ENROLLED
COMMITTEE SUBSTITUTE
FOR
H. B. 2619
(By Mr. Speaker, Mr. Chambers, and Delegate Ashley)
[By Request of the Executive]
[Passed March 11, 1995; in effect ninety days from passage].
AN ACT to amend and reenact sections two, three, four, seven,
eight, nine, eleven, twelve, fourteen, fifteen, sixteen,
seventeen, eighteen, nineteen, twenty-four, twenty-five and
twenty-six, article twenty-five-a, chapter thirty-three of
the code of West Virginia, one thousand nine hundred thirty-
one, as amended; and to further amend said article by adding
thereto three new sections, designated sections three-a,
seven-a and thirty-three, all relating to insurance; health
maintenance organization act; definitions; application for
certificate of authority; conditions precedent to issuance
of certificate of authority; issuance of certificate of
authority; effect of bankruptcy proceedings; fiduciary
duties of officers; approval of contracts by commissioner;
provider contracts; evidence of coverage; charges for health
care services; cancellation of contract by enrollee; annual
report; open enrollment period; limitation on medicare and medicaid beneficiaries; grievance procedure; prohibited
practices; licensing and appointment of agents; regulation
of marketing; powers of insurers and hospital and medical
service corporations; examinations; suspension or revocation
of certificate of authority; rehabilitation, liquidation or
conservation of health maintenance organization; statutory
construction and relationship to other laws; filings and
reports as public documents; confidentiality of medical
information; and guaranty fund plan.
Be it enacted by the Legislature of West Virginia:
That sections two, three, four, seven, eight, nine, eleven,
twelve, fourteen, fifteen, sixteen, seventeen, eighteen,
nineteen, twenty-four, twenty-five and twenty-six, article
twenty-five-a, chapter thirty-three of the code of West Virginia,
one thousand nine hundred thirty-one, as amended, be amended and
reenacted; and that said article be further amended by adding
thereto three new sections, designated sections three-a, seven-a
and thirty-three, all to read as follows:
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-2.Definitions.
(1) "Basic health care services" means physician, hospital,
out-of-area, podiatric, laboratory, X ray, emergency, short-term
mental health services not exceeding twenty outpatient visits in
any twelve-month period, and cost-effective preventive services
including immunizations, well-child care, periodic health evaluations for adults, voluntary family planning services,
infertility services and children's eye and ear examinations
conducted to determine the need for vision and hearing
corrections.
(2) "Capitation" means the fixed amount paid by a health
maintenance organization to a health care provider under contract
with the health maintenance organization in exchange for the
rendering of health care services.
(3) "Commissioner" means the commissioner of insurance.
(4) "Consumer" means any person who is not a provider of
care or an employee, officer, director or stockholder of any
provider of care.
(5) "Copayment" means a specific dollar amount, except as
otherwise provided for by statute, that the subscriber must pay
upon receipt of covered health care services and which is set at
an amount consistent with allowing subscriber access to health
care services.
(6) "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 shall be done.
(7) "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.
(8) "Enrollee", "subscriber," or "member" means an
individual who has been voluntarily enrolled in a health
maintenance organization, including individuals on whose behalf a
contractual arrangement has been entered into with a health
maintenance organization to receive health care services.
(9) "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.
(10) "Health care services" means any services or goods
included in the furnishing to any individual of medical, mental
or dental care, or hospitalization or incident to the furnishing
of the care or hospitalization, osteopathic services, home
health, health education, or rehabilitation, as well as the
furnishing to any person of any and all other services or goods
for the purpose of preventing, alleviating, curing or healing
human illness or injury.
(11) "Health maintenance organization" or "HMO" means a
public or private organization which provides, or otherwise makes
available to enrollees, health care services, including at a
minimum basic health care services which:
(a) Receives premiums for the provision of basic health care
services to enrollees on a prepaid per capita or prepaid
aggregate fixed sum basis, excluding copayments;
(b) Provides physicians' services primarily (i) directly
through physicians who are either employees or partners of the
organization, or (ii) through arrangements with individual physicians or one or more groups of physicians organized on a
group practice or individual practice arrangement, or (iii)
through some combination of paragraphs (i) and (ii) of this
subdivision;
(c) Assures the availability, accessibility and quality,
including effective utilization, of the health care services
which it provides or makes available through clearly identifiable
focal points of legal and administrative responsibility; and
(d) Offers services through an organized delivery system, in
which a primary care physician is designated for each subscriber
upon enrollment. The primary care physician is responsible for
coordinating the health care of the subscriber and is responsible
for referring the subscriber to other providers when necessary:
Provided, That when dental care is provided by the health
maintenance organization the dentist selected by the subscriber
from the list provided by the health maintenance organization
shall coordinate the covered dental care of the subscriber, as
approved by the primary care physician or the health maintenance
organization.
(12) "Impaired" means a financial situation in which, based
upon the financial information which would be required by this
chapter for the preparation of the health maintenance
organization's annual statement, the assets of the health
maintenance organization are less than the sum of all of its
liabilities and required reserves including any minimum capital
and surplus required of the health maintenance organization by this chapter so as to maintain its authority to transact the
kinds of business or insurance it is authorized to transact.
(13) "Individual practice arrangement" means any agreement
or arrangement to provide medical services on behalf of a health
maintenance organization among or between physicians or between a
health maintenance organization and individual physicians or
groups of physicians, where the physicians are not employees or
partners of the health maintenance organization and are not
members of or affiliated with a medical group.
(14) "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 health
maintenance organization's annual statement, the assets of the
health maintenance organization are less than the sum of all of
its liabilities and required reserves.
(15) "Medical group" or "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 and optometrists,
as are necessary for the provision of health services for which
the group is responsible: (a) A majority of the members of which
are licensed to practice medicine or osteopathy; (b) who as their
principal professional activity engage in the coordinated
practice of their profession; (c) 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 (d) who share medical and other records and
substantial portions of major equipment and professional,
technical and administrative staff.
(16) "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 health maintenance organization for health services
provided to an enrollee.
(17) "Primary care physician" means the general
practitioner, family practitioner, obstetrician/gynecologist,
pediatrician, or specialist in general internal medicine who is
chosen or designated for each subscriber who will be responsible
for coordinating the health care of the subscriber, including
necessary referrals to other providers.
(18) "Provider" means any physician, hospital or other
person or organization which is licensed or otherwise authorized
in this state to furnish health care services.
(19) "Uncovered expenses" means the cost of health care
services that are covered by a health maintenance organization,
for which a subscriber would also be liable in the event of the
insolvency of the organization.
(20) "Service area" means the county or counties approved
by the commissioner within which the health maintenance
organization may provide or arrange for health care services to
be available to its subscribers.
(21) "Statutory surplus" means the minimum amount of
unencumbered surplus which a corporation must maintain pursuant
to the requirements of this article.
(22) "Surplus" means the amount by which a corporation's
assets exceeds 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 health maintenance organization shall not be included in
surplus.
(23) "Surplus notes" means debt which has been subordinated
to all claims of subscribers and general creditors of the
organization.
(24) "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 health
maintenance organizations and who has no financial or employment
interest in the health maintenance organization.
§33-25A-3. Application for certificate of authority.
(1) 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 health
maintenance organization in compliance with this article. No
person shall sell health maintenance organization enrollee
contracts, nor shall any health maintenance organization commence
services, prior to receipt of a certificate of authority. Any person may, however, establish the feasibility of a health
maintenance organization prior to receipt of a certificate of
authority through funding drives and by receiving loans and
grants.
(2) Every health maintenance 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 four of this article, the applicant shall be treated
as a health maintenance organization whose certificate of
authority has been revoked. Provided, That all health
maintenance organizations in operation for at least five years
are exempt from filing applications for a new certificate of
authority.
(3) The commissioner may require any organization providing
or arranging for health care services on a prepaid per capita or
prepaid aggregate fixed sum basis to apply for a certificate of
authority under this article. The commissioner shall promulgate
rules to facilitate the enforcement of this subsection:
Provided, That any provider who is assuming risk by virtue of a
contract or other arrangement with an HMO or entity which has a
certificate, may not be required to file for a certificate:
Provided, however, That the commissioner may require such
exempted entities to file complete financial data for a determination as to their solvency. Any organization directed to
apply for a certificate of authority is subject to the provisions
of subsection (2) of this section.
(4) Each application for a certificate of authority shall be
verified by an officer or authorized representative of the
applicant, 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:
(a) The basic organizational document;
(b) The bylaws or rules;
(c) 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 health maintenance organization and the extent and nature
of any contract or financial arrangements between that person and
the health maintenance organization;
(d) A description of the health maintenance organization;
(e) A copy of each evidence of coverage form and of each
enrollee contract form;
(f) 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;
(g) (i) A description of the proposed method of marketing the plan: (ii) a schedule of proposed charges; and (iii) a
financial plan which includes a three-year projection of the
expenses and income and other sources of future capital;
(h) 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 health maintenance organization on a cause of action
arising in this state may be served;
(i) A statement reasonably describing the service area or
areas to be served and the type or types of enrollees to be
served;
(j) A description of the complaint procedures to be utilized
as required under section twelve of this article;
(k) A description of the mechanism by which enrollees will
be afforded an opportunity to participate in matters of policy
and operation under section six of this article;
(l) A complete biographical statement on forms prescribed by
the commissioner and an independent investigation report on all
of the individuals referred to in subdivision (c) of this section
and all officers, directors and persons holding five percent or
more of the common stock of the organization;
(m) 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
health maintenance organization has been projected to be
profitable for twelve consecutive months. The study must show
that the health maintenance organization would not, at the end of
any month of the projection period, have less than the minimum
capital and surplus as required by subparagraph (ii), subdivision
(c), subsection (2), section four of this article. The qualified
independent actuary shall certify that: The rates are neither
inadequate nor excessive nor unfairly discriminatory; the rates
are appropriate for the classes of risks for which they have been
computed; 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; the health
maintenance organization is actuarially sound: Provided, however
That the certification shall consider the rates, benefits, and
expenses of, and any other funds available for the payment of
obligations of, the organization; the rates being charged or to
be charged are actuarially adequate to the end of the period for
which rates have been guaranteed; and incurred but not reported
claims and claims reported but not fully paid have been
adequately provided for; and
(n) Such other information as the commissioner may require
to be provided.
(5) A health maintenance 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 shall be considered
approved and may be implemented by the health maintenance
organization.
§33-25A-3a. Conditions precedent to issuance or maintenance of
a certificate of authority; effect of bankruptcy proceedings.
(1) As a condition precedent to the issuance or maintenance
of a certificate of authority, a health maintenance organization
must file or have on file with the commissioner:
(a) 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 constitutes the
sole and exclusive method for the liquidation, rehabilitation,
reorganization, or conservation of a health maintenance
organization; and
(b) A waiver of any right to file or be subject to a
bankruptcy proceeding.
(2) After the effective date of this section, as a condition
precedent to the issuance of a certificate of authority, any
organization that has not yet obtained a certificate of authority
to operate a health maintenance organization in this state shall
be incorporated under the provisions of article one, chapter thirty-one of this code.
(3) The commencement of a bankruptcy proceeding either by or
against a health maintenance organization shall, by operation of
law:
(a) Terminate the health maintenance organization's
certificate of authority; and
(b) Vest in the commissioner for the use and benefit of the
subscribers of the health maintenance organization the title to
any deposits of the HMO held by the commissioner.
(4) If the proceeding is initiated by a party other than the
health maintenance organization, the operation of subsection (2)
of this section shall be stayed for a period of sixty days
following the date of commencement of the proceeding.
§33-25A-4. Issuance of certificate of authority.
(1) 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
health care services to be furnished has demonstrated:
(a) The willingness and potential ability of the
organization to assure that basic health services will be
provided in such a manner as to enhance and assure both the
availability and accessibility of adequate personnel and
facilities;
(b) Arrangements for an ongoing evaluation of the quality of
health care provided by the organization; and
(c) 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 such
other matters as may be reasonably required by rule.
(2) 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:
(a) The health maintenance organization's proposed plan of
operation meets the requirements of subsection (1) of this
section;
(b) The health maintenance organization will effectively
provide or arrange for the provision of at least basic health
care services on a prepaid basis except for copayments:
Provided, That nothing in this section shall be construed to
relieve a health maintenance organization from the obligations to
provide health care services 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 shall permit a health maintenance
organization to charge copayments to medicare beneficiaries or
medicaid recipients in excess of the copayments permitted under
those programs, nor shall a health maintenance organization be
required to provide services to the medicare beneficiaries or medicaid recipients in excess of the benefits compensated under
those programs;
(c) The health maintenance 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:
(i) The financial soundness of the health maintenance
organization's arrangements for health care services and the
proposed schedule of charges used in connection with the health
care services;
(ii) That the health maintenance organization has and
maintains fully paid in capital stock, if a for profit stock
corporation, or statutory surplus funds, if a nonprofit
corporation, at least one million dollars. In addition, each
health maintenance organization shall have and maintain
additional surplus funds of at least one million dollars;
(iii) Any arrangements which will guarantee for 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
(iv) Any agreement with providers for the provision of
health care services;
(d) Reasonable provisions have been made for emergency and out-of-area health care services;
(e) The enrollees will be afforded an opportunity to
participate in matters of policy and operation pursuant to
section six of this article;
(f) The health maintenance organization has demonstrated
that it will assume full financial risk on a prospective basis
for the provision of health care services, including hospital
care: Provided, That the requirement of this subdivision shall
not prohibit a health maintenance organization from obtaining
insurance or making other arrangements:
(i) For the cost of providing to any enrollee health care
services, the aggregate value of which exceeds four thousand
dollars in any year;
(ii) For the cost of providing health care services to its
members on a nonelective emergency basis, or while they are
outside the area served by the organization; or
(iii) For not more than ninety-five percent of the amount by
which the health maintenance organization's costs for any of its
fiscal years exceed one hundred five percent of its income for
those fiscal years;
(g) The ownership, control and management of the
organization is competent and trustworthy and possesses
managerial experience that would make the proposed health
maintenance 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 health maintenance 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;
(h) The health maintenance 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 one hundred thousand
dollars.
(3) A certificate of authority shall be denied only after
compliance with the requirements of section twenty-one of this
article.
(4) No person who has not been issued a certificate of
authority shall use the words "health maintenance organization"
or the initials "HMO" in its name, contracts or literature:
Provided, That persons who are operating under a contract with,
operating in association with, enrolling enrollees for, or
otherwise authorized by a health maintenance organization
licensed under this article to act on its behalf may use the
terms "health maintenance organization" or "HMO" for the limited
purpose of denoting or explaining their association or
relationship with the authorized health maintenance organization. No health maintenance organization which has a minority of board
members who are consumers shall use the words "consumer
controlled" in its name or in any way represent to the public
that it is controlled by consumers.
§33-25A-7. Fiduciary responsibilities of officers; approval of
contracts by commissioner.
(a) Any director, officer or partner of a health maintenance
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) Any contracts made with providers of health care
services enabling a health maintenance organization to provide
health care services authorized under this article shall be filed
with the commissioner. The commissioner has the power to require
immediate cancellation of the contracts or the immediate
renegotiation of the contract by the parties whenever he or she
determines that they provide for excessive payments, or that they
fail to include reasonable incentives for cost control, or that
they otherwise substantially and unreasonably contribute to
escalation of the costs of providing health care services to
enrollees.
§33-25A-7a. Provider contracts.
(1) Whenever a contract exists between a health maintenance
organization and a provider and the organization fails to meet
its obligations to pay fees for services already rendered to a subscriber, the health maintenance organization is liable for the
fee or fees rather than the subscriber; and the contract shall
state that liability.
(2) No subscriber of an HMO is liable to any provider of
health care services for any services covered by the HMO if at
any time during the provision of the services, the provider, or
its agents, are aware the subscriber is an HMO enrollee.
(3) No provider of services or any representative of the
provider shall collect or attempt to collect from an HMO
subscriber any money for services covered by an HMO and no
provider or representative of the provider may maintain any
action at law against a subscriber of an HMO to collect money
owed to the provider by an HMO.
(4) Every contract between an HMO and a provider of health
care services 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 HMO.
(5) The provisions of this section shall not be construed to
apply to the amount of any deductible or copayment which is not
covered by the contract of the HMO.
(6) For all provider contracts executed on or after the
fifteenth day of April, one thousand nine hundred ninety-five,
and within one hundred eighty days of that date for contracts in
existence on that date:
(a) The contracts must provide that the provider shall
provide sixty days advance written notice to the health maintenance organization and the commissioner before canceling
the contract with the health maintenance organization for any
reason; and
(b) The contract must also provide that nonpayment for goods
or services rendered by the provider to the health maintenance
organization is not a valid reason for avoiding the sixty day
advance notice of cancellation.
(7) Upon receipt by the health maintenance organization of a
sixty day cancellation notice, the health maintenance
organization may, if requested by the provider, terminate the
contract in less than sixty days if the health maintenance
organization is not financially impaired or insolvent.
§33-25A-8. Evidence of coverage; charges for health care
services; cancellation of contract by enrollee.
(1) (a) Every enrollee is entitled to evidence of coverage
in accordance with this section. The health maintenance
organization or its designated representative shall issue the
evidence of coverage.
(b) 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.
(c) An evidence of coverage shall contain a clear, concise
and complete statement of:
(i) The health care services and the insurance or other
benefits, if any, to which the enrollee is entitled;
(ii) Any exclusions or limitations on the services, kind of
services, benefits, or kind of benefits, to be provided,
including any copayments;
(iii) Where and in what manner information is available as
to how services, including emergency and out-of-area services,
may be obtained;
(iv) The total amount of payment and copayment, if any, for
health care services 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; and
(v) A description of the health maintenance organization's
method for resolving enrollee grievances.
(d) Any subsequent approved change in an evidence of
coverage shall be issued to each enrollee.
(e) 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 (b), subsection
(1) 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 or medical 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 (c), subsection (1) of this section, are applicable.
(2) Premiums may be established in accordance with
actuarial principles: Provided, That premiums shall not be
excessive, inadequate or unfairly discriminatory. A
certification by a qualified independent actuary shall accompany
a rate filing and shall certify that: The rates are neither
inadequate nor excessive nor unfairly discriminatory; that the
rates are appropriate for the classes of risks for which they
have been computed; provide an adequate description of the rating
methodology showing that the methodology follows consistent and
equitable actuarial principles; and the rates being charged are
actuarially adequate to the end of the period for which rates
have been guaranteed. In determining whether the charges are
reasonable, the commissioner shall consider whether the health
maintenance organization has (a) made a vigorous, good faith
effort to control rates paid to health care providers; (b)
established a premium schedule, including copayments, if any,
which encourages enrollees to seek out preventive health care
services; and (c) made a good faith effort to secure arrangements
whereby basic services can be obtained by subscribers from local
providers to the extent that the providers offer the services.
(3) Rates 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 medical and hospital benefits 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 HMO is projected to make a profit.
For this analysis, investment income shall not exceed three
percent of total projected revenues.
(4) The commissioner shall within a reasonable period
approve any form if the requirements of subsection (1) of this
section are met and any schedule of charges if the requirements
of subsection (2) 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 fifteen 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 shall be considered
approved.
(5) 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.
(6) An individual enrollee may cancel a contract with a health maintenance organization at any time for any reason:
Provided, That a health maintenance organization may require that
the enrollee give sixty 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 health
maintenance organization pursuant to the terms of that contract.
§33-25A-9. Annual report.
(1) Every health maintenance 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:
(a) 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: (i) All prepayment and other
payments received for health care services rendered; (ii)
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
health maintenance contract; and (iii) expenditures for capital
improvements, or additions thereto, including, but not limited
to, construction, renovation or purchase of facilities and
capital equipment;
(b) 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;
(c) A summary of information compiled pursuant to
subdivision (c), subsection (1), section four of this article in
such form as may be required by the department of health and
human resources or other accredited entity;
(d) A report of the names and residence addresses of all
persons set forth in subdivision (c), subsection (4), section
three of this article who were associated with the health
maintenance organization during the preceding year, and the
amount of wages, expense reimbursements, or other payments to
those individuals for services to the health maintenance
organization, including a full disclosure of all financial
arrangements during the preceding year required to be disclosed
pursuant to subdivision (c), subsection (4), section three of
this article; and
(e) Such other information relating to the performance of
the health maintenance organization as is reasonably necessary to
enable the commissioner to carry out his or her duties under this
article.
§33-25A-11. Open enrollment period; limitation on medicare and
medicaid beneficiaries.
(1) Once a health maintenance organization has been in
operation at least five years, or has enrollment of not less than
fifty thousand persons, the health maintenance organization shall, in any year following a year in which the health
maintenance organization has achieved an operating surplus,
maintain an open enrollment period of at least thirty days during
which time the health maintenance organization shall, within the
limits of its capacity, accept individuals in the order in which
they apply without regard to preexisting illness, medical
conditions or degree of disability except for individuals who are
confined to an institution because of chronic illness or
permanent injury: Provided, That no health maintenance
organization shall be required to continue an open enrollment
period after such time as enrollment pursuant to the open
enrollment period is equal to three percent of the health
maintenance organization's net increase in enrollment during the
previous year.
(2) Where a health maintenance organization demonstrates to
the satisfaction of the commissioner that it has a
disproportionate share of high-risk enrollees and that, by
maintaining open enrollment, it would be required to enroll so
disproportionate a share of high-risk enrollees as to jeopardize
its economic viability, the commissioner may:
(a) Waive the requirement for open enrollment for a period
of not more than three years; or
(b) Authorize the organization to impose such underwriting
restrictions upon open enrollment as are necessary (i) to
preserve its financial stability; (ii) to prevent excessive
adverse selection by prospective enrollees; or (iii) to avoid unreasonably high or unmarketable charges for enrollee coverage
of health services. A health maintenance organization may
receive more than one waiver or authorization.
(3) The enrollment by a health maintenance organization of
medicare beneficiaries who are at least sixty-five years of age
and medicaid beneficiaries shall not exceed fifty percent of its
total enrollee population. The commissioner may permit by
written order and upon application of a health maintenance
organization, the health maintenance organization to exceed the
fifty percent limitation, but in no event may the medicare and
medicaid beneficiaries enrollment exceed seventy-five percent of
its total enrollee population: Provided, That before the
commissioner grants such a waiver, the health maintenance
organization must provide the opinion of a qualified independent
actuary that the higher percentage of medicaid and medicare
recipients will not be detrimental to the solvency of the health
maintenance organization for a period of at least thirty-six
months into the future.
§33-25A-12. Grievance procedure.
(1) A health maintenance 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 health maintenance 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.
(2) A detailed description of the HMO'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. An HMO subscriber grievance procedure shall
include the following:
(a) 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 such forms as prescribed and received by the HMO;
(b) Each HMO shall designate at least one grievance
coordinator who is responsible for the implementation of the
HMO's grievance procedure;
(c) Phone numbers shall be specified by the HMO 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 HMO without undue delays. There must be an adequate
number of phone lines to handle incoming grievances;
(d) An address shall be included for written grievances;
(e) Each level of the grievance procedure shall have some
person with problem solving authority to participate in each step
of the grievance procedure;
(f) The HMO shall process the formal written subscriber
grievance through all phases of the grievance procedure in a
reasonable length of time not to exceed sixty days, unless the
subscriber and HMO mutually agree to extend the time frame. If
the complaint involves the collection of information outside the
service area, the HMO 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
shall be tolled after the HMO has notified the subscriber, in
writing, that additional information is required in order to
properly complete review of the grievance. Upon receipt by the
HMO of the additional information requested, the time for
completion of the grievance process set forth in this subdivision
shall resume;
(g) The subscriber grievance procedure shall state that the
subscriber has the right to appeal to the commissioner. There
shall be the additional requirement that subscribers under a
group contract between the HMO and a department or division of
the state shall first appeal to the state agency responsible for
administering the relevant program, and if either of the two
parties are not satisfied with the outcome of the appeal, they
may then appeal to the commissioner. The HMO shall provide to
the subscriber 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;
(h) The HMO shall have physician involvement in reviewing
medically related grievances. Physician involvement in the
grievance process should not be limited to the subscriber's
primary care physician, but may include at least one other
physician;
(i) The HMO 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 HMO within the service
area or at a location within the service area which is convenient
to the subscriber;
(j) The HMO may not establish time limits of less than one
year from the date of occurrence for the subscriber to file a
formal grievance;
(k) Each HMO shall maintain an accurate record of each
formal grievance. Each record shall include the following:
(i) A complete description of the grievance, the subscriber's
name and address, the provider's name and address and the HMO's
name and address; (ii) a complete description of the HMO's
factual findings and conclusions after completion of the full
formal grievance procedure; (iii) a complete description of the
HMO's conclusions pertaining to the grievance as well as the
HMO's final disposition of the grievance; and (iv) 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
HMO's entire grievance procedure.
Copies of the grievances and the responses thereto shall
be available to the commissioner, and the public for inspection
for three years.
(3) Any subscriber grievance in which time is of the
essence must be handled on an expedited basis, such 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.
(4) Each health maintenance organization shall submit to
the commissioner an annual report in a form prescribed by the
commissioner which describes such grievance procedure and
contains a compilation and analysis of the grievances filed,
their disposition, and their underlying causes.
§33-25A-14. Prohibited practices.
(1) No health maintenance 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. For purposes of this article:
(a) A statement or item of information shall be considered
to be 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 health maintenance organization;
(b) A statement or item of information shall be considered
to be 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 health
maintenance organization, if the benefit or advantage or absence
of limitation, exclusion or disadvantage does not in fact exist;
(c) An evidence of coverage shall be considered to be
deceptive if the evidence of coverage taken as a whole, and with
consideration given to typography and format, as well as
language, shall be such as to cause a reasonable person, not
possessing special knowledge regarding health maintenance
organizations, and evidences of coverage therefor, to expect
benefits, services or other advantages which the evidence of
coverage does not provide or which the health maintenance
organization issuing the evidence of coverage does not regularly
make available for enrollees covered under such evidence of
coverage; and
(d) The commissioner may further define practices which are
untrue, misleading or deceptive.
(2) No health maintenance 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
health maintenance 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. No health maintenance
organization shall 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 health maintenance organization on an individual
basis. A health maintenance 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.
(3) No health maintenance organization may use in its name,
contracts 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 health
maintenance organization has contracted with an insurance company
for any coverage permitted by this article, it may so state.
(4) The providers of a health maintenance organization who
provide health care services and the health maintenance organization shall 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.
(5) No health maintenance organization shall enroll more
than three hundred thousand persons in this state: Provided,
That a health maintenance organization may petition the
commissioner to exceed an enrollment of three hundred thousand
persons and, upon notice and hearing, good cause being shown and
a determination made that such an increase would be beneficial to
the subscribers, creditors and stockholders of the organization
or would otherwise increase the availability of coverage to
consumers within the state, the commissioner may, by written
order only, allow the petitioning organization to exceed an
enrollment of three hundred thousand persons. The health
maintenance organization may petition the commissioner to exceed
three hundred thousand persons. The commissioner may allow the
health maintenance organization to exceed the three hundred
thousand person cap without notice and hearing, provided in his
or her sole discretion, the health maintenance organization has
shown cause and the commissioner has determined the proposed
increase in enrollment would be beneficial to the subscribers,
creditors and stockholders of the organization or would otherwise
increase the availability of coverage to the insurance buying
public of the state.
(6) No health maintenance organization shall 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, shall not be considered discrimination
in enrollment policies.
(7) No agent of a health maintenance organization or person
selling enrollments in a health maintenance organization shall
sell an enrollment in a health maintenance organization unless
the agent or person shall first disclose 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, hospitals and
pharmacies associated with the health maintenance organization.
In any home solicitation, any three-day cooling-off period
applicable to consumer transactions generally applies in the same
manner as consumer transactions.
The form disclosure statement shall not be used in sales
until it has been approved by the commissioner or submitted to
the commissioner for sixty days without disapproval. 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 health maintenance organization, plus costs and a reasonable attorney's fee.
(8) No contract with an enrollee shall 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
health maintenance organization.
(9) 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.
§33-25A-15. Agent licensing and appointment required;
regulation of marketing.
(1) Health maintenance organizations are subject to the
provisions of article twelve of this chapter.
(2) After a subscriber signs an HMO enrollment application
and before the HMO can process the application changing or
initiating the subscriber coverage, each HMO must verify the
intent and desire of the individual subscriber to join the HMO.
The verification must be in writing and conducted by someone
outside the HMO's marketing department. Each verification shall
include the following:
(a) Confirmation that the subscriber intends and desires to
join the HMO;
(b) If the subscriber is a medicare or medicaid recipient,
confirmation that the subscriber understands by joining the HMO
he or she will be limited to the benefits provided by the HMO,
and medicare or medicaid will pay the HMO for the subscriber coverage;
(c) Confirmation that the subscriber understands the
applicable restrictions of HMOs, especially that he or she must
use the HMO providers and secure approval from the HMO to use
health care providers outside the plan; and
(d) If the subscriber is a member of an HMO, confirmation
that the subscriber understands he or she is transferring to
another HMO.
(e) The HMO shall not pay a commission, fee, money or any
other form of scheduled compensation to any health insurance
agent until verification from the subscriber of his or her intent
and desire to enroll into the HMO has been secured and the
enrollment process has been completed. The HMO shall verify the
intent of the subscriber to enroll with a written notice to the
subscriber stating that he or she has transferred from his or her
existing coverage (i.e. from medicare, medicaid, another HMO,
etc.) to the new HMO. Each written verification notice shall be
accompanied with printed materials explaining the nature of the
HMO and any applicable restrictions and exclusions. The
enrollment process shall be considered complete seven days after
the HMO mails the confirmation notice. Each HMO must notify the
subscriber of the date enrollment begins and when benefits will
be available. Each HMO is directly responsible for enrollment
abuses.
(3) The commissioner may, in his or her discretion, after
notice and hearing, promulgate rules as are necessary to regulate marketing of health maintenance organizations by persons
compensated directly or indirectly by the health maintenance
organizations. When necessary the rules may prohibit
door-to-door solicitations, may prohibit commission sales, and
may provide for such other proscriptions and other rules as are
required to effectuate the purposes of this article.
§33-25A-16. Powers of insurers and hospital and medical service
corporations.
(1) An insurance company licensed in this state or a
hospital or medical service corporation authorized to do business
in this state, after applying for and receiving a certificate of
authority as a health maintenance organization, may through a
subsidiary or affiliate organize and operate a health maintenance
organization under the provisions of this article.
Notwithstanding any other law to the contrary, any two or more
insurance companies, hospital or medical service corporations, or
subsidiaries or affiliates thereof, may jointly organize and
operate a health maintenance organization. The business of
insurance is considered to include the providing of health care
by a health maintenance organization owned or operated by an
insurer or a subsidiary thereof.
(2) Notwithstanding any provision of insurance and hospital
or medical service corporation laws, an insurer or a hospital or
medical service corporation may contract with a health
maintenance organization to provide insurance or similar
protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of
the failure of the health maintenance organization to meet its
obligations. The enrollees of a health maintenance organization
constitute a permissible group under such laws. Among other
things, under the contracts, the insurer or hospital or medical
service corporation may make benefit payments to health
maintenance organizations for health care services rendered by
providers.
`§33-25A-17. Examinations.
(1) The commissioner may make an examination of the affairs
of any health maintenance 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.
(2) The commissioner may contract with the department of
health and human resources or any entity contracted with by the
department of health and human resources 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 health
maintenance organization and providers with whom the organization
has contracts, agreements or other arrangements 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.
(3) Every health maintenance 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 health maintenance organization and
the principles of the providers concerning their business.
(4) The health maintenance organization is subject to the
provisions of section nine, article two of this chapter in regard
to the expense and conduct of examinations.
(5) In lieu of the examination, the commissioner may accept
the report of an examination made by other states.
§33-25A-18. Suspension or revocation of certificate of
authority.
(1) The commissioner may suspend or revoke any certificate
of authority issued to a health maintenance organization under
this article if he or she finds that any of the following
conditions exist:
(a) The health maintenance organization is operating
significantly in contravention of its basic organization
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;
(b) The health maintenance organization issues evidence of
coverage or uses a schedule of premiums for health care services
which do not comply with the requirements of section eight of
this article;
(c) The health maintenance organization does not provide or
arrange for basic health care services;
(d) The department of health and human resources or other
accredited entity certifies to the commissioner that: (i) The
health maintenance organization is unable to fulfill its
obligations to furnish health care services as required under its
contract with enrollees; or (ii) the health maintenance
organization does not meet the requirements of subsection (1),
section four of this article;
(e) The health maintenance 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;
(f) The health maintenance organization has failed to
implement a mechanism affording the enrollees an opportunity to
participate in matters of policy and operation under section six
of this article;
(g) The health maintenance organization has failed to
implement the grievance procedure required by section twelve of
this article in a manner to reasonably resolve valid grievances;
(h) The health maintenance organization, or any person on
its behalf, has advertised or merchandised its services in an
untrue, misrepresentative, misleading, deceptive or unfair
manner;
(i) The continued operation of the health maintenance
organization would be hazardous to its enrollees;
(j) The health maintenance organization has otherwise failed
to substantially comply with this article; or
(k) The health maintenance organization has violated a
lawful order of the commissioner.
(2) A certificate of authority shall be suspended or revoked
only after compliance with the requirements of section twenty-one
of this article.
(3) When the certificate of authority of a health
maintenance organization is suspended, the health maintenance
organization shall not, during the period of the suspension,
enroll any additional enrollees except newborn children or other
newly acquired dependents of existing enrollees, and shall not
engage in any advertising or solicitation whatsoever.
(4) When the certificate of authority of a health
maintenance organization is revoked, the organization shall
proceed, immediately following the effective date of the order of
revocation, to terminate its affairs, and shall conduct no further business except as may be essential to the orderly
conclusion of the affairs of the organization. It shall engage
in no further advertising or solicitation whatsoever. The
commissioner may, by written order, permit such 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
health care coverage.
§33-25A-19. Rehabilitation, liquidation or conservation of
health maintenance organization.
Any rehabilitation, liquidation or conservation of a health
maintenance organization shall be considered to be the
rehabilitation, liquidation or conservation of an insurance
company, shall be the exclusive remedy for rehabilitation,
liquidation and conservation of an HMO 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 health maintenance
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 health maintenance organization would
be hazardous either to the enrollees or to the people of this
state.
§33-25A-24. Statutory construction and relationship to other laws.
(a) Except as otherwise provided in this article, provisions
of the insurance laws and provisions of hospital or medical
service corporation laws are not applicable to any health
maintenance organization granted a certificate of authority under
this article. The provisions of this article shall not apply to
an insurer or hospital or medical service corporation licensed
and regulated pursuant to the insurance laws or the hospital or
medical service corporation laws of this state except with
respect to its health maintenance corporation activities
authorized and regulated pursuant to 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 health maintenance organization granted a
certificate of authority, or its representative shall not be
construed to violate any provision of law relating to
solicitation or advertising by health professions: Provided,
That nothing contained in this subsection shall be construed as
authorizing any solicitation or advertising which identifies or
refers to any individual provider or makes any qualitative
judgment concerning any provider.
(c) Any health maintenance organization authorized under
this article shall not be 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 fifteen, article four
(general provisions); article six-c (guaranteed loss ratio);
article seven (assets and liabilities); article eight
(investments); article nine (administration of deposits); 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 three-f, article sixteen (treatment
of temporomandibular disorder and craniomandibular disorder);
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-c (small employer group policies); article
sixteen-d (marketing and rate practices for small employers);
article twenty-seven (insurance holding company systems); 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); and
article thirty-nine (disclosure of material transactions) shall be applicable to any health maintenance organization granted a
certificate of authority under this article. In circumstances
where the code provisions made applicable to health maintenance
organizations by this section refer to the "insurer", the
"corporation" or words of similar import, the language shall be
construed to include health maintenance organizations.
(e) Any long-term care insurance policy delivered or issued
for delivery in this state by a health maintenance organization
shall comply with the provisions of article fifteen-a of this
chapter.
§33-25A-25. Filings and reports as public documents.
All applications, filings and reports required under this
article shall be treated as public documents: Provided, That
where the provisions of other articles in this chapter are
applicable to health maintenance organizations, all applications,
filings and reports required under those articles shall be
afforded the level of confidentiality as provided in those
articles.
§33-25A-26. Confidentiality of medical information.
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 health maintenance
organization shall be held in confidence and shall 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 seventeen of this article or to review the grievance procedure pursuant to section twelve 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 health maintenance organization
wherein the data or information is pertinent; or (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 HMO and the department or division of the state. A health
maintenance organization is entitled to claim any statutory
privileges against the disclosure which the provider who
furnished the information to the health maintenance organization
is entitled to claim.
§33-25A-33. Guaranty fund.
On or before the fifteenth day of January, one thousand nine
hundred ninety-six, the commissioner shall submit a report to the
Legislature setting forth a plan to establish a guaranty fund for
health maintenance organizations operating in West Virginia.