W. Va. Code R. § 114-43-3

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 114-43-3 - Intermediary Contract Requirements

3.1. A certificate of authority holder may not enter into an administrative health service contract with a health service intermediary unless the contract is in writing, is filed with the commissioner accompanied by an opinion by a qualified independent actuary which states that the entering of the contract by the certificate of authority holder is financially sound, and the contract contains provisions which:

a. Require the health service intermediary to provide the certificate of authority holder with regular written reports prepared on a West Virginia statutory accounting basis, at least quarterly, that state the health service intermediary's current assets and identify in the aggregate all payments made or owed to its providers in sufficient detail for the certificate of authority holder and the Commissioner to determine if the payments are being made in a timely manner and which identify in the aggregate the reasonably estimated incurred but not reported health care costs;

b. Require the certificate of authority holder to monitor the health service intermediary's reports required under paragraph a of this subsection;

c. Permit the certificate of authority holder and the commissioner, both singularly and jointly, upon reasonable prior notice, to audit, inspect and copy the health service intermediary's books, records, and other evidence of its operations which are, in the discretion of the certificate of authority holder or the commissioner, relevant to the intermediary's obligations under the administrative health service contract for the purpose of determining the intermediary's compliance with all requirements legally mandated by statute, rule or the administrative health service contract. Any review is subject to any confidentiality requirements imposed by State or Federal law;

d. Require the health service intermediary to maintain working capital in the form of cash or equivalent liquid assets at least equal to one month's claims calculated by using the monthly average of actual and estimated claims for the prior six months for all health services provided under the administrative health service contract;

e. Require the intermediary to create a segregated fund, which may be aggregated, equal to the entire monthly IBNR as of the first day of each month as actuarially determined by the certificate of authority holder.

A. The commissioner may upon application of the certificate of authority holder and good cause shown, give prior written approval to alternative financial arrangements between the certificate of authority holder and the intermediary, such as the use of premium withhold funds, either in conjunction with or in lieu of the capital and reserve fund requirements of paragraphs d and e of this section;

f. Require the certificate of authority holder to assume the full financial responsibility as specified in subsection 4.2. of this rule, for any valid claims presented for payment to the health service intermediary by providers for covered health care services rendered to a subscriber, policyholder, enrollee or certificate holder, as applicable, and which are not paid by the health service intermediary as provided by law and by the contract between the intermediary and provider;

g. Require that all enrollee or enrollee group contracts must be directly with the certificate of authority holder and not the intermediary;

h. Require that the intermediary provide services on behalf of the certificate of authority holder only in counties where the certificate of authority holder is authorized by the commissioner to operate;

i. Clearly delineate the responsibilities to be assumed by the intermediary and require that the intermediary adhere to all quality and accessibility standards to which the certificate of authority holder is subject;

j. Require that to the extent the intermediary is permitted to sub-contract the provision of health care services that all sub-contractors must adhere to quality and accessibility standards to which the certificate of authority holder is subject;

k. Require that the certificate of authority holder continuously monitor the intermediaries' compliance with the contract requirements;

l. Specify that the certificate of authority holder is responsible for maintaining appropriate levels of capital, surplus, claims reserves, and other financial criteria as established pursuant to statute or rule;

m. Require the health service intermediary and any entities with which the health service intermediary sub-contracts for the provision of health care services to obtain and provide to the certificate of authority holder no later than the first day of June of each year an annual audited financial report prepared by an independent certified public accountant; and

n. If the health service intermediary provides health care services on behalf of more than one entity, specify that the health service intermediary maintain records which are adequate to clearly differentiate the transactions which relate to the provision of health care services on behalf of the certificate of authority holder.

W. Va. Code R. § 114-43-3