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Chapter 33     Entire Code
‹ Chapter 32B  |  Chapter 34 › Printer Friendly Versions
Chapter 33  |  Article 33 - 25E

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

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
    33 - 25 E- 1
    33 - 25 E- 2
    33 - 25 E- 2
    33 - 25 E- 3
    33 - 25 E- 4
    33 - 25 E- 5

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

50 - PATIENT PROTECTION AND TRANSP

WVC 33 - CHAPTER 33. INSURANCE.
WVC 33 - 25 E- ARTICLE 25E. PATIENTS' EYE CARE ACT. WVC 33 - 25 E- 1 §33-25E-1. Short title.
This article may be referred to as the patients' eye care act.

WVC 33-25E-2

§33-25E-2. Definitions.

For the purposes of this article:

(1) “Commissioner” means the Insurance Commissioner of West Virginia.

(2) “Covered services” and “covered materials” means services or materials for which reimbursement from the insurer or vision care plan or vision care discount plan is available under an enrollee’s vision plan or contract, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments or other limitations.

(3) "Covered person" means an individual enrolled in a health benefit plan or an eligible dependent of that person.

(4) “Enrollee” means any individual enrolled in a health care plan, vision care plan or vision care discount plan provided by a group, employer or other entity that purchases or supplies coverage for a vision care plan or vision care discount plan.

 (5) “Eye care provider” means a licensed doctor of optometry practicing under the authority of article eight, chapter thirty of this code or a licensed medical physician specializing in ophthalmology licensed in West Virginia to practice medicine and surgery under the authority of article three, chapter thirty of this code or osteopathy under article fourteen, chapter thirty of this code.

(6) "Eye care benefits" means coverage for the diagnosis, treatment and management of eye disease and injury.

(7) "Health benefit policy" means any individual or group plan, policy or contract providing medical, hospital or surgical coverage issued, delivered, issued for delivery or renewed in this state by an insurer, after January 1, 2001. It does not include credit accident and sickness, long-term care, Medicare supplement, champus supplement, disability or limited benefits policies.

(8) "Insurer" means any health care corporation, health maintenance organization, accident and sickness insurer, nonprofit hospital service corporation, nonprofit medical service corporation or similar entity.

 (9) “Materials” means ophthalmic devices, including, but not limited to, lenses, devices containing lenses, artificial intraocular lenses, ophthalmic frames and other lens-mounting apparatus, prisms, lens treatments and coatings, contact lenses and prosthetic devices to correct, relieve or treat defects or abnormal conditions of the human eye or its adnexa.

(10) “Services” means the professional work performed by an eye care provider.

(11) “Subcontractor” means any company, group or third party entity, including, but not limited to, agents, servants, partially- or wholly-owned subsidiaries and controlled organizations that is contracted by the insurer, vision care plan or vision care discount plan to supply services or materials for an eye care provider or enrollee to fulfill the benefit plan of an insurer, vision care plan or vision care discount plan.

(12) "Vision care benefits" means benefits for the refraction of the eyes and other optical benefits.

(13) “Vision care discount plan” means a business arrangement or contract offered by an insurer in which a person, in exchange for fees, dues, charges or other consideration, offers access for its plan members to providers of eye care or ancillary services and the right to receive discounts on eye care or ancillary services provided under the discount vision care plan from those providers.

(14) “Vision care plan” means an entity that creates, promotes, sells, provides, advertises or administers an integrated or stand-alone vision benefit plan, or a vision care insurance policy or contract which provides vision benefits to an enrollee pertaining to the provision of covered services or covered materials.

WVC 33 - 25 E- 2 §33-25E-2. Definitions.
For the purposes of this article:

(a) "Covered person" means an individual enrolled in a health benefit plan or an eligible dependent of that person.

(b) "Eye care provider" means an optometrist or ophthalmologist licensed by the state of West Virginia.

(c) "Eye care benefits" means coverage for the diagnosis, treatment and management of eye disease and injury.

(d) "Health benefit policy" means any individual or group plan, policy or contract providing medical, hospital or surgical coverage issued, delivered, issued for delivery or renewed in this state by an insurer, after the first day of January, two thousand one. It does not include credit accident and sickness, long-term care, medicare supplement, champus supplement, disability or limited benefits policies.

(e) "Insurer" means any health care corporation, health maintenance organization, accident and sickness insurer, nonprofit hospital service corporation, nonprofit medical service corporation or similar entity.

(f) "Vision care benefits" means benefits for the refraction of the eyes and other optical benefits.

WVC 33 - 25 E- 3 §33-25E-3. Limitations on conditions of coverage.
(a)Health benefits policies may not require that an optometrist hold hospital staff privileges.

(b)When any health benefits policy provides for the payment of eye care benefits or vision care benefits, such policy shall be construed to include payment to all eye care providers who provide benefits within the scope of their providers' licenses.

(c)Any limitation or condition placed upon services, diagnosis or treatment by or payment to a particular type of licensed provider shall apply equally to all licensed providers without unfair discrimination as to the usual and customary treatment procedures of an eye care provider.

(d)Any health benefits policy that includes eye care benefits, including a diabetic retinal examination, shall provide each covered person diagnosed with diabetes direct access to an eye care provider of their choice from the insurer's panel of providers independent of, and without referral from, any other provider or entity for one annual diabetic retinal examination. The eye care provider shall provide copies of the results of the examination to the covered person's primary care physician. No other services shall be provided to the covered person by the eye care provider without the prior authorization of the insurer or of its designee. This benefit shall be subject to all coinsurance, deductibles, copayments and other policy requirements. When the diabetic retinal examination reveals the beginning stages of an abnormal condition, access to future examinations shall be subject to prior authorization from a primary care physician.

(e)Any health benefits policy that includes eye care benefits or vision care benefits shall include both optometrists and ophthalmologists.

(f)This article may not be construed to require any health benefits policy to cover any specific health care service.

(g)This article may not be construed to require a health benefit plan or an insurer to include on the insurer's panel of providers all providers willing to meet the terms and conditions of participation as a plan provider.

WVC 33 - 25 E- 4 §33-25E-4. Required disclosure.
Every health benefits policy that is issued, delivered, issued for redelivery or renewed in this state on or after the first day of January, two thousand one, that provides for eye care benefits, including a diabetic retinal examination, shall disclose in writing, in clear and accurate language, to enrollees, subscribers, providers and insureds that any covered person diagnosed with diabetes has the right to direct access to an eye care provider of their choice from the insurer's panel of providers for an annual diabetic retinal examination.

WVC 33-25E-5

§33-25E-5. Noncovered discounts.

(a) An agreement between an insurer, vision care plan or vision care discount plan and an eye care provider may not seek to or require that an eye care provider provide services or materials at a fee limited or set by the insurer, vision care plan or vision care discount plan, unless the services or materials are reimbursed as covered services or covered materials under the contract.

(1) An eye care provider may not charge more for services and materials that are non-covered services or non-covered materials to an enrollee of a vision care plan, vision care discount plan or insurer than his or her usual and customary rate for the services and materials.

(2) Reimbursements paid by an insurer, vision care plan or vision care discount plan for covered services and covered materials, regardless of supplier or optical lab used to obtain materials, shall be reasonable, shall be clearly listed on a fee schedule that is made available to the eye care provider prior to accepting a contract from the insurer, vision care plan or vision discount plan and shall not provide nominal reimbursement or advertise services and materials to be covered with additional copay or coinsurance if the health plan, vision care plan or vision care discount plan does not reimburse for the services or materials in order to claim that services and materials are covered services and materials.

(3) Insurers, vision care plans and vision care discount plans shall not falsely represent, publish or disseminate the benefits that are provided to groups, employers or individual enrollees as a means of selling coverage to or communicating benefit coverage to enrollees.

(4) All provisions in this section apply to any successors in interest of an insurer, vision care plan or vision care discount plan and apply to any subcontractors that are used by an insurer, vision care plan or vision care discount plan to supply materials or services to an eye care provider or enrollee and are subject to all applicable penalties as provided in this section.

(b) An agreement between an insurer, vision care plan or vision care discount plan and an eye care provider may not require that an eye care provider must participate with or be credentialed by any specific vision care plan or vision care discount plan as a condition of participation in the health care network of the insurer to provide covered medical services to its enrollees.

(1) Any insurer issuing or renewing a health benefit plan, vision care plan or vision care discount plan issued or renewed which provides coverage for services rendered by an eye care provider shall provide the same reimbursement for services to optometrists as allowed for those services rendered by physicians or osteopaths.

(2) An insurer may not require an optometrist to meet terms and conditions that are not required of a physician or osteopath as a condition for participation in its provider network for the provision of services that are within the scope of practice of an optometrist.

(3) If an eye care provider enters into any subcontract agreement with another provider to provide covered services or covered materials to an enrollee which provides that the subcontracted provider will bill the vision care plan or enrollee directly for the subcontracted services or materials, the subcontract agreement shall meet all requirements of this section.

(4) The provisions of subdivisions (1), (2) and (3) of this subsection also apply to any agreements an insurer enters into for services covered under the health benefit plan, vision care plan or vision care discount plan.

(c) An insurer, vision care plan or vision care discount plan may not change or alter an agreement entered into with an eye care provider without performing the following steps:

(1) Mailing a certified letter detailing proposed changes to the eye care provider;

(2) Obtaining agreement or disagreement to the proposed changes from the eye care provider; and

(3) Providing a new agreement after three or more material changes are made to an existing agreement from an insurer, vision care plan or vision care discount plan.

(d) An agreement between an insurer, vision care plan or vision care discount plan and an eye care provider may not restrict or limit, either directly or indirectly, the eye care provider’s choice of sources and suppliers of services or materials or use of optical labs provided by the eye care provider to an enrollee.

(e) An insurer, vision care plan or vision care discount plan may not change the terms, discounts or reimbursement rates contained in the agreement, regardless of supplier or fabricating lab used to supply materials, without a signed acknowledgement of written agreement from the eye care provider.

(f) A person or entity adversely affected by a violation of this section may bring action in a court of competent jurisdiction for injunctive relief against the insurer, vision care plan or vision care discount plan and, upon prevailing, may recover monetary damages of no more than $1,000 for each instance found to be in violation of this section, plus attorneys’ fees and costs.

(g) In a fiscal year, an insurer, vision care plan or vision care discount plan may not charge back or otherwise recoup administrative fees or other amounts from an eye care provider in a total amount of more than three percent of the payments received by the eye care provider from the insurer, vision care plan or vision care discount plan for providing services to enrollees without the written agreement of the eye care provider.

(h) The Commissioner may seek an injunction against an insurer, vision care plan or vision care discount plan in a court of competent jurisdiction for violation of this section.

(i) The requirements of this section apply to insurers, vision care plans, vision care discount plans, contracts, addendums and certificates executed, delivered, issued for delivery, continued or renewed in the State of West Virginia.

(1) An insurer, vision care plan or vision care discount plan contract may not be in effect for more than two years from the date that it was first signed.

(2) An insurer, vision care plan or vision care discount plan may not construe recredentialing as recontracting with an eye care provider.

 (j) An insurer, vision care plan or vision care discount plan may not discriminate against any eye care provider who is located within the geographic coverage area of the insurer, vision care plan or vision care discount plan and who is willing to meet the terms and conditions for participation established by the insurer, vision care plan or vision care discount plan, including West Virginia Medicaid programs and Medicaid partnerships.

(k) This section becomes effective on July 1, 2016, and applies to vision care plans and vision care discount plans which take effect or are renewed on or after July 1, 2016.

Note: WV Code updated with legislation passed through the 2016 Regular Session
The West Virginia Code Online is an unofficial copy of the annotated WV Code, provided as a convenience. It has NOT been edited for publication, and is not in any way official or authoritative.


Recent legislation affecting the Code

Citation Year/Session Short Title
§33 - 20 F- 2 - (Amended Code)
§33 - 20 F- 4 - (Amended Code)
SENATE BILL - 278
PASSED - Regular Session

SB278 SUB1 enr  (Uploaded - 03/16/2016)
Clarifying physicians' mutual insurance company is not state or quasi-state actor
§33 - 6 A- 1 - (Amended Code)
SENATE BILL - 330
PASSED - Regular Session

SB330 SUB1 ENR  (Uploaded - 03/11/2016)
Requiring automobile liability insurers provide 10 days' notice of intent to cancel due to nonpayment of premium
§33 - 24 - 4 - (Amended Code)
§33 - 25 - 6 - (Amended Code)
§33 - 25 A- 24 - (Amended Code)
§33 - 25 D- 26 - (Amended Code)
§33 - 40 - 1 - (Amended Code)
§33 - 40 - 2 - (Amended Code)
§33 - 40 - 3 - (Amended Code)
§33 - 40 - 6 - (Amended Code)
§33 - 40 - 7 - (Amended Code)
§33 - 40 A- 1 - (New Code)
§33 - 40 A- 2 - (New Code)
§33 - 40 A- 3 - (New Code)
§33 - 40 A- 4 - (New Code)
§33 - 40 A- 5 - (New Code)
§33 - 40 A- 6 - (New Code)
§33 - 40 A- 7 - (New Code)
§33 - 40 A- 8 - (New Code)
§33 - 40 A- 9 - (New Code)
§33 - 40 A- 10 - (New Code)
§33 - 40 A- 11 - (New Code)
§33 - 40 A- 12 - (New Code)
SENATE BILL - 429
PASSED - Regular Session

SB429 SUB1 ENR  (Uploaded - 03/11/2016)
Adopting two National Association of Insurance Commissioners' models to protect enrollees and general public and permit greater oversight
§33 - 31 - 2 - (Amended Code)
§33 - 46 A- 9 - (Amended Code)
SENATE BILL - 465
PASSED - Regular Session

SB465 SUB1 enr  (Uploaded - 03/18/2016)
Allowing professional employer insure certain risks through pure insurance captive
§33 - 15 - 4 M - (New Code)
§33 - 16 - 3 Y - (New Code)
§33 - 24 - 7 N - (New Code)
§33 - 25 - 8 K - (New Code)
§33 - 25 A- 8 M - (New Code)
HOUSE BILL - 4038
PASSED - Regular Session

HB4038 SUB ENR  (Uploaded - 03/23/2016)
Relating to insurance requirements for the refilling of topical eye medication
§33 - 15 - 4 O - (New Code)
§33 - 16 - 3AA - (New Code)
§33 - 24 - 7 P - (New Code)
§33 - 25 - 8 M - (New Code)
§33 - 25 A- 8 O - (New Code)
HOUSE BILL - 4040
PASSED - Regular Session

HB4040 SUB ENR  (Uploaded - 03/18/2016)
Regulating step therapy protocols in health benefit plans
§33 - 15 - 4 N - (New Code)
§33 - 16 - 3 Z - (New Code)
§33 - 24 - 7 O - (New Code)
§33 - 25 - 8 L - (New Code)
§33 - 25 A- 8 N - (New Code)
HOUSE BILL - 4146
PASSED - Regular Session

HB4146 SUB ENR  (Uploaded - 03/23/2016)
Providing insurance cover abuse-deterrent opioid analgesic drugs
§33 - 25 E- 2 - (Amended Code)
§33 - 25 E- 5 - (New Code)
HOUSE BILL - 4655
PASSED - Regular Session

hb4655 ENR  (Uploaded - 03/23/2016)
Prohibiting insurers, vision care plan or vision care discount plans from requiring vision care providers to provide discounts on noncovered services or materials
§33 - 30 - 6 - (Amended Code)
§33 - 30 - 8 - (Amended Code)
HOUSE BILL - 4734
PASSED - Regular Session

HB4734 ENR  (Uploaded - 03/11/2016)
Relating to mine subsidence insurance
§33 - 13 D- 1 - (New Code)
§33 - 13 D- 2 - (New Code)
HOUSE BILL - 4739
PASSED - Regular Session

hb4739 ENR  (Uploaded - 03/17/2016)
Unclaimed Life Insurance Benefits Act
§33 - 3 - 33 A - (Amended Code)
HOUSE BILL - 128
PASSED - 1st Special Session

hb128 ENR  (Uploaded - 06/21/2016)
Extending the Volunteer Fire Department Workers' Compensation Premium Subsidy Fund
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