Chapter 33, Chapter 33

The following words, as used in this article, have the meanings set forth below, unless the context clearly requires otherwise: (a) "Applicant aide" means an individual licensed by the state to care for the physical or emotional needs of children or an employee authorized by his …

(a) This article may be cited as the "Health Maintenance Organization Act of 1977." (b) Faced with the continuation of mounting costs of health care coupled with its inaccessibility to large segments of the population, the Legislature has determined that there is a need to encour…

Every health maintenance organization or its representative shall annually, before April 1, provide to its enrollees a summary of: Its most recent annual financial statement, including a balance sheet and statement of receipts and disbursements; a description of the health mainte…

Any corporation organized for the purposes of this article is exempt from all franchise, corporate, business and taxes of every nature levied by the state.

(a) A prepaid limited health service organization shall file with the commissioner any contracts made with providers of a limited health service, enabling the prepaid limited health service organization to provide limited health services authorized under this article. The commiss…

(a) The commissioner or his or her accredited examiners may at any reasonable time and shall, at least once every five years, visit each health care corporation and thoroughly examine its financial condition and methods of doing business and ascertain whether it has complied with…

To the extent permitted by law, if any provision of this article conflict with other state or federal law, then the provision must be construed in a manner most favorable to the enrollee.

If a corporation considers a loss ratio at the time of renewal of a policy, plan, or contract, the corporation shall, upon request of a subscriber, provide the loss ratio and the components of the loss ratio calculation to the subscriber no more than 90 days but no less than 60 d…

(a)(1) Every enrollee is entitled to evidence of coverage in accordance with this section. The prepaid limited health service organization or its designated representative shall issue the evidence of coverage. (2) No evidence of coverage, or amendment thereto, shall be issued or …

The commissioner is authorized to promulgate and adopt such rules and regulations relating to health care corporations as are necessary to discharge his duties and exercise his powers and to effectuate the provisions of this article and to protect and safeguard the interests of s…

(1) Once a health maintenance organization has been in operation at least five years, or has enrollment of not less than fifty thousand persons, the health maintenance organization shall, in any year following a year in which the health maintenance organization has achieved an op…

No person acting on behalf of the corporation executing any contracts, commitments or agreements issued pursuant to this article may be liable personally upon the contracts, commitments or agreements or be subject to any personal liability or accountability by reason thereof.

(a) A health maintenance organization shall establish and maintain a grievance procedure, which has been approved by the Commissioner, to provide adequate and reasonable procedures for the expeditious resolution of written grievances initiated by enrollees concerning any matter r…

(a) Every prepaid limited health service organization shall comply with and is subject to the provisions of section fourteen, article four of this chapter relating to filing of financial statements with the commissioner and the national association of Insurance Commissioners. The…

Each contract made by the corporation with any person (other than subscribers), corporation, association and institution, named or referred to in section three of this article shall contain the following provisions: (a) That the person, corporation, association or institution wil…

(a) Every such corporation shall deliver to each subscriber to its health care plan a copy of the contract. (b) A corporation may accept from private agencies, corporations, associations, groups or individuals, payment for or on behalf of any subscriber of all or any part of the …

Every prepaid limited health service organization or its representative shall annually, before April 1, provide to each enrollee a summary of: Its most recent annual financial statement, including a balance sheet and statement of receipts and disbursements; a description of the p…

With the exception of investments otherwise made in accordance with this article, the investable funds of a health maintenance organization shall be invested only in securities or other investments permitted by the laws of this state for the investment of assets constituting the …

(a) No health maintenance organization, or representative of a health maintenance organization, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. …

Any person may advance to such corporation any sums of money necessary for its business or to enable it to comply with any requirements of law. Such advances and such interest thereon not exceeding six percent per annum, as may be agreed upon, shall not be a liability or a claim …

(a) A prepaid limited health service organization shall establish and maintain a grievance procedure, which has been approved by the commissioner, to provide adequate and reasonable procedures for the expeditious resolution of written grievances initiated by enrollees concerning …

(a) No health maintenance organization may cancel or fail to renew the coverage of an enrollee except for: (1) Failure to pay the charge for health care coverage; (2) termination of the health maintenance organization; (3) termination of the group plan; (4) enrollee moving out of…

(a) No prepaid limited health service organization, or representative thereof, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. No advertising ma…

(1) Health maintenance organizations are subject to the provisions of article twelve of this chapter. (2) With respect to individual and group contracts covering fewer than twenty-five subscribers, after a subscriber signs a health maintenance organization enrollment application …

(a) Prepaid limited health service organizations are subject to the provisions of article twelve of this chapter. (b) With respect to individual or group contracts covering fewer than twenty-five subscribers, after a subscriber signs a prepaid limited health service organization …

(1) An insurance company licensed in this state or a hospital or medical service corporation authorized to do business in this state, after applying for and receiving a certificate of authority as a health maintenance organization, may through a subsidiary or affiliate organize a…

All licenses or renewal fees, all auditing charges and any other income derived from this article shall be deposited with the treasurer of the State of West Virginia to the credit of the Insurance Commissioner to be used only for the cost of operation of the Insurance Commissione…

(a) The Commissioner may make an examination of the affairs of any health maintenance organization and providers with whom the organization has contracts, agreements or other arrangements as often as he or she considers it necessary for the protection of the interests of the peop…

Every officer or employee of any such corporation, who is entrusted with the handling of its funds, shall furnish, in such amount as may with the approval of the commissioner be fixed by the board of directors of the corporation, a bond with corporate surety, conditioned upon fai…

(a) An insurance company licensed in this state, a hospital, medical, dental or health service corporation authorized to do business in this state or a health maintenance organization holding a certificate of authority under article twenty-five-a of this chapter, after applying f…

(a) Each health maintenance organization shall have in writing a quality assurance program that describes the program's objectives, organization and problem solving activities. (b) The scope of the quality assurance program shall include, at a minimum: (1) Organizational arrangem…

(a) The commissioner may make an examination of the affairs of any prepaid limited health service organization and providers with whom the organization has contracts, agreements or other arrangements as often as he or she considers it necessary for the protection of the interests…

(1) The commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization under this article if he or she finds that any of the following conditions exist: (a) The health maintenance organization is operating significantly in contraventio…

Every health care organization organized under the laws of this state is subject to the provisions of article thirty-three of this chapter.

Every health care corporation subject to the provisions of this article is subject to the provisions of article thirty-four of this chapter.

Any rehabilitation, liquidation or conservation of a health maintenance organization shall be considered to be the rehabilitation, liquidation or conservation of an insurance company, shall be the exclusive remedy for rehabilitation, liquidation and conservation of an HMO as prov…

(a) Each prepaid limited health service organization shall have in writing a quality assurance program approved by the commissioner which describes the program's objectives, organization and problem solving activities. (b) The scope of the quality assurance program shall include,…

The purpose of this article is to: (a) Assist, promote, encourage, develop and advance the knowledge of lower to moderate income families with dependent children of the earned income credit available for money spent on health insurance; (b) Cooperate and act in conjunction with o…

(a) This section applies to: (1) Insurers and nonprofit health service plans that provide hospital, medical, surgical or pharmaceutical benefits to individuals or groups on an expense-incurred basis under a health insurance policy or contract issued or delivered in the state; and…

For the purposes of this article: (1) “Commissioner” means the Insurance Commissioner of West Virginia. (2) “Covered services” and “covered materials” means services or materials for which reimbursement from the insurer or vision care plan or vision care discount plan is availabl…

(1) "Basic health care services" means physician, hospital, out-of-area, podiatric, chiropractic, laboratory, X ray, emergency, treatment for serious mental illness as provided in section three-a, article sixteen of this chapter, and cost-effective preventive services including i…

For purposes of this article: (a) "Commissioner" means the commissioner of insurance. (b) "Credentials" means medical training, education, specialties, and board certifications of the provider. (c) "Enrollee" is a natural person who has entered into an agreement with a health mai…

For the purpose of this article, unless the context otherwise indicates: (a) "Health care corporation" or "corporation" shall mean a corporation organized and licensed under the provisions of this article. (b) "Direct health care services" shall, subject to the limitations contai…

(a) "Capitation" means the fixed amount paid by a prepaid limited health service organization to a health care provider under contract with the prepaid limited health service organization in exchange for the rendering of no more than four limited health services. (b) "Commissione…

Notwithstanding any other provisions of law, when any health insurance policy, health care services plan or other contract provides for the payment of medical expenses, benefits or procedures, such policy, plan or contract shall be construed to include payment to all health care …

The commissioner may after notice and hearing promulgate reasonable rules and regulations in accordance with chapter twenty-nine-a of this code, as are necessary or proper to effectuate the purposes of this article and to prevent circumvention and evasion thereof.

(a) The commissioner may suspend or revoke any certificate of authority issued to a prepaid limited health service organization under this article if he or she finds that any of the following conditions exist: (1) The prepaid limited health service organization is operating signi…

The commissioner may as he deems necessary after notice and hearing promulgate rules and regulations in accordance with chapter twenty-nine-a of this code to define the commissioner's authority to consider the operating results of an insurer's affiliates and subsidiaries in in th…

Any rehabilitation, liquidation or conservation of a prepaid limited health service organization is considered to be the rehabilitation, liquidation or conservation of an insurance company, is the exclusive remedy for rehabilitation, liquidation and conservation of a prepaid limi…

(1) When the commissioner has cause to believe that grounds for the denial of an application for a certificate of authority exist, or that grounds for the suspension or revocation of a certificate of authority exist, he shall notify the health maintenance organization in writing …