W. Va. Code R. § 114-53-8

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-53-8 - Preventive Health Services

8.1. A health maintenance organization shall adopt guidelines for the use of preventive health services which must be based on reasonable medical evidence and the full service population. The guidelines shall be developed or adopted with the participation of the HMO's providers and must include a mechanism for periodic updates.

a. The guidelines and all updates shall be provided in writing to all providers and members.

b. The guidelines shall consist of the following categories:

1. Prenatal and perinatal care;

2. Preventive care for infants up to 24 months;

3. Preventive care for children and adolescents aged two through 19 years old;

4. Preventive care for adults aged 20 through 64 years old; and

5. Preventive care for those aged 65 and older.

c. Each guideline shall describe the prevention or early detection interventions and the recommended frequency and conditions under which the interventions are required. The health maintenance organization shall document the scientific basis or authority upon which it based the preventive health guidelines.

d. Providers from the health maintenance organization who have appropriate knowledge shall be involved in the adoption of the preventive health guidelines.

e. At least annually, an HMO shall monitor, evaluate and take action upon a minimum of two of the following preventive services and take action to improve the use of preventive services as appropriate:

1. Childhood immunizations recognized by the American Academy of Pediatrics or as required by state or federal law;

2. Adult immunizations including influenza vaccine, pneumococcal vaccine, Hepatitis B vaccine, diphtheria and tetanus toxoid, rubella screening for women of childbearing age or any other immunization required by state or federal law;

3. Coronary artery disease risk factor screening and/or counseling for smoking, cholesterol, exercise and hypertension;

4. Breast and cervical cancer screening;

5. Counseling for prevention of motor vehicle injury;

6. Lead toxicity screening;

7. Sexually transmitted disease screening/prevention;

8. Prenatal care;

9. HIV/Aids counseling, screening and education;

10. Prevention of unintended pregnancy;

11. Alcohol and drug abuse screening/prevention; and

12. Any other preventive services deemed appropriate by the commissioner and any other state or federal regulatory authorities.

f. Preventive health service studies shall be enrollee population-based, measuring compliance as it relates to the total at-risk population.

W. Va. Code R. § 114-53-8