West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-43A - Provider Sponsored Networks › Section 114-43A-4 - Licensing Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. Except to
				the extent provided differently by this rule, a PSN may apply for a certificate of
				authority to operate in West Virginia as a Medicaid managed care organization in
				accordance with the provisions of W.Va. Code §
									33-25A-1
et
				seq.,
W.Va. Code St. R. §114-43 and §114-46, and any other rule,
				bulletin or guidance issued by the Commissioner regarding the licensing of health
				maintenance organizations ("HMOs").
4.2.
				An applicant must demonstrate that it is controlled by one or more FQHCs. For
				purposes of this subsection, the term "controlled by" means the direct or indirect
				possession by one or more FQHCs of the power to direct or cause the direction of the
				management and policies of the organization through membership, board representation
				or an ownership interest greater than 50 percent.
4.3.a. In determining whether an applicant has
				demonstrated that it is financially responsible, the Commissioner shall take into
				consideration the factors set forth in W.Va. Code §
										33-25A-4(c)
				as well as, but not limited to, W.Va. Code St. R. § 114-43 and § 114-46,
				in the same manner as if the applicant were applying for a certificate of authority
				to operate as a HMO.
4.3.b. A PSN that
				has been issued a certificate of authority may petition the Commissioner to be
				permitted to operate with lower standards of financial responsibility than would
				otherwise be required for a HMO, including lower surplus and capital.
4.3.b.1. In ruling upon a petition submitted
				pursuant to subdivision b of this subsection, the Commissioner, in consultation with
				the Secretary, may consider actuarial evaluations and other qualified technical
				standards as well as the possible lower risks of insolvency arising from the control
				of the PSN or applicant by one or more FQHCs, any transfer of risk to a third party,
				and the restriction of the PSN to the provision of Medicaid-related services. The
				Commissioner may also require that the PSN submit such other information as maybe
				deemed necessary for a decision on the petition. A PSN will be presumed to be unable
				to operate with lower standards of financial responsibility unless it submits at
				least 3 years of audited financial statements that reflect positive net
				worth.
4.3.b.2. The decision whether and
				how to change the solvency requirements is committed to the sole discretion of the
				Commissioner.
4.4.a. Every
				application for a certificate of authority to operate as a PSN shall include a
				certification that any physician or behavioral health provider licensed by the
				appropriate West Virginia state agency or board shall be permitted to contract with
				the PSN to become a participating provider as long as he or she agrees to
				participate in the health care delivery approach designed by the PSN and such other
				applicable requirements of the Department of Health and Human Resources.
4.4.b. A PSN shall require that providers:
4.4.b.1. Agree to observe the PSN's care
				management protocols, including provisions for designations of certain services that
				may be provided only by designated providers or classes of providers;
4.4.b.2. Be credentialed before they may provide
				certain services; and
4.4.b.3. Comply
				with the PSN's utilization management programs and referral systems.
4.4.c. A PSN shall not:
4.4.c.1. Require a participating physician
				provider to sell or transfer ownership of his, her or its assets or practice
				operations to the PSN or any of the PSN's participating providers as a condition of
				participation or of being permitted access or use of the PSN's medical home
				resources and care management systems; or
4.4.c.2. Prohibit a participating provider from
				participating in or contracting with other networks or other managed care
				organizations to provide services to Medicaid beneficiaries.