(b) In carrying out this pilot program, it is the intent of the Legislature to eliminate legal, statutory and regulatory barriers to the establishment of pilot programs providing preventive and primary care services for a prepaid fee; to encourage residents of this state to establish and use a medical home; to expand preventive and primary care services for the uninsured; and to exempt health providers participating in the pilot program from regulation as an insurer, the operation of insurance laws of the state and all other laws inconsistent with the purposes of this article.
(1) "Dependent" has the same meaning set forth in subsection (d), section one-a, article sixteen, chapter thirty-three of this code;
(2) "Family" means a subscriber and his or her dependents; (3) "Medical home" means a team approach to providing health care and care management. Whether involving a primary care provider, specialist or sub-specialist, care management includes the development of a plan of care, the determination of the outcomes desired, facilitation and navigation of the health care system, provision of follow-up and support for achieving the identified outcomes. The medical home maintains a centralized, comprehensive record of all health related services to provide continuity of care;
(4) "Participating provider" means a provider under this article that has been granted a license under this article to operate as part of the pilot program;
(5) "Primary care" means basic or general health care which emphasizes the point when the patient first seeks assistance from the medical care system and the care of the simpler and more common illnesses;
(6) "Provider" has the same meaning as "ambulatory health care facility" set forth in subsection (b), section two, article two-d of this chapter or "private office practice" as set forth in subsection (a)(1), section four of said article;
(7) "Qualifying event" means loss of coverage due to: (i) Emancipation and resultant loss of coverage under a parent or guardian's plan; (ii) divorce and loss of coverage under the former spouse's plan; (iii) termination of employment and resultant loss of coverage under an employer group plan: Provided, That any rights of coverage under a COBRA continuation plan as that term is defined in section three-m, article sixteen, chapter thirty-three of this code, shall not be considered coverage under an employer group health plan; (iv) involuntary termination of coverage under a group health benefit plan except for termination due to nonpayment of premiums or fraud by the insured; or (v) exhaustion of COBRA benefits;
(8) "Subscriber" means any individual who subscribes to a prepaid program approved and operated in accordance with the provisions of this article, including an employee of any employer that has purchased a group enrollment on behalf of its employees.
(b) Subject to this article, the Health Care Authority is vested with discretion to select providers using diversity in practice organization, geographical diversity and other criteria it deems appropriate. The Health Care Authority also shall give consideration to providers located in rural areas or serving a high percentage or large numbers of uninsured.
(c) In furtherance of the objectives of this article, the Health Care Authority is authorized to accept any and all gifts, grants and matching funds whether in the form of money or services. However, no gifts, grants and matching funds shall be provided to the Health Care Authority by the State of West Virginia to further the objectives of this article.
(b) The Health Care Authority shall determine the eligibility of providers to obtain licenses on the basis of applications filed by providers on forms developed by the Health Care Authority.
(c) Upon approval of the application, the participating provider shall be granted a license to market and sell prepaid health services under such terms as may be established in guidelines developed by the Health Care Authority and the Insurance Commissioner.
(b) All fees, marketing materials and forms proposed to be used by any program applicant or participating provider are subject to prior approval of the Insurance Commissioner, which the Insurance Commissioner shall communicate to the Health Care Authority. Fees may not be excessive, inadequate, or unfairly discriminatory.
(c) The Insurance Commissioner must certify whether a program applicant or, upon the request of the Health Care Authority, an already participating provider is in a sound financial condition and capable of operating in a manner that is not hazardous to its prospective subscribers or the people of West Virginia.
(d) Every subscriber is entitled to evidence of program membership that shall contain a clear, concise and complete statement of the services provided by the participating provider and the benefits, if any, to which the subscriber is entitled; any exclusions or limitations on the service, kind of service, benefits, or kind of benefits, to be provided, including any copayments; and where and in what manner information is available as to how a service may be obtained.
(e) Fees paid to participating providers are not subject to premium taxes and surcharges imposed on insurance companies.
(f) Notwithstanding the provisions of chapter thirty-three of this code to the contrary, participation by providers in the preventive care clinic-based pilot program created and authorized pursuant to this article is not to be considered as providing insurance or as offering insurance services. Such providers and services are specifically excluded from the definitions of "insurer" and "insurance" as defined in article one, chapter thirty-three of this code, and are not subject to regulation by the Insurance Commissioner except to the extent set forth in this article, nor are participating providers unauthorized insurers pursuant to section four, article forty-four of chapter thirty-three of this code.
(1) Each participating provider and site must offer a minimum set of preventive and primary care services as established by the Health Care Authority.
(2) No participating provider may offer: (i) An individual plan to any individual who currently has a health benefit plan or who was covered by a health benefit plan within the preceding twelve months unless said coverage was lost due to a qualifying event; (ii) a family plan to any family that includes an adult to be covered who currently has a health benefit plan or who was covered by a health benefit plan within the preceding twelve months unless said coverage was lost due to a qualifying event; or (iii) an employee group plan to any employer that currently has a group health benefit plan or had a group health benefit plan covering its employees within the preceding twelve months; (iv) Notwithstanding the provisions of (i), (ii) or (iii) of this subsection, a participating provider may offer a plan to an individual if the individual is covered by a high deductible health benefit plan or policy and a participating provider may offer a plan to an employer group if the employer group is covered by a high deductible health benefit plan or policy. The participating provider shall give the perspective individual or employer a notice that indicates that the payment for the prepaid services may not count towards a health benefit plan deductible and that credit towards the deductible will depend on the health benefit policy or certificate language. The Insurance Commissioner shall approve the form of the notice to be used by the provider. For the purpose of this section, "high deductible health benefit plan" means a health benefit plan with a minimum individual annual deductible of $3,000 or, if applicable, a family annual deductible of $3,000. Any employer who has converted its health benefit plan from a low deductible plan to a high deductible health benefits plan may not purchase a plan from a participating provider for six months from the date of conversion. Any individual who has converted his or her health benefit policy from a low deductible health policy to a high deductible plan may not purchase a plan from a participating provider for three months from date of conversion.
(3) On or before July 1, 2009, the Health Care Authority and the Insurance Commissioner shall propose a rule for legislative approval in accordance with the provisions of article three, chapter twenty-nine-a of this code, to permit participation by a subscriber or employer with a comprehensive high deductible plan if the subscriber or employer is able to demonstrate that the participation will not negatively impact the coverage that is currently offered or will be offered by the employer. The rule shall provide for notice to the subscriber or employer that the payment for the prepaid services may or may not count towards the health insurance deductible, the determination of which will depend on the health insurance policy language.
(4) A participating provider must provide subscribers and, where applicable, subscribers' employers with a minimum of thirty days' notice of discontinuance or reduction of subscriber benefits.
(b) No later than the first day of December, two thousand seven and annually thereafter during the operation of the pilot program, the Health Care Authority must submit a report to the Legislative Oversight Commission of Health and Human Resources Accountability as established in article twenty-nine-e of this chapter on progress made by the pilot project including suggested legislation, necessary changes to the pilot program and suggested expansion of the pilot program.
(1) Violates any provision of this article;
(2) Fails to comply with any lawful rule or order of the Health Care Authority;
(3) Is operating in an illegal, improper or unjust manner;
(4) Is found by the Insurance Commissioner to be in an unsound condition or in such condition as to render its further operation in West Virginia hazardous to its subscribers or to the people of West Virginia;
(5) Compels subscribers under its contract to accept less service than due them or to bring suit against it to secure full service when it has no substantial defense;
(6) Refuses to be examined or to produce its accounts, records and files for examination by the Insurance Commissioner when requested to do so pursuant to section five of this article;
(7) Fails to pay any final judgment rendered against it in West Virginia within thirty days after the judgment became final or time for appeal expired, whichever is later;
(8) Fails to pay when due to the State of West Virginia any taxes, fees, charges or penalties.
(b) In addition to or in lieu of refusing to renew, revoking or suspending the license of a participating provider in any case, the Health Care Authority may, by order, require the participating provider to pay to the State of West Virginia a penalty in a sum not exceeding five thousand dollars for each violation. Upon the failure of the provider to pay such penalty within thirty days after notice thereof, the Health Care Authority shall revoke or suspend the license of such participating provider.
(c) When any license has been revoked or suspended or renewal thereof refused, the Health Care Authority may reissue, terminate the suspension of or renew such license when it is determined that the conditions causing such revocation, suspension or refusal to renew have ceased to exist and are unlikely to recur.
Note: WV Code updated with legislation passed through the 2012 1st Special Session