West Virginia Code
1 - STATE PUBLIC HEALTH SYSTEM
1A - UNIFORM CREDENTIALING FOR HEAL
1B - SKILLED NURSING FACILITIES FOR
1C - HEALTH CARE PROVIDER TRANSPARE
2 - LOCAL BOARDS OF HEALTH
2A - ALTERNATIVE METHOD OF ORGANIZI
2B - FAMILY PLANNING AND CHILD SPAC
2C - HOME HEALTH SERVICES
2D - CERTIFICATE OF NEED
2E - BIRTHING CENTERS
2F - PARENTAL NOTIFICATION OF ABORT
2G - SPECIAL SUPPLEMENTARY FOOD PRO
2H - PRIMARY CARE SUPPORT PROGRAM
2I - WOMEN'S RIGHT TO KNOW ACT
2J - PREVENTIVE CARE PILOT PROGRAM
2K - PROGRAMS OF ALL-INCLUSIVE CARE
2L - PROVIDER SPONSORED NETWORKS
16 - 2 L- 1
16 - 2 L- 2
16 - 2 L- 3
16 - 2 L- 4
16 - 2 L- 5
16 - 2 L- 6
16 - 2 L- 7
2M - THE PAIN-CAPABLE UNBORN CHILD
2N - NEONATAL ABSTINENCE CENTERS
2O - UNBORN CHILD PROTECTION FROM D
3 - PREVENTION AND CONTROL OF COMMU
3A - REPOSITORY OF INFORMATION ON M
3B - PERTUSSIS
3C - AIDS-RELATED MEDICAL TESTING A
3D - TUBERCULOSIS TESTING, CONTROL,
4 - SEXUALLY TRANSMITTED DISEASES
4A - PRENATAL EXAMINATION
4B - AUTOPSIES ON BODIES OF DECEASE
4C - EMERGENCY MEDICAL SERVICES ACT
4D - AUTOMATED EXTERNAL DEFIBRILLAT
4E - UNIFORM MATERNAL SCREENING ACT
4F - EXPEDITED PARTNER THERAPY
5 - VITAL STATISTICS
5A - CANCER CONTROL
5B - HOSPITALS AND SIMILAR INSTITUT
5C - NURSING HOMES
5D - ASSISTED LIVING RESIDENCES
5E - REGISTRATION AND INSPECTION OF
5F - HEALTH CARE FINANCIAL DISCLOSU
5G - OPEN HOSPITAL PROCEEDINGS
5H - CHRONIC PAIN CLINIC LICENSING
5I - HOSPICE LICENSURE ACT
5J - CLINICAL LABORATORIES QUALITY
5K - EARLY INTERVENTION SERVICES FO
5L - LONG-TERM CARE OMBUDSMAN PROGR
5M - OSTEOPOROSIS PREVENTION EDUCAT
5N - RESIDENTIAL CARE COMMUNITIES
5O - MEDICATION ADMINISTRATION BY U
5P - SENIOR SERVICES
5Q - THE JAMES "TIGER" MO
5R - THE ALZHEIMER'S SPECIAL CARE S
5S - OLDER WEST VIRGINIANS ACT
5T - OFFICE OF DRUG CONTROL POLICY
5U - ARTHRITIS PREVENTION EDUCATION
5V - EMERGENCY MEDICAL SERVICES RET
5W - WEST VIRGINIA OFFICIAL PRESCRI
5X - CAREGIVER ADVISE, RECORD AND E
5Y - MEDICATION-ASSISTED TREATMENT
5Z - COALITION FOR DIABETES MANAGEM
6 - HOTELS AND RESTAURANTS
7 - PURE FOOD AND DRUGS
8 - ELECTROLOGISTS
8A - NARCOTIC DRUGS
8B - DANGEROUS DRUGS ACT
9 - OFFENSES GENERALLY
9A - TOBACCO USAGE RESTRICTIONS
9B - IMPLEMENTING TOBACCO MASTER SE
9C - STATE TOBACCO GROWERS' SETTLEM
9D - ENFORCEMENT OF STATUTES IMPLEM
9E - DELIVERY SALES OF TOBACCO
9F - COUNTERFEIT CIGARETTES
10 - UNIFORM DETERMINATION OF DEAT
11 - SEXUAL STERILIZATION
12 - SANITARY DISTRICTS FOR SEWAGE
13 - SEWAGE WORKS AND STORMWATER W
13A - PUBLIC SERVICE DISTRICTS
13B - COMMUNITY IMPROVEMENT ACT
13C - DRINKING WATER TREATMENT REV
13D - REGIONAL WATER AND WASTEWATE
13E - COMMUNITY ENHANCEMENT ACT
14 - BARBERS AND COSMETOLOGISTS
15 - STATE HOUSING LAW
16 - HOUSING COOPERATION LAW
17 - NATIONAL DEFENSE HOUSING
18 - SLUM CLEARANCE
19 - ANATOMICAL GIFT ACT
20 - AIR POLLUTION CONTROL
21 - BLOOD DONATIONS
22 - DETECTION AND CONTROL OF PHEN
22A - TESTING OF NEWBORN INFANTS F
22B - BIRTH SCORE PROGRAM
23 - TRANSFUSION OF BLOOD; TRANSPL
24 - STATE HEMOPHILIA PROGRAM
25 - DETECTION OF TUBERCULOSIS, HI
26 - WEST VIRGINIA SOLID WASTE MAN
27 - STORAGE AND DISPOSAL OF RADIO
27A - BAN ON CONSTRUCTION OF NUCLE
28 - ASSISTANCE TO KOREAN AND VIET
29 - HEALTH CARE RECORDS
29A - WEST VIRGINIA HOSPITAL FINAN
29B - HEALTH CARE AUTHORITY
29C - INDIGENT CARE
29D - STATE HEALTH CARE
29E - LEGISLATIVE OVERSIGHT COMMIS
29F - UNINSURED AND UNDERINSURED P
29G - WEST VIRGINIA HEALTH INFORMA
29H - INTERAGENCY HEALTH COUNCIL
29I - WEST VIRGINIA HEALTH CARE AU
30 - WEST VIRGINIA HEALTH CARE DEC
30A - MEDICAL POWER OF ATTORNEY
30B - HEALTH CARE SURROGATE ACT
30C - DO NOT RESUSCITATE ACT
31 - COMMUNITY RIGHT TO KNOW
32 - ASBESTOS ABATEMENT
33 - BREAST AND CERVICAL CANCER PR
34 - LICENSURE OF RADON MITIGATORS
35 - LEAD ABATEMENT
36 - NEEDLESTICK INJURY PREVENTION
37 - BODY PIERCING STUDIO BUSINESS
38 - TATTOO STUDIO BUSINESS
39 - PATIENT SAFETY ACT
40 - STATEWIDE BIRTH DEFECTS INFOR
41 - ORAL HEALTH IMPROVEMENT ACT
42 - COMPREHENSIVE BEHAVIORAL HEAL
43 - ENGINE COOLANT AND ANTIFREEZE
44 - THE PULSE OXIMETRY NEWBORN TE
45 - TANNING FACILITIES
46 - ACCESS TO OPIOID ANTAGONISTS
47 - ALCOHOL AND DRUG OVERDOSE PRE
48 - WEST VIRGINIA ABLE ACT
49 - WEST VIRGINIA CLEARANCE FOR A
50 - EPINEPHRINE AUTO-INJECTOR AVA
51 - RIGHT TO TRY ACT
52 - COALITION FOR RESPONSIBLE PAI
53 - ESTABLISHING ADDITIONAL SUBST
CHAPTER 16. PUBLIC HEALTH.
ARTICLE 2L. PROVIDER SPONSORED NETWORKS.
The Legislature finds that it inures to the benefit of the state and its Medicaid populations to foster the development of care systems and Medicaid options that allow for the functional integration and participation of privately practicing physicians with provider sponsored networks who have patient-centered medical home resources and who are willing to share access and use of those resources; that privately practicing physicians provide indispensable and important health care services to Medicaid enrollees in West Virginia but many do not have the resources to develop patient-centered medical homes in their respective practices; that federally qualified health centers are deeply engaged with integrating behavioral health providers and other community services in their care of Medicaid beneficiaries and that such centers lead in the development and implementation of recognized medical homes in West Virginia; and that better health outcomes can be achieved and inappropriate utilization avoided through the integration and coordination of physical health care with mental health care. Therefore, in order to develop innovative means of meeting the health care needs of the state's citizens and to address the impact on the state's budget arising from the growing cost of Medicaid, and in recognition of the important role that federally qualified health centers play in providing health care services to Medicaid beneficiaries, the Legislature authorizes the secretary to enter into contracts with provider sponsored networks.
As used in this article, unless the context requires otherwise:
(1) "Continuity-of-care" means the clinical practice of a medical professional who provides care to patients in which:
(A) In addition to episodic or urgent care provided from time to time as needed, preventive care and counseling is provided and a patient's overall health status is monitored even when illness is not present or not in crisis; and
(B) Without being limited to discrete episodes of care, medical records and care processes are used that track and manage health status over time and allow the medical professional to refer care to, and receive reports from, other medical professionals and other care team members responsible for a patient's care.
(2) "Federally Qualified Health Center" means an entity as defined in 42 U.S.C. §1396d(l)(2)(B).
(3) "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.
(4) "Medical home" means a team-based model of care in a patient-centered medical home.
(5) "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.
(6) "Participating primary care provider" is a primary care provider who is also a participating provider.
(7) "Patient-centered medical home" means a health care setting as described in section nine, article twenty-nine-h of this chapter.
(8) "Primary care provider" means a licensed behavioral health professional or a person licensed as an allopathic or osteopathic physician primarily practicing internal medicine, family or general practice, obstetrics and gynecology, or pediatrics who provides continuity-of-care services to the majority of his or her patients.
(9) "Provider sponsored network" means an entity licensed by the West Virginia insurance commissioner in accordance with article twenty-five-g, chapter thirty-three of this code.
(10) "Secretary" means the Secretary of the West Virginia Department of Health and Human Resources.
(a) The secretary is authorized to enter into contracts with any provider sponsored network licensed by the insurance commissioner in accordance with the provisions of article twenty-five-g, chapter thirty-three of this code, to arrange for the provision of health care, services and supplies for Medicaid beneficiaries. Such contract:
(1) Shall be subject to the same criteria and standards applied to other managed care organizations; and
(2) May provide that the provider sponsored network will share with the department up to 25% of any net profits realized during the period of the contract.
(b) The service, administrative and performance criteria to be met by provider sponsored networks shall be the same as required of other managed care organizations providing services to Medicaid beneficiaries in the state.
(c) A licensed provider sponsored network shall be deemed an HMO for the purposes of federal regulations governing the Medicaid program to the extent permitted by such regulations.
(a) Notwithstanding the prior availability or utilization of other options, every licensed provider sponsored network available in a county shall be offered by the secretary as an enrollment option to that county's Medicaid beneficiaries. A provider sponsored network is deemed to be "available in a county" if the secretary has entered into a contract with it to provide services to Medicaid beneficiaries in that county.
(b) The secretary shall require that each eligible Medicaid beneficiary be given the option to choose any available managed care plan, including a provider sponsored network, to arrange for and provide his or her medical services under the Medicaid program, and nothing in this article shall be construed to remove or diminish the right of Medicaid beneficiaries to choose among such available options.
(c) The secretary shall seek approval from the Centers for Medicare and Medicaid Services to permit the assignment to an available provider sponsored network of any Medicaid beneficiary who does not exercise the option to choose a managed care plan or provider sponsored network offered to him or her. The secretary shall promulgate emergency rules and shall propose for legislative approval legislative rules as may be necessary to implement such assignment process.
(d) A Medicaid beneficiary assigned to a provider sponsored network or another managed care organization may change enrollment to any other available provider sponsored network or managed care organization as such options may be available, and nothing in this article requires that a Medicaid beneficiary who is a patient of a participating provider must remain an enrollee in the provider sponsored network with which such participating provider has a contract.
Because agreement and coordination among health care providers, who may be potential competitors with each other, is required to establish and operate provider sponsored networks, an exemption from anti-trust laws for these activities will further the purposes of this article. Therefore, the West Virginia Anti-Trust Act, article eighteen, chapter forty-seven of this code, is inapplicable to the development of provider sponsored networks, activities necessary to operate provider sponsored networks or any arrangements or agreements between or among provider sponsored networks and participating providers that are performed or entered into consistent with and pursuant to the provisions of this article and the provisions of article twenty-five-g, chapter thirty-three of this code. It is the intent of the Legislature that the federal anti-trust statutes be interpreted in this manner as well.
The secretary 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.
The secretary shall include in his or her annual report to the Legislature the status of the provider sponsored network programs operating during the previous fiscal year.