reglab/statecodes huggingface dataset:
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-86 - Preneed Life Insurance Minimum Standards For Determining Reserve Liabilities And Nonforfeiture Values › Section 114-86-4 - Minimum Valuation Interest Rate Standards

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1.
				The interest rates used in determining the minimum standard for valuation of preneed
				insurance are the calendar year statutory valuation interest rates as defined in W.
				Va. Code §
									33-7-9.
4.2. The interest rates used in determining the
				minimum standard for nonforfeiture values for preneed insurance are the calendar
				year statutory nonforfeiture interest rates as defined in W. Va. Code §
									33-13-30.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-86 - Preneed Life Insurance Minimum Standards For Determining Reserve Liabilities And Nonforfeiture Values › Section 114-86-5 - Minimum Valuation Method Standards

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. The
				method used in determining the standard for the minimum valuation of reserves of
				preneed insurance is the method defined in W. Va. Code §
									33-7-9.
5.2. The method used in determining the standard
				for the minimum nonforfeiture values for preneed insurance is the method defined in
				W. Va. Code §
									33-13-30.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-86 - Preneed Life Insurance Minimum Standards For Determining Reserve Liabilities And Nonforfeiture Values › Section 114-86-6 - Transition Rules

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. For preneed
				insurance policies issued on or after the effective date of this rule and before
				January 1, 2012, the 2001 CSO mortality table may be used as the minimum standard
				for reserves and minimum standard for nonforfeiture benefits for both male and
				female insureds.
6.2. If an insurer
				elects to use the 2001 CSO mortality table as a minimum standard for any policy
				issued on or after the effective date of this rule and before January 1, 2012, the
				insurer shall provide, as part of the actuarial opinion memorandum submitted in
				support of the company's asset adequacy testing, an annual written notification to
				the domiciliary commissioner. The notification shall include:
6.2.a. A complete list of all preneed policy forms
				that use the 2001 CSO as a minimum standard;
6.2.b. A certification signed by the appointed
				actuary stating that the reserve methodology employed by the insurer in determining
				reserves develops adequate reserves for preneed insurance policies issued after the
				effective date of this rule and using the 2001 CSO as a minimum standard. For the
				purposes of this certification, the preneed insurance policies using the 2001 CSO as
				a minimum standard cannot be aggregated with any other policies; and
6.2.c. Supporting information regarding the
				adequacy of reserves for preneed insurance policies issued after the effective date
				of this rule and using the 2001 CSO as a minimum standard for reserves.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-87 - Preventive Care Pilot Program › Section 114-87-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- The
				purpose of this rule is to permit participation in the Preventive Care Pilot Program
				by an individual or employer with a comprehensive high deductible health benefit
				plan or policy if the individual or employer is able to demonstrate that the
				participation will not negatively impact the coverage that is currently offered or
				will be offered by the employer. The rule also requires a participating provider to
				give notice to the individual or employer that the payment for the prepaid services
				may or may not count towards the health insurance deductible, the determination of
				which will depend on the health insurance policy language.
1.2. Authority. -- W. Va. Code §§
									33-2-10 and
				16-2J-7(3).
1.3. Filing Date. -- April 14, 2010.
1.4. Effective Date. -- April 14, 2010.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-87 - Preventive Care Pilot Program › Section 114-87-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. "High deductible
				plan" means a health benefit plan or policy with a minimum individual annual
				deductible of $3,000 or, if applicable, a family annual deductible of
				$3,000.
2.2. "Low deductible plan" means
				a health benefit plan or policy with a maximum individual annual deductible of
				$2,999.99 or, if applicable, a family annual deductible of $2,999.99.
2.3. "Participating provider" means a provider
				that has been granted a license under W.Va. Code §
									16-2J-1 et. seq. to offer a
				Plan and operate as part of the Preventive Care Pilot Program created by said
				article.
2.4. "Plan" means a health
				benefit plan or policy offered by a participating provider pursuant to W. Va. Code
				§
									16-2J-1, et seq.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-87 - Preventive Care Pilot Program › Section 114-87-3 - Participation in Pilot Program by Certain Individuals and Employer Groups

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. Unless otherwise
				prohibited by this rule, a participating provider may offer a Plan to an individual
				if the individual is covered by a high deductible plan and a participating provider
				may offer a Plan to an employer group if the employer group is covered by a high
				deductible plan.
3.2. An individual or
				employer with a high deductible plan may not purchase a Plan from a participating
				provider unless the subscriber or employer is able to demonstrate that participation
				in the Plan will not negatively impact the health insurance coverage that is
				currently offered or will be offered by the employer.
3.3. Any individual who has converted his or her
				health benefit plan or policy from a low deductible plan to a high deductible plan
				may not purchase a Plan from a participating provider for three (3) months from date
				of conversion.
3.4. Any employer who has
				converted its health benefit plan from a low deductible plan to a high deductible
				health benefit plan may not purchase a plan from a participating provider for six
				(6) months from the date of conversion.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-87 - Preventive Care Pilot Program › Section 114-87-4 - Notice to Individual or Employer

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1.
				Prior to the purchase of a Plan by an individual or employer having a high
				deductible plan, the participating provider shall give the individual or employer a
				notice that indicates that premiums paid under the Plan may not count towards a
				health insurance deductible. The notice shall further provide that any credit
				towards a health insurance deductible will depend on the health insurance policy or
				certificate language.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-89 - Use Of Senior-Specific Certifications And Professional Designations In The Sale Of Life Insurance And Annuities › Section 114-89-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Purpose. -- The
				purpose of this rule is to set forth standards to protect consumers from misleading
				and fraudulent marketing practices with respect to the use of senior-specific
				certifications and professional designations in the solicitation, sale or purchase
				of, or advice made in connection with, a life insurance or annuity
				product.
1.2. Scope. -- This rule
				applies to any solicitation, sale or purchase of, or advice made in connection with,
				a life insurance or annuity product by an insurance producer. The rule is based on
				the "Model Regulation on the Use of Senior Specific Certifications and Professional
				Designations in the Sale of Life Insurance and Annuities (#278)," as adopted by the
				National Association of Insurance Commissioners in the
				3rd quarter of 2008.
1.3. Authority. -- W. Va. Code §§
									33-2-10 and
				33-12-35.
1.4. Filing Date. -- April 14, 2010.
1.4. Effective Date. -- July 1, 2010.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-89 - Use Of Senior-Specific Certifications And Professional Designations In The Sale Of Life Insurance And Annuities › Section 114-89-2 - Prohibited Uses of Senior-Specific Certifications and Professional Designations

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. No producer may use
				a senior-specific certification or professional designation that indicates or
				implies in such a way as to mislead a purchaser or prospective purchaser to believe
				that the insurance producer has special certification or training in advising or
				servicing seniors in connection with the solicitation, sale or purchase of a life
				insurance or annuity product or in the provision of advice as to the value of or the
				advisability of purchasing or selling a life insurance or annuity product, either
				directly or indirectly through publications or writings, or by issuing or
				promulgating analyses or reports related to a life insurance or annuity
				product.
2.2. The prohibited use of
				senior-specific certifications or professional designations includes, but is not
				limited to, the following:
2.2.a. Use of a
				certification or professional designation by an insurance producer who has not
				actually earned or is otherwise ineligible to use such certification or
				designation;
2.2.b. Use of a nonexistent
				or self-conferred certification or professional designation;
2.2.c. Use of a certification or professional
				designation that indicates or implies a level of occupational qualifications
				obtained through education, training or experience that the insurance producer using
				the certification or designation does not have; and
2.2.d. Use of a certification or professional
				designation that was obtained from a certifying or designating organization that:
2.2.d.1. Is primarily engaged in the business of
				instruction in sales or marketing;
2.2.d.2. Does not have reasonable standards or
				procedures for assuring the competency of its certificants or designees;
2.2.d.3. Does not have reasonable standards or
				procedures for monitoring and disciplining its certificants or designees for
				improper or unethical conduct; or
2.2.d.4. Does not have reasonable continuing
				education requirements for its certificants or designees in order to maintain the
				certificate or designation.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-91 - Health Maintenance Organization Point Of Service Option › Section 114-91-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- The
				purpose of this rule is to set forth requirements to be followed by health
				maintenance organizations that offer a point of service option to its
				enrollees.
1.2. Authority. -- W. Va.
				Code §§
									33-25A-5(b)
				and
				33-2-10.
1.3. Filing Date. -- May 10, 2011.
1.4. Effective Date. -- July 1, 2011.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-91 - Health Maintenance Organization Point Of Service Option › Section 114-91-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. "Commissioner"
				means the Insurance Commissioner of the State of West Virginia.
2.2. "Enrollee" means an individual who has been
				voluntarily enrolled in a health maintenance organization, including individuals on
				whose behalf a contractual arrangement has been entered into with a health
				maintenance organization to receive health care.
2.3. "Health care services" means any services or
				goods included in the furnishing to any individual of medical, mental or dental
				care, or hospitalization or incident to the furnishing of the care or
				hospitalization, osteopathic services, chiropractic services, podiatric services,
				home health, health education or rehabilitation, as well as the furnishing to any
				person of any and all other services or goods for the purpose of preventing,
				alleviating, curing or healing human illness or injury.
2.4. "In-plan covered services" means health care
				services provided by a provider that is within the panel of providers with which a
				health maintenance organization has a contractual agreement.
2.5. "Out-of-plan covered services" means health
				care services provided by a provider that is not within the panel of providers with
				which a health maintenance organization has a contractual agreement.
2.6. "Point of service option" means a delivery
				system that permits an enrollee to receive health care services from a provider
				outside of the panel of providers with which a health maintenance organization has a
				contractual agreement under the terms and conditions of the enrollee's contract with
				the health maintenance organization or an insurance carrier that provides the point
				of service option.
2.7. "Provider" means
				a person or other entity which holds a valid license to provide health care
				services.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-91 - Health Maintenance Organization Point Of Service Option › Section 114-91-3 - Requirements for Point of Service Option

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. A
				health maintenance organization that offers a point of service option pursuant to W.
				Va. Code §
									33-25A-5(a):
3.1.a. Must include as in-plan covered services
				all services required by law to be provided by a health maintenance
				organization;
3.1.b. Must provide
				incentives, which shall include financial incentives, for enrollees to use in-plan
				covered services;
3.1.c. May not offer
				services out of plan without providing those services on an in-plan basis;
3.1.d. May not consider the following services as
				out-of-plan covered services subject to the point of service option:
3.1.d.1. Emergency medical services as defined by
				W. Va. Code §
											33-25A-8
				d(b)(5)(A); and
3.1.d.2. Any service
				performed by an out-of-network provider that has been preapproved or preauthorized
				by the health maintenance organization due to not having a panel provider available
				or capable to perform the service; and
3.1.e. Must include the following disclosure on
				its point of service contracts and evidences of coverage:
"WARNING, LIMITED BENEFITS WILL BE PAID WHEN NON-PARTICIPATING
				  PROVIDERS ARE USED. You should be aware that when you elect to utilize the services
				  of a non-participating provider for a covered service in non-emergency situations,
				  benefit payments to such non-participating providers are not based upon the amount
				  billed. The basis of your benefit payment will be determined according to your
				  policy's fee schedule, usual and customary charge (which is determined by comparing
				  charges for similar services adjusted to the geographical area where the services
				  are performed), or other method as defined by the policy. YOU CAN EXPECT TO PAY MORE
				  THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HAS PAID ITS
				  REQUIRED PORTION. Non-participating providers may bill members for any amount up to
				  the billed charge after the plan has paid its portion of the bill. Participating
				  providers have agreed to accept discounted payments for services with no additional
				  billing to the member other than co-insurance and deductible amounts. You may obtain
				  further information about the participating status of professional providers and
				  information on out-of-pocket expenses by calling the toll free telephone number on
				  your identification card."
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-93 - Mini COBRA › Section 114-93-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This rule
				provides guidelines with respect to the continuation of health insurance coverage
				for former employees of certain small employers, their dependents and other
				qualified beneficiaries who are not entitled to such coverage under the Consolidated
				Omnibus Budget Reconciliation Act of 1985 (COBRA).
This rule does not apply if continuation of coverage benefits are
				  available to covered employees or other qualified beneficiaries pursuant to a 'COBRA
				  continuation provision,' as that term is defined in W. Va. Code §
									33-16-3
				  m(a)(1)(A).
1.2. Authority. -- W. Va. Code
				§
									33-2-10.
1.3. Filing Date. -- April 20, 2012.
1.4. Effective Date. -- July 1, 2012.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-93 - Mini COBRA › Section 114-93-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. "Applicable
				premium" means, with respect to any period of continuation of coverage for qualified
				beneficiaries, the premium charged by the health benefit plan for such period of
				coverage for beneficiaries with respect to whom a qualifying event has not occurred,
				regardless of whether such premium or portions thereof are paid by the employer or
				employee.
2.2. "Carrier" means an
				insurer licensed in this state to transact accident and sickness insurance that has
				issued a health benefit plan.
2.3.
				"Commissioner" means the West Virginia Insurance Commissioner.
2.4. "Continuation coverage" means coverage under
				the health benefit plan that meets the requirements of section 3 of this
				rule.
2.5. "Covered employee" means an
				employee of a small employer who is covered under a health benefit plan by virtue of
				the employee's employment.
2.6. "Health
				benefit plan" means any group accident and sickness policy issued to a small
				employer that provides coverage for the employer's employees (including continuation
				coverage provided in accordance with this rule) and their dependents.
2.7. "Qualified beneficiary" means any individual
				who, on the day of the qualifying event for the covered employee, was covered under
				the health benefit plan by virtue of the individual being the covered employee, his
				or her spouse, or a dependent of the covered employee.
2.8. "Qualifying event" means the involuntary
				layoff or termination of an employee from employment for reasons other than
				misconduct that would disqualify such employee for unemployment benefits.
2.9. "Small employer" means any employer that is
				not subject to COBRA because it employs fewer than 20 employees.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-93 - Mini COBRA › Section 114-93-3 - Continuation of Coverage under Health Benefit Plan

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1.
Policy provisions regarding
				continuation coverage rights.
Every health benefit plan policy and
				certificate of coverage delivered or issued in this state must provide that, in the
				event of a qualifying event with respect to a covered employee, such employee and
				any other qualified beneficiary may elect continuation coverage for up to 18 months
				under the same terms and rates as would have been applicable had the qualifying
				event not occurred, except to the degree such rates and terms may be modified in
				accordance with this rule.
3.1.a. Every plan
				booklet or other explanation of rights under a health benefit plan must include all
				information necessary for a qualified beneficiary to comply with the election
				requirements of subsection 3.6 of this section and either a form for notice of such
				election to the carrier or directions on how such a form may be found on the
				Commissioner's website.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-94 - Workers' Compensation Insurance For State Agencies › Section 114-94-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- The
				purpose of this rule is to establish the procedure by which the Insurance
				Commissioner will procure workers' compensation coverage for various state agencies
				and boards.
1.2. Authority. -- W. Va.
				Code §§
									33-2-10 and
				33-2-21
				a(f).
1.3. Filing Date. -- April 20,
				2012.
1.4. Effective Date. -- April 20,
				2012.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-94 - Workers' Compensation Insurance For State Agencies › Section 114-94-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. "Commissioner"
				means the West Virginia Insurance Commissioner.
2.2. "Discretionary participant" means any
				discretionary participant as defined in W. Va. Code §
									33-2-21
				a(a)(1).
2.3. "Executive state entity"
				means the Governor's Office, including the Governor's Mansion, Office of Economic
				Opportunity, Commission for National and Community Service, Equal Employment
				Opportunity Office and the Governor's Office of Health Enhancement and Lifestyle
				Planning; the Bureau of Senior Services; and any other entity transferred to and
				incorporated in one of the executive departments created in W. Va. Code §
									5F-1-2
				and which is required to provide a detailed expenditure schedule to the Secretary of
				Revenue pursuant to W. Va. Code §
									11B-2-12.
2.4. "Experience rating" means a statistical
				procedure utilizing past risk experience to produce a prospective premium credit,
				debit or unity modification.
2.5. "Loss
				costs" are incurred losses on an accrual basis per $100 of payroll for the period
				under measurement.
2.6. "NCCI" means the
				National Council of Compensation Insurers, which was designated by the Commissioner
				as the state's rating organization in 2007 pursuant to W. Va. Code §
									23-2C-18
				a; the term also includes any successor rating organization designated by the
				Commissioner.
2.7. "Participation
				agreement" or "Agreement" means the document published on the Commissioner's website
				that contains the requirements to which all participants must adhere and which must
				be executed by the person who has the authority to legally bind that
				participant.
2.8. "State Agency Workers'
				Compensation" or "SAWC" means the procedure established by the Commissioner pursuant
				to W. Va. Code §
									33-2-21
				a and this rule to provide for the mandatory coverage of workers' compensation risks
				for all executive state entities and for those discretionary participants that
				participate in SAWC.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-94 - Workers' Compensation Insurance For State Agencies › Section 114-94-3 - Participation in SAWC; Agreement; Involuntary Removal

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. The Commissioner shall determine which
				entities meet the definition of executive state entity or discretionary participant.
3.1.a. The Commissioner shall inform:
(i) Executive state entities that they will be
				required to meet their mandatory workers' compensation coverage responsibilities
				through SAWC as of the date set by the Commissioner; and
(ii) Discretionary participants that they may
				apply for participation in SAWC during such periods and in such manner established
				by the Commissioner.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-94 - Workers' Compensation Insurance For State Agencies › Section 114-94-4 - Dispute Resolution Process

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. Any participant
				may dispute any decision by the Commissioner regarding its application to,
				participation in, or removal from SAWC in the manner set forth in W. Va. Code §
									33-2-13.
4.2. The Commissioner may designate another person
				to consider the matter under dispute, including conducting any hearing deemed
				necessary, and to make recommendations for resolution.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-95 - Utilization Review and Benefit Determination › Section 114-95-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. - This rule
				establishes standards and criteria for the structure and operation of utilization
				review and benefit determination, processes designed to facilitate ongoing
				assessment and management of health care services. This rule applies to any issuer
				offering a health benefit plan that provides or performs utilization review
				services, including prospective review or retrospective review benefit
				determinations and to any designee of the issuer or any utilization review
				organization that performs such functions on the issuer's behalf. This rule is based
				on the National Association of Insurance Commissioners' "Utilization Review Model
				Act" (Model 73), as amended in 2012.
1.2. Authority. - W. Va. Code §
									33-2-10 &
				§ 33-16H-4.
1.3. Filing Date.-June
				6,2014.
1.4. Effective Date.--July 6,
				2014.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-95 - Utilization Review and Benefit Determination › Section 114-95-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. "Adverse
				determination" means a determination by an issuer or its designee utilization review
				organization that an admission, availability of care, continued stay or other health
				care service that is a covered benefit has been reviewed and, based upon the
				information provided, does not meet the issuer's requirements for medical necessity,
				appropriateness, health care setting, level of care or effectiveness and the
				requested service or payment for the service is therefore denied, reduced or
				terminated.
2.2. "Ambulatory review"
				means utilization review of health care services performed or provided in an
				outpatient setting.
2.3. "Authorized
				representative" means:
2.3.a. A person to whom a
				covered person has given express written consent to represent the covered person in
				an external review;
2.3.b. A person
				authorized by law to provide substituted consent for a covered person;
2.3.c. In a situation in which a covered person is
				unable to provide consent, a family member of the covered person or the covered
				person's treating health care professional;
2.3.d. A health care professional when the covered
				person's health benefit plan requires that a request for a benefit under the plan be
				initiated by the health care professional; or
2.3.e. In the case of an urgent care request, a
				health care professional with knowledge of the covered person's medical condition.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-95 - Utilization Review and Benefit Determination › Section 114-95-3 - Corporate Oversight of Utilization Review Program

Current through Register Vol. XLI, No. 28, July 12, 2024
An issuer shall be responsible for monitoring all utilization
				  review activities carried out by, or on behalf of, the issuer and for ensuring that
				  all requirements of this rule are met. The issuer also shall ensure that appropriate
				  personnel have operational responsibility for the conduct of the issuer's
				  utilization review program.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-95 - Utilization Review and Benefit Determination › Section 114-95-4 - Contracting

Current through Register Vol. XLI, No. 28, July 12, 2024
Whenever an issuer contracts to have a utilization review
				  organization or other entity perform the utilization review functions required by
				  this rule, the Commissioner shall hold the issuer responsible for monitoring the
				  activities of the utilization review organization or entity with which the issuer
				  contracts and for ensuring that the requirements of this rule are
				  met.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-95 - Utilization Review and Benefit Determination › Section 114-95-5 - Scope and Content of Utilization Review Program

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. An issuer shall implement a written
				utilization review program that describes all review activities and procedures, both
				delegated and non-delegated, for:
5.1.a. The
				filing of benefit requests;
5.1.b. The
				notification of utilization review and benefit determinations; and
5.1.c. The review of adverse determinations in
				accordance with W.Va. Code of St. R. §
										114-96-1
et
				seq.
, "Health Plan Issuer Internal Grievance Procedure".
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-95 - Utilization Review and Benefit Determination › Section 114-95-9 - Emergency Services

Current through Register Vol. XLI, No. 28, July 12, 2024
9.1. When conducting
				utilization review or making a benefit determination for emergency services, an
				issuer that provides benefits for services in an emergency department of a hospital
				shall follow the provisions of this section.
9.2. An issuer shall cover emergency services to
				screen and stabilize a covered person in the following manner:
9.2.a. Without the need for prior authorization of
				such services if a prudent layperson would have reasonably believed that an
				emergency medical condition existed even if the emergency services are provided on
				an out-of-network basis;
9.2.b. Shall
				cover emergency services whether the health care provider furnishing the services is
				a participating provider with respect to such services;
9.2.c. If the emergency services are provided
				out-of-network, without imposing any administrative requirement or limitation on
				coverage that is more restrictive than the requirements or limitations that apply to
				emergency services received from network providers;
9.2.d. If the emergency services are provided
				out-of-network, by complying with the cost-sharing requirements of subdivision
				9.3.b; and
9.2.e. Without regard to any
				other term or condition of coverage, other than:
9.2.e.1. The exclusion of or coordination of
				benefits;
9.2.e.2. An affiliation or
				waiting period as permitted under section 2704 of the Public Health Service Act
				(PHSA); or
9.2.e.3. Applicable
				cost-sharing, as provided in subdivisions 9.3.a or 9.3.b.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-95 - Utilization Review and Benefit Determination › Section 114-95-10 - Confidentiality Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
An issuer shall annually certify in writing to the Commissioner
				  that the utilization review program of the issuer or its designee complies with all
				  applicable state and federal laws establishing confidentiality and reporting
				  requirements.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-95 - Utilization Review and Benefit Determination › Section 114-95-11 - Disclosure Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
11.1. In the
				certificate of coverage or member handbook provided to covered persons, an issuer
				shall include a clear and comprehensive description of its utilization review
				procedures, including the procedures for obtaining review of adverse determinations,
				and a statement of rights and responsibilities of covered persons with respect to
				those procedures.
11.2. An issuer shall
				include a summary of its utilization review and benefit determination procedures in
				materials intended for prospective covered persons.
11.3. An issuer shall print on its membership
				cards a toll-free telephone number to call for utilization review and benefit
				decisions.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-95 - Utilization Review and Benefit Determination › Section 114-95-12 - Penalties

Current through Register Vol. XLI, No. 28, July 12, 2024
Any issuer failing to comply with the requirements of this rule is
				  subject to the penalties prescribed in W.Va. Code §
									33-3-11.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-96 - Health Plan Issuer Internal Grievance Procedure › Section 114-96-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- The
				purpose of this rule is to provide standards for the establishment and maintenance
				of procedures by issuers to assure that covered persons have the opportunity for the
				appropriate resolution of grievances. This rule is based upon the National
				Association of Insurance Commissioners' "Health Carrier Grievance Procedure Act"
				(Model #72), as amended in 2012. To the extent feasible, this rule should be
				construed consistently with related state and federal laws, but to the extent any
				provision conflicts with a provision of other related rules in this title
				(including, but not limited to, series 43, 46, 50, 51 and 53 of this title), the
				provisions of this rule shall control and take precedence.
1.2. Authority. -- W.Va. Code §
									33-2-10 &
				33-16H-4.
1.3. Filing Date. -- June 6,
				2014.
1.4. Effective Date. -- July 6,
				2014.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-96 - Health Plan Issuer Internal Grievance Procedure › Section 114-96-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. "Adverse
				determination" means a determination by an issuer or its designee utilization review
				organization that an admission, availability of care, continued stay or other health
				care service that is a covered benefit has been reviewed and, based upon the
				information provided, does not meet the issuer's requirements for medical necessity,
				appropriateness, health care setting, level of care or effectiveness and the
				requested service or payment for the service is therefore denied, reduced or
				terminated.
2.2. "Ambulatory review"
				means utilization review of health care services performed or provided in an
				outpatient setting.
2.3. "Authorized
				representative" means:
2.3.a. A person to whom a
				covered person has given express written consent to represent the covered person in
				an internal review;
2.3.b. A person
				authorized by law to provide substituted consent for a covered person;
2.3.c. In a situation in which a covered person is
				unable to provide consent, a family member of the covered person or the covered
				person's treating health care professional;
2.3.d. A health care professional when the covered
				person's health benefit plan requires that a request for a benefit under the plan be
				initiated by the health care professional; or
2.3.e. In the case of an urgent care request, a
				health care professional with knowledge of the covered person's medical
				condition.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-96 - Health Plan Issuer Internal Grievance Procedure › Section 114-96-3 - Grievance Reporting and Recordkeeping Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. An issuer shall maintain written records to
				document all grievances received, including the notices and claims associated with
				the grievances.
3.1.a. The records of all
				grievances initiated in each calendar year shall be arranged in a separate register,
				the contents and form of which shall be prescribed by the Commissioner.
3.1.b. The records shall be retained for the
				longer of five years or until the Commissioner has adopted a final report of an
				examination that contains a review of the register for that calendar year.
3.1.c. The issuer shall make the records available
				for examination by the Commissioner and such other persons designated by the
				Commissioner.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-96 - Health Plan Issuer Internal Grievance Procedure › Section 114-96-4 - Grievance Review Procedures

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. Whenever an
				issuer fails to adhere to the requirements of section 5 or section 7 with respect to
				receiving and resolving grievances involving an adverse determination, the covered
				person shall be deemed to have exhausted the provisions of this rule and may file a
				request for external review in accordance with the procedures outlined in W.Va. Code
				of St. R. §
									114-97-1
et
				seq.
4.1.a. Notwithstanding subsection
				4.1, the provisions of section 5 shall not be deemed exhausted based on a
de
				minimis
violation that does not cause, and is not likely to cause,
				prejudice or harm to the covered person as long as the issuer demonstrates that the
				violation was for good cause or due to matters beyond the control of the issuer and
				that the violation occurred in the context of an ongoing, good faith exchange of
				information between the issuer and the covered person.
4.1.a.1. The exception provided in subdivision 4.1
				.a does not apply if the violation is part of a pattern or practice of violations by
				the issuer.
4.1.a.2. An issuer shall,
				within ten days of receiving a written request from a covered person, provide a
				written explanation of the basis, if any, for asserting that the alleged violation
				of section 5 or 7 does not entitle the covered person to claim exhaustion.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-96 - Health Plan Issuer Internal Grievance Procedure › Section 114-96-5 - First Level Reviews of Grievances Involving an Adverse Determination

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. Within 180 days
				after receipt of a notice of an adverse determination sent pursuant to W.Va. Code of
				St. R. §
									114-96-1
et
				seq.,
a covered person may file a grievance with the issuer requesting a
				first level review of the adverse determination.
5.2. First Level Review.
5.2.a. The issuer shall provide the covered person
				with the name, address and telephone number of a person or organizational unit
				designated to coordinate the first level review on behalf of the issuer.
5.2.b. In providing for a first level review under
				this section, the issuer shall ensure that the review is conducted in a manner under
				this section to ensure the independence and impartiality of the individuals involved
				in making the first level review decision.
5.2.c. In ensuring the independence and
				impartially of individuals involved in making the first level review decision, the
				issuer shall not make decisions related to such individuals regarding hiring,
				compensation, termination, promotion or other similar matters based upon the
				likelihood that the individual will support the denial of benefits.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-96 - Health Plan Issuer Internal Grievance Procedure › Section 114-96-6 - Standard Reviews of Grievances Not Involving an Adverse Determination

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. An issuer shall
				establish written procedures for a standard review of a grievance that does not
				involve an adverse determination.
6.2.
				The procedures shall permit a covered person to file a grievance that does not
				involve an adverse determination with the issuer under this section.
6.2.a. A covered person does not have the right to
				attend, or to have a representative in attendance at the standard review, but the
				covered person is entitled to submit written material for the person or persons
				designated by the carrier pursuant to subsection 6.3 to consider when conducting the
				review.
6.2.b.. The issuer shall make
				the provisions of subdivision 6.2.a known to the covered person within three working
				days after the date of receiving the grievance.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-96 - Health Plan Issuer Internal Grievance Procedure › Section 114-96-8 - Penalties

Current through Register Vol. XLI, No. 28, July 12, 2024
Any issuer failing to comply with the requirements of this rule is
				  subject to the penalties prescribed in W.Va. Code §
									33-3-11.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-97 - External Review of Adverse Health Insurance Determinations › Section 114-97-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- The
				purpose of this rule is to provide a process under which persons covered by health
				insurance have the opportunity for independent reviews of adverse coverage
				determinations by issuers. This rule is based on the National Association of
				Insurance Commissioners' "Uniform Health Carrier External Review Model Act" (Model
				76), as amended in 2010. This rule should be read in conjunction with series 95
				("Utilization Review") and 96 ("Health Plan Issuers Internal Grievance Process") of
				this title. Although review of adverse determinations normally proceeds first
				through the issuer's internal grievance procedure before it is assigned to an
				independent review organization, the rule permits the internal review process to be
				circumvented when the time necessary to conduct it could adversely affect the
				covered person's health.
1.2. Authority.
				- W.Va. Code §§
									33-2-10 &
				33-16H-4.
1.3. Filing Date. -- June 6,
				2014.
1.4. Effective Date. -- July 6,
				2014.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-97 - External Review of Adverse Health Insurance Determinations › Section 114-97-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. "Adverse
				determination" means a determination by an issuer or its designee utilization review
				organization that an admission, availability of care, continued stay or other
				healthcare service that is a covered benefit has been reviewed and, based upon the
				information provided, does not meet the issuer's requirements for medical necessity,
				appropriateness, health care setting, level of care or effectiveness and the
				requested service or payment for the service is therefore denied, reduced or
				terminated.
2.2. "Ambulatory review"
				means utilization review of health care services performed or provided in an
				outpatient setting.
2.3. "Authorized
				representative" means:
2.3.a. A person to whom a
				covered person has given express written consent to represent the covered person in
				an external review;
2.3.b. A person
				authorized by law to provide substituted consent for a covered person;
2.3.c. In a situation in which a covered person is
				unable to provide consent, a family member of the covered person or the covered
				person's treating health care professional;
2.3.d. A health care professional when the covered
				person's health benefit plan requires that a request for a benefit under the plan be
				initiated by the health care professional; or
2.3.e. In the case of an urgent care request, a
				health care professional with knowledge of the covered person's medical
				condition.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-97 - External Review of Adverse Health Insurance Determinations › Section 114-97-4 - Request For External Review

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. Except
				for a request for an expedited external review as set forth in section 7, all
				requests for external review shall be made in writing to the Commissioner in a form
				and manner approved by the Commissioner.
4.2. A covered person may make a request for an
				external review of an adverse determination or final adverse
				determination.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-97 - External Review of Adverse Health Insurance Determinations › Section 114-97-5 - Exhaustion of Internal Grievance Process

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. Except as provided in subsection 5.3 or if
				the exhaustion requirement is waived by the issuer, a request for external review
				pursuant to section 6, 7 or 8 may not be made until the covered person has exhausted
				the issuer's internal grievance process.
5.2. Except to the extent the covered person
				requested or agreed to a delay, he or she shall be deemed to have exhausted the
				issuer's internal grievance process for purposes of this section if he or she has
				not received a written decision from the issuer within thirty days after filing a
				grievance involving an adverse determination pursuant to the issuer's internal
				grievance process.
5.3. At the same time
				a covered person files a request for an expedited internal review of a grievance
				involving an adverse determination pursuant to W.Va. Code of St. R. §114-96,
				the covered person may file a request for an expedited external review of the
				adverse determination pursuant to either section 7 or 8, as appropriate.
5.3.a. Upon receipt of an assignment to conduct an
				expedited external review pursuant to section 7, the IRO shall determine whether the
				covered person will be required to complete the expedited review process set forth
				in W.Va. Code of St. R. §114-96.7 before it conducts the expedited external
				review.
5.3.b. Upon a determination made
				pursuant to subdivision 5.3.a that the covered person must first complete the
				expedited grievance review process set forth in W.Va. Code St. R. §114-96.7,
				the IRO shall immediately notify the covered person of this determination and that
				it will not proceed with the expedited external review set forth in section 7 until
				completion of the expedited grievance review process and the covered person's
				grievance at the completion of the expedited grievance review process remains
				unresolved.