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2023 West Virginia Code › Chapter 33. Insurance › Article 15B. Uniform Health Care Administration Act › §33-15B-2. Scope of Article

The provisions of this article apply to all health care providers in the state; all health insurers writing or issuing accident and sickness policies, including hospital service corporations, health service corporations, medical service corporations, dental service corporations and HMOs; all third party payers; all state agencies and departments, including, but not limited to, the public employees insurance agency and providers of services under Medicare and Medicaid; and all entities involved in the payment of health care claims.
2023 West Virginia Code › Chapter 33. Insurance › Article 15B. Uniform Health Care Administration Act › §33-15B-3. Insurance Commissioner to Propose Rules; Use of Standardized Forms and Classifications; Advisory Group

(a) The commissioner shall propose rules for legislative approval, in accordance with the provisions of chapter twenty-nine-a of this code, regarding the implementation and use of uniform health care administrative forms. Such rules shall establish, where practicable, the acceptance and use throughout the health care system of standard administrative forms, terms or procedures, including, but not limited to, the following:
(1) The standard CMS 1500 health insurance claim form, as amended, or other similar forms, terms, and definitions to be used which are consistent with health care and insurance industry standards.
(2) International classification of disease, ninth clinical modifications (ICD-9-CM) and common procedural terminology (CPT) codes, as amended, or other similar forms, terms, and definitions to be used which are consistent with health care and insurance industry standards.
(3) National uniform billing data element specifications (UB-04), as amended, and as supplemented by the West Virginia uniform billing committee, or other similar forms, terms, and definitions to be used which are consistent with health care and insurance industry standards.
(4) Consideration of current practices involving reimbursement of claims and explanation of benefits, and the implementation of standards and guidelines regarding explanation of benefits, including, but not limited to, consideration of line item explanations of payments or denial of payments.
(b) The legislative rules required herein shall be developed with the advice of an advisory group to be appointed by the commissioner. Such advisory group shall consist of representatives of consumers, providers, payors, and regulatory agencies, including representatives from the following: The department of health and human resources; the West Virginia health care authority; West Virginia dental association; West Virginia pharmacists association; the West Virginia hospital association; commercial health insurers; third party administrators; the West Virginia state medical association; the West Virginia nurses association; public employees insurance agency; and consumers.
(c) The commissioner and the advisory group shall review the legislative rules to be proposed pursuant to this section as necessary and update the same in a timely manner in order to conform to current legislation and health care and insurance industry standards and trends.
2023 West Virginia Code › Chapter 33. Insurance › Article 15B. Uniform Health Care Administration Act › §33-15B-5. Penalties for Violation

Any person, partnership, corporation, limited liability company, professional corporation, health care provider, insurer or other payer, or other entity violating any provision of this article shall be subject to a fine imposed by the commissioner of not more than $1000 for each violation and, in addition to or in lieu of any fine imposed, the West Virginia health care authority is empowered to withhold rate approval or a certificate of need for any health care provider violating any provision of this article.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-2. Purpose

The purpose of this article is to establish standards for discount medical plan organizations and discount prescription drug plan organizations in order to better protect consumers from unfair or deceptive marketing, sales and enrollment practices and to facilitate consumer understanding of the role and function of the organizations in providing access to medical or ancillary services.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-4. Licensing Requirements

(a) A person is required to obtain a license prior to doing business in this state as a discount medical plan organization.
(b) The commissioner shall propose rules for legislative approval in accordance with the provisions of article three, chapter twenty-nine-a of this code, as well as emergency rules in accordance with section fifteen of said article, setting forth the licensing requirements. These rules shall include, at a minimum:
(1) All necessary forms and other information considered necessary and required by the commissioner for processing the license application;
(2) Applicable fees;
(3) Reciprocity requirements;
(4) Time frames for the application and approval process;
(5) Conditions of approval of the license application or denial of the license;
(6) Renewal process;
(7) Notice requirements; and
(8) Any other provisions considered necessary by the commissioner to effectuate the provisions of this article.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-5. Minimum Capital Requirements

(a) Before the commissioner issues a license to any person required to obtain a license under section four of this article, the person seeking to operate a discount medical plan organization shall demonstrate that it has a positive net worth of at least $150,000.
(b) Each discount medical plan organization shall at all times maintain a positive net worth of at least $150,000.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-6. Surety Bond Requirements

Each licensed discount medical plan organization shall maintain in force a surety bond in its own name, in an amount not less than $35,000, in favor of the commissioner for the benefit of any person who is damaged by any violation of this article. The bond shall cover any violation occurring during the time period during which the bond is in effect and shall be issued by an insurance company licensed to do business in this state. A copy of the bond or a statement identifying the depository, trustee, and account number of the surety account, and thereafter proof of annual renewal of the bond or maintenance of the surety account, shall be filed with the commissioner.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-7. Examinations

The commissioner may examine the business and affairs of any discount medical plan organization to protect the interests of the residents of this state based on the following reasons, including complaint indices, recent complaints or information from other states, or as he or she deems necessary. An examination shall be performed in accordance with the provisions of section nine, article two of this chapter, except that a discount medical plan organization that is the subject of the examination shall pay the expenses incurred in conducting the examination. Failure by the discount medical plan organization to pay the expenses is grounds for the refusal to renew, revoke or suspend a license to operate as a discount medical plan organization.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-8. Charges and Fees; Refund Requirements; Bundling of Services

(a) A discount medical plan organization may charge a periodic charge as well as a reasonable one-time processing fee for a discount medical plan.
(b)(1) All discount medical plan certificates or other document demonstrating membership in the plan issued to persons in this state shall have a notice, prominently printed on the first page of the document or in a similarly conspicuous manner, stating that the member has the right to cancel his or her membership for any reason within thirty days of its receipt. If a member cancels his or her membership in the discount medical plan organization within the first thirty days after the date of receipt of the written document demonstrating membership, the member shall, upon return of the discount medical plan card to the discount medical plan organization, receive a reimbursement of all periodic charges and the amount of any one-time processing fee that exceeds $30. Notice of cancellation is deemed given when delivered by hand or deposited in a mailbox, properly addressed and postage prepaid to the mailing address of the discount medical plan organization or e-mailed to the e-mail address of the discount medical plan organization.
(2) If the discount medical plan organization cancels a membership for any reason other than nonpayment of charges by the member, the discount medical plan organization shall make a pro rata reimbursement of all periodic charges to the member.
(c) When a marketer or discount medical plan organization sells a discount medical plan in conjunction with any other products, the marketer or discount medical plan organization shall:
(1) Provide the charges for each discount medical plan in writing to the member; or
(2) Reimburse the member for all periodic charges for the discount medical plan and all periodic charges for any other product if the member cancels his or her membership in accordance with subdivision (1), subsection (b) of this section.
(d) A health carrier that provides a discount medical plan product that is incidental to the insured product is not subject to this section.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-9. Record Filing and Retention Requirements

(a) (1) Upon demand by the commissioner, a discount medical plan organization shall file with the commissioner a list of prospective member fees and charges associated with the discount medical plan.
(b) A copy of every form to be used by a discount medical plan organization, including the form for the written document demonstrating membership in the plan and all advertising, marketing materials and brochures, shall be retained by such organization and available for inspection by the commissioner for at least two years from the date on which such form was last used.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-10. Provider Agreements; Provider Listing Requirements

(a) (1) A discount medical plan organization shall have a written provider agreement with all providers offering medical or ancillary services to its members. The written provider agreement may be entered into directly with the provider or indirectly with a provider network to which the provider belongs.
(2) A provider agreement between a discount medical plan organization and a provider shall provide the following:
(A) A list of the medical or ancillary services and products to be provided at a discount;
(B) The amount or amounts of the discounts or, alternatively, a fee schedule that reflects the provider's discounted rates; and
(C) A written document demonstrating that the provider has agreed that it will not charge members more than the discounted rates.
(3) A provider agreement between a discount medical plan organization and a provider network shall require that the provider network have written agreements with its providers that:
(A) Contain the provisions described in subdivision (2) of this subsection;
(B) Authorize the provider network to contract with the discount medical plan organization on behalf of the provider; and
(C) Require the provider network to maintain an up-to-date list of its contracted providers and to provide the list on a monthly basis to the discount medical plan organization.
(4) A provider agreement between a discount medical plan organization and an entity that contracts with a provider network shall require that the entity, in its contract with the provider network, require the provider network to have written agreements with its providers that comply with subdivision (3) of this subsection.
(5) The discount medical plan organization shall maintain a copy of each of its active provider agreements; each such organization shall also retain a copy of every inactive provider agreement for at least two years after the expiration date of each such agreement.
(b) Each discount medical plan organization shall maintain on its Internet website page a current list of the names and addresses of the providers with which it has contracted directly or through a provider network; the address of the website shall be prominently displayed on all of the discount medical plan organization's advertisements, marketing materials, brochures and discount medical plan cards.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-11. Marketing Requirements

(a) A discount medical plan organization may market directly or contract with other marketers for the distribution of its product.
(b) (1) A discount medical plan organization shall have a written agreement with a marketer prior to the marketer's marketing, promoting, selling or distributing the discount medical plan.
(2) The agreement between the discount medical plan organization and the marketer shall prohibit the marketer from using advertising, marketing materials, brochures and discount medical plan cards without the discount medical plan organization's approval in writing.
(3) The discount medical plan organization shall be bound by and responsible for the activities of a marketer that are within the scope of the marketer's agency relationship with the organization.
(c) A discount medical plan organization shall approve in writing all advertisements, marketing materials, brochures and discount cards used by marketers to market, promote, sell or distribute the discount medical plan prior to their use.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-12. Annual Reports

(a) If the information required in subsection (b) of this section is not provided at the time of renewal of a license under section four of this article, a discount medical plan organization shall file an annual report with the commissioner in the form prescribed by the commissioner, within three months after the end of each fiscal year.
(b) The report shall include:
(1) Audited financial statements prepared in accordance with generally accepted accounting principals certified by an independent certified public accountant, including the organization's balance sheet, income statement and statement of changes in cash flow for the preceding year, except that, subject to the approval of the commissioner, an organization that is an affiliate of a parent entity that is publicly traded and that prepares audited financial statements reflecting the consolidated operations of the parent entity may instead submit the audited financial statements of the parent entity and a written guaranty that the minimum capital requirements required under section five of this article will be met by the parent entity;
(2) Any changes in the list of names and residence addresses of all persons responsible for the conduct of the organization's affairs, together with a disclosure of the extent and nature of any contracts or arrangements with these persons and the discount medical plan organization, including any possible conflicts of interest;
(3) The number of discount medical plan members in the state; and
(4) Any other information relating to the performance of the discount medical plan organization that may be required by the commissioner.
(c) Any discount medical plan organization that fails to file an annual report in the form and within the time required by this section may be fined up to $500 per day for the first ten days during which the violation continues and up to $1,000 per day after the first ten days during which the violation continues. The commissioner may also suspend the organization's authority to enroll new members or to do business in this state while the violation continues.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-13. Discount Prescription Drug Plan Organizations

(a) A discount prescription drug plan organization shall comply with sections eight, nine, ten and eleven of this article and shall report any of the information described in section twelve of this article in the form and manner as the commissioner may require. A discount prescription drug plan organization is also subject to sections fourteen, fifteen and sixteen of this article.
(b) Each discount prescription drug plan organization shall designate and provide the commissioner with the name, address and telephone number of a discount prescription drug plan compliance officer responsible for ensuring compliance with the provisions of this article that are applicable to discount prescription drug plans and discount prescription drug plan organizations.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-14. Administrative Enforcement Actions; Injunctions

(a) The commissioner may investigate the business affairs and conduct of every person applying for or holding a discount medical plan organization license and the operational affairs of a discount prescription drug plan organization to determine whether a violation of this article or any rule promulgated hereunder has occurred or is occurring.
(b) If the commissioner has cause to believe that a violation of this article or any rule promulgated hereunder has occurred or is occurring and that an enforcement action may be warranted, he or she shall notify the discount medical plan organization or discount prescription drug plan organization in writing, specifically stating the grounds for enforcement action and informing the organization that it may pursue a hearing on the matter in accordance with the provisions of section thirteen, article two of this chapter.
(c) If, after notice and hearing, a violation of this article or any legislative rule promulgated under this article is found, the Insurance Commissioner may take one or more of the following enforcement actions:
(1) Place a discount medical plan organization on probation or suspend, revoke or refuse to issue or renew the organization's license;
(2) Levy a civil penalty on the organization in an amount not exceeding $10,000 for each violation;
(3) Issue an administrative order requiring the discount medical plan organization or discount prescription drug plan organization to cease and desist from engaging in the act or practice that constitutes the violation; or
(4) Suspend the authority of the discount medical plan organization or discount prescription drug plan organization to enroll new members.
(d) In addition to the penalties and other provisions of this article, the commissioner may seek both temporary and permanent injunctive relief in the circuit court of Kanawha County when a discount medical plan is being operated by a person or entity that is not licensed pursuant to this article or any person has engaged or is engaging in any activity prohibited by this article or any rule adopted pursuant to this article.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-15. Criminal Penalties

(a) A person that willfully operates as or aids and abets another operating as a discount medical plan organization in violation of subsection (a), section four of this article is guilty of a felony and, upon conviction thereof, shall be fined not more than $20,000 for each unauthorized act or imprisoned in the state correctional facility not less than one nor more than five years, or both fined and imprisoned.
(b) No person shall collect a fee for purported membership in a discount medical plan or discount prescription drug plan and knowingly and willfully fail to provide the promised benefits of the plan.
(1) Any person who violates this subsection and in doing so collects fees totaling $1,000 or more is guilty of a felony and, upon conviction thereof, shall be fined not more than $2,500 or imprisoned in a state correctional facility not less than one nor more than ten years or, in the discretion of the court, be confined in jail for not more than one year, or both fined and imprisoned or confined.
(2) Any person who violates this subsection and in doing so collects fees totaling less than $1,000 is guilty of a misdemeanor and, upon conviction thereof, shall be fined not more than $2,500 or confined in jail not more than one year, or both fined and confined.
2023 West Virginia Code › Chapter 33. Insurance › Article 15E. Discount Medical Plan Organizations and Discount Prescription Drug Plan Organizations Act › §33-15E-17. Rules

The commissioner may propose rules for legislative approval in accordance with the provisions of article three, chapter twenty-nine-a of this code to carry out the provisions of this article. The commissioner may also promulgate emergency legislative rules to carry out the provisions of this article, including rules setting forth the requirements and prohibited practices with regard to the marketing of discount medical plans and discount prescription drug plans and for disclosures to members and prospective members of the plans.
2023 West Virginia Code › Chapter 33. Insurance › Article 16. Group Accident and Sickness Insurance › §33-16-1. Scope of Article

(a) Nothing in this article shall apply to or affect any policy of liability or workers' compensation insurance, or any policy of individual accident and sickness insurance issued in accordance with article fifteen of this chapter, or any policy issued by a fraternal benefit society.
(b) Nothing in this article shall apply to or in any way affect life insurance, endowment or annuity contracts or contracts supplemental thereto which contain no provisions relating to accident or sickness insurance except (a) such as provide additional benefits in case of death by accidental means and except (b) such as operate to safeguard such contracts against lapse, or to give a special surrender value or special benefit or an annuity in the event that the insured or annuitant shall become totally and permanently disabled as defined by the contract or supplemental contract.
(c) No accident and sickness policy or certificate shall be delivered or issued for delivery in this state insuring more than one individual (subject to the same exceptions provided for group life insurance in section one of article fourteen of this chapter) unless to one of the groups set forth in section two of this article and unless otherwise in compliance with this article.
2023 West Virginia Code › Chapter 33. Insurance › Article 16. Group Accident and Sickness Insurance › §33-16-1b. Applicability

(a) The provisions of this article which generally require policies of group accident and sickness insurance to cover specific conditions or treatments, but which are not expressly made applicable to the following types of policies, do not apply to:
(1) Coverage only for accident, or disability income insurance or any combination thereof;
(2) Coverage issued as a supplement to liability insurance;
(3) Liability insurance, including general liability insurance and automobile liability insurance;
(4) Workers' Compensation or similar insurance;
(5) Automobile medical payment insurance;
(6) Credit-only insurance;
(7) Coverage for on-site medical clinics; and
(8) Other similar insurance coverage, which may be specified by rule, under which benefits for medical care are secondary or incidental to other insurance benefits.
(b) The requirements of sections two-b, two-d, two-e and two-f, article fifteen of this chapter and the provisions of this article which generally require policies of group accident and sickness insurance to cover specific conditions or treatments, but which are not expressly made applicable to the following types of policies, do not apply to the following if provided under a separate policy, certificate, or contract of insurance:
(1) Limited scope dental or vision benefits;
(2) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof;
(3) Coverage for only a specified disease or illness;
(4) Hospital indemnity or other fixed indemnity insurance;
(5) Medicare supplement insurance (as defined under section 1882(g)(1) of the Social Security Act), coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code, and similar supplemental coverage provided to coverage under group accident and sickness insurance; and
(6) Any other benefits as may be specified by rule.
2023 West Virginia Code › Chapter 33. Insurance › Article 16. Group Accident and Sickness Insurance › §33-16-3. Required Policy Provisions

Each such policy hereafter delivered or issued for delivery in this state shall contain in substance the following provisions:
(a) A provision that the policy, the application of the policyholder, a copy of which shall be attached to such policy, and the individual applications, if any, submitted in connection with such policy by the employees or members, shall constitute the entire contract between the parties, and that all statements made by any applicant or applicants shall be deemed representations and not warranties, and that no such statement shall void the insurance or reduce benefits thereunder unless contained in a written application.
(b) A provision that the insurer will furnish to the policyholder, for delivery to each employee or member of the insured group, an individual certificate setting forth in substance the essential features of the insurance coverage of such employee or member and to whom benefits thereunder are payable. If dependents are included in the coverage, only one certificate need be issued for each family unit.
(c) A provision that all new employees or members, as the case may be, in the groups or classes eligible for insurance, shall from time to time be added to such groups or classes eligible to obtain such insurance in accordance with the terms of the policy.
(d) No provision relative to notice or proof of loss or the time for paying benefits or the time within which suit may be brought upon the policy shall be less favorable to the insured than would be permitted in the case of an individual policy by the provisions set forth in article fifteen of this chapter.
(e) A provision that all members in groups or classes eligible for insurance provided through an employee's group plan shall be permitted to pay the premiums at the same group rate and receive the same coverages for a period not to exceed eighteen months when they are involuntarily laid off from work.
(f) Such further provisions establishing group accident and sickness minimum policy coverage standards as the commissioner shall promulgate by rule pursuant to chapter twenty-nine-a of this code.
2023 West Virginia Code › Chapter 33. Insurance › Article 16. Group Accident and Sickness Insurance › §33-16-3b. Home Health Care Coverage

(a) Any insurer who, on or after January 1, 1981, delivers or issues for delivery in this state group basic hospital expense or major medical expense coverage under this article shall make available to the policyholder home health care coverage consistent with the provisions of this section. For purposes of this section, "home health care" means health services provided by a home health agency certified in the state in which the home health services are delivered or under Title XVIII of the Social Security Act.
(b) Home health care coverage offered shall include:
(1) Services provided by a registered nurse or a licensed practical nurse;
(2) Health services provided by physical, occupational, respiratory and speech therapists;
(3) Health services provided by a home health aide to the extent that such services would be covered if provided to the insured on an inpatient basis;
(4) Medical supplies, drugs, medicines and laboratory services to the extent that they would be covered if provided to the insured on an inpatient basis; and
(5) Services provided by a licensed midwife or a licensed nurse midwife as these occupations are defined in section one, article fifteen of the code.
(c) Home health care coverage may be limited to:
(1) Services provided on the written order of a licensed physician, provided such order is renewed at least every sixty days;
(2) Services provided, directly or through contractual agreements, by a home health agency certified in the state in which the home health services are rendered or under Title XVIII of the Social Security Act; and
(3) Services as set forth in subsection (b) of this section without which the insured would have to be hospitalized.
(d) Coverage under this section shall be provided for at least one hundred home visits per insured per policy year, with each home visit by a member of a home health care team to be considered as one home health care visit including up to four hours of home health care services.
(e) No such policy need provide such coverage to persons eligible for Medicare.
2023 West Virginia Code › Chapter 33. Insurance › Article 16. Group Accident and Sickness Insurance › §33-16-3bb. 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 §33-16-3bb(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 16. Group Accident and Sickness Insurance › §33-16-3c. Loss Ratio

If an insurer considers a loss ratio at the time of renewal of a policy, the insurer shall, upon request of an insured, provide the loss ratio and the components of the loss ratio calculation to the insured no more than 90 days but no less than 60 days before the renewal date of the policy. For purposes of this section, "loss ratio" means the total losses paid out in medical claims divided by the total earned premiums.
Medical claims do not include dental only or vision only coverage.
2023 West Virginia Code › Chapter 33. Insurance › Article 16. Group Accident and Sickness Insurance › §33-16-3e. Policies to Cover Nursing Services

(a) Any insurer who, on or after January 1, 1984, delivers or issues a policy of group accident and sickness insurance in this state under the provisions of this article shall make available as 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 insurer 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 areas of professional competence as established by education, training and experience.
2023 West Virginia Code › Chapter 33. Insurance › Article 16. Group Accident and Sickness Insurance › §33-16-3ee. 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 16. Group Accident and Sickness Insurance › §33-16-3f. Required Policy Provisions -- Treatment of Temporomandibular Joint Disorder and Craniomandibular Disorder

(a) The Legislature hereby finds that there is a need to provide guidelines regarding the coverage of temporomandibular joint disorder and craniomandibular disorder in policies issued pursuant to this article and article fifteen of this chapter, in order to provide for the health of our citizens. The purpose of this section is to require the Insurance Commissioner to develop standards regarding temporomandibular joint disorder and craniomandibular disorder and to require that all insurers writing accident and sickness policies which are covered by this article or article fifteen of this chapter, and the Public Employees Insurance Agency as set forth in article sixteen of chapter five make available this coverage to the policyholder or sponsor of each such policy. For purposes of this section, the Public Employees Insurance Agency is the policyholder.
(b) The Insurance Commissioner shall promulgate rules and regulations regarding the diagnosis and treatment for temporomandibular joint disorder and craniomandibular disorder coverage in accident and sickness policies covered by this article and article fifteen of this chapter. Such regulations shall prescribe the manner by which such coverage shall be offered to the policyholder or sponsor; that benefits shall apply whether administered by a physician or dentist, and findings regarding the projected actuarial costs of implementing said regulations.
(c) The regulations shall be developed by the Insurance Commissioner with the advice of a six-member panel to be appointed by the commissioner. Such panel shall consist of a general practicing dentist who shall be recommended by the West Virginia Dental Association, an oral and maxillofacial surgeon who shall be recommended by the West Virginia Society for Oral and Maxillofacial Dentists, a physician who shall be recommended by the West Virginia State Medical Association, a member from a Health Services Corporation who shall be recommended by the Health Services Corporation in this state, a member representing commercial health insurers who shall be recommended by the association representing accident and sickness insurance, and a representative of the Public Employees Insurance Association.
The Insurance Commissioner shall make his appointments to the panel based solely upon said recommendations thirty days after this section takes effect.
(d) This section shall only apply to policies of insurance which provide hospital, surgical or major medical expense insurance or any combination of these coverages.
2023 West Virginia Code › Chapter 33. Insurance › Article 16. Group Accident and Sickness Insurance › §33-16-3g. Third Party Reimbursement for Mammography, Pap Smear or Human Papilloma Virus Testing

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 the United States Preventive Services Task Force or The American College of Obstetricians and Gynecologists, for women age eighteen or over; and
(3) A test for the human papilloma virus (HPV)for women age eighteen or over, 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 and over.
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 16. Group Accident and Sickness Insurance › §33-16-3h. 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 16. Group Accident and Sickness Insurance › §33-16-3j. Hospital Benefits for Mothers and Newborns

(a) Nothing in this section shall be construed to require a mother to give birth in a hospital or to stay in the hospital for a fixed period of time following the birth of her child, but if a health benefit plan, for plan years beginning on or after January 1, 1998, provides inpatient benefits in connection with childbirth for a mother or her newborn child:
(1) The plan may not restrict benefits for any hospital stay following a normal vaginal delivery to less than forty-eight hours or following a cesarean section to less than ninety-six hours, or require a provider to obtain authorization for such length hospital stays;
(2) The plan must cover maternity and pediatric care in accordance with guidelines established by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics or other established professional medical association; and
(3) The mother and her newborn child may be discharged prior to the expiration of the minimum length of stay required under this section only in those cases in which the decision to discharge is made by an attending provider in consultation with the mother.
(b) Benefits provided for under this section may be made subject to deductibles, coinsurance or other cost-sharing if such cost-sharing is no greater than cost-sharing for any preceding portion of the mother's or newborn child's hospital stay.
(c) Nothing in this section shall be construed to prevent a health insurer from negotiating with a provider the level and type of reimbursement for inpatient maternity or newborn care provided under a health benefit plan.
2023 West Virginia Code › Chapter 33. Insurance › Article 16. Group Accident and Sickness Insurance › §33-16-3k. Limitations on Preexisting Condition Exclusions for Health Benefit Plans

(a) (1) For plan years beginning after June 30, 1997, a health benefit plan issued in connection with a group health plan may not impose a preexisting condition exclusion with respect to an employee or a dependent of an employee for losses incurred by the employee or dependent more than twelve months (or eighteen months for a late enrollee) after the earlier of the individual's date of enrollment in the health benefit plan or the first day of a waiting period for enrollment in the plan. Genetic information may not be treated as a condition for which a preexisting condition exclusion may be imposed absent a diagnosis of the condition related to the genetic information.
(2) A health benefit plan may impose a preexisting condition exclusion only if such condition relates to a physical or mental condition, regardless of its cause, for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period ending on the enrollee's enrollment date.
(3) A health benefit plan may impose no preexisting condition exclusion relating to pregnancy or in the case of a newborn covered under creditable coverage within thirty days of birth or a child adopted before the age of eighteen and covered under creditable coverage within thirty days of adoption or placement for adoption.
(b) A health maintenance organization that does not impose a preexisting condition exclusion allowed under subsection (a) of this section with respect to any particular coverage option may:
(1) Impose an affiliation period for that coverage option if the affiliation period is applied uniformly without regard to any health status-related factors and does not exceed two months (three months for a late enrollee). For purposes of this article, "affiliation period" means a period that begins on an employee's or dependent's enrollment date, runs concurrently with any waiting period under the group health plan, must expire before coverage is effective and during which the health maintenance organization need not provide medical care and may not charge any premium to the employee or dependent; or
(2) Use other alternatives approved by the commissioner to address adverse selection.
(c) Any preexisting condition exclusion period, including any waiting period or affiliation period prior to the effective date of coverage, shall be reduced by the aggregate of the periods of creditable coverage applicable to the enrollee as of the enrollment date.