
2023 West Virginia Code › Chapter 33. Insurance › Article 23. Fraternal Benefit Societies › §33-23-33. Agents

Commencing on June 1, 1989, agents for fraternal benefit societies shall be required to be licensed pursuant to chapter thirty-three of the Code of West Virginia, 1931, as amended: Provided, That any person who was acting as or serving in the role of an agent for a fraternal benefit society on or before July 1, 1989, shall be exempt from the examination requirement of subsection (e), section two, article twelve of this chapter: Provided, however, That any person who is a salaried officer, employee or member of a fraternal benefit society and who as an occasional and incidental duty of such position may solicit a fraternal insurance contract from a member of such fraternal benefit society such person shall be exempt from the continuing education requirements otherwise made subject to insurance agents by this chapter and the examination requirements of subsection (e), section two, article twelve of this chapter if such person receives no commission or other compensation based directly on such solicitation of fraternal insurance contracts and if such person makes no solicitation of insurance of any kind to or from persons who are not members of such fraternal benefit society. For the purpose of this article the solicitation of a fraternal insurance contract by such salaried officer, employee, or member from a new member of such society simultaneously with such new member's joining such society shall be deemed the solicitation of a member.
2023 West Virginia Code › Chapter 33. Insurance › Article 23. Fraternal Benefit Societies › §33-23-34. Exemption of Certain Societies

(a) Nothing contained in this article shall be so construed as to affect or apply to:
(1) Grand or subordinate lodges of societies, orders or associations now doing business in this state which provide benefits exclusively through local or subordinate lodges;
(2) Orders, societies or associations which admit to membership only persons engaged in one or more crafts or hazardous occupations, in the same or similar lines of business insuring only their own members, their families and descendants of members and the ladies' societies or ladies' auxiliaries to such orders, societies or associations;
(3) Domestic societies which limit their membership to employees of a particular city or town, designated firm, business house or corporation which provide for a death benefit of not more than $400,000 or disability benefits of not more than $350,000 to any person in any one year, or both; or
(4) Domestic societies or associations of a purely religious, charitable or benevolent description, which provide for a death benefit of not more than $2,000 or for disability benefits of not more than $350 to any one person in any one year, or both.
(b) Any such society or association described in subdivision (3) or (4), subsection (a) of this section, which provides for death or disability benefits for which benefit certificates are issued, and any such society or association included in subdivision (4) which has more than one thousand members, shall not be exempted from the provisions of this article but shall comply with all requirements thereof.
(c) No society which, by the provisions of this section, is exempt from the requirements of this article, except any society described in subdivision (2), subsection (a) of this section, shall give or allow, or promise to give or allow to any person any compensation for procuring new members.
(d) Every society which provides for benefits in case of death or disability resulting solely from accident, and which does not obligate itself to pay natural death or sick benefits shall have all of the privileges and be subject to all the applicable provisions and rules of this article except that the provisions thereof relating to medical examination, valuations of benefit certificates, and incontestability, shall not apply to such society.
(e) The commissioner may require from any society or association, by examination or otherwise, such information as will enable him to determine whether such society or association is exempt from the provisions of this article.
(f) Societies, exempted under the provisions of this section, shall also be exempt from all other provisions of this chapter.
2023 West Virginia Code › Chapter 33. Insurance › Article 23. Fraternal Benefit Societies › §33-23-35. Continuum of Care Services

Any society which, on or after July 1, 1986, delivers or issues for delivery in this state any policy under the provisions of subdivision (e), subsection (1), section seventeen of this article, shall make available for purchase, at a reasonable rate, supplemental insurance coverage for continuum of care services pursuant to article five-d, chapter sixteen of this code: 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.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-1. Declaration of Policy

In view of the desirability of making available to the people of this state increased hospital, medical, dental services and other health services, the declared policy of the Legislature in the enactment of this article is to encourage the organization, promotion and expansion of hospital service corporations, medical service corporations, dental service corporations and health service corporations by exempting them from the payment of all taxes and from the operation of the general insurance laws of this state, but at the same time subjecting them to such regulation as may be necessary for the adequate protection of those members of the public who subscribe for the services offered by such corporation.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-3. Corporations Affected by Article; Eligibility of Hospitals, Physicians, Dentists, Chiropodists-Podiatrists and Chiropractors

(a) Every such corporation operating within this state shall be subject to the provisions of this article.
(b) Every hospital or other health agency in this state meeting the standards prescribed by the board of directors of each such corporation shall be eligible for participation in any hospital service plan, or health service plan, operating in this state. Every duly licensed physician, duly licensed dentist, duly licensed chiropodist-podiatrist, duly licensed chiropractor or other health agency in this state meeting the standards prescribed by the board of directors of each such corporation shall be eligible for participation in any medical service plan, or health service plan, operating in this state. Every duly licensed dentist or duly licensed physician in this state meeting the standards prescribed by the board of directors of each such corporation shall be eligible for participation in any dental service plan, or health service plan, operating in this state. The board of directors of every such corporation may also prescribe standards for hospitals, physicians, dentists, chiropodists- podiatrists, chiropractors and other health agencies located in states adjoining this state, and all such hospitals, physicians, dentists, chiropodists-podiatrists, chiropractors and other health agencies meeting such standards shall be eligible for participation in such plans.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-5. Licenses; Name of Corporation

(a) No such corporation shall enter into any contract with a subscriber until it has obtained from the commissioner a license as provided in this section. Application for a license shall be made on forms to be prescribed and furnished by the commissioner.
(b) The application shall be accompanied by a copy of the following documents: (1) Certificate of incorporation; (2) bylaws; (3) contracts between the corporation and participating hospitals, physicians, dentists or other health agencies; (4) proposed contracts to be issued to subscribers, setting forth the hospital, medical or dental service to which subscribers are entitled, and the table of rates to be charged for such service; and (5) financial statement showing the amount of contributions paid, or agreed to be paid, to the corporation for working capital, the name or names of each contributor and the terms of each contribution.
(c) The commissioner shall, upon payment to him of a license fee of $200, issue a license authorizing the corporation to transact business in this state in the area to be served by it, if he is satisfied (1) that the applicant is incorporated in this state under the provisions of article one, chapter thirty-one of this code, as a bona fide nonprofit corporation, (2) that the contracts between the corporation and participating hospitals, physicians, dentists and other health agencies contain all the terms required by section seven of this article, (3) that the working capital available to the corporation will be sufficient to pay all operating expenses, other than payment for hospital, medical or dental services, for a reasonable period after the issuance of the license, and (4) that the proposed plan will serve the best interests of all of the people of the area in which the corporation intends to operate, regardless of their race, color or economic status. Any license so issued may be renewed annually upon payment to the commissioner of a renewal fee of $200.
(d) The term of such license, renewal, refusal to license, revocation, suspension or penalty in lieu thereof shall be governed by the provisions of sections eight, nine, ten and eleven, article three of this chapter, in the same manner that these sections are applicable to insurers generally.
(e) No such corporation shall include in its name the words "insurance," "casualty," "surety," "health and accident," "accident and sickness," "mutual," or any other words descriptive of the insurance business; nor shall its name be so similar to that of any insurer which was licensed to transact insurance in this state when such corporation was formed, as to tend, in the opinion of the commissioner, to confuse the public.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-6. Commissioner to Enforce Article; Approval of Contracts, Forms, Rates and Fees

(a) It shall be the duty of the commissioner to enforce the provisions of this article. If the commissioner finds that a corporation is impaired, he may issue such orders and otherwise require that the corporation take all actions that in his judgment are necessary for the corporation to cure the impairment. Failure of the corporation to follow such orders and directions is evidence that the management is incompetent and grounds for an order of rehabilitation or liquidation, as the commissioner deems appropriate.
(b) No such corporation shall deliver or issue for delivery any subscriber's contract, changes in the terms of such contract, application, rider or endorsement, until a copy thereof and the rates pertaining thereto have been filed with and approved by the commissioner. All such forms filed with the commissioner shall be deemed approved after the expiration of sixty days from the date of such filing unless the commissioner shall have disapproved the same, stating his reasons for such disapproval in writing. Such forms may be used prior to the expiration of such periods if written approval thereof has been received from the commissioner.
(c) No rates to be charged subscribers shall be used or established by any such corporation unless and until the same have been filed with the commissioner and approved by him The procedure for such filing and approval shall be the same as that prescribed in subsection (b) of this section for the approval of forms. The commissioner shall approve all such rates which are not excessive, inadequate or unfairly discriminatory.
(d) The commissioner shall pass upon the actuarial soundness of the schedule of fees to be paid hospitals, physicians, dentists and other health agencies.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-6a. Loss Ratio

If a corporation utilizes a groups loss ratio as a rating factor at the time of renewal of a policy, plan, or contract, the corporation shall, upon request of an insured or subscriber, provide the loss ratio and the components of the loss ratio calculation to the insured or subscriber no more than 90 days but no less than 60 days before the renewal date of the policy, plan, or contract. For purposes of this section, "loss ratio" means the total losses paid out in medical claims divided by the total earned premiums:
Provided
, That that the requirements of this section do not apply to a dental service corporation as that term is defined in this article.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7. Required Provisions in Contracts Made by Corporations With Hospitals, Physicians, Dentists and Other Health Agencies

Each contract made by the corporation with participating hospitals, physicians, dentists and other health agencies shall contain the following provisions:
(a) That the hospital, physician, dentist or other health agency will render to any subscriber such service as he may be entitled to under the terms and conditions of the contract issued to the subscriber by the corporation.
(b) That in submitting bills to the corporation for services rendered to subscribers under the terms of their contracts, the hospitals, physicians, dentists and other health agencies will make only such charges as are set forth in an agreed schedule of fees to be paid by the corporation.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7a. Contracts to Cover Nursing Service

(a) Any contract made under the provisions of this article shall, on or after January 1, 1984, contain a provision that the corporation shall make available as covered benefits to all subscribers and members coverage for primary health care nursing services as defined in section four-b, article fifteen of this chapter, if such services are currently being reimbursed when rendered by any other duly licensed health care practitioner. No corporation may be required to pay for duplicative health care services actually provided by both a registered professional nurse or licensed midwife and other health providers.
(b) Nothing in this section may be construed to permit any registered professional nurse licensee or midwife licensee to perform professional services beyond such individual's scope of professional competence as established by education, training and experience.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7b. Third Party Reimbursement for Mammography, Pap Smear or Human Papilloma Virus Testing

(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, whenever reimbursement or indemnity for laboratory or X-ray services are covered, reimbursement or indemnification shall not be denied for any of the following when performed for cancer screening or diagnostic purposes, at the direction of a person licensed to practice medicine and surgery by the Board of Medicine:
(1) Mammograms when medically appropriate and consistent with the current guidelines from the United States Preventive Services Task Force;
(2)A pap smear, either conventional or liquid-based cytology, whichever is medically appropriate and consistent with the current guidelines from either the United States Preventive Services Task Force or The American College of Obstetricians and Gynecologists, for women age eighteen or over; or
(3) A test for the human papilloma virus (HPV), when medically appropriate and consistent with the current guidelines from either the United States Preventive Services Task Force or The American College of Obstetricians and Gynecologists, for women age eighteen or over.
(b) A policy, provision, contract, plan or agreement may apply to mammograms, pap smears or human papilloma virus (HPV) test the same deductibles, coinsurance and other limitations as apply to other covered services.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7c. Third Party Reimbursement for Rehabilitation Services

(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall, on or after July 1, 1991, provide as benefits to all subscribers and members coverage for rehabilitation services as hereinafter set forth, unless rejected by the insured.
(b) For purposes of this article and section, "rehabilitation services" includes those services which are designed to remediate patient's condition or restore patients to their optimal physical, medical, psychological, social, emotional, vocational and economic status. Rehabilitative services include by illustration and not limitation diagnostic testing, assessment, monitoring or treatment of the following conditions individually or in a combination:
(1) Stroke;
(2) Spinal cord injury;
(3) Congenital deformity;
(4) Amputation;
(5) Major multiple trauma;
(6) Fracture of femur;
(7) Brain injury;
(8) Polyarthritis, including rheumatoid arthritis;
(9) Neurological disorders, including, but not limited to, multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy and Parkinson's disease;
(10) Cardiac disorders, including, but not limited to, acute myocardial infarction, angina pectoris, coronary arterial insufficiency, angioplasty, heart transplantation, chronic arrhythmias, congestive heart failure, valvular heart disease;
(11) Burns.
(c) Rehabilitative services includes care rendered by any of the following:
(1) A hospital duly licensed by the State of West Virginia that meets the requirements for rehabilitation hospitals as described in Section 2803.2 of the Medicare Provider Reimbursement Manual, Part 1, as published by the U.S. Health Care Financing Administration;
(2) A distinct part rehabilitation unit in a hospital duly licensed by the State of West Virginia. The distinct part unit must meet the requirements of Section 2803.61 of the Medicare Provider Reimbursement Manual, Part 1, as published by the U.S. Health Care Financing Administration;
(3) A hospital duly licensed by the State of West Virginia which meets the requirements for cardiac rehabilitation as described in Section 35-25, Transmittal 41, dated August, 1989, as promulgated by the U.S. Health Care Financing Administration.
(d) Rehabilitation services do not include services for mental health, chemical dependency, vocational rehabilitation, long-term maintenance or custodial services.
(e) A policy, provision, contract, plan or agreement may apply to rehabilitation services the same deductibles, coinsurance and other limitations as apply to other covered services.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7d. Required Provisions in Contracts Which Include Child Immunization Services in the Terms of the Contract

Each contract made by the corporation with participating hospitals, physicians, and other health agencies which provide immunizations to children shall require that bills submitted to the corporation for child immunization services rendered under the terms of their contracts will set forth separately those charges for said services. Charges for other health care services provided during the same visit shall not be included in the charge for immunization services.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7f. Third Party Reimbursement for Colorectal Cancer Examination and Laboratory Testing

(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement applicable to this article, reimbursement or indemnification for colorectal cancer examinations and laboratory testing may not be denied for any nonsymptomatic person fifty years of age or older, or a symptomatic person under fifty years of age, when reimbursement or indemnity for laboratory or X-ray services are covered under the policy and are performed for colorectal cancer screening or diagnostic purposes at the direction of a person licensed to practice medicine and surgery by the Board of Medicine. The tests are as follows: An annual fecal occult blood test, a flexible sigmoidoscopy repeated every five years, a colonoscopy repeated every ten years and a double contrast barium enema repeated every five years.
(b) A symptomatic person is defined as: (i) An individual who experiences a change in bowel habits, rectal bleeding or stomach cramps that are persistent; or (ii) an individual who poses a higher than average risk for colorectal cancer because he or she has had colorectal cancer or polyps, inflammatory bowel disease, or an immediate family history of such conditions.
(c) The same deductibles, coinsurance, network restrictions and other limitations for covered services found in the policy, provision, contract, plan or agreement of the covered person may apply to colorectal cancer examinations and laboratory testing.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7h. Required Use of Mail-Order Pharmacy Prohibited

(a) A corporation defined in section two of this article may not require any person covered under a contract which provides coverage for prescription drugs to obtain the prescription drugs from a mail-order pharmacy in order to obtain benefits for the drugs.
(b) A corporation may not violate the provisions of subsection (a) of this section through the use of an agent or contractor or through the action of an administrator of prescription drug benefits.
(c) The Insurance Commissioner may propose rules for legislative approval in accordance with the provisions of article three, chapter twenty-nine-a of this code to implement and enforce the provisions of this section.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7i. Third-Party Reimbursement for Kidney Disease Screening

(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement applicable to this article, reimbursement or indemnification for annual kidney disease screening and laboratory testing as recommended by the National Kidney Foundation may not be denied for any person when reimbursement or indemnity for laboratory or X-ray services are covered under the policy and are performed for kidney disease screening or diagnostic purposes at the direction of a person licensed to practice medicine and surgery by the Board of Medicine. The tests are as follows: Any combination of blood pressure testing, urine albumin or urine protein testing and serum creatinine testing.
(b) The same deductibles, coinsurance, network restrictions and other limitations for covered services found in the policy, provision, contract, plan or agreement of the covered person may apply to kidney disease screening and laboratory testing.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7j. Required Coverage for Dental Anesthesia Services

(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall, on or after July 1, 2009, provide as benefits to all subscribers and members coverage for dental anesthesia services as hereinafter set forth.
(b) For purposes of this article and section, "dental anesthesia services" means general anesthesia for dental procedures and associated outpatient hospital or ambulatory facility charges provided by appropriately licensed health care individuals in conjunction with dental care provided to an enrollee or insured if the enrollee or insured is:
(1) Seven years of age or younger or is developmentally disabled and is an individual for whom a successful result cannot be expected from dental care provided under local anesthesia because of a physical, intellectual or other medically compromising condition of the enrollee or insured and for whom a superior result can be expected from dental care provided under general anesthesia; or
(2) A child who is twelve years of age or younger with documented phobias, or with documented mental illness, and with dental needs of such magnitude that treatment should not be delayed or deferred and for whom lack of treatment can be expected to result in infection, loss of teeth or other increased oral or dental morbidity and for whom a successful result cannot be expected from dental care provided under local anesthesia because of such condition and for whom a superior result can be expected from dental care provided under general anesthesia.
(c) Prior authorization. -- An entity subject to this section may require prior authorization for general anesthesia and associated outpatient hospital or ambulatory facility charges for dental care in the same manner that prior authorization is required for these benefits in connection with other covered medical care.
(d) An entity subject to this section may restrict coverage for general anesthesia and associated outpatient hospital or ambulatory facility charges unless the dental care is provided by:
(1) A fully accredited specialist in pediatric dentistry;
(2) A fully accredited specialist in oral and maxillofacial surgery; and
(3) A dentist to whom hospital privileges have been granted.
(e) Dental care coverage not required. -- The provisions of this section may not be construed to require coverage for the dental care for which the general anesthesia is provided.
(f) Temporal mandibular joint disorders. -- The provisions of this section do not apply to dental care rendered for temporal mandibular joint disorders.
(g) A policy, provision, contract, plan or agreement may apply to dental anesthesia services the same deductibles, coinsurance and other limitations as apply to other covered services.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7l. Maternity Coverage

Notwithstanding any provision of any policy, provision, contract, plan or agreement applicable to this article, a health insurance policy subject to this article, issued or renewed on or after January 1, 2014, which provides health insurance coverage for maternity services, shall provide coverage for maternity services for all persons participating in, or receiving coverage under the policy. To the extent that the provisions of this section require benefits that exceed the essential health benefits specified under section 1302(b) of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, as amended, the specific benefits that exceed the specified essential health benefits are not required of a health benefit plan when the plan is offered by a health care insurer in this state. Coverage required under this section may not be subject to exclusions or limitations which are not applied to other maternity coverage under the policy.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7n. Eye Drop Prescription Refills

A contract, plan or agreement issued by an insurer pursuant to this article for prescription topical eye medication may not deny coverage for the refilling of a prescription for topical eye medication when:
(1) The medication is to treat a chronic condition of the eye;
(2) The refill is requested by the insured prior to the last day of the prescribed dosage period and after at least 70% of the predicted days of use; and
(3) A person licensed under chapter thirty and authorized to prescribe topical eye medication indicates on the original prescription that refills are permitted and that the early refills requested by the insured do not exceed the total number of refills prescribed.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7o. Deductibles, Copayments and Coinsurance for Abuse-Deterrent Opioid Analgesic Drugs

a) As used in this section:
(1) “Abuse-deterrent opioid analgesic drug product” means a brand name or generic opioid analgesic drug product approved by the United States Food and Drug Administration with abuse-deterrent labeling that indicates its abuse-deterrent properties are expected to deter or reduce its abuse;
(2) “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible or other out-of-pocket expense requirements;
(3) “Opioid analgesic drug product” means a drug product that contains an opioid agonist and is indicated by the United States Food and Drug Administration for the treatment of pain, regardless of whether the drug product:
(A) Is in immediate release or extended release form; or
(B) Contains other drug substances.
(b) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, on or after January 1, 2017:
(1) Coverage shall be provided for at least one abuse-deterrent opioid analgesic drug product for each active opioid analgesic ingredient;
(2) Cost-sharing for brand name abuse-deterrent opioid analgesic drug products shall not exceed the lowest tier for brand name prescription drugs on the entity’s formulary for prescription drug coverage;
(3) Cost-sharing for generic abuse-deterrent opioid analgesic drug products covered pursuant to this section shall not exceed the lowest cost-sharing level applied to generic prescription drugs covered under the applicable health plan or policy; and
(4) An entity subject to this section may not require an insured or enrollee to first use an opioid analgesic drug product without abuse-deterrent labeling before providing coverage for an abuse-deterrent opioid analgesic drug product covered on the entity's formulary for prescription drug coverage.
(c) Notwithstanding subdivision (3), subsection (b) of this section, an entity subject to this section may undertake utilization review, including preauthorization, for an abuse-deterrent opioid analgesic drug product covered by the entity, if the same utilization review requirements are applied to nonabuse-deterrent opioid analgesic drug products and with the same type of drug release, immediate or extended.
(d) For purposes of subsection (b) of this section, the lowest tier and the lowest cost-sharing level shall not mean the cost-sharing tier applicable to preventive care services which are required to be provided at no cost-sharing under the Patient Protection and Affordable Care Act.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7q. Coverage for Amino Acid-Based Formulas

(a) A policy, plan, or contract that is issued or renewed on or after January 1, 2019, and that is subject to this article shall provide coverage, through the age of 20, for amino acid-based formula for the treatment of severe protein-allergic conditions or impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length, and motility of the gastrointestinal tract. This includes the following conditions, if diagnosed as related to the disorder by a physician licensed to practice in this state pursuant to either §30-3-1 et seq. or §30-14-1 et seq. of this code:
(1) Immunoglobulin E and Nonimmunoglobulin E-medicated allergies to multiple food proteins;
(2) Severe food protein-induced enterocolitis syndrome;
(3) Eosinophilic disorders as evidenced by the results of a biopsy; and
(4) Impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length, and motility of the gastrointestinal tract (short bowel).
(b) The coverage required by §33-24-7q(a) of this code shall include medical foods for home use for which a physician has issued a prescription and has declared them to be medically necessary, regardless of methodology of delivery.
(c) For purposes of this section, “medically necessary foods” or “medical foods” shall mean prescription amino acid-based elemental formulas obtained through a pharmacy: Provided, That these foods are specifically designated and manufactured for the treatment of severe allergic conditions or short bowel.
(d) The provisions of this section shall not apply to persons with an intolerance for lactose or soy.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7t. Fairness in Cost-Sharing Calculation

(a) As used in this section:
"Cost sharing" means any copayment, coinsurance, or deductible required by or on behalf of an insured in order to receive a specific health care item or service covered by a health plan.
"Drug" means the same as the term is defined in 30-5-4 of this code.
"Person" means a natural person, corporation, mutual company, unincorporated association, partnership, joint venture, limited liability company, trust, estate, foundation, nonprofit corporation, unincorporated organization, or government or governmental subdivision or agency.
"Pharmacy benefits manager" means the same as that term is defined in 33-51-3 of this code.
(b) When calculating an insured's contribution to any applicable cost sharing requirement, including, but not limited to, the annual limitation on cost sharing subject to 42 U.S.C. 18022(c) and 42 U.S.C. 300gg-6(b):
(1) An insurer shall include any cost sharing amounts paid by the insured or on behalf of the insured by another person; and
(2) A pharmacy benefits manger shall include any cost sharing amounts paid by the insured or on behalf of the insured by another person.
(c) The commissioner is authorized to propose rules for legislative approval in accordance with 29A-3-1
et seq
. of this code, to implement the provisions of this section.
(d) This section is effective for policy, contract, plans, or agreements beginning on or after January 1, 2020. This section applies to all policies, contracts, plans, or agreements subject to this article that are delivered, executed, issued, amended, adjusted, or renewed in this state on or after the effective date of this section.
(e) If under federal law application of subsection (b) of this section would result in Health Savings Account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply only for Health Savings Account-qualified High Deductible Health Plans with respect to the deductible of such a plan after the enrollee has satisfied the minimum deductible under Section 223 of the Internal Revenue Code:
Provided
, That with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, the requirements of subsection (b) of this section shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7v. Incorporation of the Health Benefit Plan Network Access and Adequacy Act

The provisions of the Health Benefit Plan Network Access and Adequacy Act codified at 33-55-1
et seq.
of this code is made applicable to the provisions of this article.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7w. Incorporation of the Coverage for 12-Month Refill for Contraceptive Drugs

The provision requiring coverage for 12-month refill for contraceptive drugs codified at 33-58-1 of this code is made applicable to the provisions of this article.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-7x. Copayments for Certain Services

(a) A policy, provision, contract, plan, or agreement subject to this article may not impose a copayment, coinsurance, or office visit deductible amount charged to a subscriber for services rendered for each date of service by a licensed occupational therapist, licensed occupational therapist assistant, licensed speech-language pathologist, licensed speech-language pathologist assistant, licensed physical therapist, or a licensed physical therapist assistant that is greater than the copayment, coinsurance, or office visit deductible amount charged to the subscriber for the services of a primary care physician or an osteopathic physician.
(b) The policy, provision, contract, plan, or agreement shall clearly state the availability of occupational therapy, speech-language therapy, and physical therapy coverage and all related limitations, conditions, and exclusions.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-8. Contract or Certificate to Be Furnished to Policyholders and Subscribers; Payment for Health Care Rendered Needy Persons

(a) Every such corporation shall deliver to each contract holder a copy of the contract and to each holder of a master group contract for delivery to each subscriber to such group contract a certificate setting forth the essential terms of the contract to be performed.
(b) A corporation may accept from governmental agencies payment of all or part of the cost of subscriptions for hospital, medical or other health care rendered needy persons, and may accept from private agencies, corporations, associations, groups or individuals, similar payment for such service to be rendered needy or other persons.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-9. Payroll Deduction for Governmental Employees

The officer charged with the duty of preparing the payroll of any subscriber, who is an employee of the state government or of any of its political subdivisions, including state-operated educational institutions, may upon request of the subscriber deduct from his payroll the amount of the fee owed by the subscriber to any hospital service corporation or medical service corporation, provided enrollment regulations of the particular corporation are satisfied, in which case the officer shall pay over such amount to the corporation.
2023 West Virginia Code › Chapter 33. Insurance › Article 24. Hospital Service Corporations, Medical Service Corporations, Dental Service Corporations and Health Service Corporations › §33-24-10. Investments; Bonds of Corporate Officers and Employees, Minimum Statutory Surplus

(a) The funds of any corporation shall be invested only as follows:
(1) The first $2 million of the funds shall be in cash or government securities of the type described in paragraph (A) or (B), subdivision (1), subsection (a), section eleven, article eight of this chapter or paragraph (A), (B) or (C), subdivision (3) of said subsection.
(2) The balance of the funds may be in cash, invested in the classes of investments described in subdivision (1), subsection (a), section eleven, article eight of this chapter or invested in the classes of investments described in the following sections of article eight of this chapter: Subdivision (4), subsection (a) and section eleven (preferred stock), section twelve (investment pools), section thirteen (equity interests), section fourteen (tangible personal property under lease), section fifteen (mortgage loans and real estate), section sixteen (securities lending, repurchase, reverse repurchase and dollar roll transactions), section seventeen (foreign investments) and section eighteen (derivative transactions). All investments are subject to all the restrictions and conditions contained in said article eight as applying to similar investments of insurers generally.
(b) Every officer or employee of any corporation, who is entrusted with the handling of its funds, shall furnish, in an amount fixed by the board of directors of the corporation, with the approval of the commissioner, a bond with corporate surety, conditioned upon the faithful performance of all his or her duties.
(c) A corporation shall have and maintain statutory surplus funds of at least $2 million: Provided, That any corporation duly licensed under this article in West Virginia prior to the effective date of this section whose surplus requirements are increased by virtue of this section shall maintain statutory surplus funds of at least $500,000 after the effective date of this section, and any corporation is then subject to the full $2 million statutory surplus requirement.