reglab/statecodes huggingface dataset:
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-27 - AIDS Regulations › Section 114-27-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This
				legislative rule establishes standards for AIDS-related underwriting questions
				and AIDS testing in connection with applications for life or health insurance
				policies.
1.2. Authority. -- W. Va.
				Code §§
									33-2-10 and 16-3C-2.
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,
				2029.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-27 - AIDS Regulations › Section 114-27-2 - Applicability

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. Insurers --
				All insurers who deliver or issue for delivery in this state any policies for
				life or accident and sickness insurance are subject to this
				regulation.
2.2. Service
				Corporations -- All health service corporations who deliver or issue for
				delivery in this state any subscriber`s contracts for health insurance are
				subject to this regulation.
2.3.
				Health Care Corporations -- All health care corporations who issue to enrollees
				in this state evidence of health insurance coverage are subject to this
				regulation.
2.4. Fraternal Benefit
				Societies:
a. All fraternal benefit societies
				who deliver or issue for delivery life insurance benefit certificates in this
				state are subject to this regulation.
b. All domestic, foreign, or alien societies
				who issue any certificate or other evidence of any contract of accident or
				sickness insurance in this state are subject to this
				regulation.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-27 - AIDS Regulations › Section 114-27-3 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. Code -- means
				the West Virginia Code.
3.2.
				Commissioner -- means the Insurance Commissioner of the state of West
				Virginia.
3.3. Acquired
				Immunodeficiency Syndrome (AIDS) -- means the acquired immunodeficiency
				syndrome as may be from time to time defined by the Centers for Disease Control
				of the United States Public Health Service.
3.4. AIDS Related Complex (ARC) -- means a
				syndrome in which the individual displays many of the same symptoms of AIDS,
				including the presence of the HIV antibody.
3.5. Human Immunodeficiency Virus (HIV) means
				the virus responsible for the potential development of the Acquired
				Immunodeficiency Syndrome (AIDS).
3.6. Enzyme Linked Immunosorbent Assay
				(ELISA) -- means a test which has been licensed by the FDA and is used to
				determine the existence of the HIV antibody.
3.7. Insurer -- includes all entities
				providing life or accident and sickness coverage.
3.8. Western Blot -- means a test which has
				been licensed by the FDA and is used to determine the existence of the HIV
				antibody.
3.9. Health Care
				Professional or Health Care Provider -- means any physician, nurse, physician's
				assistant, or any other person providing medical, dental, nursing or other
				health care services of any kind.
3.10. FDA -- means the United States Food and
				Drug Administration.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-27 - AIDS Regulations › Section 114-27-4 - Medical/Lifestyle Applications Questions and Underwriting Guidelines

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. General
				Propositions:
a. No inquiry in an application
				for health accident and sickness or life insurance coverage, or in an
				investigation conducted by an insurer or an insurance support organization on
				its behalf in connection with an application for such coverage shall be
				directed toward determining the proposed insured's sexual
				orientation.
b. Sexual orientation
				may not be used in the underwriting process or in the determination of
				insurability.
c. Insurance support
				organizations shall be directed by insurers not to investigate, directly or
				indirectly, the sexual orientation of a proposed insured or
				beneficiary.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-27 - AIDS Regulations › Section 114-27-5 - Testing

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. AIDS- related
				testing in connection with the application for group life or accident and
				sickness insurance is prohibited; provided that an insurer may conduct such
				testing in relation to the application for group life and accident and sickness
				insurance when the insurance applied for is individually underwritten and
				evidence of insurability is required by the insurer because the proposed
				insured is either a late entrant, is applying for supplemental group life
				coverage, or is applying for small group insurance where the group consists of
				less than twenty-five members.
5.2.
				Whenever a proposed insured is requested to take an AIDS-related test in
				connection with an application for insurance, the use of such a test must be
				revealed to the proposed insured and his or her written, informed consent
				obtained.
5.3. The proposed insured
				should demonstrate an understanding that the test is being performed, of the
				nature of the test, of the persons to whom the results of that test may be
				disclosed, of the purpose for which test results may be used, of any
				limitations on the accuracy and meaning of the test results, and of any
				foreseeable risks and benefits resulting from the test.
5.4. The person requesting the test, and not
				the individual or individual's health care provider, must underwrite the cost
				of the test.
5.5. The individual
				undergoing the test has a choice to receive the test result directly or to
				designate in writing, prior to the administration of the test, any other
				person, such as a health care professional or clergyman, who may receive the
				results.
5.6. The testing must be
				performed by an individual who is properly trained in the administration of the
				test; holds an appropriate medical license, if state or federal law requires
				licensure in order to perform the testing procedure; and is properly supervised
				in accordance with state and federal law and FDA approval
				requirements.
5.7. The insurer and
				its agents shall not release or disclose either that a HIV test has been
				conducted or the test results to any other party except under the following
				limited circumstances:
a. Negative test
				results only may be disclosed to a reinsurer where either:
1. The reinsurer is to reinsure a portion of
				the risk on a facultative basis; or
2. The reinsurer is to reinsure a portion of
				a block of business on a treaty basis and where the release of HIV test
				information is disclosed by the ceding insurer only to the extent that the
				reinsurer is permitted to perform limited underwriting audits of the ceding
				insurer's underwriting files to verify that proper HIV underwriting has
				occurred.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-27 - AIDS Regulations › Section 114-27-6 - Notice and Consent Form

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1.
				A notice and consent form must be executed by each proposed insured before
				AIDS-related testing is performed as to such proposed insured on behalf of any
				insurer.
6.2. The notice and
				consent form required by subsection 6.1 shall be as is set out in Appendix A
				attached hereto unless an alternative form is approved by the commissioner in
				writing.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-27A - AIDS Regulations › Section 114-27A-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- Series 27
				of the Insurance Commissioner's rules, 114CSR27, establishes the standards for AIDS
				related underwriting health and lifestyle questions and AIDS testing in connection
				with applications for life or health insurance policies. This interpretive rule sets
				forth an additional protocol which the underwriter and the proposed insured may
				agree to use in lieu of the protocol established in 114CSR27, §5. This
				additional protocol allows the use of urine specimens as the exclusive method for
				HIV testing in connection with applications for life or health insurance policies,
				as an alternative to the use of blood or oral specimens.
1.2. Authority. -- W. Va. Code §§
									33-2-10 and
				16-3C-2(j).
1.3. Filing Date. -- August 2, 2002.
1.4. Effective Date. -- September 1,
				2002.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-27A - AIDS Regulations › Section 114-27A-2 - Interpretive Note

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. Technology has
				advanced in recent years with regard to HIV testing, and since promulgation of the
				AIDS Regulation, 114CSR27 §1, et seq., the U.S. Food and Drug Administration
				has approved the use of urine specimens to determine the presence of HIV. This
				interpretive rule shall be read in pari materia with the AIDS Regulations (114CSR27,
				§1, et seq.) previously promulgated by the Insurance Commissioner pursuant to
				authority granted by the Legislature in W. Va. Code §§ 33-2-35 and
				16-3C-2(j).
				The definitions, applicability provisions and all other provisions provided in
				114CSR27, §1, et seq. are equally applicable to this interpretive rule, with
				the exception of the provisions in 114CSR27, subsections 5.9 and 5.10, to the extent
				they are inconsistent with this interpretive rule. Appendix B and Appendix C to
				114CSR27 are also applicable to this interpretive rule. Appendix A, attached hereto,
				has been modified slightly to reflect that any abnormalities, not just blood
				abnormalities, will adversely affect an application for insurance, consistent with
				the allowance of an alternative testing protocol to blood tests as set forth in this
				interpretive rule.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-27A - AIDS Regulations › Section 114-27A-3 - Allowance of FDA Approved Urine HIV Tests

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1.
				Any HIV Testing that is authorized by section 5 of the AIDS Regulations, 114CSR27,
				§5, or this rule, is required to be administered on a nondiscriminatory basis
				for all individuals in the same underwriting class. No proposed insured may be
				denied coverage or rated a substandard risk on the basis of HIV testing unless an
				acceptable testing protocol is followed, including the use of FDA-licensed tests. In
				lieu of the HIV protocol established in 114CSR27, §5, the Insurance
				Commissioner will allow underwriters and a proposed insured to agree to use the
				following protocol:
a. An initial enzyme linked
				immunosorbent assay (ELISA) test is administered to the proposed insured, and it
				indicates the presence of HIV antibodies; and
b. A second ELISA test is administered and it
				indicates the presence of HIV antibodies; and
c. A Western Blot test is conducted and it
				confirms the results of the two ELISA tests.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-27A - AIDS Regulations › Section 114-27A-4 - Compliance with Protocol established in Interpretive Rule

Current through Register Vol. XLI, No. 28, July 12, 2024
An underwriter who follows the protocol established in section 3
				  of this interpretive rule will not be found by the Insurance Commissioner to be in
				  violation of legislative rule 114CSR27, §5 for not following the protocol
				  established in section 5 of that rule.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-27A - AIDS Regulations › Section 114-27A-5 - Sunset Date

Current through Register Vol. XLI, No. 28, July 12, 2024
The Insurance Commissioner has proposed an amendment to
				  legislative rule 114CSR27 that replaces the existing HIV protocol in section 5 with
				  the protocol in section 3 of this interpretive rule, and makes a minor change to
				  Appendix A to the rule. This interpretive rule shall terminate and be of no further
				  effect on the day the Insurance Commissioner's proposed amended legislative rule,
				  114CRS27, takes effect following its authorization by the
				  Legislature.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-28 - Coordination Of Health Benefits › Section 114-28-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This rule
				is applicable to every insurance contract which provides health care benefits and
				which is issued on or after January 21, 2011. Insurance contracts which provide
				health care benefits and which were issued before January 21, 2011 shall be brought
				into compliance by the later of the next anniversary date or renewal date of the
				contract or the expiration of any applicable collectively bargained contract
				pursuant to which it was written. This rule is based on the "Coordination of
				Benefits Model Regulation (Model 120)" adopted by the National Association of
				Insurance Commissioners, as amended in 2005.
1.2. Authority. -- W. Va. Code §§
									33-2-10,
1.3. Filing Date. -- April 14, 2010.
1.4. Effective Date. -- April 14, 2010.
1.5. Purpose. -- The purpose of this rule is to:
1.5.a. Establish a uniform order of benefit
				determination under which plans pay claims;
1.5.b. Reduce duplication of benefits by
				permitting a reduction of the benefits paid by a plan that, pursuant to this rule,
				does not have to pay its benefits first; and
1.5.c. Provide greater efficiency in the
				processing of claims when a person is covered under more than one plan.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-28 - Coordination Of Health Benefits › Section 114-28-3 - Model COB Contract Provision

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. Appendix A
				contains a model COB provision for use in contracts. That use is subject to the
				provisions of subsections 3.2, 3.3 and 3.4 of this section and to the provisions of
				Section 5 of this rule.
3.2. Appendix B
				is a plain language description of the COB process that explains to the covered
				person how health plans will implement coordination of benefits. It is not intended
				to replace or change the provisions that are set forth in the contract. Its purpose
				is to explain the process by which the two (2) or more plans will pay for or provide
				benefits.
3.3. The COB provision
				contained in Appendix A and the plain language explanation in Appendix B do not have
				to use the specific words and format shown in Appendix A or Appendix B. Changes may
				be made to fit the language and style of the rest of the group contract or to
				reflect the difference among plans which provide services, which pay benefits for
				expenses incurred, and which indemnify. No other substantive changes are
				allowed.
3.4. A COB provision may not be
				used that permits a plan to reduce its benefits on the basis that:
3.4.a. Another plan exists and the covered person
				did not enroll in that plan;
3.4.b. A
				person is or could have been covered under another plan, except with respect to Part
				B of Medicare; or
3.4.c. A person has
				elected an option under another plan providing a lower level of benefits than
				another option which could have been elected.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-28 - Coordination Of Health Benefits › Section 114-28-4 - Rules for Coordination of Benefits

Current through Register Vol. XLI, No. 28, July 12, 2024
When a person is covered by two (2) or more plans, the rules for
				  determining the order of benefit payments are as follows:
4.1.
4.1.a. The
				Primary Plan must pay or provide its benefits as if the Secondary Plan or Plans did
				not exist. .
4.1.b. If the Primary Plan
				is a closed panel plan and the Secondary Plan is not a closed planel plan, the
				Secondary Plan shall pay or provide benefits as if it were the Primary Plan when a
				covered person uses a non-panel provider, except for emergency services or
				authorized referrals that are paid or provided by the primary plan.
4.1.c. When multiple contracts providing
				coordinated coverage are treated as a single plan under this rule, this section
				applies only to the plan as a whole, and coordination among the component contracts
				is governed by the terms of the contracts. If more than one carrier pays or provides
				benefits under the plan, the carrier designated as primary within the plan shall be
				responsible for the plan's compliance with this rule.
4.1.d. If a person is covered by more than one
				secondary plan, the order of benefit determination rules of this rule decide the
				order in which secondary plans benefits are determined in relation to each other.
				Each secondary plan shall take into consideration the benefits of the primary plan
				or plans and the benefits of any other plan, which, under the rules of this rule,
				has its benefits determined before those of that secondary plan.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-28 - Coordination Of Health Benefits › Section 114-28-5 - Procedure to be Followed by Secondary Plan to Calculate Benefits and Pay a Claim

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. In determining the
				amount to be paid by the secondary plan on a claim, should the plan wish to
				coordinate benefits, the secondary plan shall calculate the benefits it would have
				paid on the claim in the absence of other health care coverage and apply that
				calculated amount to any allowable expense under its plan that is unpaid by the
				primary plan. The secondary plan may reduce its payment by the amount so that, when
				combined with the amount paid by the primary plan, the total benefits paid or
				provided by all plans for the claim do not exceed one-hundred percent (100%) of the
				total allowable expense for that claim. In addition, the secondary plan shall credit
				to its plan deductible any amounts it would have credited to its deductible in the
				absence of other health care coverage.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-28 - Coordination Of Health Benefits › Section 114-28-6 - Notice to Covered Persons

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. A plan shall in
				its explanation of benefits provided to covered persons, include the following
				language: "If you are covered by more than one health benefit plan, you should file
				all your claims with each plan." Upon request of a plan, the Commissioner may
				approve an alternative method of communicating this notice to covered
				persons.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-28 - Coordination Of Health Benefits › Section 114-28-7 - Miscellaneous Provisions

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. A Secondary
				Plan that provides benefits in the form of services may recover the reasonable cash
				value of the services from the Primary Plan, to the extent that benefits for the
				services are covered by the Primary Plan and have not already been paid or provided
				by the Primary Plan. Nothing in this provision shall be interpreted to require a
				plan to reimburse a covered person in cash for the value of services provided by a
				plan which provides benefits in the form of services.
7.2.
7.2.a. A
				plan with order of benefit determination rules that comply with this rule (Complying
				Plan) may coordinate its benefits with a plan that is "excess" or "always secondary"
				or that uses order of benefit determination rules that are inconsistent with those
				contained in this rule (Noncomplying Plan) on the following basis:
7.2.a.1. If the Complying Plan is the Primary
				Plan, it shall pay or provide its benefits first;
7.2.a.2. If the Complying Plan is the Secondary
				Plan, it shall pay or provide its benefits first, but the amount of the benefits
				payable shall be determined as if the Complying Plan were the Secondary Plan. In
				such a situation, the payment shall be the limit of the Complying Plan's liability;
				and
7.2.a.3. If the Noncomplying Plan
				does not provide the information needed by the Complying Plan to determine its
				benefits within a reasonable time after it is requested to do so, the Complying Plan
				shall assume that the benefits of the Noncomplying Plan are identical to its own,
				and shall pay its benefits accordingly. If, within two (2) years of payment, the
				complying plan receives information as to the actual benefits of the non-complying
				plan, it shall adjust payments accordingly.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-29 - Health Insurance Benefits For Temporomandibular And Craniomandibular Disorders › Section 114-29-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This
				legislative rule establishes requirements and standards for accident and sickness
				insurance coverage of temporomandibular disorder (TMD) and craniomandibular disorder
				(CMD).
1.2. Authority. -- W. Va. Code
				''33-2-10, 33-6-8, 33-6-9, 33-23-24, 33-24-6, 33-25-11, 33-25A-3(1), 33-25A-20, and
				33-16-3f(b).
1.3. Filing Date. -- May
				31, 1991
1.4. Effective Date. -- May 31,
				1991
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-29 - Health Insurance Benefits For Temporomandibular And Craniomandibular Disorders › Section 114-29-2 - Applicability

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. Insurers. -- All
				insurers who deliver or issue for delivery in this state any policies for accident
				and sickness insurance are subject to this rule.
2.2. Service Corporations. -- All health service
				corporations who deliver or issue for delivery in this state any subscriber's
				contracts for accident and sickness insurance are subject to this rule.
2.3. Health Care Corporations. -- All health care
				corporations who deliver or who issue for delivery to enrollees in this state
				evidence of accident and sickness insurance coverage are subject to this
				rule.
2.4. Fraternal Benefit Societies:
2.4.1. All fraternal benefit societies who deliver
				or issue for delivery accident and sickness insurance benefit certificates, or other
				evidence of coverage in this state, are subject to this rule.
2.4.2. All domestic, foreign, or alien societies
				who issue any certificate or other evidence of any contract of accident or sickness
				insurance in this state are subject to this rule.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-29 - Health Insurance Benefits For Temporomandibular And Craniomandibular Disorders › Section 114-29-3 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. Temporomandibular
				Disorder(s) (TMD) -- means a group of musculoskeletal conditions, often overlapping,
				that involve the temporomandibular joint (TMJ) or joints, the masticatory
				musculature, or both. These conditions are typically characterized by pain in the
				preauricular area which is usually aggravated by chewing or jaw function, and are
				frequently accompanied, either singly or in combination, by limitation of jaw
				movement, joint sounds, palpable muscle tenderness or joint soreness. Although pain
				and dysfunction in the orofacial or craniofacial regions have multiple sources and
				etiologies that may coexist with temporomandibular disorders or show signs similar
				to those of temporomandibular disorders, temporomandibular disorders are limited to
				pain and dysfunction arising in and from the masticatory musculoskeletal
				system.
3.2. Craniomandibular
				Disorder(s) (CMD) -- means problems of the stomatognathic system and include
				disorders of the temporomandibular joint, muscles of mastication and the related
				occlusion.
3.3. Commissioner -- means
				the West Virginia Insurance Commissioner.
3.4. PEIA -- means the West Virginia Public
				Employees Insurance Agency.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-29 - Health Insurance Benefits For Temporomandibular And Craniomandibular Disorders › Section 114-29-4 - Mandatory Coverage

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. All accident
				and sickness coverage which provides hospital, surgical, or major medical coverage
				or any combination of those coverages and which is offered by any of the entities
				set out in Section 2 of this rule shall provide benefits for the diagnosis and
				treatment of temporomandibular disorders (TMD) and craniomandibular disorders (CMD).
				This applies to both renewed coverage and new coverage. This requirement shall not
				apply to insurance policies or other forms of coverage which provide benefits only
				for specific illnesses such as "cancer policies" or "intensive care policies."
4.1.1. An insured shall be given the option of
				declining coverage for temporomandibular disorders (TMD) and craniomandibular
				disorders (CMD) and the insurer must provide an appropriate waiver form or
				incorporate such waiver form into the insurance policy or other evidence of
				coverage.
4.1.1.1. Such waiver form must clearly
				indicate that the prospective insured understands that coverage is available for
				temporomandibular disorders (TMD) and craniomandibular disorders (CMD), but that the
				insured does not desire such coverage; all of which shall be witnessed by the
				signature of the insured and the date signed.
4.1.1.2. Such waiver form shall be subject to the
				prior approval of the Commissioner.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-29 - Health Insurance Benefits For Temporomandibular And Craniomandibular Disorders › Section 114-29-5 - Procedures Covered

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. The insurance
				coverage required by this rule shall at a minimum include benefits for the following
				procedures:
5.1.1. Health history (medical and/or
				dental) pertinent to symptoms;
5.1.2.
				Clinical examination related to the presenting symptoms;
5.1.3. Imaging procedures; provided, that
				radiographs must be diagnostic for temporomandibular disorders (TMD) and/or
				craniomandibular disorders (CMD);
5.1.4.
				Conventional diagnostic and therapeutic injections;
5.1.5. Temporary orthotics; provided that splints
				or appliances may be limited to one every three (3) years, and that all adjustments
				to the appliance performed during the first six (6) months of its installation are
				considered part of the total appliance fee. Those appliances designed for
				orthodontic purposes such as bionators, functional regulators, Frankel devices, and
				similar devices are not covered;
5.1.6.
				Physical medicine and physiotherapy which shall include:
5.1.6.1. Ultrasound
5.1.6.2. Diathermy
5.1.6.3. High Voltage Galvanic
				Stimulation
5.1.6.4. Transcutaneous
				Nerve Stimulation.
5.1.7.
				Surgery on the Temporomandibular Joint which includes, but is not limited to,
				arthotomy and diagnostic arthroscopy.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-29 - Health Insurance Benefits For Temporomandibular And Craniomandibular Disorders › Section 114-29-6 - Rate and Form Filings

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. Entities
				subject to this rule shall file with the Commissioner such amended or new
				contractual or other forms as are necessary to accomplish the requirement of this
				rule by August 1, 1990, and may file appropriately adjusted premium rates consistent
				with any increased or decreased risk associated with the coverage of
				temporomandibular disorders (TMD) and craniomandibular disorders (CMD).
6.1.1. Premiums shall be structured so as to
				provide appropriate premiums as to both insureds who retain coverage for
				temporomandibular disorders (TMD) and craniomandibular disorders (CMD) and those
				insureds who exercise their option to waive such coverage.
6.1.2. All premium rates and forms filed due to
				this rule shall be filed in accordance with West Virginia Insurance Commissioner
				Administrative Regulations, Series 26 -- Accident and Sickness Rate Filing, and
				shall be subject to the prior approval of the Commissioner before they become
				effective. This section shall not apply to group accident and health insurance plans
				upon which premiums are negotiated with the individual policyholder and are based on
				the historic and projected loss experience of the group to be insured.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-29 - Health Insurance Benefits For Temporomandibular And Craniomandibular Disorders › Section 114-29-7 - Separability

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. If any provision of
				this regulation or the application thereof to any person or circumstance is for any
				reason held to be invalid, the remainder of the regulation and the application
				thereof to other persons or circumstances shall not be affected thereby.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-30 - "Tail" Malpractice Insurance Covering Certain Medical And Allied Health Care Providers › Section 114-30-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This
				legislative rule provides for premium payment amortization, under certain
				circumstances specified in the rule, for "tail" professional malpractice insurance
				covering medical physicians, osteopathic physicians, podiatrists, chiropractors,
				dentists, midwives nurse practitioners and hospitals.
1.2. Authority. -- W. Va. Code §§
									33-20D-4,
				33-2-10.
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 114-30 - "Tail" Malpractice Insurance Covering Certain Medical And Allied Health Care Providers › Section 114-30-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
As used in this legislative rule:
2.1. "'Claims made' malpractice insurance" means a
				policy which covers claims which are reported during the policy period, meet the
				provisions specified by the policy, and are for an incident which occurred during
				the policy period, or occurred prior to the policy period, as is specified by the
				policy.
2.2. "Commissioner" means the
				Insurance Commissioner of the State of West Virginia.
2.3. "'Tail' insurance" means insurance which
				covers a professional insured once a "claims made" malpractice insurance policy is
				cancelled, not renewed or terminated and covers claims made after such cancellation
				or termination for acts occurring during the period the prior malpractice insurance
				was in effect.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-30 - "Tail" Malpractice Insurance Covering Certain Medical And Allied Health Care Providers › Section 114-30-3 - Applicability

Current through Register Vol. XLI, No. 28, July 12, 2024
This rule applies to premium payment amortization for "tail"
				  malpractice insurance offered to the medical and allied health care providers
				  enumerated in subsection 1.1 herein whose prior "claims made" malpractice insurance
				  policy had been in effect for at least sixty (60) days: Provided, That each
				  quarterly amortized premium paid pursuant to this rule shall not be less than seven
				  hundred fifty dollars ($750.00).
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-30 - "Tail" Malpractice Insurance Covering Certain Medical And Allied Health Care Providers › Section 114-30-4 - "Tail" Insurance Offer Mandated

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. Upon
				cancellation, nonrenewal or termination of any "claims made" professional
				malpractice insurance policy to which this rule is applicable as set forth in
				section 3 herein, the insurer shall offer to the insured "tail" insurance
				coverage.
4.2. Such offer of "tail"
				insurance shall expire forty-five (45) days after the cancellation, nonrenewal,
				expiration or other termination of the insured's "claims made" professional
				malpractice insurance policy, unless the "tail" insurance offer is accepted sooner,
				in writing, by the insured.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-30 - "Tail" Malpractice Insurance Covering Certain Medical And Allied Health Care Providers › Section 114-30-5 - Premium Payment Amortization

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. Upon
				cancellation, nonrenewal or termination of any "claims made" professional
				malpractice insurance policy to which this rule is applicable, the insurer shall
				offer to any eligible professional who is licensed and practicing in the state of
				West Virginia, or who, prior to retirement, last practiced in the state of West
				Virginia, the opportunity to amortize the payment of quarterly premiums for "tail"
				insurance over twelve (12), twenty-four (24) or thirty-six (36) months.
5.2. Such quarterly premium payments for "tail"
				insurance shall be amortized at a per annum rate of interest equal to two (2)
				percentage points above the prime interest rate reported in the Wall Street Journal
				on the date when the insurer or its agent receives the insured's written request to
				purchase "tail" insurance, or on the next publication date of the Wall Street
				Journal following the effective date of the "tail" insurance policy if the Wall
				Street Journal is not published on the date when the insurer or its agent receives
				the insured's written request to purchase "tail" insurance.
5.3. The insured shall not be entitled to pay
				amortized premiums pursuant to this rule unless each quarterly premium payment, as
				computed applying the amortization rate set forth in subsection 5.2, equals at least
				seven hundred fifty dollars ($750.00).
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-30 - "Tail" Malpractice Insurance Covering Certain Medical And Allied Health Care Providers › Section 114-30-6 - Premium Due Dates; Acceleration of Premium Due upon Payment Default

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. The first quarterly payment due for "tail"
				insurance pursuant to this rule shall be payable contemporaneously with the issuance
				of the "tail" insurance policy. Subsequent payments shall be due and payable
				quarterly thereafter.
6.2. In the event
				of the insured's default in making a premium payment when due, the insurer shall
				notify the insured by certified mail that the entire balance is due and payable in
				full within 30 days of receipt of said notice. If the entire balance is not timely
				paid in full, the "tail" insurance coverage limits shall be determined in accordance
				with the plan filed by the carrier and approved by the commissioner.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-30 - "Tail" Malpractice Insurance Covering Certain Medical And Allied Health Care Providers › Section 114-30-7 - Penalty for Insurer's Non-Compliance

Current through Register Vol. XLI, No. 28, July 12, 2024
Any professional malpractice insurer subject to the provisions of
				  this rule that fails to offer "tail" insurance to an eligible insured, or that
				  violates in any way the provisions of article 20D, chapter 33 of the West Virginia
				  code, shall be assessed a penalty by the commissioner equal to the total amount of
				  premium due for the "tail" insurance that the insurer is required to
				  offer.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-30 - "Tail" Malpractice Insurance Covering Certain Medical And Allied Health Care Providers › Section 114-30-8 - Separability

Current through Register Vol. XLI, No. 28, July 12, 2024
If any provision of this rule or the application thereof to any
				  person or circumstance is for any reason held to be invalid, the remainder of the
				  rule and the application of such provisions to other persons or circumstances shall
				  not be affected thereby.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-31 - Guaranteed Loss Ratios as Applied To Individual Sickness And Accident Insurance Policies › Section 114-31-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This
				legislative rule implements the provisions of Article 6C, Chapter thirty-three of
				the West Virginia Code. That article permits, but does not require, an insurer
				offering individual sickness and accident insurance policies to operate on the basis
				of a guaranteed loss ratio established by the Insurance Commissioner. Any insurer
				that is approved to operate on a guaranteed loss ratio basis is exempt from filing
				rate increase applications as would otherwise be required by the
				Commissioner.
1.2. Authority. -- W. Va.
				Code §§
									33-2-10 and
				33-6C-3.
1.3. Filing Date. -- April 29, 2008.
1.4. Effective Date. -- April 29, 2008.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-31 - Guaranteed Loss Ratios as Applied To Individual Sickness And Accident Insurance Policies › Section 114-31-2 - Application to Operate on a Guaranteed Loss Ratio Basis

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. In order to implement a guaranteed loss ratio
				as established by the Commissioner, an insurer offering individual sickness and
				accident insurance policies must make application to the Commissioner on the form
				described in subsection 2.2 of this rule. The Commissioner shall have the discretion
				to approve or reject any such application after reviewing the same. The application
				form is set forth in Appendix A to this rule.
2.2. Each application filed with the Commissioner
				pursuant to this rule must include a written loss ratio guarantee that at minimum
				contains the following information:
a. Policy form
				number;
b. The anticipated lifetime and
				durational target loss ratios contained in the original actuarial memorandum filed
				with the policy form when it was originally approved;
c. A designation of the first calendar year in
				which the loss ratio guarantee is to be effective;
d. A guarantee that the actual West Virginia or,
				if applicable, national loss ratios for each experience period shall meet or exceed
				the anticipated lifetime and durational target loss ratios contained in the original
				actuarial memorandum described in subdivision b of this subsection;
e. The source and dates of data used by the
				insurer in determining lifetime and durational target loss ratios and credibility
				data;
f. A guarantee that the actual
				West Virginia, or, if applicable, national, loss ratio results for the experience
				period at issue will be independently audited as described more fully in Section 4
				of this rule;
g. The name and
				qualifications of the independent auditor who will perform the annual audit
				described in Section 4 of this rule;
h.
				A guarantee that if the actual loss ratio during an experience period is less than
				the anticipated loss ratio for that period, then West Virginia policyholders shall
				receive proportional refunds based on premium earned, which refunds shall be
				calculated and paid pursuant to W. Va. Code §
										33-6C-5;
i. A sample calculation and illustration of the
				refund methodology used to comply with this rule;
j. A non-discrimination guarantee as required by
				W. Va. Code §
										33-6C-4(c)(5);
				and
k. The signature of an officer of
				the insurer.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-31 - Guaranteed Loss Ratios as Applied To Individual Sickness And Accident Insurance Policies › Section 114-31-3 - Guaranteed Loss Ratio Filings

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. The
				initial filing of a loss ratio guarantee must include the policy form, schedule of
				rates and an actuarial memorandum which shall include information prescribed in the
				National Association of Insurance Commissioners' rate filing guidelines, durational
				and lifetime target loss ratios, and a projection of the actual loss ratio which
				shall include interest and lapse rates.
3.2. All rate increase filings shall include
				information prescribed in the National Association of Insurance Commissioners' rate
				filing guidelines, as well as the following:
a. An
				outline of coverage;
b. Any change in
				rate relationships;
c. The cumulative,
				to-date loss ratios; and
d. The
				projected lifetime loss ratios.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-31 - Guaranteed Loss Ratios as Applied To Individual Sickness And Accident Insurance Policies › Section 114-31-4 - Annual Audit

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. An independent
				audit of the actual West Virginia, or, if applicable, national, loss ratio results
				for the experience period at issue shall be conducted and filed with the
				Commissioner on an annual basis. The audit must be conducted during the second
				quarter of the year following the end of the experience period and be filed with the
				Commissioner no later than June 30 of that year.
4.2. The audit must include at minimum:
a. A statement of the durational and lifetime loss
				ratio guarantees;
b. A statement of the
				earned premium and incurred claims for the audited experience period;
c. A statement of the experience by duration of
				the most recent calendar year;
d. A
				statement of claim reserves included in incurred claims;
e. A statement that no active life reserves are
				included in the calculation of the actual loss ratio;
f. A statement that no reinsurance premiums are
				included in the calculation of the actual loss ratio;
g. A statement of refunds paid during any previous
				years; and
h. A statement of any
				refunds due for the current experience period and the calculation of the refunds
				due.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-31 - Guaranteed Loss Ratios as Applied To Individual Sickness And Accident Insurance Policies › Section 114-31-5 - Rejection or Cancellation of Loss Ratio Guarantee

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. The Commissioner may reject a loss ratio
				guarantee or cancel an existing loss ratio guarantee for any of the following
				reasons which shall be a non-exclusive list:
a.
				The insurer has demonstrated an inability to adequately monitor its loss
				ratios;
b. The insurer has failed to
				take timely rate increases in accordance with sound actuarial principles during the
				three-year period prior to filing the loss ratio guarantee;
c. The insurer has not complied with the terms of
				a previously filed loss ratio guarantee;
d. The insurer has submitted false, misleading or
				fraudulent material or information to the Commissioner.
e. The insurer is impaired, insolvent, in
				hazardous financial condition or such other similar financial condition as defined
				in W. Va. Code §§
										33-10-1 et seq.,
				33-24-1 et seq.,
				33-34A-1 et seq., or any other article of this chapter;
f. The Commissioner determines that the insurer
				has not complied with the provisions of the guarantee or this article.
g. The insurer's data reflects a guaranteed loss
				ratio of less than sixty percent (60%);
h. The insurer has failed to comply with W. Va.
				Code §
										33-6-34,
				form and rate filing fee requirement or other department filing procedure;
i. The insurer fails to provide information, data,
				or documentation reasonably requested by the Commissioner;
j. The insurer violates any provision of W. Va.
				Code §
										33-1-1 et seq. or the rules
				promulgated thereunder;
k. The insurer
				refuses to permit the Commissioner to examine and copy such records as the
				Commissioner deems necessary to determine compliance with W. Va. Code §
										33-6C-1
				et seq.
l. The insurer fails or refuses
				to pay the reasonable costs of the Commissioner arising out of the Commissioner's
				examination of the insurer's records to determine compliance with W. Va. Code §
										33-6C-1
				et seq.