Current through Register Vol. XLI, No. 38, September 20, 2024
4.1. A health maintenance organization shall
develop a quality assurance program which adheres to all applicable state and
federal laws, federal regulations and state rules.
a. A health maintenance organization that has
obtained full accreditation or equal status from a nationally recognized
accreditation and review organization approved by the commissioner pursuant to W.
Va. Code §
33-25A-17a is deemed
to be in compliance with this rule. If, at any time subsequent to the granting of
full accreditation or equal status by a nationally recognized accreditation and
review organization, the commissioner determines that the quality assurance program
of the health maintenance organization has become deficient in any significant area,
the commissioner, in addition to other remedies available, may establish a
corrective action plan that the HMO must follow as a condition to the issuance or
maintenance of a certificate of authority.
4.2. Each application for a certificate of
authority or renewal thereof filed with the commissioner pursuant to the Health
Maintenance Organization Act, W. Va. Code §§
33-25A-1 et
seq., shall be accompanied by a description of a health maintenance organization's
quality assurance program, which shall include, but not be limited to, the
requirements of the quality assurance program set forth in this rule. The HMO's
quality assurance program may be inspected by providers, enrollees or their agents
at the offices of the commissioner pursuant to the provisions of the West Virginia
Freedom of Information Act, W.Va. Code §§
29B-1-1 et seq.
a. Pursuant to the requirements of W. Va. Code
§
33-25A-3,
a health maintenance organization shall file notice with the commissioner prior to
any modification of the quality assurance program.
4.3. A health maintenance organization shall have
a program for quality assurance which clearly defines the structure, design and
responsibilities of both delegated and non-delegated activities.
a. The basic components of the quality assurance
program shall include:
1. Organizational
arrangements and responsibilities for quality management and improvement
processes;
2. A documented utilization
review program;
3. Written policies and
procedures for credentialing and recredentialing physicians and other licensed
providers;
4. A written policy
addressing members' rights and responsibilities; and
5. The adoption of practice guidelines for the use
of preventive health services.
b. Utilization management rules contained in 114
CSR 51 shall be incorporated in and made a part of this rule.
4.4. If a health maintenance organization
delegates any quality assurance activity to contractors, there shall be evidence of
oversight and auditing of the contracted activity.
a. The HMO shall maintain a written description of
the delegated activities, the contractor's accountability for the activities, the
frequency of reporting to the HMO, the process by which the delegation will be
evaluated and the remedies available, including revocation of delegation, if the
contractor does not fulfill its obligations.
b. The HMO shall maintain evidence of its regular
evaluation and approval of the delegated activities by the contractor.
c. The HMO shall be responsible for monitoring the
activities of the contractor to which it delegates quality assurance activities and
for ensuring that the requirements of this rule are met.
4.5. No health maintenance organization may place
restrictions upon any provider or upon any primary care physician which would serve
to limit the communication of medical advice or options available to the member,
subscriber or enrollee or would act in any way to limit the communication between
the provider or physician and his or her patient. An HMO may not prevent any
provider from advising an enrollee whether or not a treatment is covered by the
plan.
a. No health maintenance organization may
provide to any provider or any primary care physician an incentive or disincentive
plan that includes specific payment made directly or indirectly, in any form, to the
provider or primary care physician as an inducement to deny, release, limit, or
delay specific, medically necessary and appropriate services provided with respect
to a specific enrollee or groups of enrollees with similar medical
conditions.
4.6. Data or
information pertaining to the diagnoses, treatment or health of a member obtained
from the member or from a provider by a health maintenance organization is
confidential and shall not be disclosed to any person except:
a. To the extent that it may be necessary to carry
out the purposes of these rules and as allowed by state law;
b. Upon the express consent of the
member;
c. Pursuant to statute or court
order for the production of evidence or the discovery thereof;
d. In the event of a claim or litigation between
the member and the health maintenance organization where the data or information is
pertinent, regardless of whether the information is in the form of paper, preserved
on microfilm, or stored in computer retrievable form.
4.7. If any data or information pertaining to the
diagnosis, treatment or health of any enrollee or applicant is disclosed pursuant to
the provisions of subsection 4.6, the health maintenance organization making this
required disclosure shall not be liable for the disclosure or any subsequent use or
misuse of the data.
