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1,652 sections in this chapter.
W. Va. Code § 33-25B-7 Allowable commission for applicant aides; prohibited practices
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(a) Applicant aides may receive a commission not to exceed five percent of the voucher, from an approved provider. No commission may be paid until the fund is fully reimbursed for the voucher. Applicant aides may not solicit or accept any compensation from guardians or potential …
W. Va. Code § 33-25-7 Licenses
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(a) Before it may issue any contract to a subscriber, a corporation desiring to establish, maintain and operate a direct health care plan must first obtain from the commissioner a license as provided in this section. (b) Applications for an original license shall be made on forms…
W. Va. Code § 33-25A-7 Fiduciary responsibilities of officers; fidelity bond; approval of contracts by commissioner
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(a) Any director, officer or partner of a health maintenance organization who receives, collects, disburses or invests funds in connection with the activities of the organization is responsible for the funds in a fiduciary relationship to the enrollees. (b) A health maintenance o…
W. Va. Code § 33-25D-7 Powers of organization
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(a) Upon obtaining a certificate of authority as required under this article, a prepaid limited health service organization may enter into limited health service contracts in this state and engage in any activities, consistent with the purposes and provisions of this article, whi…
W. Va. Code § 33-25A-7A Provider contracts
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(1) Whenever a contract exists between a health maintenance organization and a provider and the organization fails to meet its obligations to pay fees for services already rendered to a subscriber, the health maintenance organization is liable for the fee or fees rather than the …
W. Va. Code § 33-25A-7B Loss ratio
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If a health maintenance organization considers a loss ratio at the time of renewal of a policy, plan, or contract, the health maintenance organization shall, upon request of a subscriber, provide the loss ratio and the components of the loss ratio calculation to the subscriber no…
W. Va. Code § 33-25C-8 Delegation of duties
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Each managed care plan is accountable for and must oversee any activities required by this article that it delegates to any subcontractor. No contract with a subcontractor executed by the managed care plan or the subcontractor may relieve the managed care plan of its obligations …
W. Va. Code § 33-25B-8 Activities not deemed the sale of insurance; exemptions from benefits and taxation
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(a) Assisting individuals in the preparation of applications to the fund and selection of the providers does not constitute the sale of insurance and shall not be subject to regulation by the Insurance Commissioner. (b) Insurance coverage bought by the guardian through the use of…
W. Va. Code § 33-25D-8 Governing body; enrollee participation
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(a) The governing body of any prepaid limited health service organization may include enrollees, providers, or other individuals. (b) The governing body shall establish a mechanism to afford the enrollees an opportunity to participate in matters of policy and operation through th…
W. Va. Code § 33-25-8 Commissioner to enforce article; approval of contracts, forms and rates; reserve fund; membership fee
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(a) It shall be the duty of the commissioner to enforce the provisions of this article. (b) No such corporation shall deliver or issue for delivery any subscriber's contract, changes in the terms of such contract, application, rider or endorsement until a copy thereof and the rat…
W. Va. Code § 33-25A-8 Evidence of coverage; charges for health care services; review of enrollee records; cancellation of contract by enrollee
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(1) (a) Every enrollee is entitled to evidence of coverage in accordance with this section. The health maintenance organization or its designated representative shall issue the evidence of coverage. (b) No evidence of coverage, or amendment thereto, shall be issued or delivered t…
W. Va. Code § 33-25A-8A Third party reimbursement for mammography, pap smear or human papilloma virus testing
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(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, whenever reimbursement or indemnity for laboratory or X-ray services are covered, reimbursement or indemnification shall not be denied for any of the following w…
W. Va. Code § 33-25-8A Third party reimbursement for mammography or pap smear or human papilloma virus testing
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(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, whenever reimbursement or indemnity for laboratory or X-ray services are covered, reimbursement or indemnification shall not be denied for any of the following w…
W. Va. Code § 33-25-8B Third party reimbursement for rehabilitation services
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(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall on or after July 1, 1991, provide as benefits to all subscribers and members coverage for rehabilitation services as h…
W. Va. Code § 33-25A-8B Third party reimbursement for rehabilitation services
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(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall, on or after July 1, 1991, provide as benefits to all subscribers and members coverage for rehabilitation services as …
W. Va. Code § 33-25-8C Third party payment for child immunization services
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Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall, on or after July 1, 1994, provide as benefits to all subscribers and members coverage for child immunization services as …
W. Va. Code § 33-25A-8C Third party payment for child immunization services
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Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall, on or after July 1, 1994, provide as benefits to all subscribers and members coverage for child immunization services as …
W. Va. Code § 33-25-8D Coverage of emergency services
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(a) Notwithstanding any provision of any policy, provision, contract, plan, or agreement to which this article applies, any entity regulated by this article shall provide as benefits to all subscribers and members coverage for emergency services. A policy, provision, contract, pl…
W. Va. Code § 33-25A-8D Coverage of emergency services
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(a) Notwithstanding any provision of any policy, provision, contract, plan, or agreement to which this article applies, any entity regulated by this article shall provide as benefits to all subscribers and members coverage for emergency services. A policy, provision, contract, pl…
W. Va. Code § 33-25A-8E Third party reimbursement for colorectal cancer examination and laboratory testing
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(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement applicable to this article, reimbursement or indemnification for colorectal cancer examinations and laboratory testing may not be denied for any nonsymptomatic person fifty years of age or old…
W. Va. Code § 33-25-8E Third party reimbursement for colorectal cancer examination and laboratory testing
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(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement applicable to this article, reimbursement or indemnification for colorectal cancer examinations and laboratory testing may not be denied for any nonsymptomatic person fifty years of age or old…
W. Va. Code § 33-25-8F Required use of mail-order pharmacy prohibited
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(a) A health care corporation issuing a contract under the provisions of this article may not require any person covered under a contract which provides coverage for prescription drugs to obtain the prescription drugs from a mail-order pharmacy in order to obtain benefits for the…
W. Va. Code § 33-25A-8F Required coverage for reconstruction surgery following mastectomies
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(a) Any policy of insurance described in this article which provides medical and surgical benefits with respect to a mastectomy shall provide, in a case of a participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects breast reconstruction …
W. Va. Code § 33-25-8G Third-party reimbursement for kidney disease screening
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(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement applicable to this article, reimbursement or indemnification for annual kidney disease screening and laboratory testing as recommended by the National Kidney Foundation may not be denied for a…
W. Va. Code § 33-25A-8G Required use of mail-order pharmacy prohibited
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(a) A health maintenance organization issuing coverage in this state pursuant to the provisions of this article may not require any person covered under a contract which provides coverage for prescription drugs to obtain the prescription drugs from a mail-order pharmacy in order …
W. Va. Code § 33-25-8H Required coverage for dental anesthesia services
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(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall, on or after July 1, 2009, provide as benefits to all subscribers and members coverage for dental anesthesia services …
W. Va. Code § 33-25A-8H Third-party reimbursement for kidney disease screening
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(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement applicable to this article, reimbursement or indemnification for annual kidney disease screening and laboratory testing as recommended by the National Kidney Foundation may not be denied for a…
W. Va. Code § 33-25-8I Maternity coverage
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Notwithstanding any provision of any policy, provision, contract, plan or agreement applicable to this article, a health insurance policy subject to this article, issued or renewed on or after January 1, 2014, which provides health insurance coverage for maternity services, shall…
W. Va. Code § 33-25A-8I Third-party reimbursement for dental anesthesia services
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(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall, on or after July 1, 2009, provide as benefits to all subscribers and members coverage for dental anesthesia services …
W. Va. Code § 33-25A-8J Coverage for diagnosis and treatment of autism spectrum disorders
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(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article for policies issued or renewed on or after January 1, 2012, which delivers, renews or issues a policy of group accident and …
W. Va. Code § 33-25-8J Deductibles, copayments and coinsurance for anti-cancer medications
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(a) Notwithstanding any provision of any policy, contract, plan or agreement to which this article applies, a policy, contract, plan or agreement issued to a member or subscriber by an entity regulated by this article that covers anti-cancer medications that are injected or intra…
W. Va. Code § 33-25A-8K Maternity coverage
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Notwithstanding any provision of any policy, provision, contract, plan or agreement applicable to this article, a health insurance policy subject to this article, issued or renewed on or after January 1, 2014, which provides health insurance coverage for maternity services, shall…
W. Va. Code § 33-25-8K Eye drop prescription refills
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A contract, plan or agreement issued by an insurer pursuant to this article for prescription topical eye medication may not deny coverage for the refilling of a prescription for topical eye medication when: (1) The medication is to treat a chronic condition of the eye; (2) The re…
W. Va. Code § 33-25-8L Deductibles, copayments and coinsurance for abuse-deterrent opioid analgesic drugs
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(a) As used in this section: (1) “Abuse-deterrent opioid analgesic drug product” means a brand name or generic opioid analgesic drug product approved by the United States Food and Drug Administration with abuse-deterrent labeling that indicates its abuse-deterrent properties are …
W. Va. Code § 33-25A-8L Deductibles, copayments and coinsurance for anti-cancer medications
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(a) Notwithstanding any provision of any policy, contract, plan or agreement to which this article applies, any policy, contract, plan or agreement issued by a health maintenance organization pursuant to this article that covers anti-cancer medications that are injected or intrav…
W. Va. Code § 33-25-8M Step therapy
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(a) As used in this article: (1) “Health benefit plan” means a policy, contract, certificate or agreement entered into, offered or issued by a health plan issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. (2) “Health plan iss…
W. Va. Code § 33-25A-8M Eye drop prescription refills
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A contract, plan or agreement issued by an insurer pursuant to this article for prescription topical eye medication may not deny coverage for the refilling of a prescription for topical eye medication when: (1) The medication is to treat a chronic condition of the eye; (2) The re…
W. Va. Code § 33-25A-8N Deductibles, copayments and coinsurance for abuse-deterrent opioid analgesic drugs
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(1) “Abuse-deterrent opioid analgesic drug product” means a brand name or generic opioid analgesic drug product approved by the United States Food and Drug Administration with abuse-deterrent labeling that indicates its abuse-deterrent properties are expected to deter or reduce i…
W. Va. Code § 33-25-8N Coverage for amino acid-based formulas
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(a) A policy, plan, or contract that is issued or renewed on or after January 1, 2019, and that is subject to this article shall provide coverage, through the age of 20, for amino acid-based formula for the treatment of severe protein-allergic conditions or impaired absorption of…
W. Va. Code § 33-25-8O Substance use disorder
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(a) As used in this section, the following words have the following meanings: (1) “Concurrent review” means inpatient care is reviewed as it is provided. Medically qualified reviewers monitor appropriateness of the care, the setting, and patient progress, and, as appropriate, the…
W. Va. Code § 33-25A-8O Step therapy
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(a) As used in this article: (1) “Health benefit plan” means a policy, contract, certificate or agreement entered into, offered or issued by a health plan issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. (2) “Health plan iss…
W. Va. Code § 33-25A-8P Lyme disease to be covered by all health insurance policies
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A health maintenance organization issuing coverage in this state pursuant to the provisions of this article shall make available as benefits to all subscribers and members coverage on an expense-incurred basis and individual and group service or indemnity type contracts issued by…
W. Va. Code § 33-25-8P Prior authorization
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(a) As used in this section, the following words and phrases have the meanings given to them in this section unless the context clearly indicates otherwise: "Episode of care" means a specific medical problem, condition, or specific illness being managed including tests, procedure…
W. Va. Code § 33-25-8Q Fairness in Cost-Sharing Calculation
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(a) As used in this section: "Cost sharing" means any copayment, coinsurance, or deductible required by or on behalf of an insured in order to receive a specific health care item or service covered by a health plan. "Drug" means the same as the term is defined in §30-5-4 of this …
W. Va. Code § 33-25A-8Q Coverage for amino acid-based formulas
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(a) A policy, plan, or contract that is issued or renewed on or after January 1, 2019, and that is subject to this article shall provide coverage, through the age of 20, for amino acid-based formula for the treatment of severe protein-allergic conditions or impaired absorption of…
W. Va. Code § 33-25A-8R Substance use disorder
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(a) As used in this section, the following words have the following meanings: (1) “Concurrent review” means inpatient care is reviewed as it is provided. Medically qualified reviewers monitor appropriateness of the care, the setting, and patient progress, and, as appropriate, the…
W. Va. Code § 33-25-8R Mental health parity
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(a) As used in this section, the following words and phrases have the meaning given them in this section unless the context clearly indicates otherwise: To the extent that coverage is provided “behavioral health, mental health, and substance use disorder” means a condition or dis…
W. Va. Code § 33-25-8S Incorporation of the Health Benefit Plan Network Access and Adequacy Act
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The provisions of the Health Benefit Plan Network Access and Adequacy Act codified at §33-55-1 et seq. of this code are made applicable to the provisions of this article.
W. Va. Code § 33-25A-8S Prior authorization
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(a) As used in this section, the following words and phrases have the meanings given to them in this section unless the context clearly indicates otherwise: "Episode of care" means a specific medical problem, condition, or specific illness being managed including tests, procedure…
W. Va. Code § 33-25A-8T Fairness in Cost-Sharing Calculation
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(a) As used in this section: "Cost sharing" means any copayment, coinsurance, or deductible required by or on behalf of an insured in order to receive a specific health care item or service covered by a health plan. "Drug" means the same as the term is defined in §30-5-4 of this …
