W. Va. Code R. § 114-43-2

Current through Register Vol. XLII, No. 1, January 3, 2025

Section 114-43-2 - Definitions

2.1. "Administrative health service contract" means an agreement between a certificate of authority holder and a health service intermediary or between health service intermediaries in which:

a. The intermediary accepts payments, including payments on a fixed per capita fixed aggregate sum or percentage of premium basis, from the certificate of authority holder or from another health service intermediary for one or more health care services to be rendered by providers to subscribers, members, policyholders, or certificate-holders, as applicable, of a certificate of authority holder, where the intermediary assumes financial risk for payments to providers; and

b. The intermediary contracts with providers to render one or more health care services to subscribers, policyholders or certificateholders, as applicable, of a certificate of authority holder.

2.2. "Certificate of authority holder" means an entity which holds a valid certificate of authority from the commissioner to operate a health maintenance organization under W. Va. Code '33-25A-1 et seq.

2.3. "Commissioner" means the Insurance Commissioner of the State of West Virginia.

2.4. "Financially sound" or "fiscally and financially sound" means that according to presently accepted actuarial standards of practice, consistently applied and fairly stated, that the respective considerations to the parties under the contract, including, but not limited to, reserves, the investment earnings on such considerations, the considerations anticipated to be received and retained by the parties under the contract, and related actuarial values, make adequate provision for the anticipated cash flows required by the contractual obligations and related expenses of the parties.

2.5. "Group Practice" means a professional corporation, partnership, association, or other organization composed solely of health professionals licensed to practice medicine or osteopathy and of such other licensed health professionals, including podiatrists, dentists and optometrists, as are necessary for the provision of the health services for which the group is responsible:

a. who engage in a single field of medical practice or specialty or who all practice at a single location;

b. a majority of the members of which are licensed to practice medicine or osteopathy;

c. who as their principal professional activity engage in the coordinated practice of their profession;

d. who pool their income for practice as members of the group and distribute it among themselves according to a prearranged salary, drawing account or other plan; and

e. who share medical and other records and substantial portions of major equipment and professional, technical and administrative staff.

2.6. "Health care services" or "health services" means services, medical equipment, and supplies furnished by a provider, which may include, but which are not limited to, medical, surgical, or dental care; psychological, optometric, optic, chiropractic, podiatric, nursing, physical therapy, mental health, substance abuse, or pharmaceutical services; health education, preventive medical, rehabilitative, or home health services; inpatient or outpatient hospital services; extended care; nursing home care; convalescent institutional care; technical and professional clinical pathology laboratory services; laboratory and ambulance services; appliances, drugs, medicines, and supplies; or any other care, service, or treatment of disease, or correction of defects for human beings.

2.7. "Health service intermediary" or "intermediary" means a physician, hospital, physician-hospital organization, independent provider organization, independent provider network, or other entity or person that arranges for one or more health care services to be rendered by providers to subscribers, policyholders, or certificateholders, as applicable, of a certificate of authority holder. "Health service intermediary" or "intermediary" does not include:

a. A provider directly contracting with a certificate of authority holder for the provider to render health care services, when that provider renders those services directly and only through its own professional license or licenses or, in the case when the provider is a "group practice" the group practice utilizes only its employees, partners or shareholders and their professional licenses to render those services.

b. A certificate of authority holder.

2.8. "Incurred but not reported health care costs" or "IBNR" means the cost of health care services rendered to subscribers, policyholders or certificateholders, as applicable, of a certificate of authority holder by providers during the reporting period and for which the health service intermediary is financially responsible, but which are not reported to the intermediary until after the reporting period.

2.9. "Independent certified public accountant" means an independent certified public accountant who holds a valid license to practice, issued by the state in which he or she resides or has his or her principal place of business who has experience auditing or performing accounting functions for health maintenance organizations and who does not have a financial or other interest in a given entity which could influence his or her professional judgement.

2.10. "Provider" means a person or other entity which holds a valid license to provide specific health care services in the State of West Virginia.

2.11. "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 certificate of authority holder or the health care intermediary.

W. Va. Code R. § 114-43-2