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Chapter 33     Entire Code
‹ Chapter 32B  |  Chapter 34 › Printer Friendly Versions
Chapter 33  |  Article 33 - 16F

1 - DEFINITIONS

2 - INSURANCE COMMISSIONER

3 - LICENSING, FEES AND TAXATION OF

3A - STATE OF ENTRY FOR FOREIGN INS

4 - GENERAL PROVISIONS

4A - ALL-PAYER CLAIMS DATABASE

5 - ORGANIZATION AND PROCEDURES OF

6 - THE INSURANCE POLICY

6A - CANCELLATION OR NONRENEWAL OF

6B - DECLINATION OF AUTOMOBILE LIAB

6C - GUARANTEED LOSS RATIOS AS APPL

6D - MOTOR VEHICLE REPAIR AND REPLA

6F - DISCLOSURE OF NONPUBLIC PERSON

7 - ASSETS AND LIABILITIES

8 - INVESTMENTS

8A - USE OF CLEARING CORPORATIONS A

9 - ADMINISTRATION OF DEPOSITS

10 - REHABILITATION AND LIQUIDATIO

11 - UNFAIR TRADE PRACTICES

11A - INSURANCE SALES CONSUMER PRO

12 - INSURANCE PRODUCERS AND SOLIC

12A - CONTRACTUAL RELATIONSHIPS BE

12B - ADJUSTERS

12C - SURPLUS LINE

13 - LIFE INSURANCE

13A - VARIABLE CONTRACTS

13B - CHARITABLE GIFT ANNUITIES

13C - VIATICAL SETTLEMENTS ACT

14 - GROUP LIFE INSURANCE

15 - ACCIDENT AND SICKNESS INSURAN

15A - WEST VIRGINIA LONG-TERM CARE

15B - UNIFORM HEALTH CARE ADMINIST

15C - DIABETES INSURANCE

15D - INDIVIDUAL LIMITED HEALTH BE

15E - DISCOUNT MEDICAL PLAN ORGANI

16 - GROUP ACCIDENT AND SICKNESS I

16A - GROUP HEALTH INSURANCE CONVE

16B - ACCIDENT AND SICKNESS RATES

16C - EMPLOYER GROUP ACCIDENT AND

16D - MARKETING AND RATE PRACTICES

16E - CONTRACEPTIVE COVERAGE

16F - GROUP LIMITED HEALTH BENEFIT
    33 - 16 F- 1
    33 - 16 F- 2
    33 - 16 F- 3
    33 - 16 F- 4
    33 - 16 F- 5
    33 - 16 F- 6
    33 - 16 F- 7
    33 - 16 F- 8
    33 - 16 F- 9
    33 - 16 F- 10

16G - WEST VIRGINIA HEALTH BENEFIT

16H - REVIEW OF ADVERSE DETERMINAT

17 - FIRE AND MARINE INSURANCE

17A - PROPERTY INSURANCE DECLINATI

18 - CASUALTY INSURANCE

19 - SURETY INSURANCE

20 - RATES AND RATING ORGANIZATION

20A - WEST VIRGINIA ESSENTIAL INSU

20B - RATES AND MALPRACTICE INSURA

20C - CANCELLATION OR NONRENEWAL O

20D - TAIL INSURANCE

20E - WEST VIRGINIA MEDICAL PROFES

20F - PHYSICIANS' MUTUAL INSURANCE

21 - RECIPROCAL INSURERS

22 - FARMERS' MUTUAL FIRE INSURANC

23 - FRATERNAL BENEFIT SOCIETIES

24 - HOSPITAL SERVICE CORPORATIONS

25 - HEALTH CARE CORPORATIONS

25A - HEALTH MAINTENANCE ORGANIZAT

25B - FEDERAL INSURANCE SUBSIDY FO

25C - HEALTH MAINTENANCE ORGANIZAT

25D - PREPAID LIMITED HEALTH SERVI

25E - PATIENTS' EYE CARE ACT

25F - COVERAGE FOR PATIENT COST OF

25G - PROVIDER SPONSORED NETWORKS

26 - WEST VIRGINIA GUARANTY ASSOCI

26A - WEST VIRGINIA LIFE AND HEALT

26B - WEST VIRGINIA HEALTH MAINTEN

27 - INSURANCE HOLDING COMPANY SYS

28 - INDIVIDUAL ACCIDENT AND SICKN

29 - LIFE AND ACCIDENT AND SICKNES

30 - MINE SUBSIDENCE INSURANCE

31 - CAPTIVE INSURANCE

31A - SPONSORED CAPTIVE INSURANCE

32 - RISK RETENTION ACT

33 - ANNUAL AUDITED FINANCIAL REPO

34 - ADMINISTRATIVE SUPERVISION

34A - STANDARDS AND COMMISSIONER'S

35 - CRIMINAL SANCTIONS FOR FAILUR

36 - BUSINESS TRANSACTED WITH PROD

37 - MANAGING GENERAL AGENTS

38 - REINSURANCE INTERMEDIARY ACT

39 - DISCLOSURE OF MATERIAL TRANSA

40 - RISK-BASED CAPITAL (RBC) FOR

41 - PRIVILEGES AND IMMUNITY

42 - WOMEN'S ACCESS TO HEALTH CARE

43 - INSURANCE TAX PROCEDURES ACT

44 - UNAUTHORIZED INSURERS ACT

45 - ETHICS AND FAIRNESS IN INSURE

46 - THIRD-PARTY ADMINISTRATOR ACT

46A - PROFESSIONAL EMPLOYER ORGANI

47 - INTERSTATE INSURANCE PRODUCT

48 - MODEL HEALTH PLAN FOR UNINSUR

49 - FLOOD INSURANCE

WVC 33 - CHAPTER 33. INSURANCE.
WVC 33 - 16 F- ARTICLE 16F. GROUP LIMITED HEALTH BENEFITS PLANS.

WVC 33 - 16 F- 1 §33-16F-1. Legislative intent.
The Legislature finds that the inability of a significant number of state residents to obtain affordable health insurance coverage adversely affects everyone in our state. Therefore, it is the intent of the Legislature to expand the availability of health care options for uninsured residents by developing affordable health care products that emphasize coverage for basic and preventive health care services, provide inpatient hospital and emergency care services and offer optional catastrophic coverage.

WVC 33 - 16 F- 2 §33-16F-2. Definitions.
As used in this article:

"West Virginia affordable health care plan" means a health insurance plan approved under this article.

"West Virginia affordable health care plan entity" or "plan entity" means an entity licensed under this chapter that develops and proposes a West Virginia affordable health care plan and, if the plan is approved, is responsible for administering the plan and paying claims of plan enrollees.

"Enrollee" means an individual who has been determined to be eligible for and is receiving health insurance coverage under a West Virginia affordable health care plan.

WVC 33 - 16 F- 3 §33-16F-3. Plan proposals; approval of plans.
(a) The commissioner shall announce, no later than July 1, 2009, an invitation to prospective West Virginia affordable health care plan entities to submit West Virginia affordable health care plan proposals. The invitation shall include guidelines for the review of West Virginia affordable health care plan applications, policies and associated rates.

(b) In reviewing proposals under this article, the commissioner shall consider the proposed plans' effectiveness in improving the health status of individuals, their impact on maintaining and improving health and their potential to reduce the unnecessary consumption of health care services.

WVC 33 - 16 F- 4 §33-16F-4. Required plan provisions; grounds for disapproval; alternative plans.

(a) To be approved, plan entities must assure that each proposed plan will provide cost containment through the use of plan design features such as limits on the number of services, caps on benefit payments or copayments for services.

(b) To provide consumer choice, plan entities must develop and submit two alternative benefit option plans having different cost and benefit levels, including at least one plan that provides catastrophic coverage. Plans providing catastrophic coverage must, at a minimum, provide coverage for preventive health services and inpatient hospital stays and may also include coverage of one or more of the following: Hospital emergency care services and outpatient facility services; outpatient surgery; or outpatient diagnostic services.

(c) All plans must offer prescription drug benefit coverage.

(d) Plan enrollment materials must provide information in plain language on policy benefit coverage, benefit limits, cost-sharing requirements, exclusions and a clear representation of what is not covered in the plan. The enrollment materials must include a standard disclosure form developed by the commissioner that must be reviewed and executed by all consumers purchasing West Virginia affordable health care plan coverage.

(e) The commissioner shall disapprove any plan that:

(1) Contains any ambiguous, inconsistent or misleading provisions or any exceptions or conditions that deceptively affect or limit the benefits purported to be assumed in the general coverage provided by the plan;

(2) Provides benefits that are unreasonable in relation to the premium charged; or

(3) Contains provisions that are unfair or inequitable, contrary to the public policy of this state, encourage misrepresentation or result in unfair discrimination in sales practices.

WVC 33 - 16 F- 5 §33-16F-5. Eligibility of individuals and groups.
(a) Individuals. -- Eligibility to enroll in an individual West Virginia affordable health care plan is limited to any resident of this state who:

(1) Is not covered by a private insurance policy and is not eligible for coverage under an employer-sponsored group plan or through a public health insurance program, such as Medicare, Medicaid or the state Children's Health Insurance Program; and

(2) Has not been covered by any health insurance program at any time during the past six months, unless coverage under a health insurance program was terminated within the previous six months due to loss of a job that provided an employer-sponsored health benefit plan or death of, or divorce from, a spouse who was provided an employer-sponsored health benefit plan or, with respect to a public health insurance program, eligibility for such program was lost due to an inability to meet income or categorical requirements: Provided, That an individual may not be excluded from enrollment in a West Virginia affordable health care plan on the ground that he or she is eligible for or is enrolled in a COBRA plan.

(b) Group. -- An otherwise eligible group may not obtain coverage under a West Virginia affordable health care plan unless the group has not had coverage under any health insurance plan at any time during the previous six months.

WVC 33 - 16 F- 6 §33-16F-6. Regulation and marketing of plans.
(a) The commissioner shall issue guidelines to ensure that West Virginia affordable health care plans meet minimum standards for quality of and access to care.

(b) Initial filings and changes in West Virginia affordable health care plan benefits, premiums and policy forms are subject to regulatory oversight by the commissioner.

(c) The commissioner shall develop a public awareness program to be implemented throughout the state for the promotion of the plans approved under this article, which may include assistance from state health insurance benefits advisors.

(d) Each West Virginia affordable health care plan must maintain enrollment data and provide network data and reasonable records to enable the commissioner to assess the plans.

WVC 33 - 16 F- 7 §33-16F-7. Applicability of certain provisions; commissioner's authority to forbear from applying certain provisions.
(a) Individual plans. -- Only the following provisions of article fifteen of this chapter apply to West Virginia entities offering individual plans pursuant to this article: Sections two-a, two-d, two-e, three, four, four-c, four-e, four-f, four-g, five, six, seven, eight, nine, thirteen, fourteen, sixteen, seventeen, eighteen, nineteen and twenty. Notwithstanding any other provision of this code, the provisions of article twenty-eight of this chapter and legislative rules regulating individual accident and sickness policies, including the rule contained in series 12, title 114 of the West Virginia Code of State Rules, do not apply to individual plans issued pursuant to this article unless and to the extent specifically incorporated in rules promulgated pursuant to the authority conferred by section eleven of this article.

(b) Group plans. -- Only the following provisions of article sixteen of this chapter apply to insurers offering group plans pursuant to this article: Sections one-a, three, three-g, three-j, three-k, three-l, three-m, three-n, three-o, three-p, four, five, six, seven, nine, ten, eleven, twelve, thirteen, fourteen and fifteen; all other provisions of article sixteen do not apply to group plans approved pursuant to this article unless and to the extent the provisions are specifically incorporated in rules promulgated by the commissioner. Notwithstanding any other provision of this code or of the code of state rules, the provisions of article sixteen-e of this chapter and of legislative rules regulating group accident and sickness policies, including the rule set forth in series 39, title 114 of the West Virginia Code of State Rules, do not apply to group plans approved pursuant to this article unless and to the extent specifically incorporated in rules promulgated by the commissioner pursuant to the authority conferred by section eleven of this article.

(c) Small group plans. -- With respect to any group plan approved under this article and offered to any "small employer", as that term is defined in section two, article sixteen-d of this chapter, the following provisions of article sixteen-d apply: Sections two, four, seven, eight, twelve, thirteen and fourteen: Provided, That only the sentence preceding the proviso in section thirteen, article sixteen-d of this chapter applies to small employer plans approved pursuant to this article. Notwithstanding any other provision of this code, all other provisions of article sixteen-d of this chapter do not apply to small employer plans approved pursuant to this article unless and to the extent such provisions are specifically incorporated in rules promulgated by the commissioner.

(d) Forbearance by the commissioner. -- The commissioner may forbear from applying any other statutory or regulatory requirements to an insurer offering an individual or group plan approved pursuant to this article, including any requirements in articles twenty-four and twenty-five-a of this chapter, if he or she determines that such forbearance serves the principles set forth in section one of this article.

(e) Existing limited benefit plans. -- Plans approved pursuant to the provisions of article fifteen-d of this chapter, as that article existed prior to its repeal during the 2009 regular legislative session, and this article, as that it existed prior to its amendment and reenactment during the 2009 regular legislative session, remain in effect and are subject to those provisions.

WVC 33 - 16 F- 8 §33-16F-8. Assessment of the West Virginia program.
The commissioner shall:

(1) Provide an assessment of the West Virginia affordable health care plans and their potential applicability in other settings;

(2) Use West Virginia affordable health care plans to gather more information to evaluate low-income, consumer-driven benefit packages; and

(3) Submit by March 1, 2011, and annually thereafter, a report to the Governor, the President of the Senate and the Speaker of the House of Delegates that provides the information specified in this section and recommendations relating to the successful implementation and administration of the program.

WVC 33 - 16 F- 9 §33-16F-9. Nonentitlement.
Coverage under a West Virginia affordable health care plan is not an entitlement and a cause of action does not arise against the state, a local government entity, any other political subdivision of the state or any agency for failure to make coverage available to eligible persons under this article.

WVC 33 - 16 F- 10 §33-16F-10. Emergency and legislative rules authorized.
The commissioner may promulgate emergency and legislative rules under the provisions of article three, chapter twenty-nine-a of this code, to prescribe requirements regarding rate making, which may include rules establishing loss ratio standards for the plans; to place limitations on eligibility for coverage under the approved plans; to establish standards to determine whether a plan qualifies as creditable coverage; to determine what medical treatments, procedures and related health services benefits must be included in the plans; and to provide for any other matters deemed necessary to further the intent of this article.

Note: WV Code updated with legislation passed through the 2014 1st Special Session
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