H. B. 4553
(By Delegates Douglas and Beane)
[Introduced February 25, 1998; referred to the
Committee on Banking and Insurance then Finance.]
A BILL to amend and reenact section two-a, article twelve,
chapter thirty-three of the code of West Virginia, one
thousand nine hundred thirty-one, as amended; and to amend
and reenact section nineteen, article fifteen of said
chapter; and to amend and reenact section four, article
fifteen-a of said chapter; and to further amend said chapter
by adding thereto a new article, designated article twenty- five-c, all relating to prepaid limited health service
organizations; establishing requirements for doing business;
continuing education requirements for their agents;
coordination with medicaid; the relationship to long-term
care insurance; conditions for and revocation of
certificates of authority; providing minimum capital
requirements; establishing powers of a prepaid limited
health service organization; providing enrollee participation; setting requirements for provider contracts;
setting requirements for premiums; requiring approval of
approval forms; requiring financial statements; setting
grievance procedures; regulating marketing; providing for
financial examinations; establishing a quality assurance
program; providing for civil and criminal penalties and
enforcement; and dictating statutory construction and
relationship to other laws.
Be it enacted by the Legislature of West Virginia:
That section two-a, article twelve, chapter thirty-three of
the code of West Virginia, one thousand nine hundred thirty-one,
as amended, be amended and reenacted; and that section nineteen,
article fifteen of said chapter be amended and reenacted; and
that section four, article fifteen-a of said chapter be amended
and reenacted; and that said chapter be further amended by adding
thereto a new article, designated article twenty-five-c, all to
read as follows:
ARTICLE 12. AGENTS, BROKERS, SOLICITORS AND EXCESS LINE.
§33-12-2a. Continuing education required.
(a) The purpose of this provision is to provide continuing
education under guidelines set up under the insurance
commissioner's office, effective the first day of July, one
thousand nine hundred ninety-two with the guidelines to be set
up under the board of insurance agent education. Nothing in this section shall prohibit prohibits an individual from receiving
commissions which have been vested and earned while that
individual maintained an approved insurance agent's license.
(a) (b) This section applies to persons licensed to engage
in the sale of the following types of insurance:
(1) Life insurance, annuity contracts, variable annuity
contracts and variable life insurance;
(2) Sickness, accident and health insurance;
(3) All lines of property and casualty insurance; and
(4) All other lines of insurance for which an examination is
required for licensing.
(b) (c) This section does not apply to:
(1) Persons holding resident licenses for any kind or kinds
of insurance offered in connection with loans or other credit
transactions or insurance for which an examination is not
required by the commissioner, nor does it apply to any such
limited or restricted license as the commissioner may exempt;
(2) Individuals selling credit life or credit accident and
health insurance.
(c) (d) (1) The board of insurance agent education as
established by section two of this article shall develop a
program of continuing insurance education and submit the proposal
for the approval of the commissioner on or before the
thirty-first day of December of each year. Each year after the first day of July, one thousand nine hundred ninety-seven, The
program shall contain a requirement that any person appointed to
be an agent on behalf of a licensed health maintenance
organization
or prepaid limited health service organization
at
any time during the relevant biennium must shall, as a component
of his or her mandatory continuing insurance education, complete
a minimum of six hours of continuing insurance education during
the biennium which is on topics specific to health maintenance
managed care organizations.
No program shall may be approved by the commissioner that
includes a requirement that any agent complete more than thirty
hours of continuing insurance education biennially. No program
shall may be approved by the commissioner that includes a
requirement that any of the following individuals complete more
than six hours of continuing insurance education biennially:
(A) Insurance agents who sell only preneed burial insurance
contracts; and
(B) Insurance agents who engage solely in telemarketing
insurance products by a scripted presentation which scripted
presentation has been filed with and approved by the
commissioner.
(2) The commissioner and the board, under standards
established by the board, may approve any course or program of
instruction developed or sponsored by an authorized insurer, accredited college or university, agents' association, insurance
trade association or independent program of instruction that
presents the criteria and the number of hours that the board and
commissioner determine appropriate for the purpose of this
section.
(d) (e) Persons licensed to sell insurance and who are not
otherwise exempt shall satisfactorily complete the courses or
programs of instructions the commissioner may prescribe.
(e) (f) Every person, subject to the continuing education
requirements shall furnish, at intervals and on forms as may be
prescribed by the commissioner, written certification listing the
courses, programs or seminars of instruction successfully
completed by the person. The certification shall be executed by,
or on behalf of, the organization sponsoring the courses,
programs or seminars of instruction.
(f) (g) Any person, failing to meet the requirements
mandated in this section, and who has not been granted an
extension of time, with respect to such the requirements, or who
has submitted to the commissioner a false or fraudulent
certificate of compliance shall is, after a hearing thereon,
which hearing may be waived by the person, be subjected subject
to suspension of all licenses issued for any kind or kinds of
insurance. No further license may be issued to the person for
any kind or kinds of insurance until he or she has demonstrated to the satisfaction of the commissioner that he or she has
complied with all of the requirements mandated by this section
and all other applicable laws or rules.
(g) (h) Hearings for the violation of any provision of this
section, and the administrative procedure prior to, during and
following these hearings, shall be conducted in accordance with
the provisions of article two of this chapter.
(h) (i) The commissioner is authorized to hire personnel and
make reasonable expenditures as deemed considered necessary for
purposes of establishing and maintaining a system of continuing
education for insurers.
ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.
§33-15-19. Coordination of benefits with medicaid.
Any health insurer, health maintenance organization as
defined in article twenty-five-a of this chapter,
prepaid limited
health service organization as defined in article twenty-five-c
of this chapter
or hospital and medical service corporations as
defined in article twenty-four of this chapter is prohibited from
considering the availability or eligibility for medical
assistance in this or any other state under 42 U.S.C. § 1396a,
Section 1902 of the Social Security Act, herein referred to in
this article as medicaid, when considering eligibility for
coverage or making payments under its plan for eligible
enrollees, subscribers, policyholders or certificateholders.
ARTICLE 15A. WEST VIRGINIA LONG-TERM CARE INSURANCE ACT.
§33-15A-4. Definitions.
(a) "Long-term care insurance" means any insurance policy or
rider advertised, marketed, offered or designed to provide
benefits for not less than twenty-four consecutive months for
each covered person on an expense incurred, indemnity, prepaid
or other basis; for one or more necessary or medically necessary
diagnostic, preventive, therapeutic, rehabilitative, maintenance
or personal care services, provided in a setting other than an
acute care unit of a hospital. Such The term includes group and
individual policies or riders whether issued by insurers;
fraternal benefit societies; nonprofit health, hospital, and
medical service corporations; prepaid health plans; health
maintenance organizations,
prepaid limited health service
organizations
or any similar organization. Any insurance policy
which is offered primarily to provide basic medicare supplement
coverage, basic hospital expense coverage, basic medical-surgical
expense coverage, hospital confinement indemnity coverage, major
medical expense coverage, disability income protection coverage,
accident only coverage, specified disease or specified accident
coverage, or limited benefit health coverage which also contains
long-term care insurance benefits for at least six months shall
comply with the provisions of this act article.
(b) "Applicant" means:
(1) In the case of an individual long-term care insurance
policy, the person who seeks to contract for benefits, and
(2) In the case of a group long-term care insurance policy,
the proposed certificate holder.
(c) "Certificate" means, for the purposes of this act
article,
any certificate issued under a group long-term care
insurance policy, which policy has been delivered or issued for
delivery in this state.
(d) "Commissioner" means the insurance commissioner of this
state.
(e) "Group long-term care insurance" means a long-term care
insurance policy which is delivered or issued for delivery in
this state and issued to:
(1) One or more employers or labor organizations, or to a
trust or to the trustees of a fund established by one or more
employers or labor organizations, or a combination thereof, for
employees or former employees or a combination thereof or for
members or former members or a combination thereof, of the labor
organizations; or
(2) Any professional, trade or occupational association for
its members or former or retired members, or combination thereof,
if such the association:
(A) Is composed of individuals all of whom are or were
actively engaged in the same profession, trade or occupation; and
(B) Has been maintained in good faith for purposes other
than obtaining insurance; or
(3) An association or a trust or the trustee (s) or trustees
of a fund established, created or maintained for the benefit of
members of one or more associations. Prior to advertising,
marketing or offering such the policy within this state, the
association or associations, or the insurer of the association or
associations, shall file evidence with the commissioner that the
association or associations have at the outset a minimum of one
hundred persons and have been organized and maintained in good
faith for the purposes other than that of obtaining insurance;
have been in active existence for at least one year; and have a
constitution and bylaws which provide that:
(A) The association or associations hold regular meetings
not less than annually to further purposes of the members;
(B) Except for credit unions, the association or
associations collect dues or solicit contributions from members;
and
(C) The members have voting privileges and representation on
the governing board and committees.
Thirty days after such the filing the association or
associations will be deemed to satisfy such organizational
requirements, unless the commissioner makes a finding that the
association or associations do not satisfy those organizational requirements.
(4) A group other than as described in subdivisions (1), (2)
and (3), subsection (e) of this section, subject to a finding by
the commissioner that:
(A) The issuance of the group policy is not contrary to the
best interest of the public;
(B) The issuance of the group policy would result in
economies of acquisition or administration;
(C) The benefits are reasonable in relation to the premiums
charged.
(f) "Policy" means, for the purposes of this act article,
any policy, contract, subscriber agreement, rider or endorsement
delivered or issued for delivery in this state by an insurer;
fraternal benefit society; nonprofit health, hospital, or medical
service corporation; prepaid health plan; health maintenance
organization,
prepaid limited health service organization
or any
similar organization.
ARTICLE 25C. PREPAID LIMITED HEALTH SERVICE ORGANIZATION ACT.
§33-25C-1. Short title.
This article may be cited as the "Prepaid Limited Health
Service Organization Act."
§33-25C-2. Definitions.
(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) "Commissioner" means the commissioner of insurance.
(c) "Consumer" means any person who is not a provider of
care or an employee, officer, director or stockholder of any
provider of care.
(d) "Coordinating provider" means the provider of a
particular limited health service who is chosen or designated for
each subscriber and who will be responsible for coordinating the
provision of that particular limited health service to the
subscriber, including necessary referrals to other providers of
the limited health service: Provided, That if a subscriber is
also enrolled in a health maintenance organization, the
coordinating provider shall send a written report at least
annually to the subscriber's primary care physician, as defined
in article twenty-five-a of this chapter, describing the limited
health service provided to the subscriber: Provided, however,
That the coordinating provider may disclose data or information
only as permitted under section twenty-eight of this article.
(e) "Copayment" means a specific dollar amount, except as
otherwise provided for by statute, that the subscriber must pay
upon receipt of covered limited health services and which is set
at an amount consistent with allowing the subscriber access to covered limited health services.
(f) "Employee" means a person in some official employment or
position working for a salary or wage continuously for no less
than one calendar quarter and who is in such a relation to
another person that the latter may control the work of the former
and direct the manner in which the work is done.
(g) "Employer" means any individual, corporation,
partnership, other private association, or state or local
government that employs the equivalent of at least two full-time
employees during any four consecutive calendar quarters.
(h) "Enrollee," "subscriber," or "member" means an
individual who has been voluntarily enrolled in a prepaid limited
health service organization, including individuals on whose
behalf a contractual arrangement has been entered into with a
prepaid limited health service organization to receive no more
than four limited health services.
(i) "Evidence of coverage" means any certificate, agreement
or contract issued to an enrollee setting out the coverage and
other rights to which the enrollee is entitled.
(j) "Group practice" means a professional corporation,
partnership, association, or other organization composed solely
of health professionals licensed to practice medicine or
osteopathy and of such other licensed health professionals,
including podiatrists, dentists, optometrists and chiropractors, as are necessary for the provision of limited health services for
which the group is responsible:
(1) A majority of the members of which are licensed to
practice medicine, osteopathy or chiropractic;
(2) Who as their principal professional activity engage in
the coordinated practice of their profession;
(3) Who pool their income for practice as members of the
group and distribute it among themselves according to a
prearranged salary, drawing account or other plan; and
(4) Who share medical and other records and substantial
portions of major equipment and professional, technical and
administrative staff.
(k) "Impaired" means a financial situation in which, based
upon the financial information which would be required by this
chapter for the preparation of the prepaid limited health service
organization's annual statement, the assets of the prepaid
limited health service organization are less than the sum of all
of its liabilities and required reserves including any minimum
capital and surplus required of the prepaid limited health
service organization by this chapter so as to maintain its
authority to transact the kinds of business or insurance it is
authorized to transact.
(l) "Individual practice arrangement" means any agreement or
arrangement to provide medical services on behalf of a prepaid limited health service organization among or between providers or
between a prepaid limited health service organization and
individual providers or groups of providers, where the providers
are not employees or partners of the prepaid limited health
service organization and are not members of or affiliated with a
group practice.
(m) "Insolvent" or "insolvency" means a financial situation
in which, based upon the financial information which would be
required by this chapter for the preparation of the prepaid
limited health service organization's annual statement, the
assets of the prepaid limited health service organization are
less than the sum of all of its liabilities and required
reserves.
(n) "Limited health service" means ambulance services,
dental care services, vision care services, mental or behavioral
health services, substance abuse services, chiropractic services,
podiatric care services, or pharmaceutical services, together
with any services or goods included in the furnishing to any
individual of a limited health service. "Limited health service"
does not include inpatient services, hospital surgical services
or emergency services except as such services are provided
incident to a limited health service set forth in this
subsection.
(o) "Premium" means a prepaid per capita or prepaid aggregate fixed sum unrelated to the actual or potential
utilization of services of any particular person which is charged
by the prepaid limited health service organization for health
services provided to an enrollee.
(p) "Prepaid limited health service organization" means a
public or private organization which provides, or otherwise makes
available to enrollees, no more than four limited health services
and which:
(1) Receives premiums for the provision of no more than four
limited health services to enrollees on a prepaid per capita or
prepaid aggregate fixed sum basis, excluding copayments;
(2) Provides no more than four limited health services
primarily:
(A) Directly through an exclusive panel of physicians or
other providers who are employees or partners of the
organization;
(B) Through arrangements with individual physicians or other
providers or one or more groups of physicians or other providers
organized on a group practice or individual practice arrangement;
or
(C) Some combination of paragraphs (A) and (B) of this
subdivision;
(3) Assures the availability, accessibility and quality,
including effective utilization, of the limited health service or services that it provides or makes available through clearly
identifiable focal points of legal and administrative
responsibility; and
(4) Offers services through an organized delivery system, in
which a coordinating provider of a limited health service is
designated for each subscriber to that limited health service.
Prepaid limited health service organization does not include an
entity otherwise authorized pursuant to the laws of this state to
indemnify for any limited health service, or a provider or entity
when providing a limited health service pursuant to a contract
with a prepaid limited health service organization, a health
maintenance organization, a health insurer or a self-insurance
plan.
(q) "Provider" means any physician or other person or
organization licensed or otherwise authorized in this state to
furnish a limited health service.
(r) "Qualified independent actuary" means an actuary who is
a member of the American academy of actuaries or the society of
actuaries and has experience in establishing rates for prepaid
limited health service organizations and who has no financial or
employment interest in the prepaid limited health service
organization.
(s) "Quality assurance" means an ongoing program designed to
objectively and systematically monitor and evaluate the quality and appropriateness of the enrollee's care, pursue opportunities
to improve the enrollee's care, and resolve identified problems
at the prevailing professional standard of care.
(t) "Service area" means the county or counties approved by
the commissioner within which the prepaid limited health service
organization may provide or arrange for a limited health service
to be available to its subscribers.
(u) "Statutory surplus" means the minimum amount of
unencumbered surplus which a corporation must maintain pursuant
to the requirements of this article.
(v) "Surplus" means the amount by which a corporation's
assets exceed its liabilities and required reserves based upon
the financial information which would be required by this chapter
for the preparation of the corporation's annual statement except
that assets pledged to secure debts not reflected on the books of
the prepaid limited health service organization shall not be
included in surplus.
(w) "Surplus notes" means debt which has been subordinated
to all claims of subscribers and all creditors of the
organization.
(x) "Uncovered expenses" means the cost of a limited health
service covered by a prepaid limited health service organization,
for which a subscriber would also be liable in the event of the
insolvency of the organization.
(y) "Utilization management" means a system for the
evaluation of the necessity, appropriateness, and efficiency of
the use of health care services, procedures and facilities.
§33-25C-3. Application for certificate of authority; addition
of services.
(a) Notwithstanding any law of this state to the contrary,
any person may apply to the commissioner for and obtain a
certificate of authority to establish or operate a prepaid
limited health service organization in compliance with this
article: Provided, That the organization for which a certificate
of authority to operate a prepaid limited health service
organization is sought shall be incorporated under the provisions
of article one, chapter thirty-one of this code. No person may
sell prepaid limited health service organization enrollee
contracts, nor may any prepaid limited health service
organization commence services, prior to receipt of a certificate
of authority from the commissioner. Any person may, however,
establish the feasibility of a prepaid limited health service
organization prior to receipt of a certificate of authority
through funding drives and by receiving loans and grants.
(b) Every prepaid limited health service organization in
operation as of the effective date of this article shall submit
an application for a certificate of authority under this section
within thirty days of the effective date of this article. Each applicant may continue to operate until the commissioner acts
upon the application. In the event that an application is denied
pursuant to section five of this article, the applicant shall be
treated as a prepaid limited health service organization whose
certificate of authority has been revoked.
(c) The commissioner may require any organization providing
or arranging for one or more limited health services on a prepaid
per capita or prepaid aggregate fixed sum basis to apply for a
certificate of authority under this article. Any organization
directed to apply for a certificate of authority is subject to
the provisions of subsection (b) of this section.
(d) Each application for a certificate of authority shall be
sworn to by an officer or authorized representative of the
applicant before a notary public, shall be in a form prescribed
by the commissioner and shall set forth or be accompanied by any
and all information required by the commissioner, including:
(1) The basic organizational document;
(2) The bylaws or rules;
(3) A list of the names, addresses and official positions
of each member of the governing body, which shall contain a full
disclosure in the application of any financial interest by the
officer or member of the governing body or any provider or any
organization or corporation owned or controlled by that person
and the prepaid limited health service organization and the extent and nature of any contract or financial arrangements
between that person and the prepaid limited health service
organization;
(4) A description of the prepaid limited health service
organization and the limited health service or services to be
offered;
(5) A copy of each evidence of coverage form and of each
enrollee contract form;
(6) Financial statements which include the assets,
liabilities and sources of financial support of the applicant and
any corporation or organization owned or controlled by the
applicant;
(7)(A) A description of the proposed method of marketing the
plan;
(B) A schedule of proposed charges; and
(C) A financial plan which includes a three-year projection
of the expenses and income and other sources of future capital;
(8) A power of attorney duly executed by the applicant, if
not domiciled in this state, appointing the commissioner and his
or her successors in office, and duly authorized deputies, as the
true and lawful attorney of the applicant in and for this state
upon whom all lawful process in any legal action or proceeding
against the prepaid limited health service organization on a
cause of action arising in this state may be served;
(9) A statement reasonably describing the service area or
areas to be served and the type or types of enrollees to be
served;
(10) A description of the complaint procedures to be
utilized as required under section fourteen of this article;
(11) A description of the mechanism by which enrollees will
be afforded an opportunity to participate in matters of policy
and operation under section eight of this article;
(12) A complete biographical statement on forms prescribed
by the commissioner and an independent investigation report on
all of the individuals referred to in subdivision (3) of this
subsection and all officers, directors and persons holding five
percent or more of the common stock of the organization;
(13) A comprehensive feasibility study, performed by a
qualified independent actuary in conjunction with a certified
public accountant which shall contain a certification by the
qualified actuary and an opinion by the certified public
accountant as to the feasibility of the proposed organization.
The study shall be for the greater of three years or until the
prepaid limited health service organization has been projected to
be profitable for twelve consecutive months. The study shall show
that the prepaid limited health service organization would not,
at the end of any month of the projection period, have less than
the minimum capital and surplus as required by section six of this article. The qualified independent actuary shall certify
that:
(A) The rates for each limited health service offered are
neither inadequate nor excessive nor unfairly discriminatory;
(B) The rates are appropriate for the classes of risks for
which they have been computed;
(C) The rating methodology is appropriate: Provided, That
the certification shall include an adequate description of the
rating methodology showing that the methodology follows
consistent and equitable actuarial principles;
(D) The prepaid limited health service organization is
actuarially sound: Provided, That the certification shall
consider the rates, benefits, and expenses of, and any other
funds available for the payment of obligations of, the
organization;
(E) The rates being charged or to be charged are actuarially
adequate to the end of the period for which rates have been
guaranteed; and
(F) Incurred but not reported claims and claims reported but
not fully paid have been adequately provided for.
(14) A description of the prepaid limited health service
organization's quality assurance program; and
(15) Such other information as the commissioner may require
to be provided.
(e) A prepaid limited health service organization shall,
unless otherwise provided for by rules promulgated by the
commissioner, file notice prior to any modification of the
operations or documents filed pursuant to this section or as the
commissioner may require by rule. If the commissioner does not
disapprove of the filing within ninety days of filing, it is
considered approved and may be implemented by the prepaid limited
health service organization: Provided, That an application to add
one or more limited health services to those offered by the
organization shall be submitted and reviewed in accordance with
subsection (f) of this section.
(f) If a prepaid limited health service organization wishes
to offer one or more additional limited health services to
subscribers, the organization shall submit an application in
accordance with the procedure set forth in subsection (d) of this
section, with respect to the additional service or services:
Provided, That the organization may not at any time offer more
than four limited health services. The organization is not
required to submit the information required by subdivisions (1),
(2), (3), (8), (10), (11) or (12), subsection (d) of this
section, if there has been no change in the information required
by the respective subdivisions since the information was most
recently filed with the commissioner.
§33-25C-4. Conditions precedent to issuance or maintenance of a certificate of authority; renewal of certificate of
authority; effect of bankruptcy proceedings.
(a) As a condition precedent to the issuance or maintenance
of a certificate of authority, a prepaid limited health service
organization shall file or have on file with the commissioner:
(1) An acknowledgment that a delinquency proceeding pursuant
to article ten of this chapter or supervision by the commissioner
pursuant to article thirty-four of this chapter is the sole and
exclusive method for the liquidation, rehabilitation,
reorganization, or conservation of a prepaid limited health
service organization;
(2) A waiver of any right to file or be subject to a
bankruptcy proceeding;
(3) Within thirty days of any change in the membership of
the governing body of the organization or in the officers or
persons holding five percent or more of the common stock of the
organization, or as otherwise required by the commissioner:
(A) An amended list of the names, addresses and official
positions of each member of the governing body, and a full
disclosure of any financial interest by a member of the governing
body or any provider or any organization or corporation owned or
controlled by that person and the prepaid limited health service
organization and the extent and nature of any contract or
financial arrangements between that person and the prepaid limited health service organization; and
(B) A complete biographical statement on forms prescribed by
the commissioner and an independent investigation report on each
such person for whom a biographical statement and independent
investigation report have not previously been submitted; and
(b) All certificates of authority issued to prepaid limited
health service organizations expire at midnight on the thirty- first day of May of each year. The commissioner shall renew
annually the certificates of authority of all prepaid limited
health service organizations which continue to meet all
requirements of this section and subsection (b), section five of
this article, make application therefor upon a form prescribed by
the commissioner and pay the renewal fee prescribed: Provided,
That a prepaid limited health service organization does not
qualify for renewal of its certificate of authority if the
organization has no subscribers in this state within twelve
months after issuance of the certificate of authority: Provided,
however, That an organization not qualifying for renewal may
apply for a new certificate of authority under section three of
this article.
(c) The commencement of a bankruptcy proceeding either by or
against a prepaid limited health service organization, by
operation of law:
(1) Terminates the prepaid limited health service organization's certificate of authority; and
(2) Vests in the commissioner for the use and benefit of the
subscribers of the prepaid limited health service organization
the title to any deposits of the prepaid limited health service
organization held by the commissioner.
(d) If the bankruptcy proceeding is initiated by a party
other than the prepaid limited health service organization, the
operation of subsection (c) of this section is stayed for a
period of sixty days following the date of commencement of the
proceeding.
§33-25C-5. Issuance of certificate of authority.
(a) Upon receipt of an application for a certificate of
authority, the commissioner shall determine whether the
application for a certificate of authority, with respect to
limited health services to be furnished has demonstrated:
(1) The willingness and potential ability of the
organization to assure that limited health services will be
provided in such a manner as to enhance and assure both the
availability and accessibility of adequate personnel and
facilities;
(2) Arrangements for an ongoing evaluation of the quality of
health care provided by the organization and utilization review
which meet the minimum standards set forth in section nineteen of
this article;
(3) That the organization has a procedure to develop,
compile, evaluate and report statistics relating to the cost of
its operations, the pattern of utilization of its services, the
quality, availability and accessibility of its services, and
other matters as may be reasonably required by rule.
(b) The commissioner shall issue or deny a certificate of
authority to any person filing an application within one hundred
twenty days after receipt of the application. Issuance of a
certificate of authority shall be granted upon payment of the
application fee prescribed, if the commissioner is satisfied that
the following conditions are met:
(1) The prepaid limited health service organization's
proposed plan of operation meets the requirements of subsection
(a) of this section;
(2) The prepaid limited health service organization will
effectively provide or arrange for the provision of no more than
four limited health services on a prepaid basis except for
copayments: Provided, That nothing in this section relieves a
prepaid limited health service organization from the obligations
to provide a limited health service because of the nonpayment of
copayments unless the enrollee fails to make payment in at least
three instances over any twelve-month period: Provided, however,
That nothing in this section permits a prepaid limited health
service organization to charge copayments to medicare beneficiaries or medicaid recipients in excess of the copayments
permitted under those programs, nor is a prepaid limited health
service organization required to provide a limited health service
to medicare beneficiaries or medicaid recipients in excess of the
benefits compensated under those programs;
(3) The prepaid limited health service organization is
financially responsible and may reasonably be expected to meet
its obligations to enrollees and prospective enrollees. In making
this determination, the commissioner may consider:
(A) The financial soundness of the prepaid limited health
service organization's arrangements for no more than four limited
health services and the proposed schedule of charges used in
connection with each limited health service offered;
(B) Arrangements for maintenance of the minimum capital and
surplus required under section six of this article;
(C) Any arrangements which will guarantee the continuation
of benefits and payments to providers for services rendered both
prior to and after insolvency for the duration of the contract
period for which payment has been made, except that benefits to
members who are confined on the date of insolvency in an
inpatient facility shall be continued until their discharge; and
(D) Any agreement with providers for the provision of
limited health care services;
(4) The enrollees will be afforded an opportunity to participate in matters of policy and operation pursuant to
section eight of this article;
(5) The prepaid limited health service organization has
demonstrated that it will assume full financial risk on a
prospective basis for the provision of no more than four limited
health services: Provided, That notwithstanding the requirement
of this subdivision, a prepaid limited health service
organization may obtain reinsurance acceptable to the
commissioner from an accredited reinsurer or make other
arrangements:
(A) For the cost of providing to any enrollee limited health
services, the aggregate value of which exceeds four thousand
dollars in any year;
(B) For the cost of providing no more than four limited
health services to its enrollees on a nonelective emergency
basis; or
(C) For not more than ninety-five percent of the amount by
which the prepaid limited health service organization's costs for
any of its fiscal years exceed one hundred five percent of its
income for those fiscal years;
(6) The ownership, control and management of the prepaid
limited health service organization is competent and trustworthy
and possesses managerial experience that would make the proposed
organization operation beneficial to the subscribers. The commissioner may, at his or her discretion, refuse to grant or
continue authority to transact the business of a prepaid limited
health service organization in this state at any time during
which the commissioner has probable cause to believe that the
ownership, control or management of the organization includes any
person whose business operations are or have been marked by
business practices or conduct that is to the detriment of the
public, stockholders, investors or creditors; and
(7) The prepaid limited health service organization has
deposited and maintained in trust with the state treasurer, for
the protection of its subscribers or its subscribers and
creditors, cash or government securities eligible for the
investment of capital funds of domestic insurers as described in
section seven, article eight of this chapter in the amount of
fifty thousand dollars.
(c) A certificate of authority may be denied only after
compliance with the requirements of section twenty-three of this
article.
(d) No person who has not been issued a certificate of
authority may use the words "prepaid limited health service
organization" or the initials "PLHSO" in its name, contracts,
logo or literature: Provided, That persons who are operating
under a contract with, operating in association with, enrolling
enrollees for, or otherwise authorized by a prepaid limited health service organization licensed under this article to act on
its behalf may use the terms "prepaid limited health service
organization" or "PLHSO" for the limited purpose of denoting or
explaining their association or relationship with the authorized
prepaid limited health service organization. No prepaid limited
health service organization which has a minority of board members
who are consumers may use the words "consumer controlled" in its
name or in any way represent to the public that it is controlled
by consumers.
§33-25C-6. Minimum capital.
(a) Each prepaid limited health service organization shall
have and maintain fully paid-in capital stock, if a for-profit
stock corporation, or statutory surplus funds, if a nonprofit
corporation, totaling at least:
(1) The greater of two hundred fifty thousand dollars or ten
percent of its expenses for the previous twelve-month period as
reported in its most recent financial statement filed pursuant to
subsection (a), section twelve of this article, with respect to
each limited health service for which the organization will not
offer inpatient services up to a maximum total for all limited
health services of the required capital and surplus for an
insurer under article three, section five-b of this chapter; and
(2) The greater of one million dollars or ten percent of its
expenses for the previous twelve-month period as reported in its most recent financial statement filed pursuant to subsection (a),
section twelve of this article, with respect to each limited
health service for which the organization will offer inpatient
services up to a maximum total for all limited health services of
the required capital and surplus for an insurer under article
three, section five-b of this chapter.
(b) For purposes of this section, "expenses" means those
costs set forth by the national association of insurance
commissioners (NAIC) in the statement of revenues, expenses and
net worth contained in the annual statement instruction--limited
health service organization and the official NAIC annual
statement blanks--limited health service organization.
§33-25C-7. Powers of organization.
(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, which are necessary to the
performance of its obligations under such contracts, subject to
the limitations provided for in this article: Provided, That
nothing in this article authorizes any prepaid limited health
service organization to transact any insurance other than that
for which the organization is granted a certificate of authority
under this article.
(b) The commissioner may propose rules for legislative
approval in accordance with the provisions of article three,
chapter twenty-nine-a of this code, limiting or regulating the
powers of prepaid limited health service organizations which he
or she finds to be in the public interest.
§33-25C-8. Governing body; enrollee participation.
(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 the establishment of advisory panels, by
the use of advisory referenda on major policy decisions, or
through the use of other mechanisms as may be prescribed by the
commissioner.
§33-25C-9. Fiduciary responsibilities of managers; fidelity
bond.
(a) Any director, officer or other manager of a prepaid
limited health service 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 prepaid limited health service organization shall
maintain a blanket fidelity bond covering all directors, officers, managers and employees of the organization who receive,
collect, disburse or invest funds in connection with the
activities of the organization, issued by an insurer licensed in
this state or, if the fidelity bond required by this subdivision
is not available from an insurer licensed in this state, a
fidelity bond procured by an excess line broker licensed in this
state, in an amount at least equal to the minimum amount of
fidelity insurance as provided in the national association of
insurance commissioners handbook, as amended, or as the
commissioner may by rule, propose for legislative approval in
accordance with the provisions of article three, chapter twenty- nine-a of this code, require.
§33-25C-10. Provider contracts.
(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 commissioner may require the
immediate cancellation of a contract or the immediate
renegotiation of a contract by the parties if he or she
determines that a contract provides for excessive payments, fails
to include reasonable incentives for cost control, or otherwise
substantially and unreasonably contributes to escalation of the
costs of providing a limited health service to enrollees.
(b) Whenever a contract exists between a prepaid limited
health service organization and a provider and the organization
fails to meet its obligations to pay fees for services already
rendered to a subscriber, the prepaid limited health service
organization is liable for the fee or fees rather than the
subscriber; and the contract shall state that liability.
(c) No enrollee of a prepaid limited health service
organization is liable to any provider of a limited health
service for any service covered by the prepaid limited health
service organization if at any time during the provision of the
service, the provider or its agents are aware the individual to
whom the service is provided is an enrollee of a prepaid limited
health service organization.
(d) If at any time during the provision of a limited health
service, a provider or its agents are aware that the subscriber
is a prepaid limited health service organization enrollee for the
service provided, the provider of services or any agent or
representative of the provider may not collect or attempt to
collect from a subscriber any money for services covered by a
prepaid limited health service organization, and no provider or
agent or representative of the provider may maintain any action
at law against a subscriber of a prepaid limited health service
organization to collect money owed to the provider by a prepaid
limited health service organization.
(e) Every contract between a prepaid limited health service
organization and a provider of a limited health service shall be
in writing and shall contain a provision that the subscriber is
not liable to the provider for any services covered by the
subscriber's contract with the prepaid limited health service
organization.
(f) The provisions of this section do not apply to the
amount of any deductible or copayment not payable by the prepaid
limited health service organization pursuant to its contract with
its subscriber.
(g) When a subscriber receives covered emergency health care
services from a noncontracting provider, the prepaid limited
health service organization is responsible for payment of the
provider's normal charges for the health care services, exclusive
of any applicable deductibles or copayments.
(h) For all provider contracts executed on or after the
effective date of this article and within one hundred eighty days
of that date for contracts in existence on that date:
(1) The contracts shall provide that the provider provide
sixty days advance written notice to the prepaid limited health
service organization and the commissioner before canceling the
contract with the prepaid limited health service organization for
any reason; and
(2) The contract shall provide that nonpayment for goods or services rendered by the provider to the prepaid limited health
service organization is not a valid reason for avoiding the sixty
day advance notice of cancellation.
(i) Upon receipt by the prepaid limited health service
organization of a sixty day cancellation notice, the prepaid
limited health service organization may, if requested by the
provider, terminate the contract in less than sixty days if the
prepaid limited health service organization is not financially
impaired or insolvent.
§33-25C-11. Evidence of coverage; review of enrollee records;
charges for limited health services; cancellation
of contract by enrollee.
(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 delivered to any person in this state until a copy of
the form of the evidence of coverage, or amendment thereto, has
been filed with and approved by the commissioner.
(3) An evidence of coverage shall contain a clear, concise
and complete statement of:
(A) The limited health service and the insurance or other
benefits, if any, to which the enrollee is entitled;
(B) Any exclusions or limitations on the service, kind of
service, benefits, or kind of benefits, to be provided, including
any copayments;
(C) Where and in what manner information is available as to
how a service may be obtained: Provided, That with respect to any
limited health service for which inpatient services, hospital
surgical services or emergency services are provided, the
evidence of coverage shall contain a definition of inpatient
services, hospital surgical services or emergency services,
respectively; describe procedures for determination by the
prepaid limited health service organization of whether the
services qualify for reimbursement as inpatient services,
hospital surgical services or emergency services; and contain
specific examples of situations in which the services would be
made available;
(D) The total amount of payment and copayment, if any, for
the limited health service and the indemnity or service benefits,
if any, which the enrollee is obligated to pay with respect to
individual contracts, or an indication whether the plan is
contributory or noncontributory with respect to group
certificates;
(E) A description of the prepaid limited health service
organization's method for resolving enrollee grievances; and
(F) The following exact statement in bold print:
"Each subscriber or enrollee, by acceptance of the benefits
described in this evidence of coverage, consents to the
examination of his or her medical records for purposes of
utilization review, quality assurance and peer review by the
prepaid limited health service organization or its designee."
(4) Any subsequent approved change in an evidence of
coverage shall be issued to each enrollee.
(5) A copy of the form of the evidence of coverage to be
used in this state, and any amendment thereto, is subject to the
filing and approval requirements of subdivision (2), subsection
(a) of this section, unless the commissioner promulgates a rule
dispensing with this requirement or unless it is subject to the
jurisdiction of the commissioner under the laws governing health
insurance or hospital, medical, dental or health service
corporations, in which event the filing and approval provisions
of those laws apply. To the extent, however, that those
provisions do not apply the requirements in subdivision (3),
subsection (a) of this section, are applicable.
(b)(1) Premiums for each limited health service offered may
be established in accordance with actuarial principles: Provided,
That premiums may not be excessive, inadequate, or unfairly
discriminatory. A certification by a qualified independent
actuary shall accompany a rate filing for each limited health
service offered and shall certify that:
(A) The rates are neither inadequate nor excessive nor
unfairly discriminatory;
(B) That the rates are appropriate for the classes of risks
for which they have been computed;
(C) Provide an adequate description of the rating
methodology showing that the methodology follows consistent and
equitable actuarial principles; and
(D) The rates being charged are actuarially adequate to the
end of the period for which rates have been guaranteed.
(2) In determining whether the charges are reasonable, the
commissioner shall consider whether the prepaid limited health
service organization has:
(A) Made a vigorous, good faith effort to control rates paid
to limited health service providers;
(B) Established a premium schedule, including copayments, if
any, which encourages enrollees to seek out preventive limited
health services; and
(C) Made a good faith effort to secure arrangements whereby
the limited health service can be obtained by subscribers from
local providers to the extent that the providers offer the
services.
(c) Rates for a particular limited health service are
inadequate if the premiums derived from the rating structure,
plus investment income, copayments, and revenues from coordination of benefits and subrogation, fees-for-service and
reinsurance recoveries are not set at a level at least equal to
the anticipated cost of benefits for the limited health service
during the period for which the rates are to be effective and the
other expenses which would be incurred if other expenses were at
the level for the current or nearest future period during which
the prepaid limited health service organization is projected to
make a profit. For this analysis, total investment income added
to premiums, copayments and revenues from coordination of
benefits and subrogation, fees-for-service and reinsurance
recoveries with respect to all limited health services offered
may not exceed three percent of the prepaid limited health
service organization's total projected revenues.
(d) The commissioner shall within a reasonable period
approve any form if the requirements of subsection (a) of this
section are met and any schedule of charges if the requirements
of subsections (b) and (c) of this section are met. It is
unlawful to issue the form or to use the schedule of charges
until approved. If the commissioner disapproves of the filing,
he or she shall notify the filer promptly. In the notice, the
commissioner shall specify the reasons for his or her disapproval
and the findings of fact and conclusions which support his or her
reasons. A hearing will be granted by the commissioner within
forty-five days after a request in writing, by the person filing, has been received by the commission. If the commissioner does
not disapprove any form or schedule of charges within sixty days
of the filing of the forms or charges, they are approved.
(e) The commissioner may require the submission of whatever
relevant information in addition to the schedule of charges which
he or she considers necessary in determining whether to approve
or disapprove a filing made pursuant to this section.
(f) An individual enrollee may cancel a contract with a
prepaid limited health service organization at any time for any
reason: Provided, That a prepaid limited health service
organization may require that the enrollee give thirty days
advance notice: Provided, however, That an individual enrollee
whose premium rate was determined pursuant to a group contract
may cancel a contract with a prepaid limited health service
organization pursuant to the terms of that contract.
§33-25C-12. Annual and quarterly reports.
(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 annual financial statement required
by that section shall include, but not be limited to, the
following:
(1) A statutory financial statement 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:
(A) All prepayment and other payments received for limited
health services rendered;
(B) 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 limited health service contract;
(C) Expenditures for capital improvements, or additions
thereto, including, but not limited to, construction, renovation
or purchase of facilities and capital equipment; and
(D) The organization's fidelity bond;
(2) 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 on a form prescribed by
the commissioner;
(3) A summary of information compiled pursuant to
subdivision (3), subsection (a), section five of this article in
such form as the commissioner requires;
(4) A report of the names and residence addresses of all
persons set forth in subdivision (3), subsection (d), section
three of this article who were associated with the prepaid
limited health service organization during the preceding year, and the amount of wages, expense reimbursements, or other
payments to those individuals for services to the prepaid limited
health service organization, including a full disclosure of all
financial arrangements during the preceding year required to be
disclosed pursuant to subdivision (3), subsection (d), section
three of this article; and
(5) Other information relating to the performance of the
prepaid limited health service organization as is reasonably
necessary to enable the commissioner to carry out his or her
duties under this article.
§33-25C-13. Annual report to enrollees.
Every prepaid limited health service organization or its
representative shall annually, before the first day of April,
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 prepaid limited
health service organization, each limited health service offered,
its facilities and personnel for each limited health service
offered, any material changes therein since the last report, the
current evidence of coverage for each limited health service for
which the enrollee is enrolled, and a clear and understandable
description of the prepaid limited health service organization's
method for resolving enrollee complaints: Provided, That with
respect to enrollees who have been enrolled through contracts between a prepaid limited health service organization and an
employer, the prepaid limited health service organization
satisfies the requirement of this section by providing the
requisite summary to each enrolled employee: Provided, however,
That with respect to medicaid recipients enrolled under a group
contract between a prepaid limited health service organization
and the governmental agency responsible for administering the
medicaid program, the prepaid limited health service organization
satisfies the requirement of this section by providing the
requisite summary to each local office of the governmental agency
responsible for administering the medicaid program for inspection
by enrollees of the prepaid limited health service organization.
§33-25C-14. Grievance procedure.
(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 any matter relating to any
provisions of the organization's limited health service
contracts, including, but not limited to, claims regarding the
scope of coverage for health care services; denials,
cancellations or nonrenewals of enrollee coverage; observance of
an enrollee's rights as a patient; and the quality of the health
care services rendered.
(b) A detailed description of the prepaid limited health
service organization's subscriber grievance procedure shall be
included in all group and individual contracts as well as any
certificate or member handbook provided to subscribers. This
procedure shall be administered at no cost to the subscriber. A
prepaid limited health service organization subscriber grievance
procedure shall include the following:
(1) Both informal and formal steps shall be available to
resolve the grievance. A grievance is not considered formal
until a written grievance is executed by the subscriber or
completed on forms prescribed and received by the prepaid limited
health service organization;
(2) Each prepaid limited health service organization shall
designate at least one grievance coordinator who is responsible
for the implementation of the prepaid limited health service
organization's grievance procedure;
(3) Phone numbers shall be specified by the prepaid limited
health service organization for the subscriber to call to present
an informal grievance or to contact the grievance coordinator.
Each phone number shall be toll free within the subscriber's
geographic area and provide reasonable access to the prepaid
limited health service organization without undue delays. There
shall be an adequate number of phone lines to handle incoming
grievances;
(4) An address shall be included for written grievances;
(5) Each level of the grievance procedure shall have some
person with problem solving authority to participate in each step
of the grievance procedure;
(6) The prepaid limited health service organization shall
process the formal written subscriber grievance through all
phases of the grievance procedure in a reasonable length of time
not to exceed forty-five days, unless the subscriber and prepaid
limited health service organization mutually agree to extend the
time frame. If the complaint involves the collection of
information outside the service area, the prepaid limited health
service organization has thirty additional days to process the
subscriber complaint through all phases of the grievance
procedure. The time limitations prescribed in this subdivision
requiring completion of the grievance process within sixty days
are tolled after the prepaid limited health service organization
has notified the subscriber, in writing, that additional
information is required in order to properly complete review of
the grievance. Upon receipt by the prepaid limited health
service organization of the additional information requested, the
time for completion of the grievance process set forth in this
subdivision resumes;
(7) The subscriber grievance procedure shall state that the
subscriber has the right to appeal to the commissioner within thirty days of receipt by the subscriber of a written ruling by
the prepaid limited health service organization which denies, in
whole or in part, relief requested by the subscriber in a formal
written subscriber grievance. There shall be the additional
requirement that subscribers under a group contract between the
prepaid limited health service organization and a department or
division of the state shall first appeal to the state agency
responsible for administering the relevant program, and if either
party is not satisfied with the outcome of the appeal, the
unsatisfied party may appeal to the commissioner. The prepaid
limited health service organization shall provide the subscriber
a written notice of the right to appeal upon completion of the
full grievance procedure and supply the commissioner with a copy
of the final decision letter. A subscriber has thirty days after
receipt of the written notice to appeal to the commissioner if
the prepaid limited health service organization's ruling denies
the relief requested by the subscriber, in whole or in part;
(8) The prepaid limited health service organization shall
have provider involvement in reviewing grievances related to a
provider's services. Provider involvement in the grievance
process may not be limited to the subscriber's coordinating
provider, but shall include at least one other provider;
(9) The prepaid limited health service organization shall
offer to meet with the subscriber during the formal grievance process. The location of the meeting shall be at the
administrative offices of the prepaid limited health service
organization within the service area or at a location within the
service area which is convenient to the subscriber;
(10) The prepaid limited health service organization may not
establish time limits of less than one year from the date of
occurrence for the subscriber to file a formal grievance. The
date of occurrence is the date upon which a claim, service or
other matter sought by the subscriber was denied by the prepaid
limited health service organization or date of occurrance of the
event which gave rise to the grievance;
(11) Each prepaid limited health service organization shall
maintain an accurate record of each formal grievance. Each
record shall include the following:
(A) A complete description of the grievance, the
subscriber's name and address, the provider's name and address
and the prepaid limited health service organization's name and
address;
(B) A complete description of the prepaid limited health
service organization's factual findings and conclusions after
completion of the full formal grievance procedure;
(C) A complete description of the prepaid limited health
service organization's conclusions pertaining to the grievance as
well as the prepaid limited health service organization's final disposition of the grievance; and
(D) A statement as to which levels of the grievance
procedure the grievance has been processed and how many more
levels of the grievance procedure are remaining before the
grievance has been processed through the prepaid limited health
service organization's entire grievance procedure.
(12) Copies of the grievances and the responses thereto
shall be available to the commissioner and the public for
inspection for three years.
(c) Any subscriber grievance in which time is of the essence
shall be handled on an expedited basis, so that a reasonable
person would believe that a prevailing subscriber would be able
to realize the full benefit of a decision in his or her favor.
(d) Each prepaid limited health service organization shall
submit to the commissioner an annual report in a form prescribed
by the commissioner which describes the grievance procedure and
contains a compilation and analysis of the grievances filed,
their disposition, and their underlying causes.
§33-25C-15.Prohibited practices.
(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 may be used until it has been approved by the commissioner. Advertising which has not been
disapproved by the commissioner within sixty days of filing is
considered approved. For purposes of this article:
(1) A statement or item of information is untrue if it does
not conform to fact in any respect which is or may be significant
to an enrollee of, or person considering enrollment in, a prepaid
limited health service organization;
(2) A statement or item of information is misleading,
whether or not it may be literally untrue, if, in the total
context in which the statement is made or the item of information
is communicated, the statement or item of information may be
reasonably understood by a reasonable person, not possessing
special knowledge regarding health care coverage, as indicating
any benefit or advantage or the absence of any exclusion,
limitation, or disadvantage of possible significance to an
enrollee of, or person considering enrollment in, a prepaid
limited health service organization, if the benefit or advantage
or absence of limitation, exclusion or disadvantage does not in
fact exist;
(3) An evidence of coverage is deceptive if the evidence of
coverage taken as a whole, and with consideration given to
typography and format, as well as language, causes a reasonable
person, not possessing special knowledge regarding prepaid
limited health service organizations, and evidences of coverage therefor, to expect benefits, services or other advantages which
the evidence of coverage does not provide or which the prepaid
limited health service organization issuing the evidence of
coverage does not regularly make available for enrollees covered
under the evidence of coverage; and
(4) The commissioner may further define practices which are
untrue, misleading or deceptive.
(b)(1) No prepaid limited health service organization may
cancel or fail to renew the coverage of an enrollee except for: (A) Failure to pay the charge for health care coverage;
(B) Termination of the prepaid limited health service
organization;
(C) Termination of the group plan;
(D) Enrollee moving out of the area served;
(E) Enrollee moving out of an eligible group; or
(F) Other reasons established in rules promulgated by the
commissioner.
(2) No prepaid limited health service organization may use
any technique of rating or grouping to cancel or fail to renew
the coverage of an enrollee. An enrollee shall be given thirty
days' notice of any cancellation or nonrenewal and the notice
shall include the reasons for the cancellation or nonrenewal:
Provided, That each enrollee moving out of an eligible group
shall be granted the opportunity to enroll in the prepaid limited health service organization on an individual basis. A prepaid
limited health service organization may not disenroll an enrollee
for nonpayment of copayments unless the enrollee has failed to
make payment in at least three instances over any twelve-month
period: Provided, however, That the enrollee may not be
disenrolled if the disenrollment would constitute abandonment of
a patient. Any enrollee wrongfully disenrolled shall be
reenrolled.
(c)(1) No prepaid limited health service organization may
use in its name, contracts, logo or literature any of the words
"insurance," "casualty," "surety," "mutual" or any other words
which are descriptive of the insurance, casualty or surety
business or deceptively similar to the name or description of any
insurance or surety corporation doing business in this state:
Provided, That when a prepaid limited health service organization
has contracted with another insurer for any coverage permitted by
this article, it may so state; and
(2) No person who has not been issued a certificate of
authority under this article may use the words "prepaid limited
health service organization" or the initials "PLHSO" in its name,
contracts, logo or literature to imply, directly or indirectly,
that it is a prepaid limited health service organization or hold
itself out to be a prepaid limited health service organization.
(d) The providers of a prepaid limited health service organization who provide limited health services and the prepaid
limited health service organization do not have recourse against
enrollees for amounts above those specified in the evidence of
coverage as the periodic prepayment or copayment for health care
services.
(e) No prepaid limited health service organization may
discriminate in enrollment policies or quality of services
against any person on the basis of race, sex, age, religion,
place of residence, health status or source of payment: Provided,
That differences in rates based on valid actuarial distinctions,
including distinctions relating to age and sex, are not
considered discrimination in enrollment policies.
(f) (1) No agent of a prepaid limited health service
organization or person selling enrollments in a prepaid limited
health service organization may sell an enrollment in a prepaid
limited health service organization unless the agent or person
first discloses in writing to the prospective purchaser the
following information using the following exact terms in bold
print:
(A) "Services offered," including any exclusions or
limitations;
(B) "Full cost," including copayments;
(C) "Facilities available and hours of services";
(D) "Transportation services";
(E) "Disenrollment rate"; and
(F) "Staff," including the names of all full-time staff
physicians, consulting specialists and inpatient facilities, if
any, associated with the prepaid limited health service
organization.
(2) In any home solicitation, any three-day cooling-off
period applicable to consumer transactions generally applies in
the same manner as consumer transactions.
(3) The form disclosure statement may not be used in sales
until it has been approved by the commissioner. Any person who
fails to disclose the requisite information prior to the sale of
an enrollment may be held liable in an amount equivalent to one
year's subscription rate to the prepaid limited health service
organization, plus costs and a reasonable attorney's fee.
(g) No contract with an enrollee may prohibit an enrollee
from canceling his or her enrollment at any time for any reason
except that the contract may require thirty days' notice to the
prepaid limited health service organization.
(h) No contract with an enrollee may contain any provision
purporting to make any portion of the articles of incorporation,
charter, bylaws or other organizational document of the prepaid
limited health service organization a part of the contract unless
the provision is set forth in full in the contract.
(i) Any person who in connection with an enrollment violates any subsection of this section may be held liable for an amount
equivalent to one year's subscription rate, plus costs and a
reasonable attorney's fee.
§33-25C-16. Agent licensing and appointment required;
regulation of marketing.
(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 enrollment
application and before the prepaid limited health service
organization may process the application changing or initiating
the subscriber coverage, each prepaid limited health service
organization shall verify in writing, in a form prescribed by the
commissioner, the intent and desire of the individual subscriber
to join the prepaid limited health service organization. The
verification shall be conducted by someone outside the prepaid
limited health service organization's marketing department and
shall show that:
(1) The subscriber intends and desires to join the prepaid
limited health service organization;
(2) If the subscriber is a medicare or medicaid recipient,
the subscriber understands that by joining the prepaid limited
health service organization he or she will be limited to the benefits provided by the prepaid limited health service
organization, and medicare or medicaid will pay the prepaid
limited health service organization for the subscriber coverage;
(3) The subscriber understands the applicable restrictions
of prepaid limited health service organizations, especially that
he or she must use the prepaid limited health service
organization providers and secure approval from the prepaid
limited health service organization to use health care providers
outside the plan; and
(4) If the subscriber is a member of a prepaid limited
health service organization, the subscriber understands that he
or she is transferring to another prepaid limited health service
organization.
(c) The prepaid limited health service organization may not
pay a commission, fee, money or any other form of scheduled
compensation to any health insurance agent until the subscriber's
application has been processed and the prepaid limited health
service organization has confirmed the subscriber's enrollment by
written notice in the form prescribed by the commissioner. The
confirmation notice shall be accompanied by the evidence of
coverage required by section eleven of this article and shall
confirm:
(1) The subscriber's transfer from his or her existing
coverage, such as from medicare, medicaid, another prepaid limited health service organization, etc., to the new prepaid
limited health service organization; and
(2) The date enrollment begins and when benefits will be
available.
(d) The enrollment process is considered complete seven days
after the prepaid limited health service organization mails the
confirmation notice and evidence of coverage to the subscriber.
Each prepaid limited health service organization is directly
responsible for enrollment abuses.
(5) The commissioner may propose rules for legislative
approval in accordance with the provisions of article three,
chapter twenty-nine-a of this code, to regulate marketing of
prepaid limited health service organizations by persons
compensated directly or indirectly by the prepaid limited health
service organization. The rules may prohibit door-to-door
solicitations, may prohibit commission sales, and may provide for
other proscriptions required to effectuate the purposes of this
article.
§33-25C-17. Powers of insurers, hospital service corporations,
medical service corporations, dental service
corporations, health service corporations and
health maintenance organizations.
(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 article, after applying for and receiving a certificate of
authority as a prepaid limited health service organization, may
through a subsidiary or affiliate organize and operate a prepaid
limited health service organization under the provisions of this
article. Notwithstanding any other law to the contrary, any two
or more insurance companies, hospital, medical, dental or health
service corporations, health maintenance organizations or
subsidiaries or affiliates thereof, may jointly organize and
operate a prepaid limited health service organization. The
business of insurance is considered to include the providing of
health care by a prepaid limited health service organization
owned or operated by an insurer or a subsidiary of the insurer.
(b) Notwithstanding any provision of insurance, hospital,
medical, dental or health service corporation or health
maintenance organization laws, an insurer, a hospital, medical,
dental or health service corporation or a health maintenance
organization may contract with a prepaid limited health service
organization to provide insurance or similar protection against
the cost of care provided through prepaid limited health service
organizations and to provide coverage in the event of the failure
of the prepaid limited health service organization to meet its
obligations. The enrollees of a prepaid limited health service organization constitute a permissible group under those laws.
Under the contracts, the insurer or hospital, medical, dental or
health service corporation or health maintenance organization may
make benefit payments to prepaid limited health service
organizations for limited health services rendered by providers.
(c) Notwithstanding any provision of insurance, hospital,
medical, dental or health service corporation or health
maintenance organization laws, an insurer, a hospital, medical,
dental or health service corporation or a health maintenance
organization may exclude in any contract or policy issued to a
group, any coverage which would duplicate the coverage of a
prepaid limited health service organization, whether for
services, supplies or reimbursement, to the extent that the
coverage or service is provided in accordance with this chapter
pursuant to a contract or policy issued to the same group or to
a part of that group by a prepaid limited health service
organization.
§33-25C-18. Examinations.
(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 of the people of this state but not
less frequently than once every three years.
(b) The commissioner may contract with the department of
health and human resources, any entity which has been accredited
by a nationally recognized accrediting organization and has been
approved by the commissioner to make examinations concerning the
quality of health care services of any prepaid limited health
service organization and providers with whom the organization has
contracts, agreements or other arrangements, or any such entity
contracted with by the department of health and human resources,
as often as it considers necessary for the protection of the
interests of the people of this state, but not less frequently
than once every three years: Provided, That in making the
examination, the department of health and human resources or the
accredited entity shall utilize the services of persons or
organizations with demonstrable expertise in assessing quality of
health care.
(c) Every prepaid limited health service organization and
affiliated provider shall submit its books and records to the
examinations and in every way facilitate them. For the purpose
of examinations, the commissioner and the department of health
and human resources have all powers necessary to conduct the
examinations, including, but not limited to, the power to issue
subpoenas, the power to administer oaths to and examine the
officers and agents of the prepaid limited health service
organization and the principals of the providers concerning their business.
(d) The prepaid limited health service organization is
subject to the provisions of section nine, article two of this
chapter in regard to the expense and conduct of examinations.
(e) In lieu of the examination, the commissioner may accept
the report of an examination made by another state.
(f) The expenses of an examination assessing quality of
health care under subsection (b) of this section and section
nineteen of this article shall be reimbursed pursuant to
subdivision (5), subsection (i), section nine, article two of
this chapter.
§33-25C-19. Quality Assurance.
(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, at a minimum:
(1) Organizational arrangements and responsibilities for
quality management and improvement processes;
(2) A documented utilization management program;
(3) Written policies and procedures for credentialing and
recredentialing physicians and other licensed providers who fall
under the scope of authority of the prepaid limited health service organization;
(4) A written policy that addresses enrollees' rights and
responsibilities;
(5) The adoption of practice guidelines for the use of
preventive health services; and
(6) Any other criteria considered necessary by the
commissioner.
(c) This section becomes effective on the first day of May,
one thousand nine hundred ninety-nine.
§33-25C-20. Suspension or revocation of certificate of
authority.
(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 significantly in contravention of its basic
organizational document, in any material breach of contract with
an enrollee, or in a manner contrary to that described in and
reasonably inferred from any other information submitted under
section three of this article unless amendments to the
submissions have been filed with an approval of the commissioner;
(2) The prepaid limited health service organization issues
an evidence of coverage or uses a schedule of premiums limited health services which do not comply with the requirements of
section eleven of this article;
(3) The prepaid limited health service organization does not
provide or arrange for those limited health services which it has
contracted to provide to enrollees;
(4) The department of health and human resources or other
accredited entity certifies to the commissioner that:
(A) The prepaid limited health service organization is
unable to fulfill its obligations to furnish limited health
services as required under its contract with enrollees; or
(B) The prepaid limited health service organization does not
meet the requirements of subsection (a), section five of this
article;
(5) The prepaid limited health service organization is no
longer financially responsible and may reasonably be expected to
be unable to meet its obligations to enrollees or prospective
enrollees or is otherwise determined by the commissioner to be in
a hazardous financial condition;
(6) The prepaid limited health service organization has
failed to implement a mechanism affording the enrollees an
opportunity to participate in matters of policy and operation
under section eight of this article;
(7) The prepaid limited health service organization has
failed to implement the grievance procedure required by section fourteen of this article in a manner to reasonably resolve valid
grievances;
(8) The prepaid limited health service organization, or any
person on its behalf, has advertised or merchandised its services
in an untrue, misrepresentative, misleading, deceptive or unfair
manner;
(9) The continued operation of the prepaid limited health
service organization would be hazardous to its enrollees;
(10) The prepaid limited health service organization has
otherwise failed to substantially comply with this article;
(11) The prepaid limited health service organization has
violated a lawful order of the commissioner; or
(12) The prepaid limited health service organization has
failed to implement or maintain a quality assurance program
considered satisfactory by the commissioner which meets the
minimum standards set forth in section nineteen of this article.
(b) A certificate of authority may be suspended or revoked
only after compliance with the requirements of section
twenty-three of this article.
(c) When the certificate of authority of a prepaid limited
health service organization is suspended, the prepaid limited
health service organization may not, during the period of the
suspension, enroll any additional enrollees except newborn
children or other newly acquired dependents of existing enrollees, and may not engage in any advertising or solicitation.
(d) When the certificate of authority of a prepaid limited
health service organization is revoked, the organization shall
proceed, immediately following the effective date of the order of
revocation, to terminate its affairs, and may conduct no further
business except as may be essential to the orderly conclusion of
the affairs of the organization. It may engage in no further
advertising or solicitation. The commissioner may, by written
order, permit further operation of the organization as he or she
may find to be in the best interests of enrollees, to the end
that enrollees will be afforded the greatest practical
opportunity to obtain continuing limited health service coverage.
§33-25C-21. Rehabilitation, liquidation or conservation of
prepaid limited health service organization.
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 limited health service organization
as provided by this article and shall be conducted under the
supervision of the commissioner pursuant to the law governing the
rehabilitation, liquidation or conservation of insurance
companies. The commissioner may apply for an order directing him
or her to rehabilitate, liquidate or conserve a prepaid limited health service organization upon any one or more grounds set out
in the rehabilitation statutes or when, in his or her opinion,
the continued operation of the prepaid limited health service
organization would be hazardous either to the enrollees or to the
people of this state.
§33-25C-22. Rules.
The commissioner may propose rules for legislative approval
in accordance with the provisions of article three, chapter
twenty-nine-a of this code:
(1) To effectuate the purposes of this article and to
prevent circumvention and evasion thereof; and
(2) To define the commissioner's authority to consider the
operating results of a prepaid limited health service
organization's affiliates and subsidiaries in the rate making and
solvency determination of that prepaid limited health service
organization.
§33-25C-23. Administrative procedures.
(a) 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 or she shall notify the
prepaid limited health service organization in writing
specifically stating the grounds for denial, suspension or
revocation and fixing a time of at least twenty days thereafter for a hearing on the matter.
(b) After the hearing, or upon the failure of the prepaid
limited health service organization to appear at the hearing, the
commissioner shall take action as is considered advisable on
written findings which shall be mailed to the prepaid limited
health service organization. The action of the commissioner is
subject to review. The court may modify, affirm or reverse the
order of the commissioner, in whole or in part.
(c) Proceedings under this article are governed by the
provisions of section thirteen, article two of this chapter.
§33-25C-24. Fees.
Every prepaid limited health service organization subject to
this article shall pay to the commissioner the following fees: (1) For filing an application for a certificate of authority
or amendment thereto, two hundred dollars;
(2) For each renewal of a certificate of authority, the
annual fee as provided in section thirteen, article three of this
chapter;
(3) For each form filing and for each rate filing, the fee
as provided in section thirty-four, article six of this chapter;
and
(4) For filing each annual report, twenty-five dollars.
Fees charged under this section are for the purposes set
forth in section thirteen, article three of this chapter.
§33-25C-25. Penalties and enforcement.
(a) The commissioner may, in lieu of suspension or
revocation of a certificate of authority under section twenty of
this article, levy an administrative penalty in an amount not
less than one hundred dollars nor more than five thousand
dollars, if reasonable notice in writing is given of the intent
to levy the penalty and the prepaid limited health service
organization has a reasonable time within which to remedy the
defect in its operations which gave rise to the penalty citation.
The commissioner may augment this penalty by an amount equal to
the sum that he or she calculates to be the damages suffered by
enrollees or other members of the public.
(b) Any person who violates any provision of this article is
guilty of a misdemeanor and, upon conviction thereof, shall be
fined not less than one thousand dollars nor more than ten
thousand dollars, or confined in the county jail not more than
one year, or both fined and confined.
(c)(1) If the commissioner, for any reason, has cause to
believe that any violation of this article or rules promulgated
pursuant thereto has occurred or is threatened, prior to the levy
of a penalty or suspension or revocation of a certificate of
authority, the commissioner may give notice to the prepaid
limited health service organization and to the representatives,
or other persons who appear to be involved in the suspected violation, to arrange a conference with the alleged violators or
their authorized representatives for the purpose of attempting to
ascertain the facts relating to the suspected violation, and, in
the event it appears that any violation has occurred or is
threatened, to arrive at an adequate and effective means of
correcting or preventing the violation.
(2) Proceedings under this subsection are not governed by
any formal procedural requirements, and may be conducted in a
manner as the commissioner considers appropriate under the
circumstances. Enrollees shall be afforded notice by publication
of proceedings under this subsection and shall be afforded the
opportunity to intervene.
(d)(1) The commissioner may issue an order directing a
prepaid limited health service organization or a representative
of a prepaid limited health service organization to cease and
desist from engaging in any act or practice in violation of the
provisions of this article or rules promulgated pursuant this
article.
(2) Within ten days after service of the order of cease and
desist, the respondent may request a hearing on the question of
whether acts or practices in violation of this article have
occurred. The hearings shall be conducted pursuant to section
thirteen, article two of this chapter.
(e) In the case of any violation of the provisions of this article or rules promulgated pursuant this article, if the
commissioner elects not to issue a cease and desist order, or in
the event of noncompliance with a cease and desist order issued
pursuant to subsection (d) of this section, the commissioner may
institute a proceeding to obtain injunctive relief, or seek other
appropriate relief, in the circuit court of the county of the
principal place of business of the prepaid limited health service
organization.
(f) Any enrollee of or resident of this state may bring an
action against the prepaid limited health service organization to
enforce any provision, standard or rule enforceable by the
commissioner: Provided, That this subsection does not authorize
a civil action against the commissioner, his or her employees or
any other agency or instrumentality of this state. In the case
of any successful action to enforce this article, or accompanying
standards or rules, the individual shall be awarded the costs of
the action together with a reasonable attorney's fee as
determined by the court.
§33-25C-26. Statutory construction and relationship to other
laws.
(a) Except as otherwise provided in this article, provisions
of the insurance laws, provisions of hospital, medical, dental or
health service corporation laws and provisions of health
maintenance organization laws are not applicable to any prepaid limited health service organization granted a certificate of
authority under this article. The provisions of this article do
not apply to an insurer, hospital, medical, dental or health
service corporation, or health maintenance organization licensed
and regulated pursuant to the insurance laws, hospital, medical,
dental or health service corporation laws or health maintenance
organization laws of this state except with respect to its
prepaid limited health service corporation activities authorized
and regulated pursuant to this article. The provisions of this
article do not apply to an entity properly licensed by a
reciprocal state to provide a limited health care service to
employer groups, where residents of West Virginia are members of
an employer group, and the employer group contract is entered
into in the reciprocal state. For purposes of this subsection,
a "reciprocal state" means a state which physically borders West
Virginia and which has subscriber or enrollee hold harmless
requirements substantially similar to those set out in section
ten of this article.
(b) Factually accurate advertising or solicitation regarding
the range of services provided, the premiums and copayments
charged, the sites of services and hours of operation, and any
other quantifiable, nonprofessional aspects of its operation by
a prepaid limited health service organization granted a
certificate of authority, or its representative do not violate any provision of law relating to solicitation or advertising by
health professions: Provided, That nothing contained in this
subsection authorizes any solicitation or advertising which
identifies or refers to any individual provider or makes any
qualitative judgment concerning any provider.
(c) Any prepaid limited health service organization
authorized under this article is not considered to be practicing
medicine and is exempt from the provision of chapter thirty of
this code, relating to the practice of medicine.
(d) The provisions of section nine, article two,
examinations; section thirteen, article two, hearings; sections
fifteen and twenty, article four, general provisions; section
twenty, article five, borrowing by insurers; section seventeen,
article six, noncomplying forms; article six-c, guaranteed loss
ratio; article seven, assets and liabilities; article eight,
investments; article nine, administration of deposits; article
ten, rehabilitation and liquidation; article twelve, agents,
brokers, solicitors and excess line; section fourteen, article
fifteen, individual accident and sickness insurance; section
sixteen, article fifteen, coverage of children; section eighteen,
article fifteen, equal treatment of state agency; section
nineteen, article fifteen, coordination of benefits with
medicaid; article fifteen-b, uniform health care administration
act; section three, article sixteen, required policy provisions; section eleven, article sixteen, coverage of children; section
thirteen, article sixteen, equal treatment of state agency;
section fourteen, article sixteen, coordination of benefits with
medicaid; article sixteen-a, group health insurance conversion;
article sixteen-d, marketing and rate practices for small
employers; article twenty-seven, insurance holding company
systems; article thirty-three, annual audited financial report;
article thirty-four, administrative supervision; article
thirty-four-a, standards and commissioner's authority for
companies deemed to be in hazardous financial condition; article
thirty-five, criminal sanctions for failure to report impairment;
article thirty-seven, managing general agents; article
thirty-nine, disclosure of material transactions; and article
forty-one, privileges and immunity, all of this chapter are
applicable to any prepaid limited health service organization
granted a certificate of authority under this article. In
circumstances where the code provisions made applicable to
prepaid limited health service organizations by this section
refer to the "insurer," the "corporation" or words of similar
import, the language includes prepaid limited health service
organizations.
(e) Any long-term care insurance policy delivered or issued
for delivery in this state by a prepaid limited health service
organization shall comply with the provisions of article fifteen-a of this chapter.
(f) A prepaid limited health service organization granted a
certificate of authority under this article is exempt from paying
municipal business and occupation taxes on gross income it
receives from its enrollees, or from their employers or others on
their behalf, for health care items or services provided directly
or indirectly by the prepaid limited health service organization.
§33-25C-27. Filings and reports as public documents.
All applications, filings and reports required under this
article are public documents: Provided, That where the provisions
of other articles in this chapter are applicable to prepaid
limited health service organizations, all applications, filings
and reports required under those articles shall be afforded the
level of confidentiality as provided in those articles.
§33-25C-28. Confidentiality of medical information.
(a) Any data or information pertaining to the diagnosis,
treatment or health of any enrollee or applicant obtained from
that person or from any provider by any prepaid limited health
service organization shall be held in confidence and may not be
disclosed to any person except:
(1) To the extent that it may be necessary to facilitate an
assessment of the quality of care delivered pursuant to section
eighteen of this article or to review the grievance procedure
pursuant to section fourteen of this article;
(2) Upon the express written consent of the enrollee or his
or her legally authorized representative;
(3) Pursuant to statute or court order for the production
of evidence or the discovery thereof;
(4) In the event of claim or litigation between that person
and the prepaid limited health service organization where the
data or information is pertinent;
(5) To a department or division of the state pursuant to
the terms of a group contract for the provision of health care
services between the prepaid limited health service organization
and the department or division of the state; or
(6) For a medicaid recipient enrolled under a group
contract between a prepaid limited health service organization
and the governmental agency responsible for administering the
medicaid program, in accordance with confidentiality rules
applicable to the medicaid program.
(b) A prepaid limited health service organization is
entitled to claim any statutory privileges against the disclosure
which the provider who furnished the information to the prepaid
limited health service organization is entitled to claim.
(c) Any information provided to the division of insurance
that is part of the division investigation or examination is
confidential and exempt from disclosure under subsection (a) of
this section or otherwise until the investigation is completed or ceases to be active. For purposes of this subsection, an
investigation is considered "active" while the investigation is
being conducted by the division with a reasonable, good faith
belief that it may lead to the filing of administrative, civil,
or criminal proceedings. An investigation does not cease to be
active if the division is proceeding with reasonable dispatch and
there is a good faith belief that action may be initiated by the
division or other administrative or law enforcement agency.
After an investigation or examination is completed or ceases to
be active, portions of the records relating to the investigation
or examination remain confidential and are exempt from disclosure
under subsection (a) of this section or otherwise if the
disclosure would:
(1) Jeopardize the integrity of another active
investigation;
(2) Impair the safety and financial soundness of the
licensee or affiliated party;
(3) Reveal personal financial information;
(4) Reveal the identity of a confidential source;
(5) Defame or cause unwarranted damage to the good name or
reputation of an individual or jeopardize the safety of an
individual; or
(6) Reveal investigative techniques or procedures.
§33-25C-29. Authority to contract with prepaid limited health service organizations under medicaid.
The department of health and human resources is authorized
to enter into contracts with prepaid limited health service
organizations certified and permitted to market under the laws of
this state, and to furnish to recipients of medical assistance
under Title XIX of the Social Security Act, 42 U.S.C. § 1396, et
seq., limited health services offered to such recipients under
the medical assistance plan of West Virginia.
§33-25C-30. Authority of commissioner to propose rules
regarding affiliate and subsidiary operating
results.
The commissioner may after notice and hearing propose rules
for legislative approval in accordance with the provisions of
article three, 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 the rate making and
solvency determination of that insurer.
NOTE: The purpose of this bill is to authorize the creation
of prepaid limited health service organizations and provide for
their regulation.
Strike-throughs indicate language that would be stricken
from present law, and underscoring indicates new language that
would be added.
Article 25C is new; therefore, strike-throughs and
underscoring have been omitted.