COMMITTEE SUBSTITUTE
FOR
H. B. 2619
(By Mr. Speaker, Mr. Chambers, and Delegate Ashley)
[By Request of the Executive]
(Introduced February 22, 1995; referred to the
Committee on Banking and Insurance)
A BILL to amend and reenact sections two, 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
four new sections, designated sections three-a, three-b,
seven-a and thirty-three, all relating to insurance; health
maintenance organization act; definitions; conditions
precedent to issuance of certificate of authority; application
for certificate of authority; issuance of certificate of
authority; 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; enrollment limitations; complaint
system; prohibited practices; 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
provisions for establishing a guaranty fund.
Be it enacted by the Legislature of West Virginia:
That sections two, 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 four new
sections, designated sections three-a, three-b, seven-a and thirty-
three, all to read as follows:
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-2. Definitions.
(a) "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.
(b) "Commissioner" means the commissioner of insurance.
(c) "Consumer" means any person who is not a provider of care
or an employee, officer, director or stockholder of any provider of
care.
(d) "Copayment" means a
specific dollar amount, except as
otherwise provided for by statute or rule, 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.nominal payment required of enrollees as a condition
of the receipt of specific health services.
(e) "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.
(f) "Employer" means any individual, corporation, partnership,
other private association, or state or local government that
employs the equivalent of at least
twenty-five two full-time
employees during any four consecutive calendar quarters.
(g) "Enrollee",
"subscriber," "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.
(h) "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.
(i) "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
such care or hospitalization, osteopathic services, home health,
health education, 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.
(j) "Health maintenance organization or HMO" means a public or
private organization which provides, or otherwise makes available,
health care services, including, but not limited to basic health care services, to its enrollees and which:
(1) Is compensated Receives premiums for the provision of
such health care services on a predetermined prepaid per capita or
prepaid aggregate fixed-sum predetermined periodic rate basis,
excluding copayments;
(2) Provides physician services primarily (i) directly through
physicians who are either employees or partners of such
organization, and/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
a combination of (i) and (ii) above;
(3) Assures the availability, accessibility, including
effective utilization, and quality of the health care services
which it provides or makes available through clearly identifiable
focal points of legal and administrative responsibility; and
(4) Offers services through an organized delivery system in
which a primary-care physician for each subscriber is selected 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.
(k) "Impaired" means a financial situation in which, based
upon the financial information 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 its liabilities and required reserves,
including any minimum capital and surplus required of that insurer
by this chapter so as to maintain its authority to transact the
kinds of business or insurance it is so authorized to transact.
(l) "Individual practice arrangement basis" 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 such health maintenance organization and are not
members of or affiliated with a medical group.
(m) "Insolvent" or "insolvency" means a financial situation in
which, based upon the financial information required by this
chapter for the preparation of its annual statement, the assets of
a health maintenance organization are less than the sum of its
liabilities and required reserves.
(n) "Medical group" or "group practice" means: (1) A
professional corporation, partnership, association, or other
organization which is 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; (2) a majority of the members
of which are licensed to practice medicine or osteopathy; (3) as
their principal professional activity engage in the coordinated
practice of their profession; (4) 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 (5)
share medical and other records and substantial portions of major
equipment and professional, technical and administrative staff.
(o) "Premium" means a predetermined periodic rate per capita
or per 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.
(p) "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 upon enrollment and who will be
responsible for coordinating the health care of the subscriber,
including necessary referrals to other providers.
(q) "Provider" means any physician, hospital or other person or organization which is licensed or otherwise authorized in this
state to furnish health care services.
(r) "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.
(s) "Service area" means the county or counties which have
been approved by the commissioner within which the health
maintenance organization may provide or arrange for health care
services to be available to its subscribers. area identified by a
health maintenance organization as the area within which health
care services will be provided by the health maintenance
organization
(t) "Surplus" means the amount by which a an association's or
corporation's organization's assets exceeds its liabilities and
required reserves, based upon the financial information required by
this chapter for the preparation of the association's or
corporation's organization'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.
(u) "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-3a. Conditions precedent to issuance or maintenance of
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.
(b) A waiver of any right to file or be subject to a
bankruptcy proceeding.
(2) 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.
(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. If the proceeding is
initiated by a party other than the health maintenance
organization, the operation of subsection (2) shall be stayed for
a period of sixty days following the date of commencement of the
proceeding.
§33-25A-3b. 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. and preliminary payments. The
commissioner shall promulgate regulations in accordance herewith
establishing methods of determining the feasibility of operating
prospective health maintenance organizations.
(2) Within thirty days of the effective date of this article, every health maintenance organization doing business in
West Virginia shall submit an application for a certificate of
authority under this section, but may continue to operate until the
commissioner acts upon the application. Upon the denial of such
application, pursuant to section four of this article, the
applicant shall be treated as a health maintenance organization
whose certificate of authority has been revoked.
(3) The commissioner may require any organization providing,
or arranging, or assuming risk for health care services on a
predetermined per capita or aggregate fixed sum basis predetermined
periodic rate to apply for a certificate of authority under this
article, and 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, shall not be required to file for
a certificate: And further provided 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 shall be 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 and regulations;
(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 such
officer or member of the governing body or any provider or any
organization or corporation owned or controlled by such person and
the health maintenance organization and the extent and nature of
any contract or financial arrangements between such persons and the
health maintenance organization;
(d) 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) A description of the proposed method of marketing the
plan, a schedule of proposed charges, and 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 such applicant, if
not domiciled in this state, appointing the commissioner and his
successors in office, and duly authorized deputies, as the true and
lawful attorney of such 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 geographic 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 (5%) 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 independent 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, such certification
shall include an adequate description of the rating methodology
showing that such methodology follows consistent and equitable
actuarial principles; the health maintenance organization is
actuarial sound, which 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 actuarial 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
(l) (n) Such other information as the commissioner may require
to be provided.
(5) A health maintenance organization shall, unless otherwise
provided for by regulations 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 regulation. If the commissioner does not disapprove of the
filing within ninety thirty days of filing, it shall be deemed
approved and may be implemented by the health maintenance
organization.
§33-25A-4. Issuance of certificate of authority.
(a) 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:
(1) The willingness and potential ability 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;
(2) Arrangements for an ongoing evaluation of the quality of
health care;
(3) 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 regulation.
(b) 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:
(1) The health maintenance organization's proposed plan of
operation meets the requirements of subsection (1) of this section;
(2) 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 herein 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 herein 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 such medicare
beneficiaries or medicaid recipients in excess of the benefits
compensated under such programs;
(3) 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:
(A) The financial soundness of the health maintenance
organization's arrangements for health care services and proposed
schedule of charges used in connection therewith;
(B) That the health maintenance organization shall have and
maintain fully paid in capital stock, if a for profit stock
corporation, or statutory surplus, funds, if a nonprofit
corporation, of at least one million dollars. In addition, each
such health maintenance organization shall have and maintain
additional surplus funds of at least one million dollars: Provided,
That health maintenance organizations duly licensed under this
article prior to the effective date of this section whose fully paid-in capital stock and surplus requirements are increased by
virtue of this section shall be required to maintain fully paid in
capital stock, if a for profit stock corporation, or statutory
surplus funds, if a nonprofit corporation, be at least two hundred
fifty thousand dollars and additional surplus funds of two hundred
fifty thousand dollars after the first day of January, one thousand
nine hundred ninety-two. Any such corporation shall then be
subject to the full paid-in capital and surplus requirements of
this section after the first day of January, one thousand nine
hundred ninety-four;
(C) 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 for a reasonable
period of time the continued availability or payment of the cost of
health care services in the event of discontinuance of the plan;
(D) Any agreement with providers for the provision of health
care services; and
(4) Reasonable provisions have been made for emergency and
out-of-area health care services;
(5) The enrollees will be afforded an opportunity to
participate in matters of policy and operation pursuant to section
six of this article;
(6) 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:
(A) For the cost of providing to any enrollee comprehensive
health maintenance care services, the aggregate value of which
exceeds four thousand dollars in any year;
(B) For the cost of providing comprehensive health care
services to its members on a nonelective emergency basis, or while
they are outside the area served by the organization; or
(C) 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 such
fiscal years;
(7) The ownership, control, and management of the entity 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 if he or she 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.
(8) 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 (of the type described in section seven of
article eight of this chapter) under this chapter in the amount of
one hundred thousand dollars.
(c) A certificate of authority shall be denied only after
compliance with the requirements of section twenty-one of this
article.
(d) Except as provided in subsection (2), section three three-
c of this article, 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 such organization shall be
responsible for such funds in a fiduciary relationship to the
enrollees.
(b) Any contracts made with providers of health care hospitals
and practitioners of medical, dental and related services enabling
a health maintenance organization to provide health care services
authorized under this article shall be filed with the commissioner. The commissioner shall have the power to require immediate
renegotiation or cancellation of such contracts whenever he
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 shall be liable for
such fee or fees rather than the subscriber; and the contract shall
so state.
(2) No subscriber of an HMO shall be liable to any provider of
health care services for any services covered by the HMO if at any
time during the provision of such services, the provider, or its
agents, are aware the subscriber is an HMO enrollee.
(3) No provider of services or any representative of such
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 such provider may maintain any action at law against a subscriber of an HMO to collect money owed to such
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 shall not be 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 said 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 shall not be 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.
(a)(1) 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.
(2) 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.
(3) An evidence of coverage shall contain a clear, concise and
complete statement of:
(A) The health care services and the insurance or other
benefits, if any, to which the enrollee is entitled;
(B) Any exclusions or limitations on the services, kind of
services, benefits, or kind of benefits, to be provided, including
any copayments;
(C) Where and in what manner information is available as to how services, including emergency and out-of-area services, may be
obtained;
(D) 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
(E) A description of the health maintenance organization's
method for resolving enrollee complaints.
(4) Any subsequent approved change in an evidence of coverage
shall be issued to each enrollee.
(5) A copy of the form of the evidence of coverage to be used
in this state, and any amendment thereto, shall be subject to the
filing and approval requirements of subdivision (b), subsection (1)
of this section, unless the commissioner promulgates a regulation
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 such laws shall apply.
To the extent, however, that such provisions do not apply the
requirements in subdivision (c), subsection (1) of this section,
shall be applicable.
(b) Such charges 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 the 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 such
methodology follows consistent and equitable actuarial principles;
and the rates being charged are actuarial adequate to the end of
the period for which rates have been guaranteed. to the
appropriateness of the charges based on reasonable assumptions
shall accompany the filing along with adequate supporting
information. In determining whether such charges are reasonable,
the commissioner shall consider whether such 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) has made a
good faith effort to secure arrangements whereby basic services can
be obtained by subscribers from all local providers to the extent
that such providers offer such services.
(c) Rates are inadequate if the premiums derived from the
rating structure, plus investment income, co-payments, 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.
(d) (3) The commissioner shall within a reasonable period
approve any form if the requirements of subsection (1) are met and
any schedule of charges if the requirements of subsection (2) are
met. It shall be unlawful to issue such form or to use such
schedule of charges until approved. If the commissioner
disapproves of such filing, he 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 such forms or charges, they
shall be deemed approved.
(e) (4) The commissioner may require the submission of
whatever relevant information in addition to the schedule of
charges which he deems necessary in determining whether to approve
or disapprove a filing made pursuant to this section.
(f) (5) An individual enrollee shall be allowed to cancel a
contract with a health maintenance organization at any time for any
reason: Provided, That a health maintenance may require that he or
she give sixty days advance notice. such cancellation disenrollment
to such organization. An individual enrollee whose premium rate
was determined pursuant to a group contract and on an aggregate
fixed-sum basis shall be allowed to cancel a contract with a health
maintenance organization pursuant to the terms of that contract.
§33-25A-9. Annual report.
(a) Every health maintenance organization shall annually, on
or before the first day of March, file a report verified by at
least two principal officers with the commissioner, covering the
preceding calendar year. comply with and be 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 said section shall include,
but not be limited to, the following:
(2) Such report shall be required by section fourteen, article
four of this chapter and shall include:
(1) 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.
(2) 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;
(3) 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;
(4) 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 such 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
(5) Such other information relating to the performance of the
health maintenance organization as is reasonably necessary to
enable the commissioner to carry out his duties under this article.
§33-25A-11. Open enrollment period; limitation on medicare and
medicaid beneficiaries.
(a) Once a health maintenance organization has been in
operation at least five years, or has enrollment of not less than
fifty thousand persons, such 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 such open enrollment period is equal to three percent
of the health maintenance organization's net increase in enrollment
during the previous year.
(b) 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:
(1) Waive such requirement for open enrollment for a period of
not more than three years; or
(2) Authorize such 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 such waiver or authorization.
(3) The sum of enrollees who are either (i) medicaid
beneficiaries, or (ii) medicare beneficiaries who are at least
sixty-five years of age, shall not exceed fifty percent of the
total enrolled population of a health maintenance organization. The
commissioner may waive this requirement with respect to any health
maintenance organization intending to enroll at least forty percent
of its enrollees from medically underserved areas, as defined by
the commissioner, if he is satisfied that such organization is
making substantial progress toward achieving compliance. Upon
written application of a health maintenance organization, the
commissioner may, after December 31, l996, by written order only,
waive such fifty percent limitation: Provided, That no health
maintenance organization shall be permitted an enrollment in which
the sum of such medicaid beneficiaries and medicare beneficiaries
who are at least sixty-five years of age constitute greater than
seventy-five percent of the total enrollment.
§33-25A-12. Complaint system.
(a) A health maintenance organization shall establish and
maintain a complaint system, which has been approved by the
commissioner, to provide adequate and reasonable procedures for the
expeditious resolution of written complaints initiated by enrollees concerning any matter relating to any provisions of such
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.
(b) 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 must include
the following:
(1) Both informal and formal steps shall be available to
resolve the grievance. A grievance is not considered formal until
a written complaint is executed by the subscriber or completed on
such forms as prescribed and received by the HMO;
(2) Each HMO shall designate at least one grievance
coordinator who will be responsible for the implementation of the
HMO's grievance procedure;
(3) 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;
(4) An address shall be included for written grievances;
(5) Each level of the grievance procedure shall have some
person with problem solving authority to participate in each step
of the grievance procedure;
(6) 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 will have thirty additional days to process
the subscriber complaint through all phases of the grievance
procedure. The time limitations prescribed in this paragraph
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 complaint. Upon receipt by the HMO
of the additional information requested, the time for completion of
the grievance process set forth herein shall resume.
(7) 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 department or division of the state
responsible for administering the relevant program, and if either
of the two parties are not satisfied with the outcome of such
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;
(8) 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;
(9) 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;
(10) 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;
(11) 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 complaint has been processed and how many
more levels of the grievance procedure are remaining before the
complaint has been processed through the HMO's entire grievance
procedure.
A health maintenance organization shall give a timely and
reasoned response, in writing, to each written complaint it
receives. Copies of such complaints and the responses thereto
shall be available to the commissioner, and the public for
inspection for three years.
(c) 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. Each health maintenance organization shall submit to the commissioner an
annual report in a form prescribed by the commissioner which
describes such complaint system and contains a compilation and
analysis of the complaints filed, their disposition, and their
underlying causes.
§33-25A-14. Prohibited practices.
(a) 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:
(1) A statement or item of information shall be deemed 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;
(2) A statement or item of information shall be deemed to be
misleading, whether or not it may be literally untrue, if, in the
total context in which such statement is made or such item of
information is communicated, such 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 such benefit or advantage or absence of
limitation, exclusion or disadvantage does not in fact exist;
(3) An evidence of coverage shall be deemed 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 such evidence of coverage does not
regularly make available for enrollees covered under such evidence
of coverage; and
(4) The commissioner may further define practices which are
untrue, misleading or deceptive.
(b) 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 regulations 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, including therein the reason therefor: 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; however, the enrollee may not be
disenrolled if the disenrollment would constitute abandonment of a
patient. Any enrollee wrongfully disenrolled shall be reenrolled.
(c) 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.
(d) The providers of under agreement with a health maintenance organization who to 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.
(e) 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.
(f) 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.
(g) 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 such
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 shall apply 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 ten 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.
(h) No contract with an enrollee shall prohibit an enrollee from canceling his or her enrollment at any time for any reason
except that such contract may require thirty days' notice to the
health maintenance organization.
(i) 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.
(a) Health maintenance organizations are subject to the
provisions of article twelve of this chapter.
(b) After a subscriber, who has been solicited on an
individual basis, 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:
(1) Confirmation that the subscriber intends and desires to
join the HMO;
(2) If the subscriber is a medicare or medicaid recipient,
confirmation must be provided that the subscriber understands by joining the HMO they will be limited to the benefits provided by
the HMO, and medicare or medicaid will pay the HMO for the
subscriber coverage;
(3) Confirmation that the subscriber understands the
applicable restrictions of HMOs, especially that they must use the
HMO providers and secure approval from the HMO to use health care
providers outside the plan; and
(4) If the subscriber is a member of an HMO, confirmation must
be provided that the subscriber understands they are transferring
to another HMO.
(5) 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 their 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 they have transferred from their 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
deemed 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 by the HMO, its agents, or
employees.
(c) (1) The commissioner may, in his or her discretion, after
notice and hearing, promulgate rules and regulations as are
necessary to regulate marketing of health maintenance organizations
by persons compensated directly or indirectly by such health
maintenance organizations. When necessary such rules and
regulations may prohibit door-to-door solicitations, may prohibit
commission sales, and may provide for such other proscriptions and
other regulations as are required to effectuate the purposes of
this article.
§33-25A-16. Powers of insurers and hospital and medical service
corporations.
(a) 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 either directly or
through a subsidiary or affiliate organize and operate a health
maintenance organization under the provisions of this article.
Notwithstanding any other law which may be inconsistent herewith, any two or more such 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 deemed to include the providing of
health care by a health maintenance organization owned or operated
by an insurer or a subsidiary thereof.
(b) 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 such 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.
(a) The commissioner may make an examination of the affairs of
any health maintenance organization and providers with whom such
organization has contracts, agreements or other arrangements as often as he deems it necessary for the protection of the interests
of the people of this state but not less frequently than once every
three years.
(b) The commissioner may shall contract with the department of
health or any entity contracted with by the department of health
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 such
organization has contracts, agreements or other arrangements as
often as it deems 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 foregoing examination,
the department of health or accredited entity shall utilize the
services of persons or organizations with demonstrable expertise in
assessing quality of health care.
(c) Every health maintenance organization and affiliated
provider shall submit its books and records to such examinations
and in every way facilitate them. For the purpose of examinations,
the commissioner and the department of health shall have all powers
necessary to conduct such 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 such providers concerning their
business.
(d) The health maintenance organization shall be subject to
the provisions of section nine, article two of this chapter in
regard to the expense and conduct of examinations.
(e) In lieu of such examination, the commissioner may accept
the report of an examination made by other states.
§33-25A-18. Suspension or revocation of certificate of
authority.
(a) The commissioner may suspend or revoke any certificate of
authority issued to a health maintenance organization under this
article if he finds that any of the following conditions exist:
(1) 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 such submissions have been filed with an
approval of the commissioner;
(2) 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;
(3) The health maintenance organization does not provide or
arrange for basic health care services;
(4) The department of health 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;
(5) 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;
(6) 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;
(7) The health maintenance organization has failed to
implement the complaint system required by section twelve of this
article in a manner to reasonably resolve valid complaints;
(8) 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;
(9) The continued operation of the health maintenance
organization would be hazardous to its enrollees;
(10) The health maintenance organization has otherwise failed
to substantially comply with this article; or
(11) The health maintenance organization has violated a lawful
order of the commissioner.
(b) A certificate of authority shall be suspended or revoked
only after compliance with the requirements of section twenty-one
of this article.
(c) When the certificate of authority of a health maintenance
organization is suspended, the health maintenance organization
shall not, during the period of such 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.
(d) When the certificate of authority of a health maintenance
organization is revoked, such 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 such 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 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 deemed to be the rehabilitation,
liquidation or conservation of an insurance company, and shall be
the exclusive remedy for rehabilitation, liquidation and
conservation, as set forth in section three of 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 to rehabilitate, liquidate or conserve
a health maintenance organization upon any one or more grounds set
out in the vocational 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 shall not be applicable to any health maintenance
organization granted a certificate of authority under this article.
This provision 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 herein 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 deemed to be practicing medicine and shall be
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); and 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, such
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 such 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 complaint system
pursuant to section twelve of this article; (2) upon the express
written consent of the enrollee or legally authorized
representative; (3) pursuant to statute or court order for the
production of evidence or the discovery thereof; or (4) in the
event of claim or litigation between such person and the health
maintenance organization wherein such 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 such department or division of the
state. A health maintenance organization shall be entitled to claim any statutory privileges against such disclosure which the
provider who furnished such information to the health maintenance
organization is entitled to claim.
§33-25A-33. Guaranty fund.
On or before January 15, l996, 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.