reglab/statecodes huggingface dataset:
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 114-97-6 - Standard External Review

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. Within four months
				of receipt of a notice of an adverse determination or final adverse determination, a
				covered person may file a request for an external review with the Commissioner and,
				within two business of receipt of such a request, the Commissioner shall forward a
				copy to the issuer,
6.2. Within five
				business days following receipt of a copy of a covered person's external review
				request from the Commissioner, the issuer shall send the Commissioner and the
				covered person its determination whether the request is complete and if it is
				eligible for external review; such determinations shall be based on consideration of
				the following:
6.2.a. The individual is or was a
				covered person at the time the health care service was requested or, in the case of
				retrospective review, was a covered person in the health benefit plan at the time
				the health care service was provided;
6.2.b. The health care service that is the subject
				of the adverse determination or the final adverse determination is a covered service
				under the health benefit plan, but for a determination by the issuer that the health
				care service is not covered because it does not meet the issuer's requirements for
				medical necessity, appropriateness, health care setting, level of care or
				effectiveness;
6.2.c. The covered person
				is deemed to have exhausted the issuer's internal grievance process; and
6.2.d. The covered person has provided all the
				information and forms required to process an external review.
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 114-97-7 - Expedited External Review

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. Except for
				retrospective adverse or final adverse determinations, a covered person may make a
				written request for an expedited external review with the Commissioner at the time
				the covered person receives an adverse determination that meets the conditions
				described in the notice required by subdivision 3.1.e or a notice of a final adverse
				determination that meets any of the conditions described in the notice required by
				subdivision 3.1.f.
7.2. The Commissioner
				shall immediately send a copy of a request for an expedited external review to the
				issuer, who shall immediately make an initial determination whether the request
				meets the reviewability requirements set forth in subsection 6.2 and immediately
				notify the Commissioner and the covered person of its initial determination.
7.2.a. If the issuer's initial determination is
				that an external review request is ineligible for review, the notice required under
				subsection 7.2 shall include a statement informing the covered person that the
				initial determination may be appealed to the Commissioner.
7.2.b. Notwithstanding an issuer's initial
				determination to the contrary, the Commissioner may determine that a request is
				eligible for external review and require that it be referred for external review;
				such decision is not reviewable and must be made in accordance with the terms of the
				covered person's plan, subject to the provisions of this rule.
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 114-97-9 - Binding Nature of External Review Decision; Judicial Review of IRO Decisions

Current through Register Vol. XLI, No. 28, July 12, 2024
9.1. An issuer or
				covered person adversely affected by a final decision rendered by an IRO in
				accordance with this rule is entitled to judicial review thereof, but nothing in
				this rule shall be deemed to prevent other means of redress or relief provided by
				law. The Commissioner may enforce a final decision of an IRO in the same manner and
				to the same extent as an order issued by him or her.
9.2.
Judicial Proceedings.
9.2.a. Proceedings for review of a final decision
				of an IRO shall be instituted by filing a petition in the circuit court of the
				county in West Virginia:
9.2.a.1. In which covered
				person resides;
9.2.a.2. If the covered
				person is a non-resident of West Virginia, in which he or she works;
9.2.a.3. If the covered person neither lives nor
				works in West Virginia, in which the employer is primarily located; or
9.2.a.4. If none of the preceding paragraphs
				apphes, Kanawha County.
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 114-97-10 - Approval of IROs

Current through Register Vol. XLI, No. 28, July 12, 2024
10.1. The Commissioner
				shall approve IROs eligible to be assigned to conduct external reviews under this
				rule.
10.2. In order to be eligible for
				approval by the Commissioner under this section to conduct external reviews under
				this rule, an IRO:
10.2.a. Except as otherwise
				provided in this section, shall be accredited by a nationally recognized private
				accrediting entity that the Commissioner has determined has IRO accreditation
				standards that are equivalent to or exceed the minimum qualifications for IROs
				established under section 11; and
10.2.b. Shall submit an application for approval
				in accordance with subsection 10.4.
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 114-97-11 - Minimum Qualifications for IROs

Current through Register Vol. XLI, No. 28, July 12, 2024
11.1.
				To be approved under section 10 to conduct external reviews, an IRO shall have and
				maintain written policies and procedures that govern all aspects of both the
				standard external review process and the expedited external review process set forth
				in this rule that include, at a minimum:
11.1.a. A
				quality assurance mechanism in place that:
11.1.a.1. Ensures that external reviews are
				conducted within the specified time frames and required notices are provided in a
				timely manner;
11.1.a.2. Ensures the
				selection of qualified and impartial clinical reviewers to conduct external reviews
				on behalf of the IRO and suitable matching of reviewers to specific cases that the
				IRO employs or contracts with an adequate number of clinical reviewers to meet this
				objective;
11.1.a.3. Ensures the
				confidentiality of medical and treatment records and clinical review criteria;
				and
11.1.a.4. Ensures that any person
				employed by or under contract with the IRO adheres to the requirements of this
				rule;
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 114-97-12 - External Review Reporting Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
12.1.
				An IRO assigned pursuant to section 6, 7 or 8 to conduct an external review shall
				maintain written records in the aggregate by state and by issuer on all requests for
				external review for which it conducted an external review during a calendar year
				and, upon request, submit a report to the Commissioner, as required under
				subdivision 12.1.a.
12.1.a. Each IRO required to
				maintain written records on all requests for external review pursuant to this
				subsection for which it was assigned to conduct an external review shall submit to
				the Commissioner, upon request, a report in the format specified by the
				Commissioner.
12.1.b. The report shall
				include in the aggregate by state, and for each issuer:
12.1.b.1. The total number of requests for
				external review;
12.1.b.2. The number of
				requests for external review resolved and, of those resolved, the number resolved
				upholding the adverse determination or final adverse determination and the number
				resolved reversing the adverse determination or final adverse
				determination;
12.1.b.3. The average
				length of time for resolution;
12.1.b.4.
				A summary of the types of coverages or cases for which an external review was
				sought, as provided in the format required by the Commissioner;
12.1.b.5. The number of external reviews pursuant
				to subsection 8.8 that were terminated as the result of a reconsideration by the
				issuer of its adverse determination or final adverse determination after the receipt
				of additional information from the covered person or the covered person's authorized
				representative; and
12.1.b.6. Any other
				information the Commissioner may request or require.
12.1.c. The IRO shall retain the written records
				required pursuant to this subsection for at least three years.
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 114-97-13 - Funding of External Review

Current through Register Vol. XLI, No. 28, July 12, 2024
The issuer against which a request for a standard external review
				  or an expedited external review is filed shall pay the cost of the IRO for
				  conducting the external review.
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 114-97-14 - Disclosure Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
14.1. Each
				issuer shall include a description of the external review procedures in or attached
				to the policy, certificate, membership booklet, outline of coverage or other
				evidence of coverage it provides to covered persons.
14.2. The description required under subsection
				14.1 shall be in a format prescribed by the Commissioner that informs the covered
				person of his or her right to file a request for an external review of an adverse
				determination or final adverse determination with the Commissioner; explains that
				external review is available when the adverse determination or final adverse
				determination involves an issue of medical necessity, appropriateness, health care
				setting, level of care or effectiveness; and that includes the telephone number and
				address of the Commissioner.
14.3. In
				addition to subsection 14.2, the statement shall inform the covered person that,
				when filing a request for an external review, the covered person will be required to
				authorize the release of any medical records of the covered person that may be
				required to be reviewed for the purpose of reaching a decision on the external
				review.
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 114-97-15 - 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 114-98 - Adoption of Valuation Manual › Section 114-98-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- The
				purpose of this rule is to formally adopt the most recent changes to the Valuation
				Manual adopted by the National Association of Insurance Commissioners ("NAIC") as
				specified in W.Va. Code §
									33-7-9(n).
1.2. Authority. -- W. Va. Code §§
									33-7-9(n)
				and
				33-2-10.
1.3. Filing date. - June 6, 2022.
1.4. Effective date. - July 1, 2022.
1.5. Sunset date. - This rule shall terminate and
				have no further force or effect on August 1, 2027.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-98 - Adoption of Valuation Manual › Section 114-98-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. For purposes of
				this section, "Valuation Manual" shall have the meaning ascribed in W. Va. Code
				§
									33-7-9(a)(11).
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-98 - Adoption of Valuation Manual › Section 114-98-3 - Determination of Operative Date of Valuation Manual

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. The Insurance Commissioner has made the
				following determinations:
3.1.a. The Valuation
				Manual was adopted by the NAIC on December 2, 2012 by an affirmative vote of 43
				members, representing over three-fourths of the members voting.
3.1.b. The Standard Valuation Law, as amended by
				the NAIC in 2009, or legislation including substantially similar terms and
				conditions, has been enacted by states representing over 77% of the direct premiums
				written as reported in the following annual statements submitted in 2008: Life,
				accident and health annual statements; health annual statements; or fraternal annual
				statements.
3.1.c. The Standard
				Valuation Law, as amended by the NAIC in 2009, or legislation including
				substantially similar terms and conditions, has been enacted by 44
				states.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-98 - Adoption of Valuation Manual › Section 114-98-4 - Adoption of Valuation Manual

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. In
				accordance with W. Va. Code §
									33-7-9, the
				Valuation Manual (and any amendments to such manual as may be subsequently approved
				by the NAIC) is hereby adopted by this state to become effective January 1,
				2017.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-99 - Pharmacy Auditing Entities and Pharmacy Benefit Managers › Section 114-99-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- The
				purpose of this rule is to provide for the regulation of pharmacy auditing entities
				and pharmacy benefit managers and to provide licensing, reporting and activity
				standards for pharmacy benefit managers. The rule also provides registration
				requirements for pharmacy auditing entities.
1.2. Authority. -- W. Va. Code §§
									33-51-8,
				33-51-9,
				33-51-10,
				33-51-12 and
				33-2-10.
1.3. Filing Date. - March 29, 2023
1.4. Effective Date. - April 1, 2023.
1.5. Sunset provision. -- This rule shall
				terminate and have no further force or effect upon August 1, 2028.
1.6. Applicability. -- This rule applies to
				pharmacy benefit managers (PBMs) and persons or companies that perform pharmacy
				audits, as provided in Article 51, Chapter 33 of the West Virginia Code. Certain
				regulatory sections of this rule may not apply to Medicare Part D plans or Medicare
				Advantage plans that offer prescription drug coverage because
				42 U.S.C. §
										1395w-26(b)(3) and
				42 U.S.C. §
										1395w-112(g) provide that
				standards established under 42
				U.S.C. §
										1395w-101
et seq
.
				and 42 U.S.C. §
										1395w-21
et seq
. shall supersede
				any state law or regulation, other than state licensing laws or state laws relating
				to plan solvency. PBMs that perform pharmacy benefits management for Medicare Part D
				plans and Medicare Advantage plans in this state must be appropriately licensed.
				Additionally, certain sections of this rule may not be applicable to health benefit
				plans that are subject to the Employee Retirement Income Security Act of 1974
				("ERISA") if the subject provision of the rule is preempted by ERISA because it
				regulates a key facet or essential part of plan administration or design. However,
				certain sections of this rule that only affect costs, pricing or alter incentives
				for ERISA plans are not preempted by ERISA and may be applicable to PBMs providing
				pharmacy benefits management for ERISA plans. This section does not limit the
				applicability of other sections to PBMs providing pharmacy benefits management for
				ERISA plans should federal statutory or common law afford the state authority to
				regulate. PBMs that perform pharmacy benefits management for ERISA plans in this
				state must be appropriately licensed. This rule applies to PBMs that manage
				prescription drug coverage for workers' compensation insurers and employers who are
				self-insured for workers' compensation in this state because workers' compensation
				insurers and self-insured employers are "healthcare payors."
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-99 - Pharmacy Auditing Entities and Pharmacy Benefit Managers › Section 114-99-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. "340B entity" means
				an entity participating in the federal 340B drug discount program, as described in
				42 U.S.C. §
										256b, including its pharmacy or pharmacies, or any
				pharmacy or pharmacies, contracted with the participating entity to dispense drugs
				purchased through such program.
2.2.
				"Affiliate" means a pharmacy, pharmacist or pharmacy technician which, either
				directly or indirectly through one or more intermediaries:
2.2.1. Has an investment or ownership interest in
				a PBM;
2.2.2. Shares common ownership
				with a PBM; or
2.2.3. Has an investor or
				ownership interest holder which is a PBM.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-99 - Pharmacy Auditing Entities and Pharmacy Benefit Managers › Section 114-99-3 - Registration of Auditing Entities

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. Prior
				to conducting business in this state, an auditing entity shall make an application
				on a form and in a manner prescribed by the Commissioner.
3.2. An initial registration application shall
				include the following:
3.2.1. The identity, address
				and telephone number of the applicant;
3.2.2. The name, business address and telephone
				number of the contact person for the applicant;
3.2.3. When applicable, the federal employer
				identification number for the applicant; and
3.2.4. A nonrefundable filing fee sufficient to
				fund the Commissioner's regulatory duties in relation to Article 51, Chapter 33 of
				the West Virginia Code and this rule, not to exceed $1,000, which shall be set
				annually by the Commissioner via Bulletin or Notice on or before July 1.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-99 - Pharmacy Auditing Entities and Pharmacy Benefit Managers › Section 114-99-4 - Licensure of Pharmacy Benefit Managers

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. A person or organization may not establish or
				operate as a PBM in this state without first obtaining a license from the
				Commissioner.
4.1.1. A PBM shall apply for a
				license on a form and in a manner prescribed by the Commissioner.
4.1.2. The term of licensure shall be two years.
				However, the Commissioner may, in his or her discretion, fix the date of expiration
				regarding the initial license of a PBM in any manner as is considered by him or her
				to be advisable for an efficient distribution of the workload of his or her office,
				including fixing the date of expiration for the initial license of a PBM for a
				period less than or more than two years.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-99 - Pharmacy Auditing Entities and Pharmacy Benefit Managers › Section 114-99-5 - Responsibilities and Prohibited Acts

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. A PBM
				shall not cause or knowingly permit the use of any advertisement, promotion,
				solicitation, representation, proposal or offer that is untrue, deceptive or
				misleading.
5.2. An auditing entity
				conducting a pharmacy audit or person acting on behalf of the auditing entity may
				not seek any fee, charge-back, recoupment or other adjustment for a dispensed
				product, or any portion of a dispensed product, unless one of the following has
				occurred:
5.2.1. Fraud or other intentional and
				willful misrepresentation as evidenced by a review of the claims data, statements,
				physical review or other investigative methods;
5.2.2. Dispensing in excess of the benefit design,
				as established by the plan sponsor;
5.2.3. Prescriptions not filled in accordance with
				the prescriber's order; or
5.2.4. Actual
				overpayment to the pharmacy.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-99 - Pharmacy Auditing Entities and Pharmacy Benefit Managers › Section 114-99-6 - Network Adequacy and Reporting Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1.
				Network adequacy and prohibition against required use of mail-order pharmacy.
6.1.1. A PBM shall maintain a reasonably adequate
				and accessible network for the provision of prescription drugs for a health benefit
				plan. The network shall provide for convenient patient access to pharmacies within a
				reasonable distance from a patient's residence. A network shall not be comprised
				only of mail-order benefits but must have a mix of mail-order benefits and physical
				stores in this state.
6.1.1.a. Pursuant to W. Va.
				Code §§
											33-16-3q,
				33-24-7h,
				33-25-8f and
				33-25A-8g, an insurer issuing a group
				accident and sickness policy, a hospital, medical, dental or health service
				corporation, a health care corporation, or a health maintenance organization may not
				require any covered individual to obtain prescription drugs from a mail-order
				pharmacy in order to obtain prescription drug benefits, and may not violate this
				prohibition by using an agent, contractor or administrator that requires the covered
				person to obtain prescription drugs from a mail-order pharmacy. An insurer,
				hospital, medical, dental or health service corporation, a health care corporation,
				or a health maintenance organization that violates W. Va. Code §§
											33-16-3q,
				33-24-7h,
				33-25-8f and
				33-25A-8g through the use of a PBM may
				be subject to regulatory action as permitted under Chapter 33 of the West Virginia
				Code.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-99 - Pharmacy Auditing Entities and Pharmacy Benefit Managers › Section 114-99-7 - Examinations

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. The Commissioner
				may examine the affairs of a PBM for compliance with Article 51, Chapter 33 of the
				West Virginia Code or the requirements of this rule.
7.2. Any examination permitted under this section
				shall follow the examination procedures and requirements applicable to covered
				entities under W. Va. Code §
									33-2-9, and the Commissioner may assess
				the costs of the examination or audit to the PBM.
7.3. A PBM shall not be regularly examined under
				the same time periods of insurers as required under W. Va. Code §
									33-2-9; however, the Commissioner may
				examine the PBM, pursuant to this section, at any time in which he or she believes
				it reasonably necessary to ensure compliance with Article 51, Chapter 33 of the West
				Virginia Code or the provisions of this rule.
7.4. The information and data obtained by the
				Commissioner from a PBM under this section shall be considered proprietary and
				confidential by law and privileged, exempt from disclosure pursuant to Chapter 29B
				of the West Virginia Code as a "trade secret", is not open to public inspection, is
				not subject to subpoena, is not subject to discovery or admissible in evidence in
				any criminal, private civil or administrative action and is not subject to
				production pursuant to court order. The Commissioner is authorized to use the
				documents, materials or other information in the furtherance of any regulatory or
				legal action brought as part of the Commissioner's official duties.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-99 - Pharmacy Auditing Entities and Pharmacy Benefit Managers › Section 114-99-8 - Penalties and Reimbursement

Current through Register Vol. XLI, No. 28, July 12, 2024
8.1. If the
				Commissioner finds that a licensed PBM has violated any provisions of this rule or
				Article 51, Chapter 33 of the West Virginia Code that are applicable to the PBM, the
				Commissioner may, in addition to or in lieu of a licensure suspension or revocation,
				order the PBM to pay a penalty in a sum not to exceed $10,000 per violation. If the
				PBM fails to pay the penalty within 30 days after notice of the penalty, the
				Commissioner may revoke or suspend the license of the PBM. This section shall not
				affect the right of a PBM to make a written demand for a hearing before the
				Commissioner pursuant to the provisions of W. Va. Code §
									33-2-13 or the right of any party to
				request judicial review of an order of the Commissioner.
8.2. If the Commissioner finds that a registered
				auditing entity has violated any provisions of this rule or any provisions of
				Article 51, Chapter 33 of the West Virginia Code, the Commissioner may, in addition
				to or in lieu of a registration suspension or revocation, order the auditing entity
				pay a penalty in a sum not to exceed $2,500 per violation. If the auditing entity
				fails to pay the penalty within 30 days after notice of the penalty, the
				Commissioner may revoke or suspend the registration of the auditing entity. This
				section shall not affect the right of an auditing entity to make a written demand
				for a hearing before the Commissioner pursuant to the provisions of W. Va. Code
				§
									33-2-13 or the right of any party to
				request judicial review of an order of the Commissioner.
8.3. With respect to any person or entity
				operating in this state as a PBM without a license, the Commissioner may do one or
				both of the following:
8.3.1. File a complaint in
				the Circuit Court of Kanawha County, or in any county in which a PBM has operated
				without a license, to enjoin the PBM from operating;
8.3.2. After notice and hearing in accordance with
				W. Va. Code §
										33-2-13, assess restitution in an
				amount sufficient to reimburse any person adversely affected by the operation of the
				unlicensed PBM and, in addition to or in lieu of restitution, impose a fine in a sum
				not to exceed $20,000 for each unauthorized act; and
8.3.3. This section shall not affect the right of
				a PBM to make a written demand for a hearing before the Commissioner pursuant to the
				provisions of W. Va. Code §
										33-2-13 or the right of any party to
				request judicial review of an order of the Commissioner.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-99 - Pharmacy Auditing Entities and Pharmacy Benefit Managers › Section 114-99-9 - Consumer Choice for Pharmacy Benefits

Current through Register Vol. XLI, No. 28, July 12, 2024
9.1.
				Applicability.
9.1.1. Section 9 of this rule
				applies to all PBMs and health benefit plans providing pharmaceutical services or
				pharmacy benefits, including but not limited to prescription drugs, to any resident
				of West Virginia.
9.1.2. Section 9 of
				this rule does not apply to any entity that has its own facility, employs or
				contracts with physicians, pharmacists, nurses and other health care personnel, and
				that dispenses prescription drugs from its own pharmacy to its employees and
				dependents enrolled in its health benefit plan.
9.1.3. Section 9 of this rule applies to an entity
				otherwise excluded under subsection 9.1.2 of this rule that contracts with an
				outside pharmacy or group of pharmacies to provide prescription drugs and
				services.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-99 - Pharmacy Auditing Entities and Pharmacy Benefit Managers › Section 114-99-10 - Specialty Drug Complaints

Current through Register Vol. XLI, No. 28, July 12, 2024
10.1. A covered
				individual, beneficiary, pharmacy or pharmacist may file a specialty drug complaint
				with the Commissioner alleging that a PBM or health benefit plan has prohibited or
				otherwise limited access to a covered prescription drug from a pharmacy or
				pharmacist enrolled with the health benefit plan by unreasonably designating the
				drug as a "specialty drug," as that term is defined in W. Va. Code §
									33-51-3 and section 2.24 of this
				rule.
10.2. The specialty drug complaint
				should be filed on a form provided by the Commissioner and state with specificity
				the following:
10.2.1. The name and dosage of the
				prescription drug that has been designated as a specialty drug;
10.2.2. The name of the PBM;
10.2.3. The name of the health benefit plan or
				insurer, if known;
10.2.4. The name and
				group number of the health benefit plan, specifically including any separate group
				number for the health benefit plan's pharmacy plan;
10.2.5. The name of the covered individual or
				beneficiary of the health benefit plan, and the covered individual's or
				beneficiary's plan identification number;
10.2.6. The RxBIN for the health benefit plan or
				pharmacy plan;
10.2.7. The name of any
				individual or other entity involved in the alleged unreasonable designation of the
				drug as a specialty drug; and
10.2.8.
				Any other information the Commissioner may require.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-100 - Health Benefit Plan Network Access And Adequacy › Section 114-100-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This
				rule provides insurance carriers offering health benefit plans with standards
				and guidance regarding network access plan filings and provider directories.
				These standards shall serve as the measurable criteria used by the Commissioner
				to evaluate the adequacy of carrier network access plan filings and provider
				directories. This rule applies to all health carriers that offer network plans
				in West Virginia.
1.2. Authority.
				-- W. Va. Code §§
									33-2-10 and 33-55-9.
1.3. Filing Date. -- March 27,
				2024.
1.4. Effective Date. - April
				1, 2024.
1.5. Sunset Provision. --
				This rule shall terminate and have no further force or effect upon August 1,
				2034.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-100 - Health Benefit Plan Network Access And Adequacy › Section 114-100-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. "Commissioner"
				means the Insurance Commissioner of this state.
2.2. "County designation" means the
				classification of each county based upon population size and density. These
				parameters are set annually by the Centers of Medicare and Medicaid Services
				(CMS). There are five classifications: Large Metro, Metro, Micro, Rural, and
				Counties with Extreme Access Considerations (CEAC). A county must meet both the
				population and density threshold for the designation:
County Type Classification
Population
Density(person/mi2)
Large
Metro
>1,000,000
> 1,000/mi2
--
500,000 - 999,999
>1,500/mi2
--
Any
> 5,000/mi2
Metro
> 1,000,000
10 - 999.9/mi2
--
500,000 - 999,999
10 - 1,499.9/mi2
--
200,000 - 499,999
10 - 4,999.9/mi2
--
50,000 - 199,999
100 - 4,999.9/mi2
--
10,000 - 49,999
1,000 - 4,999.9/mi2
Micro
50,000 - 199,999
10 - 99.9 /mi2
--
10,000 - 49,999
50 - 999.9/mi2
Rural
10,000 - 49,999
10 - 49.9/mi2
--
<10,000
10 - 4,999.9/mi2
CEAC
Any
<10/mi2
2.3.
				"Covered benefit" or "benefit" means those health care services to which a
				covered person is entitled under the terms of a health benefit plan.
2.4. "Covered person" means a policyholder,
				subscriber, enrollee, or other individual participating in a health benefit
				plan.
2.5. "Essential community
				provider" or "ECP" means a provider that:
2.5.1. Serves predominantly low-income,
				medically underserved individuals, including a health care provider defined in
				Section 340B(a)(4) of the Public Health Service Act (PHSA); or
2.5.2. Is described in Section
				1927(c)(1)(D)(i)(IV) of the Social Security Act, as set forth by   Section 221 of
				Pub. L. 111-8.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-100 - Health Benefit Plan Network Access And Adequacy › Section 114-100-3 - Network Adequacy Standards

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. The geographic accessibility standards
				set forth in Appendix A shall be met by a health carrier in order to comply
				with network adequacy requirements.
3.1.1.
				The Commissioner shall publish a notice with the county designation of each
				West Virginia county by July 1st of each year or as soon as that information
				becomes available from CMS.
3.1.2.
				The geographic accessibility standards for dental shall be met by limited scope
				dental plans and by health benefit plans with embedded dental
				benefits.
3.1.3. At least 90
				percent of a health carrier's members must live within the maximum distance to
				at least one provider of each type to satisfy geographic accessibility network
				adequacy standards.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-100 - Health Benefit Plan Network Access And Adequacy › Section 114-100-5 - Coordination and Continuity of Care

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. A health carrier shall address its
				process for ensuring the coordination and continuity of care for its covered
				persons in the access plan for each network offered by the carrier.
5.2. The process for ensuring the
				coordination and continuity of care shall include, but is not limited to, the
				following:
5.2.1. The heath carrier's
				documented process for ensuring the coordination and continuity of care for
				covered persons referred to specialty providers;
5.2.2. The health carrier's documented
				process for ensuring the coordination and continuity of care for covered
				persons using ancillary services, including social services and other community
				resources;
5.2.3. The health
				carrier's documented process for ensuring appropriate discharge
				planning;
5.2.4. The health
				carrier's process for enabling covered persons to change primary care
				providers; and
5.2.5. The health
				carrier's proposed plan and process for providing continuity of care in the
				event of contract termination between the carrier and any of its participating
				providers or in the event of the carrier's insolvency or other inability to
				continue operations. The proposed plan and process shall include an explanation
				of how covered persons will be notified in the case of a provider contract
				termination, the health carrier's insolvency, or of any other cessation of
				operations, as well as how policyholders impacted by such events will be
				transferred to other providers in a timely manner.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-100 - Health Benefit Plan Network Access And Adequacy › Section 114-100-6 - Network Access Plan Disclosures; Attestations

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. In the access plan for each network plan
				offered, a health carrier shall explain its method for informing covered
				persons of the plan's services and features through disclosures to covered
				persons.
6.1.1. Required disclosures include:
6.1.1.a. The health carrier's grievance and
				appeal procedures;
6.1.1.b. The
				extent to which specialty medical services, including but not limited to
				physical therapy, occupational therapy and rehabilitation services, are
				available;
6.1.1.c. The health
				carrier's procedures for providing and approving emergency and non-emergency
				medical care;
6.1.1.d. The health
				carrier's process for choosing and changing network providers;
6.1.1.e. The health carrier's documented
				process to address the needs, including access and accessibility of services,
				of covered persons with limited English proficiency and illiteracy, with
				diverse cultural and ethnic backgrounds, and with physical or mental
				disabilities; and
6.1.1.f. The
				health carrier's documented process to identify the potential needs of special
				populations.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-100 - Health Benefit Plan Network Access And Adequacy › Appendix A

Current through Register Vol. XLI, No. 28, July 12, 2024
Provider Specialty
Geographic Accessibility
							 Standards
Maximum Time (in minutes) and Distance
							 (in miles) Standards
Large Metro
Metro
Micro
Rural
CEAC
Time
Distance
Time
Distance
Time
Distance
Time
Distance
Time
Distance
Allergy and Immunology
30
15
45
30
80
60
90
75
125
110
Cardiology
20
10
30
20
50
35
75
60
95
85
Cardiothoracic Surgery
30
15
60
40
100
75
110
90
145
130
Chiropractor
30
15
45
30
80
60
90
75
125
110
Dermatology
20
10
45
30
60
45
75
60
110
100
Dental
30
15
45
30
80
60
90
75
125
110
Emergency Medicine
20
10
45
30
80
60
75
60
110
100
Endocrinology
30
15
60
40
100
75
110
90
145
130
ENT/Otolaryngology
30
15
45
30
80
60
90
75
125
110
Gastroenterology
20
10
45
30
60
45
75
60
110
100
General Surgery
20
10
30
20
50
35
75
60
95
85
Gynecology, OB/GYN
10
5
15
10
30
20
40
30
70
60
Infectious Diseases
30
15
60
40
100
75
110
90
145
130
Nephrology
30
15
45
30
80
60
90
75
125
110
Neurology
20
10
45
30
60
45
75
60
110
100
Neurosurgery
30
15
60
40
100
75
110
90
145
130
Occupational Therapy
20
10
45
30
80
60
75
60
110
100
Oncology - Medical, Surgical
20
10
45
30
60
45
75
60
110
100
Oncology - Radiation
30
15
60
40
100
75
110
90
145
130
Ophthalmology
20
10
30
20
50
35
75
60
95
85
Orthopedic Surgery
20
10
30
20
50
35
75
60
95
85
Outpatient Clinical Behavioral Health
10
5
15
10
30
20
40
30
70
60
Physical Medicine and Rehabilitation
30
15
45
30
80
60
90
75
125
110
Physical Therapy
20
10
45
30
80
60
75
60
110
100
Plastic Surgery
30
15
60
40
100
75
110
90
145
130
Podiatry
20
10
45
30
60
45
75
60
110
100
Primary Care - Adult
10
5
15
10
30
20
40
30
70
60
Primary Care - Pediatric
10
5
15
10
30
20
40
30
70
60
Psychiatry
20
10
45
30
60
45
75
60
110
100
Pulmonology
20
10
45
30
60
45
75
60
110
100
Rheumatology
30
15
60
40
100
75
110
90
145
130
Speech Therapy
20
10
45
30
80
60
75
60
110
100
Urology
20
10
45
30
60
45
75
60
110
100
Vascular Surgery
30
15
60
40
100
75
110
90
145
130
Acute Inpatient Hospitals
(must have Emergency services available 24/7)
20
10
45
30
80
60
75
60
110
100
Cardiac Catheterization Services
30
15
60
40
160
120
145
120
155
140
Cardiac Surgery
30
15
60
40
160
120
145
120
155
140
Critical Care Services (ICU)
20
10
45
30
160
120
145
120
155
140
Diagnostic Radiology
20
10
45
30
80
60
75
60
110
100
Inpatient or Residential Behavioral Health Facility
							 Services
30
15
70
45
100
75
90
75
155
140
Mammography
20
10
45
30
80
60
75
60
110
100
Outpatient Infusion/Chemotherapy
20
10
45
30
80
60
75
60
110
100
Skilled Nursing
20
10
45
30
80
60
75
60
95
85
Surgical Services
20
10
45
30
80
60
75
60
110
100
Urgent Care
20
10
45
30
80
60
75
60
110
100
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-101 - Exempt Purchasing › Section 114-101-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This rule
				contains the procedures of the West Virginia Insurance Commissioner for procurements
				exempt from the requirements of the West Virginia State Purchasing Division in
				compliance with W. Va. Code §
									5A-1-12,
				under which agencies exempt from some or all of the requirements of Chapter 5A of
				the West Virginia Codeare to adopt purchasing procedures.
1.2. Authority. -- W. Va. Code §
									5A-1-12,
				W. Va. Code §
									23-1-1f,
				W.Va. Code §
									23-1-1g,
				W. Va. Code §
									33-2-9,
				W. Va. Code §
									33-2-21a,
				W. Va. Code §
									33-4A-3,
				and W. Va. Code §
									33-20E-7.
1.3. Filing Date. --February 2, 2021.
1.4. Effective Date. --March 4, 2021.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-101 - Exempt Purchasing › Section 114-101-3 - General information

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. OIC
				procurements for commodities and services shall be centrally processed within the
				OIC to provide economical and efficient services at a reasonable cost, using fair
				and reasonable competition methods and providing equitable treatment of
				vendors.
3.2. Methods used to determine
				the appropriate commodities and services needed by the OIC may include:
3.2.1. Best value procurement;
3.2.2. Life cycle costing; and
3.2.3. Total ownership or operational costing.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-101 - Exempt Purchasing › Section 114-101-4 - Purchasing requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1.
				Documentation associated with all procurements shall be maintained in files in
				accordance with OIC record retention policy.
4.2. All purchases of commodities and services
				shall be subject to expenditure approval.
4.3. Contracts shall be issued for all
				procurements regardless of dollar amounts to assist with tracking and ensure proper
				internal controls. As defined herein, the term contract includes purchase orders.
4.4. Vendors shall be responsible for
				submitting a correct and accurate bid to OIC Procurement by the specified bid
				opening time, date, and location and in accordance with the procurement documents.
4.5. Prior to an award of a contract,
				vendors must be a registered vendor as required by the West Virginia State
				Purchasing Division, document any required license or insurance, and be in good
				standing with state and local entities, including but not limited to the OIC with
				respect to workers' compensation insurance and the West Virginia Secretary of State.
4.6. Vendors to be awarded a contract
				of $1 million or more or a series of related contracts for which the cumulative
				total exceeds $1 million shall submit to the OIC a fully completed Disclosure of
				Interested Parties form authorized by the West Virginia Ethics Commission.
4.7. A vendor shall not commence work
				on any procurement without receipt of the awarded contract and any required notice
				to proceed. The OIC shall not be responsible for any work by a vendor prior to and
				not in accordance with the contract awarded.
4.8. All requests for commodities or services
				shall be submitted in a requisition to OIC Procurement via email, written memo, or
				other acceptable method. All requests require the approval of a division director or
				other person with the appropriate signature authority.
4.9. Upon receipt, a requisition shall be reviewed
				to determine the sourcing method for the procurement.
4.9.1. Sourcing methods to be considered shall
				include review of inventory from stockroom; state sources (e.g., correctional
				industries, sheltered workshops, surplus property); statewide or agency master
				agreements; cooperative contracts; or obtaining bids if required by the procurement
				method levels.
4.9.2. Any OIC contract
				usable by another state entity or a political subdivision shall declare such use.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-101 - Exempt Purchasing › Section 114-101-5 - Formal procurement documents and processes

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1.
				Request for Quotation (RFQ)
5.1.1. An RFQ shall
				contain a detailed description of, or specification for, the item(s) being
				purchased, any required delivery date, quantities, bid price per unit, and
				information on how to complete and submit the RFQ bid and deadlines.
5.1.2. Bids shall be reviewed by OIC Procurement
				and the OIC division requesting the item(s) to verify each bid meets the
				requirements of the RFQ.
5.1.3. An
				award shall be made to the responsible and responsive vendor having the lowest
				bid.