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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 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 25G. PROVIDER SPONSORED NETWORKS.

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 27A. WEST VIRGINIA MUTUAL TO MUTUAL INSURANCE HOLDING COMPANY ACT.

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. WEST VIRGINIA INSURANCE FRAUD PREVENTION ACT.

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 53. CERTIFICATES OF INSURANCE.

ARTICLE 54. REQUIRING ACCOUNTABLE PHARMACEUTICAL TRANSPARENCY, OVERSIGHT, AND REPORTING ACT.

ARTICLE 55. HEALTH BENEFIT PLAN NETWORK ACCESS AND ADEQUACY ACT.

ARTICLE 56. HEALTH CARE SERVICES PROVIDED BY PHARMACISTS.

ARTICLE 57. REQUIRED COVERAGE FOR HEALTH INSURANCE.

ARTICLE 58. REQUIRED COVERAGE FOR HEALTH INSURANCE.

ARTICLE 59. REQUIRED COVERAGE FOR HEALTH INSURANCE.

ARTICLE 60. INSURANCE INNOVATION.

ARTICLE 61. MINING MUTUAL INSURANCE COMPANY.

ARTICLE 4A. ALL-PAYER CLAIMS DATABASE.

§33-4A-1. Definitions.

(a) “All-payer claims database” or “APCD” means the program authorized by this article that collects, retains, uses, and discloses information concerning the claims and administrative expenses of health care payers.

(b) “Commissioner” means the West Virginia Insurance Commissioner.

(c) “Data” means the data elements from enrollment and eligibility files, specified types of claims, and reference files for data elements not maintained in formats consistent with national coding standards.

(d) “Health care payer” means any entity that pays or administers the payment of health insurance claims or medical claims under workers’ compensation insurance to providers in this state, including workers’ compensation insurers; accident and sickness insurers; nonprofit hospital service corporations, medical service corporations, and dental service organizations; nonprofit health service corporations; prepaid limited health service organizations; health maintenance organizations; and government payers, including, but not limited to, Medicaid, Medicare, and the Public Employees Insurance Agency; the term also includes any third-party administrator, including any pharmacy benefits manager, that administers a fully funded plan:

A “health insurance claim” does not include:

(1) Any claim paid under an individual or group policy providing coverage only for accident or disability income insurance or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability; credit-only insurance; coverage for on-site medical clinics; other similar insurance coverage, which may be specified by rule, under which benefits for medical care are secondary or incidental to other insurance benefits; or

(2) Any of the following if provided under a separate policy, certificate, or contract of insurance: Limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; coverage for only a specified disease or illness; or hospital indemnity or other fixed indemnity insurance.

“Health insurance claims” shall only include information from Medicare supplemental policies if the same information is obtained with respect to Medicare.

(e) “Personal identifiers” means information relating to an individual member or insured that identifies, or can be used to identify, locate, or contact a particular individual member or insured, including, but not limited to, the individual’s name, street address, Social Security number, e-mail address, and telephone number.

(f) “Secretary” means the Secretary of the West Virginia Department of Health and Human Resources.

(g) “Third-party administrator” has the same meaning ascribed to it in §33-46-2 of this code.

§33-4A-2. Establishment and development of an all-payer claims database.

(a) The secretary shall have primary responsibility for the collection, retention, and dissemination of the data in an all-payer claims database (APCD). The commissioner shall have primary responsibility for enforcement of data collection.

(b) The secretary shall provide for the development of a plan for the financial stability of the APCD.

(c) The secretary shall provide for the use of the hospital uniform billing data collected by the West Virginia Department of Health and Human Resources as a tool in the validation of APCD reports.

§33-4A-3. Powers of the secretary; exemption from purchasing rules.

(a) The secretary may:

(1) Accept gifts, bequests, grants, or other funds dedicated to the furtherance of the goals of the all-payer claim database (APCD);

(2) Select a vendor to handle data collection and processing and such other tasks as deemed appropriate;

(3) Enter into agreements with other states to perform joint administrative operations, share information, and assist in the development of multistate efforts to further the goals of this article: Provided, That any such agreements must include adequate protections with respect to the confidentiality of the information to be shared and comply with all state and federal laws and regulations;

(4) Enter into memoranda of understanding with other governmental agencies to carry out any of its functions, including contracts with other states to perform joint administrative functions;

(5) Attempt to ensure that the requirements with respect to the reporting of data be standardized;

(6) Enter into voluntary agreements to obtain data from payers not subject to mandatory reporting under this article; and

(7) Exempt a payer or class of payers from the requirements of this article for cause.

(b) Contracts for professional services for the development and operation of the APCD are not subject to the provisions of §5A-3-1 et seq. of this code relating to the Purchasing Division of the Department of Administration. The award of such contracts shall be subject to a competitive process established by the secretary.

(c) The secretary shall make an annual report to the Governor, which shall also be filed with the Joint Committee on Government and Finance, summarizing the activities of the APCD in the preceding calendar year.

§33-4A-4. Data subject to this article.

(a) All health care payers shall submit data to the secretary, or an entity designated by the secretary, at such times and in a form specified in rule. Any health care payer that the secretary or commissioner determines paid or administered the payment of health insurance claims in this state for policies on fewer than 500 covered lives in the previous calendar year is exempt from the requirements of this article.

(b) Data submitted in accordance with this article shall be considered confidential by law and privileged, are exempt from disclosure pursuant to §29B-1-1 et seq. of this code, are not open to public inspection, are not subject to subpoena, are not subject to discovery or admissible in evidence in any criminal, private, civil, or administrative action, are not subject to production pursuant to court order, and shall only be used and disclosed pursuant to law and legislative rules promulgated pursuant to this article.

(c)(1) Data submitted to and retained by the all-payer claims database (APCD) shall be available as a resource for the secretary and commissioner to conduct public health analyses, conduct program analyses, review health care utilization, expenditures, and performance in West Virginia, conduct academic research, and to enhance the ability of consumers to make informed and cost-effective health care decisions.

(2) Data submitted to and retained by the APCD may, in accordance with this article and the legislative rules promulgated pursuant to this article, also be available as a resource for insurers, researchers, employers, providers, purchasers of health care, consumers, and state agencies. Any such use shall be limited to public health, research, consumer reporting, and program evaluation purposes.

(d) Notwithstanding any other provision of law to the contrary, the APCD may not disclose any data that contain personal identifiers. The secretary, in accordance with procedures and standards set forth in legislative rule, may approve access to data elements not prohibited from disclosure by the APCD, as well as synthetic or created unique identifiers, for use by researchers, including government agencies, with established protocols for safeguarding confidential or privileged information. Use of the data by the secretary and commissioner shall not constitute a disclosure.

§33-4A-5. User fees; waiver.

Reasonable user fees may be set by the secretary, in the manner established in legislative rule, for the right to access and use the data available from the all-payer claim database (APCD). The secretary may reduce or waive the fee if he or she determines that the user is unable to pay the scheduled fees and that the user has a viable plan to use the data or information in research of general value to the public health.

§33-4A-6. Enforcement; injunctive relief.

If there is any violation of this article or any rule adopted thereunder, the commissioner or secretary may seek to enjoin a further violation in the circuit court of Kanawha County. Injunctive relief ordered pursuant to this section may be in addition to any other remedies and enforcement actions available to the secretary and commissioner under this chapter.

§33-4A-7. Special revenue account created.

(a) There is hereby created a special revenue account in the State Treasury, designated the West Virginia All-Payer Claims Database Fund, which shall be an interest-bearing account and may be invested in the manner permitted by §12-6-1 et seq. of this code, with the interest income a proper credit to the fund and which shall not revert to the general revenue, unless otherwise designated in law. The fund shall be overseen by the secretary and shall be used to pay all proper costs incurred in implementing the provisions of this article.

(b) The following funds shall be paid into this account:

(1) Penalties imposed on health care payers pursuant to this article and rules promulgated thereunder;

(2) Funds received from the federal government;

(3) Appropriations from the Legislature; and

(4) All other payments, gifts, grants, bequests, or income from any source.

§33-4A-8. Rule-making authority.

To effectuate the provisions of this article, the secretary and commissioner may propose joint rules for legislative approval in accordance with the provisions of §29A-3-1 et seq. of this code as necessary to implement this article. Such rules may include, but are not limited to, the following:

(a) Procedures for the collection, retention, use, and disclosure of data from the all-payer claims database (APCD), including procedures and safeguards to protect the privacy, integrity, confidentiality, and availability of any data;

(b) Penalties against health care payers for violation of rules governing the submission of data, including a schedule of fines for failure to file data or to pay assessments;

(c) Fees payable by users of the data and the process for a waiver or reduction of user fees. Any such fees shall be established at a level that, when considered together with other available funding sources, is deemed necessary to sustain the operation of the APCD;

(d) A proposed time frame for the creation of the database;

(e) Criteria for determining whether data collected, beyond the listed personal identifiers, is confidential clinical data, confidential financial data, or privileged medical information, and procedures to give affected providers and health care payers notice and opportunity to comment in response to requests for information that may be considered confidential or privileged;

(f) Penalties, including fines and other administrative sanctions, that may be imposed by the commissioner for a health care payer’s failure to comply with requirements of this article and rules adopted thereunder; and

(g) Establishment of advisory boards to provide advice to the secretary with respect to the various functions of the APCD.

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