West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-43 - Health Maintenance Organization › Section 114-43-3 - Intermediary Contract Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. A
				certificate of authority holder may not enter into an administrative health service
				contract with a health service intermediary unless the contract is in writing, is
				filed with the commissioner accompanied by an opinion by a qualified independent
				actuary which states that the entering of the contract by the certificate of
				authority holder is financially sound, and the contract contains provisions which:
a. Require the health service intermediary to
				provide the certificate of authority holder with regular written reports prepared on
				a West Virginia statutory accounting basis, at least quarterly, that state the
				health service intermediary's current assets and identify in the aggregate all
				payments made or owed to its providers in sufficient detail for the certificate of
				authority holder and the Commissioner to determine if the payments are being made in
				a timely manner and which identify in the aggregate the reasonably estimated
				incurred but not reported health care costs;
b. Require the certificate of authority holder to
				monitor the health service intermediary's reports required under paragraph a of this
				subsection;
c. Permit the certificate of
				authority holder and the commissioner, both singularly and jointly, upon reasonable
				prior notice, to audit, inspect and copy the health service intermediary's books,
				records, and other evidence of its operations which are, in the discretion of the
				certificate of authority holder or the commissioner, relevant to the intermediary's
				obligations under the administrative health service contract for the purpose of
				determining the intermediary's compliance with all requirements legally mandated by
				statute, rule or the administrative health service contract. Any review is subject
				to any confidentiality requirements imposed by State or Federal law;
d. Require the health service intermediary to
				maintain working capital in the form of cash or equivalent liquid assets at least
				equal to one month's claims calculated by using the monthly average of actual and
				estimated claims for the prior six months for all health services provided under the
				administrative health service contract;
e. Require the intermediary to create a segregated
				fund, which may be aggregated, equal to the entire monthly IBNR as of the first day
				of each month as actuarially determined by the certificate of authority holder.
A. The commissioner may upon application of the
				certificate of authority holder and good cause shown, give prior written approval to
				alternative financial arrangements between the certificate of authority holder and
				the intermediary, such as the use of premium withhold funds, either in conjunction
				with or in lieu of the capital and reserve fund requirements of paragraphs d and e
				of this section;
f. Require
				the certificate of authority holder to assume the full financial responsibility as
				specified in subsection 4.2. of this rule, for any valid claims presented for
				payment to the health service intermediary by providers for covered health care
				services rendered to a subscriber, policyholder, enrollee or certificate holder, as
				applicable, and which are not paid by the health service intermediary as provided by
				law and by the contract between the intermediary and provider;
g. Require that all enrollee or enrollee group
				contracts must be directly with the certificate of authority holder and not the
				intermediary;
h. Require that the
				intermediary provide services on behalf of the certificate of authority holder only
				in counties where the certificate of authority holder is authorized by the
				commissioner to operate;
i. Clearly
				delineate the responsibilities to be assumed by the intermediary and require that
				the intermediary adhere to all quality and accessibility standards to which the
				certificate of authority holder is subject;
j. Require that to the extent the intermediary is
				permitted to sub-contract the provision of health care services that all
				sub-contractors must adhere to quality and accessibility standards to which the
				certificate of authority holder is subject;
k. Require that the certificate of authority
				holder continuously monitor the intermediaries' compliance with the contract
				requirements;
l. Specify that the
				certificate of authority holder is responsible for maintaining appropriate levels of
				capital, surplus, claims reserves, and other financial criteria as established
				pursuant to statute or rule;
m. Require
				the health service intermediary and any entities with which the health service
				intermediary sub-contracts for the provision of health care services to obtain and
				provide to the certificate of authority holder no later than the first day of June
				of each year an annual audited financial report prepared by an independent certified
				public accountant; and
n. If the health
				service intermediary provides health care services on behalf of more than one
				entity, specify that the health service intermediary maintain records which are
				adequate to clearly differentiate the transactions which relate to the provision of
				health care services on behalf of the certificate of authority holder.