Current through Register Vol. XLI, No. 35, August 30, 2024
Section 85-21-5 - Application Process5.1. The following process shall govern the application process for managed health care plans submitted to the Commission or upon termination of the Commission, the insurance commissioner, for approval pursuant to West Virginia Code Section 23-4-3(b)(2). All managed health care plans must be approved by the Commission or upon termination of the Commission, the insurance commissioner, before utilized. Employers may participate in one (1) or more approved managed health care plans. Applications for initial certification and renewal shall be submitted, in triplicate, in a form acceptable to the Commission or upon termination of the Commission, the insurance commissioner, and shall contain the following information:a. Plan identification. 1. Plan name and address.2. Date and state of incorporation.3. Name, address, and phone number of each corporate officer and director, and of the person who will be the day-to-day plan administrator.4. Name and address of each owner of more than five (5) percent of the stock or controlling interest in the entity.5. Name, address, and phone number of the medical director, who shall be a medical doctor (M.D. or D.O. physician) and who shall oversee and monitor compliance with the quality care, utilization review and credentialing provisions of the managed care plan.6. Name, address, and phone number of the case manager who shall be qualified as either a certified case manager, certified rehabilitation counselor, certified insurance rehabilitation specialist, or certified rehabilitation registered nurse who shall oversee and monitor case management provisions of the managed care plan.7. Description of the system's organizational structure.b. Plan qualifications. 1. Description and map of the plan's service area.2. Name, address, phone number, and specialty of all participating providers. The plan shall provide assurance that all licensing, registration, or certification requirements have been met and are current for the providers to practice in West Virginia (or border states wherein the provider practices) and that each participating provider shall maintain in full force and effect a professional malpractice policy with limits of no less than $1,000,000 for an occurrence of professional negligence, unless the Commission, or upon termination of the Commission, the insurance commissioner determines, in its sole discretion, that a different malpractice limit is more appropriate given the providers' specialty or discipline.3. A specimen of the agreement that each class of medical provider shall execute to participate in the plan.4. Specimens of the materials which the plan shall provide to workers setting forth the grievance procedure and form, the requirements and restrictions of the plan, and the means of accessing services and treatment within and outside of the service area. The applicant shall detail the time and means by which the materials shall be delivered to employees and employers.5. Specimens of materials directed at management employees informing supervisors of the necessity of channeling injured workers to the managed health care plan providers and giving immediate notice to the employer, insurance carrier, and plan of the occurrence of an injury.6. A plan to transition current injured workers to providers within the approved plan; provided that said transfer shall not be mandated any sooner than sixty (60) days from the date approval is received from the commission and , upon termination of the commission, the insurance commissioner.c. Financial Ability. Each managed health care plan shall demonstrate to the Commission or upon termination of the Commission, the insurance commissioner, that it has sufficient financial resources and professional expertise to perform all of the necessary functions of a managed health care plan. Each managed health care plan requesting certification shall demonstrate such resources and ability to the Commission or upon termination of the Commission, the insurance commissioner, by the following:1. In the event the applicant has previously provided managed care or other similar medical and administrative services in West Virginia, the applicant shall provide a summary and description of the administrative and medical services provided, together with a list of representative entities for which managed care related administrative or medical services have been provided; and2. In the event the applicant has not previously provided services related to the delivery of managed care in West Virginia, it shall be required that, prior to certification, that the applicant post either a performance bond, cash surety deposit, bank letter of credit, or other approved instrument in an amount of $500,000 with the Commission or upon termination of the Commission, the insurance commissioner, to demonstrate sufficient financial resources to provide all of the administrative and medical services required to be performed under a managed care plan. The bond or cash surety shall be released by the Commission or upon termination of the Commission, the insurance commissioner, sixty (60) days after the managed health care system demonstrates to the Commission or upon termination of the Commission, the insurance commissioner, that all of its arrangements for rendering workers' compensation managed care services in the state have been terminated.3. If the applicant has an audited financial statement addressing any of its prior operations for the preceding year, a copy of the applicant's most recent audited financial statement shall be submitted to the Commission or upon termination of the Commission, the insurance commissioner.