reglab/statecodes huggingface dataset:
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-45 - Recognizing Annuity Mortality Tables for Use in Determining Reserve Liabilities for Annuities › Appendix II

Current through Register Vol. XLI, No. 28, July 12, 2024
2012 IAM Period Table Male, Age Nearest Birthday
AGE
1000 *
						  qx2012
AGE
1000 *
						  qx2012
AGE
1000 *
						  qx2012
AGE
1000 *
						  qx2012
0
1.605
30
0.741
60
5.096
90
109.993
1
0.401
31
0.751
61
5.614
91
123.119
2
0.275
32
0.754
62
6.169
92
137.168
3
0.229
33
0.756
63
6.759
93
152.171
4
0.174
34
0.756
64
7.398
94
168.194
5
0.168
35
0.756
65
8.106
95
185.260
6
0.165
36
0.756
66
8.548
96
197.322
7
0.159
37
0.756
67
9.076
97
214.751
8
0.143
38
0.756
68
9.708
98
232.507
9
0.129
39
0.800
69
10.463
99
250.397
10
0.113
40
0.859
70
11.357
100
268.607
11
0.111
41
0.926
71
12.418
101
290.016
12
0.132
42
0.999
72
13.675
102
311.849
13
0.169
43
1.069
73
15.150
103
333.962
14
0.213
44
1.142
74
16.860
104
356.207
15
0.254
45
1.219
75
18.815
105
380.000
16
0.293
46
1.318
76
21.031
106
400.000
17
0.328
47
1.454
77
23.540
107
400.000
18
0.359
48
1.627
78
26.375
108
400.000
19
0.387
49
1.829
79
29.572
109
400.000
20
0.414
50
2.057
80
33.234
110
400.000
21
0.443
51
2.302
81
37.533
111
400.000
22
0.473
52
2.545
82
42.261
112
400.000
23
0.513
53
2.779
83
47.441
113
400.000
24
0.554
54
3.011
84
53.233
114
400.000
25
0.602
55
3.254
85
59.855
115
400.000
26
0.655
56
3.529
86
67.514
116
400.000
27
0.688
57
3.845
87
76.340
117
400.000
28
0.710
58
4.213
88
86.388
118
400.000
29
0.727
59
4.631
89
97.634
119
400.000
120
1000.000
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-45 - Recognizing Annuity Mortality Tables for Use in Determining Reserve Liabilities for Annuities › Appendix III

Current through Register Vol. XLI, No. 28, July 12, 2024
Projection Scale G2 Female, Age Nearest Birthday
AGE
G2X
AGE
G2X
AGE
G2X
AGE
G2X
0
0.010
30
0.010
60
0.013
90
0.006
1
0.010
31
0.010
61
0.013
91
0.006
2
0.010
32
0.010
62
0.013
92
0.005
3
0.010
33
0.010
63
0.013
93
0.005
4
0.010
34
0.010
64
0.013
94
0.004
5
0.010
35
0.010
65
0.013
95
0.004
6
0.010
36
0.010
66
0.013
96
0.004
7
0.010
37
0.010
67
0.013
97
0.003
8
0.010
38
0.010
68
0.013
98
0.003
9
0.010
39
0.010
69
0.013
99
0.002
10
0.010
40
0.010
70
0.013
100
0.002
11
0.010
41
0.010
71
0.013
101
0.002
12
0.010
42
0.010
72
0.013
102
0.001
13
0.010
43
0.010
73
0.013
103
0.001
14
0.010
44
0.010
74
0.013
104
0.000
15
0.010
45
0.010
75
0.013
105
0.000
16
0.010
46
0.010
76
0.013
106
0.000
17
0.010
47
0.010
77
0.013
107.
0.000
18
0.010
48
0.010
78
0.013
108
0.000
19
0.010
49
0.010
79
0.013
109
0.000
20
0.010
50
0.010
80
0.013
110
0.000
21
0.010
51
0.010
81
0.012
111
0.000
22
0.010
52
0.011
82
0.012
112
0.000
23
0.010
53
0.011
83
0.011
113
0.000
24
0.010
54
0.011
84
0.010
114
0.000
25
0.010
55
0.012
85
0.010
115
0.000
26
0.010
56
0.012
86
0.009
116
0.000
27
0.010
57
0.012
87
0.008
117
0.000
28
0.010
58
0.012
88
0.007
118
0.000
29
0.010
59
0.013
89
0.007
119
0.000
120
0.000
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-45 - Recognizing Annuity Mortality Tables for Use in Determining Reserve Liabilities for Annuities › Appendix IV

Current through Register Vol. XLI, No. 28, July 12, 2024
Projection Scale G2 Male, Age Nearest Birthday
AGE
G2X
AGE
G2X
AGE
G2X
AGE
G2X
0
0.010
30
0.010
60
0.015
90
0.007
1
0.010
31
0.010
61
0.015
91
0.007
2
0.010
32
0.010
62
0.015
92
0.006
3
0.010
33
0.010
63
0.015
93
0.005
4
0.010
34
0.010
64
0.015
94
0.005
5
0.010
35
0.010
65
0.015
95
0.004
6
0.010
36
0.010
66
0.015
96
0.004
7
0.010
37
0.010
67
0.015
97
0.003
8
0.010
38
0.010
68
0.015
98
0.003
9
0.010
39
0.010
69
0.015
99
0.002
10
0.010
40
0.010
70
0.015
100
0.002
11
0.010
41
0.010
71
0.015
101
0.002
12
0.010
42
0.010
72
0.015
102
0.001
13
0.010
43
0.010
73
0.015
103
0.001
14
0.010
44
0.010
74
0.015
104
0.000
15
0.010
45
0.010
75
0.015
105
0.000
16
0.010
46
0.010
76
0.015
106
0.000
17
0.010
47
0.010
77
0.015
107
0.000
18
0.010
48
0.010
78
0.015
108
0.000
19
0.010
49
0.010
79
0.015
109
0.000
20
0.010
50
0.010
80
0.015
110
0.000
21
0.010
51
0.011
81
0.014
111
0.000
22
0.010
52
0.011
82
0.013
112
0.000
23
0.010
53
0.012
83
0.013
113
0.000
24
0.010
54
0.012
84
0.012
114
0.000.
25
0.010
55
0.013
85
0.011
115
0.000
26
0.010
56
0.013
86
0.010
116
0.000.
27
0.010
57
0.014
87
0.009
117
0.000
28
0.010
58
0.014
88
0.009
118
0.000
29
0.010
59
0.015
89
0.008
119
0.000
120
0.000
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-46 - Filing Procedures For Health Maintenance Organizations › Section 114-46-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This rule
				applies to all persons or entities which are licensed or which may be required to be
				licensed pursuant to the provisions of W. Va. Code '33-25A-1 et
				seq.
1.2. Authority. -- W. Va. Code
				''33-25A-3, 12, 15, 20 and 22.
1.3.
				Filing Date. -- April 2, 1996.
1.4.
				Effective Date. -- April 2, 1996.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-46 - Filing Procedures For Health Maintenance Organizations › Section 114-46-3 - Application for Amendment to Certificate of Authority

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. Each application for an amendment to a health
				maintenance organization's certificate of authority must be accompanied by a
				completed "Application for Amendment to Certificate of Authority Filing Fee
				Remittance Form" provided by the Insurance Commissioner and a check in the amount of
				two hundred dollars ($200.00) payable to the "West Virginia Insurance
				Commissioner."
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-46 - Filing Procedures For Health Maintenance Organizations › Section 114-46-4 - Annual Financial Statement

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. Each annual
				financial statement submitted by a health maintenance organization to the
				commissioner shall include, but not be limited to:
a. A financial statement on a West Virginia
				statutory accounting basis of the organization, including its balance sheet and
				receipts and disbursements for the preceding year certified by an independent
				certified public accountant, reflecting at least (i) all prepayment and other
				payments received for health care services rendered; (ii) expenditures to all
				providers, by classes or groups of providers, and insurance companies or nonprofit
				health service plan corporations engaged to fulfill obligations arising out of the
				health maintenance contract; and (iii) expenditures for capital improvements, or
				additions thereto, including, but not limited to, construction, renovation or
				purchase of facilities and capital equipment;
b. The number of new enrollees enrolled during the
				year, the number of enrollees as of the end of the year and the number of enrollees
				terminated during the year, using the "Health Maintenance Organization County
				Enrollment Worksheet Form" provided by the Insurance Commissioner;
c. A summary of information compiled in such form
				as may be required by the West Virginia department of health and human resources or
				other accredited entity, relating to the cost of the health maintenance
				organization's operations, the pattern of utilization of its services and the
				quality, availability and accessibility of its services;
d. report of the names and residence addresses of
				all persons responsible for the conduct of the health maintenance organization's
				affairs, including all officers of the health maintenance organization, members of
				its board of directors or other governing body, providers and persons owning five
				percent (5%) or more of the health maintenance organization, who were associated
				with the health maintenance organization during the preceding year, and the amount
				of wages, expense reimbursements, or other payments to those individuals for
				services to the health maintenance organization, including a full disclosure of any
				contract or financial arrangement between that person and the health maintenance
				organization during the preceding year; and
e. such other information relating to the health
				maintenance organization as the commissioner may request during review of the
				financial statement.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-46 - Filing Procedures For Health Maintenance Organizations › Section 114-46-5 - Grievance Procedure Annual Report

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1.
				Each health maintenance organization shall file an annual report on its grievance
				procedure, using the AHMO Grievance Report for the Year _A Form provided by the
				Insurance Commissioner to describe its grievance procedure and to report actual
				grievances filed against the health maintenance organization, their disposition and
				their underlying causes.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-46 - Filing Procedures For Health Maintenance Organizations › Section 114-46-6 - Regulation of Marketing

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. After a
				subscriber signs an enrollment application and before the health maintenance
				organization may process the application changing or initiating the subscriber
				coverage, the health maintenance organization must verify the intent and desire of
				the individual to join the health maintenance organization.
a. The verification must be in writing and must be
				conducted by someone outside the health maintenance organization's marketing
				department.
b. Each verification, using
				the Subscriber Verification Form provided by the Insurance Commissioner, shall
				confirm that:
A. The subscriber intends and desires
				to join the health maintenance organization;
B. If the subscriber is a Medicare or Medicaid
				recipient, the subscriber understands that, by joining the health maintenance
				organization, he or she will be limited to the benefits provided by the health
				maintenance organization, and Medicare or Medicaid will pay the health maintenance
				organization for the subscriber coverage;
C. The subscriber understands the applicable
				restrictions of health maintenance organizations, especially that he or she must use
				the health maintenance organization providers and secure approval from the health
				maintenance organization to use health care providers outside the plan;
				and
D. If the subscriber is enrolled as
				a member of a health maintenance organization, the subscriber understands that he or
				she is transferring to another health maintenance organization.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-48 - Life And Health Reinsurance Agreements › Section 114-48-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This rule
				shall apply to all domestic life and accident and sickness insurers and to all other
				licensed life and accident and sickness insurers which are not subject to a
				substantially similar rule in their domiciliary state. This rule shall also
				similarly apply to licensed property and casualty insurers with respect to their
				accident and sickness business. This rule shall not apply to assumption reinsurance,
				yearly renewable term reinsurance or certain nonproportional reinsurance such as
				stop loss or catastrophe reinsurance.
1.2. Authority. -- This rule is issued under the
				authority of W. Va. Code ''33-4-15b(h) and 33-2-10.
1.3. Filing Date. -- May 16, 1997.
1.4. Effective Date. -- May 16, 1997.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-48 - Life And Health Reinsurance Agreements › Section 114-48-2 - Preamble

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. The West Virginia
				Insurance commissioner recognizes that licensed insurers routinely enter into
				reinsurance agreements that yield legitimate relief to the ceding insurer from
				strain to surplus.
2.2. However, it is
				improper for a licensed insurer, in the capacity of ceding insurer, to enter into
				reinsurance agreements for the principal purpose of producing significant surplus
				aid for the ceding insurer, typically on a temporary basis, while not transferring
				all of the significant risks inherent in the business being reinsured. In substance
				or effect, the expected potential liability to the ceding insurer remains basically
				unchanged by the reinsurance transaction, notwithstanding certain risk elements in
				the reinsurance agreement, such as catastrophic mortality or extraordinary survival.
				The terms of such agreements referred to herein and described in section 3 of this
				rule violate:
a. W. Va. Code '33-4-14(a),
				relating to financial statements which do not properly reflect the financial
				condition of the ceding insurer;
b. W.
				Va. Code '33-4-15(c),
				relating to reinsurance reserve credits, thus resulting in a ceding insurer
				improperly reducing liabilities or establishing assets for reinsurance ceded; and
c. W. Va. Code '
				33-10-5(j),
				relating to creating a situation that may be hazardous to policyholders and the
				people of this state.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-48 - Life And Health Reinsurance Agreements › Section 114-48-4 - Written Agreements

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. No reinsurance
				agreement or amendment to any agreement may be used to reduce any liability or to
				establish any asset in any financial statement filed with the commissioner unless
				the agreement, amendment or a binding letter of intent has been duly executed by
				both parties no later than the "as of date" of the financial statement.
4.2. In the case of a letter of intent, a
				reinsurance agreement or an amendment to a reinsurance agreement must be executed
				within a reasonable period of time, not exceeding ninety (90) days from the
				execution date of the letter of intent, in order for credit to be granted for the
				reinsurance ceded.
4.3. The reinsurance
				agreement shall contain provisions which provide that:
a. The agreement shall constitute the entire
				agreement between the parties with respect to the business being reinsured
				thereunder and that there are no understandings between the parties other than as
				expressed in the agreement; and
b. Any
				change or modification to the agreement shall be null and void unless made by
				amendment to the agreement and signed by both parties.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-48 - Life And Health Reinsurance Agreements › Section 114-48-5 - Existing Agreements

Current through Register Vol. XLI, No. 28, July 12, 2024
Insurers subject to this rule shall reduce to zero by December 31,
				  1998 any reserve credits or assets established with respect to reinsurance
				  agreements entered into prior to the effective date of this rule which, under the
				  provisions of this rule would not be entitled to recognition of the reserve credits
				  or assets; provided, however, that the reinsurance agreements shall have been in
				  compliance with laws or rules in existence immediately preceding the effective date
				  of this rule.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-48 - Life And Health Reinsurance Agreements › Section 114-48-6 - Severability

Current through Register Vol. XLI, No. 28, July 12, 2024
If any provision of this rule, or their application to any person
				  or circumstance, is held invalid, that determination shall not affect other
				  provisions or applications of this rule which can be given effect without the
				  invalid provision or application, and to that end the provisions of this rule are
				  separable.
TABLE 114-48A
Product
Risk category
A
B
C
D
E
F
Health Insurance - other than LTC/LTD*
+
0
+
0
0
0
Health Insurance - LTC/LTD*
+
0
+
+
+
0
Immediate Annuities
0
+
0
+
+
0
Single Premium Deferred Annuities
0
0
+
+
+
+
Flexible Premium Deferred Annuities
0
0
+
+
+
+
Guaranteed Interest Contracts
0
0
0
+
+
+
Other Annuity Deposit Business
0
0
+
+
+
+
Single Premium Whole Life
0
+
+
+
+
+
Traditional Non-Par Permanent
0
+
+
+
+
+
Traditional Non-Par Term
0
+
+
0
0
0
Traditional Par Permanent
0
+
+
+
+
+
Traditional Par Term
0
+
+
0
0
0
Adjustable Premium Permanent
0
+
+
+
+
+
Indeterminate Premium Permanent
0
+
+
+
+
+
Universal Life Flexible Premium
0
+
+
+
+
+
Universal Life Fixed Premium
0
+
+
+
+
+
Universal Life Fixed Premium
0
+
+
+
+
+
dump-in premiums allowed
*LTC ' Long Term Care Insurance; LTD ' Long Term Disability
				  Insurance
+ - Significant 0 - Insignificant
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-50 - Emergency Medical Services › Section 114-50-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. The purpose
				of this rule is to set forth requirements for a health maintenance organization's
				provision of emergency medical services to its enrollees.
1.2. Applicability. This rule applies to all
				health maintenance organizations holding a valid certificate of authority granted by
				the commissioner. All health maintenance organization provider contracts for
				emergency medical services to enrollees through a health service intermediary shall
				be subject to 114CSR43.
1.3. Authority.
				-- W. Va. Code '' 33-2-10, 33-25A-7a, 8, 8d, 34.
1.4. Filing Date. -- May 16, 1997.
1.5. Effective Date. -- May 16, 1997.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-50 - Emergency Medical Services › Section 114-50-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
Terms not defined in this rule shall have the meanings given in W.
				  Va. Code '33-25A-1 et
				  seq. As used in this legislative rule:
2.1.
				"Acute Emergency Medical Service" means emergency medical services rendered in
				response to a request by an enrollee or a person acting on behalf of an enrollee,
				through "911," a community dispatcher or otherwise, either with the enrollee's
				permission or without the enrollee's permission if the enrollee is incapacitated,
				where:
a. there has been no precertification or
				preauthorization for the services by the health maintenance organization;
b. the emergency medical services were not
				scheduled in advance; and
c. the person
				making the request for emergency medical services does so in response to what the
				person perceives to be an emergency situation.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-50 - Emergency Medical Services › Section 114-50-3 - Emergency Medical Service Provider Contracts

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. A contract between a health maintenance
				organization and an emergency medical service provider must:
a. List and define duties to be assumed by the
				health maintenance organization and the participating provider,
				respectively;
b. Specify how the health
				maintenance organization will determine whether emergency medical services rendered
				by the participating provider qualify as covered emergency medical
				services;
c. Require the health
				maintenance organization to pay the participating provider in full under terms of
				contract for any valid claim for the covered emergency medical services rendered by
				the participating provider to an enrollee of the health maintenance organization,
				but a valid claim shall not include the amount of any deductible or copayment
				payable by the enrollee;
d. Require the
				participating provider to meet all applicable standards to which the health
				maintenance organization is subject;
e.
				Specify the service area in which the participating provider will provide emergency
				medical services;
f. Require the
				participating provider to maintain records of emergency medical services provided to
				an enrollee of the health maintenance organization;
g. Specify that the health maintenance
				organization, not its enrollee, is liable for covered emergency medical services
				provided to the enrollee and that the participating provider may not collect or
				attempt to collect from an enrollee, by action at law or otherwise, any money for
				covered emergency medical services rendered to the enrollee, other than a deductible
				or copayment payable by the enrollee;
h.
				Require the participating provider to give sixty (60) days advance written notice to
				the health maintenance organization and the commissioner before canceling the
				contract for any reason and specify that the health maintenance organization's
				nonpayment of one or more valid claims is not a valid reason for avoiding the sixty
				(60) day advance notice of cancellation; and
i. Specify that upon the health maintenance
				organization's receipt of a participating provider's sixty (60) day cancellation
				notice, the health maintenance organization may, in its discretion, if requested by
				the participating provider, terminate the contract in less than sixty (60) days if
				the health maintenance organization is not financially impaired or
				insolvent.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-50 - Emergency Medical Services › Section 114-50-4 - Requirements for Emergency Medical Services

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. If a health maintenance organization enters
				into a contract with an emergency medical service provider:
a. The health maintenance organization shall file
				with the commissioner a copy of the executed contract and all exhibits, attachments,
				addenda, schedules or other documents relevant to the contract forty-five (45) days
				after the calendar quarter end next following the execution date of an emergency
				medical service provider contract;
b.
				The health maintenance organization shall report any new or deleted emergency
				medical service providers on the provider list submitted to the commissioner with
				its quarterly financial statement; and
c. A health maintenance organization is
				responsible for compliance by the participating provider with all applicable
				standards required by W. Va. Code '33-25A-1 et
				seq. as to any services performed on behalf of the health maintenance
				organization.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-51 - Utilization Management › Section 114-51-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- The
				purpose of this rule is to set forth standards for utilization management programs
				established as a component of the health maintenance organizations' quality
				assurance programs.
1.2. Authority. --
				W. Va. Code ''33-2-10, 33-25A-4(1)(b), and 33-25A-17a.
1.3. Filing Date. -- May 16, 1997.
1.4. Effective Date. -- May 16, 1997.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-51 - Utilization Management › Section 114-51-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. "Concurrent review"
				means the process of continued reassessment of the medical necessity and
				appropriateness of inpatient care during hospitalization.
2.2. "Criteria" means systematically developed
				statements used to assess the appropriateness of specific health care decisions,
				services and outcomes.
2.3. "Health
				maintenance organization" or "HMO" means a public or private organization which
				provides, or otherwise makes available to enrollees, health care services, including
				at a minimum basic health care services, which:
a.
				Receives premiums for the provision of basic health care services to enrollees on a
				prepaid per capita or prepaid aggregate fixed sum basis, excluding
				copayments;
b. Primarily provides
				physicians' services:
1. Directly through
				physicians who are either employees or partners of the organization;
2. Through arrangements with individual physicians
				or one or more groups of physicians organized on a group practice or individual
				practice arrangement; or
3. Through some
				combination of paragraphs 1 and 2 of this subdivision;
c. Assures the availability, accessibility and
				quality, including appropriate utilization, of the health care services that it
				provides or makes available through clearly identifiable focal points of legal and
				administrative responsibility; and
d.
				Offers services through an organized delivery system, in which a primary care
				physician is designated for each subscriber upon enrollment. The primary care
				physician is responsible for coordinating the health care of the subscriber and is
				responsible for referring the subscriber to other providers when necessary:
				Provided, that when dental care is provided by the health maintenance organization
				the dentist selected by the subscriber from the list provided by the health
				maintenance organization shall coordinate the covered dental care of the subscriber,
				as approved by the primary care physician or the health maintenance
				organization.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-51 - Utilization Management › Section 114-51-3 - Goals of Utilization Management Program

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. The goals of a health maintenance
				organization's utilization management program shall be to:
a. Assure the provision of appropriate medical
				services delivered to members, while simultaneously addressing the effectiveness and
				quality of care;
b. Monitor, evaluate
				and improve the delivery of health care and resource utilization;
c. Provide a systematic process that promotes the
				delivery of medically appropriate care in a timely, effective and efficient manner,
				while maintaining the quality of health care;
d. Continually upgrade monitoring procedures to
				re-evaluate performance goals;
e.
				Monitor utilization practices of provider physicians, hospitals and ancillary
				providers; and
f. Direct members and
				providers toward the goal of quality, cost effective health care.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-51 - Utilization Management › Section 114-51-4 - Requirements of Utilization Management Program

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. A health maintenance organization shall
				develop a utilization management (UM) program which adheres to all applicable state
				and federal laws, federal regulations and state rules.
4.2. Each application for a certificate of
				authority or renewal thereof filed with the commissioner pursuant to the Health
				Maintenance Organization Act, W. Va. Code '
				33-25A-1 et
				seq., shall be accompanied by a description of the health maintenance organization's
				utilization management program, which shall include, but not be limited to, the
				requirements of the utilization management program set forth in this rule.
a. Pursuant to the requirements of W. Va. Code
				'33-25A-3,
				a health maintenance organization shall file notice with the commissioner prior to
				any modification of the utilization management program.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-52 - Diabetes Regulation › Section 114-52-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- The
				purpose of this rule is to set forth the equipment and supplies for the treatment
				and/or management of diabetes which shall be covered by major medical or similar
				comprehensive-type medical coverage if medically necessary and either prescribed by
				a licensed physician or upon written order by a licensed physician.
1.2. Authority. -- W. Va. Code ''33-2-10, 33-15C-1
				and 33-16-16.
1.3. Filing Date. -- May
				16, 1997.
1.4. Effective Date. -- May
				16, 1997.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-52 - Diabetes Regulation › Section 114-52-2 - Insurance Coverage for Diabetics

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. Except as
				provided in W. Va. Code '33-15-6,
				any policy which provides major medical or similar comprehensive-type medical
				coverage shall include coverage for the following equipment and supplies for the
				treatment and/or management of diabetes for both insulin dependent and noninsulin
				dependent persons with diabetes and those with gestational diabetes, if medically
				necessary because of the diabetic condition and either prescribed by a licensed
				physician or upon written order by a licensed physician:
a. Urine ketone testing strips;
b. Urine microalbumin test;
c. Blood pressure monitoring device;
d. Podiatric appliances and therapeutic footwear;
				and
e. Orthopedic appliances including
				canes, crutches and walkers.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-53 - Quality Assurance › Section 114-53-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- The
				purpose of this rule is to set forth standards for quality assurance programs
				established as a component of a health maintenance organization's overall
				structure.
1.2. Authority. -- W. Va.
				Code §§
									33-2-10,
				33-25A-4(1)(b),
				and 33-25A-17a.
1.3. Filing Date. --
				April 3, 2003.
1.4. Effective Date. --
				April 3, 2003.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-53 - Quality Assurance › Section 114-53-3 - Goals of a Quality Assurance Program

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. The
				goals of a health maintenance organization's quality assurance program shall be to:
a. Assure the provision of appropriate medical
				services delivered to members, while simultaneously addressing the effectiveness of
				quality of care;
b. Monitor, evaluate
				and improve the quality of health care;
c. Provide a systematic process that promotes the
				delivery of medically appropriate care in a timely, effective and efficient manner,
				while maintaining the quality of health care;
d. Direct members and providers toward the goal of
				quality, cost effective health care.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-53 - Quality Assurance › Section 114-53-4 - Requirements of a Quality Assurance Program

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. A health maintenance organization shall
				develop a quality assurance program which adheres to all applicable state and
				federal laws, federal regulations and state rules.
a. A health maintenance organization that has
				obtained full accreditation or equal status from a nationally recognized
				accreditation and review organization approved by the commissioner pursuant to W.
				Va. Code §
										33-25A-17a is deemed
				to be in compliance with this rule. If, at any time subsequent to the granting of
				full accreditation or equal status by a nationally recognized accreditation and
				review organization, the commissioner determines that the quality assurance program
				of the health maintenance organization has become deficient in any significant area,
				the commissioner, in addition to other remedies available, may establish a
				corrective action plan that the HMO must follow as a condition to the issuance or
				maintenance of a certificate of authority.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-53 - Quality Assurance › Section 114-53-5 - Quality Management & Improvement

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1.
				Organizational arrangements and responsibilities for quality management and
				improvement processes shall be clearly defined and assigned to appropriate
				individuals.
a. There shall be a detailed written
				description of the program which shall be reviewed annually and updated as
				necessary.
b. A senior executive shall
				be responsible for program implementation.
c. A medical director shall be employed by the
				health maintenance organization and have substantial involvement in quality
				improvement activities.
1. Upon application to and
				approval by the commissioner, a health maintenance organization may employ a medical
				director on a part-time basis during the first two years of the HMO's
				operation.
2. All health maintenance
				organizations are required to employ a full-time medical director no later than the
				first day of the third year of the HMO's operation.
d. A committee shall be created to oversee quality
				improvement and shall include HMO providers as active participants. The committee
				shall keep contemporaneous written records reflecting all of its actions.
e. The role, structure and function, including
				frequency of meetings, of the quality improvement committee shall be specified in
				the program description.
f. Adequate
				resources including, but not limited to, personnel, analytic capabilities and data
				resources shall be dedicated to meet program needs.
g. A written quality improvement work plan shall
				be prepared annually and shall include: the objectives, scope and planned projects
				or activities for the year; planned monitoring of previously identified issues,
				including tracking of issues over time; and planned evaluation of the quality
				improvement program.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-53 - Quality Assurance › Section 114-53-6 - Credentialing & Recredentialing

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. A
				health maintenance organization shall ensure that its network has sufficient numbers
				and types of providers. The HMO shall have a written access plan outlining its
				strategy for maintaining an adequate network and shall implement mechanisms designed
				to assure the availability of primary care and specialty practitioners.
6.2. A health maintenance organization shall have
				written policies and procedures for the credentialing of all providers that include
				the original credentialing, recredentialing, recertification and or reappointment of
				physicians and other licensed independent practitioners who fall under its scope of
				authority and action.
a. The governing body, or
				the group or individual to whom the governing body has formally delegated the
				credentialing function, shall review and approve credentialing policies and
				procedures.
b. A credentialing committee
				or other peer review body shall be established to make recommendations regarding
				credentialing decisions. The committee shall include providers, including but not
				limited to physicians, as voting members.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-53 - Quality Assurance › Section 114-53-7 - Members' Rights & Responsibilities

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1.
				An HMO shall demonstrate a commitment to treating members with respect by developing
				written policies giving them the right to:
a.
				Voice grievances about the HMO or care provided;
b. Have information concerning the HMO, its
				services, the practitioners providing care and members' rights and
				responsibilities;
c. Participate in
				decision-making regarding health care; and
d. Be treated with respect and recognition of
				their dignity and need for privacy.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-53 - Quality Assurance › Section 114-53-8 - Preventive Health Services

Current through Register Vol. XLI, No. 28, July 12, 2024
8.1. A health
				maintenance organization shall adopt guidelines for the use of preventive health
				services which must be based on reasonable medical evidence and the full service
				population. The guidelines shall be developed or adopted with the participation of
				the HMO's providers and must include a mechanism for periodic updates.
a. The guidelines and all updates shall be
				provided in writing to all providers and members.
b. The guidelines shall consist of the following
				categories:
1. Prenatal and perinatal
				care;
2. Preventive care for infants up
				to 24 months;
3. Preventive care for
				children and adolescents aged two through 19 years old;
4. Preventive care for adults aged 20 through 64
				years old; and
5. Preventive care for
				those aged 65 and older.
c.
				Each guideline shall describe the prevention or early detection interventions and
				the recommended frequency and conditions under which the interventions are required.
				The health maintenance organization shall document the scientific basis or authority
				upon which it based the preventive health guidelines.
d. Providers from the health maintenance
				organization who have appropriate knowledge shall be involved in the adoption of the
				preventive health guidelines.
e. At
				least annually, an HMO shall monitor, evaluate and take action upon a minimum of two
				of the following preventive services and take action to improve the use of
				preventive services as appropriate:
1. Childhood
				immunizations recognized by the American Academy of Pediatrics or as required by
				state or federal law;
2. Adult
				immunizations including influenza vaccine, pneumococcal vaccine, Hepatitis B
				vaccine, diphtheria and tetanus toxoid, rubella screening for women of childbearing
				age or any other immunization required by state or federal law;
3. Coronary artery disease risk factor screening
				and/or counseling for smoking, cholesterol, exercise and hypertension;
4. Breast and cervical cancer screening;
5. Counseling for prevention of motor vehicle
				injury;
6. Lead toxicity
				screening;
7. Sexually transmitted
				disease screening/prevention;
8.
				Prenatal care;
9. HIV/Aids counseling,
				screening and education;
10. Prevention
				of unintended pregnancy;
11. Alcohol and
				drug abuse screening/prevention; and
12.
				Any other preventive services deemed appropriate by the commissioner and any other
				state or federal regulatory authorities.
f. Preventive health service studies shall be
				enrollee population-based, measuring compliance as it relates to the total at-risk
				population.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-53 - Quality Assurance › Section 114-53-9 - Medical Records

Current through Register Vol. XLI, No. 28, July 12, 2024
9.1. A health
				maintenance organization shall require all of its providers to have an organized
				medical recordkeeping system. Medical records shall be maintained in a manner that
				is current, detailed, organized and permits effective patient care and quality
				review. Records shall also reflect all aspects of patient care including ancillary
				services.
a. An HMO shall set forth in writing
				appropriate standards for medical records, the systematic review for conformance and
				the institution of corrective action when standards are not met. Copies of all
				standards and goals and any updates shall be provided to all
				providers
.
b. Records shall
				be available to health care practitioners at each patient visit and to nationally
				and state recognized reviewing bodies sanctioned by the commissioner.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-53 - Quality Assurance › Section 114-53-10 - Severability

Current through Register Vol. XLI, No. 28, July 12, 2024
10.1. This rule is
				subject to the anti-discrimination provisions of W.Va. Code §
									33-25A-31.
10.2. If any provision of this rule or the
				application of this rule to any person or circumstances is for any reason held to be
				invalid, the remainder of the rule and the application of the provisions to other
				persons or circumstances shall not be affected by the holding.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-54 - Group Accident And Sickness Insurance Issuance, Portability And marketing Requirements › Section 114-54-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope and
				applicability. -- This rule applies to health benefit plans issued in connection
				with a group health plan by insurance companies; fraternal benefit societies;
				hospital, medical, dental and health service corporations and health care
				corporations; and health maintenance organizations, and delivered or issued for
				delivery in this state on and after the effective date hereof for group health plan
				years beginning after June 30, 1997, or as otherwise provided in this rule. This
				rule does not apply to:
a. Individual policies or
				contracts issued pursuant to a conversion privilege under a policy or contract of
				group insurance;
b. Individual policies
				or contracts issued to eligible individuals, as defined in W. Va. Code
				'33-15-2a(e);
c. A health benefit plan for any group health plan
				year if, on the first day of the group health plan year, the group health plan has
				fewer than two participants who are current employees;
d. Coverage under the West Virginia Public
				Employees Insurance Act (W. Va. Code '5-16-1
				et seq.): Provided, That this rule applies to a health benefit plan issued by a
				health insurer to provide medical care under the West Virginia Public Employees
				Insurance Act;
e. Coverage under
				Medicare or Medicaid: Provided, That this rule applies to a health benefit plan
				issued by a health insurer to provide medical care under Medicare or
				Medicaid;
f. Coverage that consists
				solely of excepted benefits;
g. Coverage
				under health benefit plans issued to or through bona fide associations, if such
				coverage is not related to a group health plan;
h. Accident and sickness insurance contracts
				covering members of fraternal benefit societies organized pursuant to West Virginia
				Code ''33-23-1 et seq., if not issued in connection with a group health
				plan;
i. Credit accident and sickness
				insurance subject to WV 114CSR6 "Regulation of Credit Life Insurance and Credit
				Accident and Sickness Insurance;"
j.
				Medicare supplement insurance policies subject to WV 114CSR24 "Medicare Supplement
				Insurance;"
k. Long-term care insurance
				policies subject to WV 114CSR32 "Long-Term Care Insurance;"
l. Individual limited benefits policies subject to
				the requirements of W. Va. Code '33-16E-1 et seq.
The requirements contained in this rule are in addition to WV
				  114CSR39 "Group Accident and Sickness Insurance Minimum Policy Coverage Standards"
				  and any other applicable rules previously adopted.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-54 - Group Accident And Sickness Insurance Issuance, Portability And marketing Requirements › Section 114-54-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
As used in this legislative rule:
2.1. "Affiliation period" means, with respect to a
				health maintenance organization, a period that begins on an individual's enrollment
				date, runs concurrently with any waiting period under the group health plan, expires
				before coverage is effective and during which the health maintenance organization
				need not provide medical care and may not charge any premium to the
				individual.
2.2. "Bona fide association"
				means an association which:
a. has been organized
				in good faith for purposes other than that of obtaining or providing
				insurance;
b. has a minimum of one
				hundred members;
c. has been actively in
				existence for at least five years;
d.
				has a constitution and bylaws providing that:
1.
				the association holds annual meetings to further purposes of its members;
2. except in the case of credit unions, the
				association collects dues or solicits contributions from members; and
3. the members have voting privileges and
				representation on the governing board and committees that exist under the authority
				of the association;
e. does
				not condition membership in the association on any health status-related factor
				relating to an individual;
f. makes
				accident and sickness insurance offered through the association available to all
				members regardless of any health status-related factor relating to members or
				individuals eligible for coverage through a member;
g. does not make accident and sickness insurance
				coverage offered through the association available other than in connection with a
				member of the association; and
h. meets
				any additional requirements as may be set forth in chapter thirty-three of the West
				Virginia Code or by rule.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-54 - Group Accident And Sickness Insurance Issuance, Portability And marketing Requirements › Section 114-54-3 - Limitations on Preexisting Condition Exclusion Period

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. Subject to subsection 3.2 of this rule, a
				health insurer may impose a preexisting condition exclusion with respect to an
				individual covered under a health benefit plan only if medical advice, diagnosis,
				care or treatment for the condition was recommended or received within the six-month
				period which began on the six-month anniversary date preceding the individual's
				enrollment date and ends on the enrollment date.
a. Medical advice, diagnosis, care or treatment is
				taken into account only if it is recommended by, or received from, a medical care
				provider.
b. Genetic information is not
				a preexisting condition unless a condition related to the information has been
				diagnosed.
c. Pregnancy may not be
				excluded from coverage as a preexisting condition.