Current through Register Vol. XLI, No. 38, September 20, 2024
4.1. Except to
the extent provided differently by this rule, a PSN may apply for a certificate of
authority to operate in West Virginia as a Medicaid managed care organization in
accordance with the provisions of W.Va. Code §
33-25A-1et
seq., W.Va. Code St. R. §114-43 and §114-46, and any other rule,
bulletin or guidance issued by the Commissioner regarding the licensing of health
maintenance organizations ("HMOs").
4.2.
An applicant must demonstrate that it is controlled by one or more FQHCs. For
purposes of this subsection, the term "controlled by" means the direct or indirect
possession by one or more FQHCs of the power to direct or cause the direction of the
management and policies of the organization through membership, board representation
or an ownership interest greater than 50 percent.
4.3.a. In determining whether an applicant has
demonstrated that it is financially responsible, the Commissioner shall take into
consideration the factors set forth in W.Va. Code §
33-25A-4(c)
as well as, but not limited to, W.Va. Code St. R. § 114-43 and § 114-46,
in the same manner as if the applicant were applying for a certificate of authority
to operate as a HMO.
4.3.b. A PSN that
has been issued a certificate of authority may petition the Commissioner to be
permitted to operate with lower standards of financial responsibility than would
otherwise be required for a HMO, including lower surplus and capital.
4.3.b.1. In ruling upon a petition submitted
pursuant to subdivision b of this subsection, the Commissioner, in consultation with
the Secretary, may consider actuarial evaluations and other qualified technical
standards as well as the possible lower risks of insolvency arising from the control
of the PSN or applicant by one or more FQHCs, any transfer of risk to a third party,
and the restriction of the PSN to the provision of Medicaid-related services. The
Commissioner may also require that the PSN submit such other information as maybe
deemed necessary for a decision on the petition. A PSN will be presumed to be unable
to operate with lower standards of financial responsibility unless it submits at
least 3 years of audited financial statements that reflect positive net
worth.
4.3.b.2. The decision whether and
how to change the solvency requirements is committed to the sole discretion of the
Commissioner.
4.4.a. Every
application for a certificate of authority to operate as a PSN shall include a
certification that any physician or behavioral health provider licensed by the
appropriate West Virginia state agency or board shall be permitted to contract with
the PSN to become a participating provider as long as he or she agrees to
participate in the health care delivery approach designed by the PSN and such other
applicable requirements of the Department of Health and Human Resources.
4.4.b. A PSN shall require that providers:
4.4.b.1. Agree to observe the PSN's care
management protocols, including provisions for designations of certain services that
may be provided only by designated providers or classes of providers;
4.4.b.2. Be credentialed before they may provide
certain services; and
4.4.b.3. Comply
with the PSN's utilization management programs and referral systems.
4.4.c. A PSN shall not:
4.4.c.1. Require a participating physician
provider to sell or transfer ownership of his, her or its assets or practice
operations to the PSN or any of the PSN's participating providers as a condition of
participation or of being permitted access or use of the PSN's medical home
resources and care management systems; or
4.4.c.2. Prohibit a participating provider from
participating in or contracting with other networks or other managed care
organizations to provide services to Medicaid beneficiaries.
