W. Va. Code R. § 114-43-4

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

Section 114-43-4 - HMO Requirements

4.1. Upon entry of a health service intermediary contract, a certificate of authority holder shall immediately file with the commissioner a full executed copy of the contract and all exhibits, attachments, addenda, schedules or other documents relevant to the contract.

a. Upon filing a health service intermediary contract with the commissioner, the certificate of authority holder shall simultaneously file the opinion of a qualified independent actuary which expresses the opinion of the qualified independent actuary that the entry of the contract by the certificate of authority holder:

A. Is a fiscally and financially sound transaction;

B. Does not cause excessive payments to the intermediary;

C. Provides for reasonable incentives to the intermediary for cost control; and

D. Does not contribute to the escalation of the cost of providing health care to enrollees.

4.2. A certificate of authority holder is financially responsible for any valid claims for covered health care services, exclusive of unpaid claims of providers who have contracted with the health service intermediary, presented for payment to a health service intermediary and which are not paid by the health service intermediary.

4.3. All affected master group contracts or evidences of coverage must reflect that the certificate of authority holder retains financial responsibility as specified in subsection 4.2. of this rule when health care services are provided through a health care intermediary.

4.4. A certificate of authority holder is responsible for compliance by the health care intermediary with all applicable standards required by W. Va. Code '33-25A-1, et. seq. as to any services performed on behalf of the certificate of authority holder.

4.5. No health care intermediary may contract directly with enrollees or subscribers without first having obtained a certificate of authority to operate a health maintenance organization.

4.6. All financial statements provided by the certificate of authority holder to the commissioner must fully and accurately reflect on a West Virginia statutory accounting basis the costs and liabilities to the certificate of authority holder associated with any health service intermediary contract including those liabilities assumed by the health service intermediary.

4.7. A certificate of authority holder is responsible for taking all reasonable measures to provide the commissioner full access to all books and records of any health service intermediary with which it contracts and to the books and records of any entity with which the intermediary sub-contracts for the provision of health care services, to the same extent the commissioner is given access to the books and records of the certificate of authority holder pursuant to W. Va. Code ''33-25A-17 and 33-2-9. The certificate of authority holder is financially responsible for any costs of examining the books and records of the health service intermediary or sub-contractor consistent with W. Va. Code '33-2-9.

4.8. A certificate of authority holder must within ten days of receipt of the annual audited financial report of a health service intermediary, file a full copy of the report with the commissioner.

4.9. The commissioner may require immediate cancellation or renegotiation of any administrative health service contract when the commissioner determines that the contract does any of the following:

a. Provides for excessive payments;

b. Fails to include reasonable incentives for cost control; or

c. Otherwise substantially or unreasonably contributes to the escalation of the cost of providing health care services to enrollees.

W. Va. Code R. § 114-43-4