The national Medical Plans guide covers plan types (indemnity, HMO, PPO, POS, HDHP with HSA), cost sharing and the federal ACA rules. This guide covers the West Virginia rules: HMO sales and contract rules, nonprofit service corporations, mandated coverage for children, prompt payment of health claims, and the state's minimum standards for individual health policies.

HMOs (W. Va. Code 33-25A)

• An HMO takes prepaid premiums for basic services, either per person or as a fixed total. It designates a primary care provider for each subscriber, who coordinates care and makes referrals to specialists. This is the gatekeeper model.

• The evidence of coverage is the certificate, agreement or contract that sets out an enrollee's coverage and rights.

• HMO advertising must be filed before use. It is approved if not disapproved within 60 days.

• An HMO can't use words like "insurance," "casualty," "surety" or "mutual" in its name or literature, except to say it contracts with an insurer.

• An enrollee may cancel at any time. The contract may require 30 days' notice.

• Agent disclosure: before enrolling someone, an agent discloses in writing, in specified bold terms:

  • services offered and full cost
  • facilities and transportation
  • the disenrollment rate and staff

  An enrollment sold in the home has a three-day cooling-off period.

• A violator may owe the enrollee one year's subscription cost plus attorney fees.

Service corporations (W. Va. Code 33-24)

• Hospital service corporations and dental service corporations are nonprofit, nonstock corporations. They contract with the public and with providers to deliver services to subscribers.
• No more than 20% of the board may be health care providers. At least 80% represent consumers, the elderly, labor and business subscribers.
• Service corporations are exempt from property and other taxes.

Required coverage for children

• Newborns are covered from birth, including congenital defects. If extra premium is needed, the policy may require notice and payment within 31 days (33-6-32).
• Adopted children are covered from placement on the same terms as natural children (33-15-16(b)).
• A child can't be denied enrollment because they were born out of wedlock, aren't claimed as a tax dependent or don't live with the parent. Under a court order, a child may be enrolled outside the enrollment season (33-15-16).
• Insurers may not consider Medicaid eligibility when deciding eligibility or paying claims (33-16-14).

Individual health policy standards

• An individual accident and sickness policy must be guaranteed renewable at the insured's option, with limited exceptions (33-15-2(d)).
• Text must be at least 10-point type, and the first page states the renewal terms.
• Minimum standards (33-28-5) apply to:
  • basic hospital and basic medical-surgical
  • hospital confinement indemnity
  • major medical
  • disability income
  • accident-only
  • specified disease coverage
• Free look: 10 days from receipt (33-6-11b).

Prompt payment (W. Va. Code 33-11-4(9)(o))

• The insurer notifies the claimant within 15 calendar days of proof of loss, and updates every 30 days if it needs more time.
• A claim not paid within 90 days, without a legitimate dispute or fraud, earns interest at the prime rate plus 1%.

Guaranty protection

The West Virginia Life and Health Insurance Guaranty Association covers health benefit plans up to $500,000 (33-26A-3).

Common exam traps

• An HMO enrollee may cancel anytime, with up to 30 days' notice.
• HMO home sales have a 3-day cooling-off period.
• HMO ads are deemed approved after 60 days.
• Service corporations are nonprofit, with at least 80% consumer-side board members.
• West Virginia's newborn notice and premium window is 31 days.
• Unpaid health claims earn prime + 1% after 90 days.
• Individual A&S policies must be guaranteed renewable.