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Chapter 33     Entire Code


ARTICLE 1. DEFINITIONS.

ARTICLE 2. INSURANCE COMMISSIONER.

ARTICLE 3. LICENSING, FEES AND TAXATION OF INSURERS.

ARTICLE 3A. STATE OF ENTRY FOR FOREIGN INSURERS.

ARTICLE 4. GENERAL PROVISIONS.

ARTICLE 4A. ALL-PAYER CLAIMS DATABASE.

ARTICLE 5. ORGANIZATION AND PROCEDURES OF DOMESTIC STOCK AND MUTUAL INSURERS.

ARTICLE 6. THE INSURANCE POLICY.

ARTICLE 6A. CANCELLATION OR NONRENEWAL OF AUTOMOBILE LIABILITY POLICIES.

ARTICLE 6B. DECLINATION OF AUTOMOBILE LIABILITY INSURANCE.

ARTICLE 6C. GUARANTEED LOSS RATIOS AS APPLIED TO INDIVIDUAL SICKNESS AND ACCIDENT INSURANCE POLICIES.

ARTICLE 6D. MOTOR VEHICLE REPAIR AND REPLACEMENT REFERRALS.

ARTICLE 6F. DISCLOSURE OF NONPUBLIC PERSONAL INFORMATION.

ARTICLE 7. ASSETS AND LIABILITIES.

ARTICLE 8. INVESTMENTS.

ARTICLE 8A. USE OF CLEARING CORPORATIONS AND FEDERAL RESERVE BOOK-ENTRY SYSTEM.

ARTICLE 9. ADMINISTRATION OF DEPOSITS.

ARTICLE 10. REHABILITATION AND LIQUIDATION.

ARTICLE 11. UNFAIR TRADE PRACTICES.

ARTICLE 11A. INSURANCE SALES CONSUMER PROTECTION ACT.

ARTICLE 12. INSURANCE PRODUCERS AND SOLICITORS.

ARTICLE 12A. CONTRACTUAL RELATIONSHIPS BETWEEN INSURANCE COMPANIES AND AGENTS.

ARTICLE 12B. ADJUSTERS.

ARTICLE 12C. SURPLUS LINE.

ARTICLE 13. LIFE INSURANCE.

ARTICLE 13A. VARIABLE CONTRACTS.

ARTICLE 13B. CHARITABLE GIFT ANNUITIES.

ARTICLE 13C. VIATICAL SETTLEMENTS ACT.

ARTICLE 13D. UNCLAIMED LIFE INSURANCE BENEFITS ACT.

ARTICLE 14. GROUP LIFE INSURANCE.

ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.

ARTICLE 15A. WEST VIRGINIA LONG-TERM CARE INSURANCE ACT.

ARTICLE 15B. UNIFORM HEALTH CARE ADMINISTRATION ACT.

ARTICLE 15C. DIABETES INSURANCE.

ARTICLE 15D. INDIVIDUAL LIMITED HEALTH BENEFITS PLANS.

ARTICLE 15E. DISCOUNT MEDICAL PLAN ORGANIZATIONS AND DISCOUNT PRESCRIPTION DRUG PLAN ORGANIZATIONS ACT.

ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.

ARTICLE 16A. GROUP HEALTH INSURANCE CONVERSION.

ARTICLE 16B. ACCIDENT AND SICKNESS RATES.

ARTICLE 16C. EMPLOYER GROUP ACCIDENT AND SICKNESS INSURANCE POLICIES.

ARTICLE 16D. MARKETING AND RATE PRACTICES FOR SMALL EMPLOYER ACCIDENT AND SICKNESS INSURANCE POLICIES.

ARTICLE 16E. CONTRACEPTIVE COVERAGE.

ARTICLE 16F. GROUP LIMITED HEALTH BENEFITS PLANS.

ARTICLE 16G. WEST VIRGINIA HEALTH BENEFIT EXCHANGE ACT.

ARTICLE 16H. REVIEW OF ADVERSE DETERMINATIONS.

ARTICLE 17. FIRE AND MARINE INSURANCE.

ARTICLE 17A. PROPERTY INSURANCE DECLINATION, TERMINATION AND DISCLOSURE.

ARTICLE 18. CASUALTY INSURANCE.

ARTICLE 19. SURETY INSURANCE.

ARTICLE 20. RATES AND RATING ORGANIZATIONS.

ARTICLE 20A. WEST VIRGINIA ESSENTIAL INSURANCE COVERAGE ACT.

ARTICLE 20B. RATES AND MALPRACTICE INSURANCE POLICIES.

ARTICLE 20C. CANCELLATION OR NONRENEWAL OF MALPRACTICE INSURANCE POLICIES.

ARTICLE 20D. TAIL INSURANCE.

ARTICLE 20E. WEST VIRGINIA MEDICAL PROFESSIONAL LIABILITY INSURANCE JOINT UNDERWRITING ASSOCIATION ACT.

ARTICLE 20F. PHYSICIANS\' MUTUAL INSURANCE COMPANY.

ARTICLE 21. RECIPROCAL INSURERS.

ARTICLE 22. FARMERS\' MUTUAL FIRE INSURANCE COMPANIES.

ARTICLE 23. FRATERNAL BENEFIT SOCIETIES.

ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH SERVICE CORPORATIONS.

ARTICLE 25. HEALTH CARE CORPORATIONS.

ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.

ARTICLE 25B. FEDERAL INSURANCE SUBSIDY FOR CHILDREN\'S HEALTH.

ARTICLE 25C. HEALTH MAINTENANCE ORGANIZATION PATIENT BILL OF RIGHTS.

ARTICLE 25D. PREPAID LIMITED HEALTH SERVICE ORGANIZATION ACT.

ARTICLE 25E. PATIENTS\' EYE CARE ACT.

ARTICLE 25F. COVERAGE FOR PATIENT COST OF CLINICAL TRIALS.

ARTICLE 26. WEST VIRGINIA GUARANTY ASSOCIATION ACT.

ARTICLE 26A. WEST VIRGINIA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT.

ARTICLE 26B. WEST VIRGINIA HEALTH MAINTENANCE ORGANIZATION GUARANTY ASSOCIATION.

ARTICLE 27. INSURANCE HOLDING COMPANY SYSTEMS.

ARTICLE 28. INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS.

ARTICLE 29. LIFE AND ACCIDENT AND SICKNESS INSURANCE POLICY LANGUAGE SIMPLIFICATION ACT.

ARTICLE 30. MINE SUBSIDENCE INSURANCE.

ARTICLE 31. CAPTIVE INSURANCE.

ARTICLE 31A. SPONSORED CAPTIVE INSURANCE COMPANY FORMATION.

ARTICLE 32. RISK RETENTION ACT.

ARTICLE 33. ANNUAL AUDITED FINANCIAL REPORT.

ARTICLE 34. ADMINISTRATIVE SUPERVISION.

ARTICLE 34A. STANDARDS AND COMMISSIONER\'S AUTHORITY FOR COMPANIES DEEMED TO BE IN HAZARDOUS FINANCIAL CONDITION.

ARTICLE 35. CRIMINAL SANCTIONS FOR FAILURE TO REPORT IMPAIRMENT.

ARTICLE 36. BUSINESS TRANSACTED WITH PRODUCER-CONTROLLED PROPERTY/CASUALTY INSURER ACT.

ARTICLE 37. MANAGING GENERAL AGENTS.

ARTICLE 38. REINSURANCE INTERMEDIARY ACT.

ARTICLE 39. DISCLOSURE OF MATERIAL TRANSACTIONS.

ARTICLE 40. RISK-BASED CAPITAL (RBC) FOR INSURERS.

ARTICLE 40A. RISKED-BASED CAPITAL FOR HEALTH ORGANIZATIONS.

ARTICLE 40B. RISK MANAGEMENT AND OWN RISK AND SOLVENCY ASSESSMENT ACT.

ARTICLE 41. PRIVILEGES AND IMMUNITY.

ARTICLE 42. WOMEN\'S ACCESS TO HEALTH CARE ACT.

ARTICLE 43. INSURANCE TAX PROCEDURES ACT.

ARTICLE 44. UNAUTHORIZED INSURERS ACT.

ARTICLE 45. ETHICS AND FAIRNESS IN INSURER BUSINESS PRACTICES.

ARTICLE 46. THIRD-PARTY ADMINISTRATOR ACT.

ARTICLE 46A. PROFESSIONAL EMPLOYER ORGANIZATIONS.

ARTICLE 47. INTERSTATE INSURANCE PRODUCT REGULATION COMPACT.

ARTICLE 48. MODEL HEALTH PLAN FOR UNINSURABLE INDIVIDUALS ACT.

ARTICLE 49. FLOOD INSURANCE.

ARTICLE 50. PATIENT PROTECTION AND TRANSPARENCY ACT.

ARTICLE 51. PHARMACY AUDIT INTEGRITY ACT.

ARTICLE 52. CORPORATE GOVERNANCE ANNUAL DISCLOSURE ACT.

ARTICLE 25G. PROVIDER SPONSORED NETWORKS.

§33-25G-1. Legislative findings.

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

§33-25G-2. Definitions.

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

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

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

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

(e) "Secretary" means the Secretary of the West Virginia Department of Health and Human Resources.

§33-25G-3. Licensing of provider sponsored networks.

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

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

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

§33-25G-4. Provider participation.

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

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

(c) A participating provider shall have the right to participate in, and contract with, other networks or other managed care organizations to provide services to Medicaid beneficiaries.

§33-25G-5. Rules.

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

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