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Chapter 33     Entire Code
‹ Chapter 32B  |  Chapter 34 › Printer Friendly Versions
Chapter 33  |  Article 33 - 25G  |  Section 3

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

25F - COVERAGE FOR PATIENT COST OF

25G - PROVIDER SPONSORED NETWORKS
    33 - 25 G- 1
    33 - 25 G- 2
    33 - 25 G- 3
    33 - 25 G- 4
    33 - 25 G- 5

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.
ARTICLE 25G - PROVIDER SPONSORED NETWORKS ARTICLE 25G. PROVIDER SPONSORED NETWORKS. WVC 33 - 25 G- 1 §33-25G-1. Legislative findings.

     The Legislature finds that, in light of the need to provide health care to a Medicaid population that is expected to rise dramatically in the near future, new models of managed care should be explored in order to enhance the state's ability to improve health outcomes and to manage the financial risk associated with the provision of such care. This article provides a licensing and regulatory scheme for provider sponsored networks, an alternative managed care model recognized in federal law, that recognizes the unique features of such entities. WVC 33 - 25 G- 2 §33-25G-2. Definitions.

     (a) "Federally Qualified Health Center" means an entity as defined in 42 U.S.C. §1396d(l)(2)(B).

     (b) "Medicaid beneficiary" means any person participating, through either a state plan amendment or waiver demonstration, in any Medicaid program administered by the West Virginia Department of Health and Human Resources or its Bureau for Medical Services.

     (c) "Participating provider" means a licensed health care provider who has entered into a contract with a provider sponsored network to provide services to Medicaid enrollees.

     (d) "Provider sponsored network" means an entity that satisfies the definition of a "Medicaid managed care organization" set forth in 42 U.S.C. §1396b(m)(1)(A), is controlled by one or more Federally Qualified Health Centers, as set forth in 42 U.S.C. §1396b(m)(1)(C)(ii)(IV), and provides or otherwise makes available health care services solely to Medicaid beneficiaries or beneficiaries of medicaid or medicare pursuant to contract with the secretary executed in accordance with article two-l, chapter sixteen of this code.

     (e) "Secretary" means the Secretary of the West Virginia Department of Health and Human Resources. WVC 33 - 25 G- 3 §33-25G-3. Licensing of provider sponsored networks.

     (a) Except to the extent provided otherwise in this article, a provider sponsored network is subject to the provisions of article twenty-five-a of this chapter to the same extent as an HMO.

     (b) Notwithstanding the provisions of section four, article twenty-five-a of this chapter, in determining whether a provider sponsored network has demonstrated in its application for a certificate of authority or at a later time that it is financially responsible and may reasonably be expected to meet its obligations to Medicaid beneficiaries, the commissioner may, in his or her sole discretion and after consultation with the secretary, impose lower or different solvency requirements, including lower surplus and capital. In deciding whether to permit lower or different solvency standards, the commissioner shall consider actuarial evaluations and other qualified technical standards and may also consider factors such as a lower risk of insolvency, any transfer of risk to a third party, and the restriction of the provider sponsored network to the provision of Medicaid-related services; these same factors may also be considered in reviewing and acting upon a provider sponsored network's RBC report.

     (c) A provider sponsored network may at any time seek to convert its certificate of authority granted pursuant to this article to a certificate of authority to operate as an HMO by filing an application in accordance with the provisions of article twenty-five-a of this chapter. WVC 33 - 25 G- 4 §33-25G-4. Provider participation.

     (a) Any willing physician or licensed behavioral health provider is entitled to participate in a provider sponsored network provided that he or she is willing to participate in the health care delivery approach designed by the provider sponsored network and such other applicable requirements of the Department of Health and Human Resources.

     (b) As a condition of provider participation, including participation by hospitals, a provider sponsored network may require that its care management protocols be observed, including provisions for designations of certain services that may be provided only by designated providers or classes of providers, requirements that providers be credentialed before they may provide certain services, and requirements that providers comply with utilization management programs and referral systems as established by the provider sponsored network. A provider sponsored network may not require a participating physician provider to sell or transfer ownership of his, her or its assets or practice operations to the provider sponsored network or any of its participating providers as a condition of participation or of being permitted access or use of the provider sponsored network's medical home resources and care management systems.

     (c) A participating provider shall have the right to participate in, and contract with, other networks or other managed care organizations to provide services to Medicaid beneficiaries. WVC 33 - 25 G- 5 §33-25G-5. Rules.

     The commissioner may promulgate emergency rules and shall propose for legislative approval legislative rules, in accordance with the provisions of article three, chapter twenty-nine-a of this code, as are necessary to provide for implementation and enforcement of the provisions of this article.

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