W. Va. Code R. § 114-100-2

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

Section 114-100-2 - Definitions

2.1. "Commissioner" means the Insurance Commissioner of this state.

2.2. "County designation" means the classification of each county based upon population size and density. These parameters are set annually by the Centers of Medicare and Medicaid Services (CMS). There are five classifications: Large Metro, Metro, Micro, Rural, and Counties with Extreme Access Considerations (CEAC). A county must meet both the population and density threshold for the designation:

County Type Classification	Population	Density(person/mi2)
Large Metro	>1,000,000	> 1,000/mi2
--	500,000 - 999,999	>1,500/mi2
--	Any	> 5,000/mi2
Metro	> 1,000,000	10 - 999.9/mi2
--	500,000 - 999,999	10 - 1,499.9/mi2
--	200,000 - 499,999	10 - 4,999.9/mi2
--	50,000 - 199,999	100 - 4,999.9/mi2
--	10,000 - 49,999	1,000 - 4,999.9/mi2
Micro	50,000 - 199,999	10 - 99.9 /mi2
--	10,000 - 49,999	50 - 999.9/mi2
Rural	10,000 - 49,999	10 - 49.9/mi2
--	<10,000	10 - 4,999.9/mi2
CEAC	Any	<10/mi2

2.3. "Covered benefit" or "benefit" means those health care services to which a covered person is entitled under the terms of a health benefit plan.

2.4. "Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.

2.5. "Essential community provider" or "ECP" means a provider that:

2.5.1. Serves predominantly low-income, medically underserved individuals, including a health care provider defined in Section 340B(a)(4) of the Public Health Service Act (PHSA); or

2.5.2. Is described in Section 1927(c)(1)(D)(i)(IV) of the Social Security Act, as set forth by Section 221 of Pub. L. 111-8.

2.6. "Facility" means an institution providing health care services or a health care setting, including, but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, urgent care centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.

2.7. "Health benefit plan" means a policy, contract, certificate or agreement entered into, offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.

2.8. "Health care professional" means a physician or other health care practitioner licensed, accredited or certified to perform specified (physical, mental or behavioral) health care services consistent with their scope of practice under state law.

2.9. "Health care provider" or "provider" means a health care professional, a pharmacy or a facility.

2.10. "Health care services" means services for the diagnosis, prevention, treatment, cure or relief of a physical, mental or behavioral health condition, illness, injury, or disease, including mental health and substance use disorders.

2.11. "Health carrier" or "carrier" means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an insurer issuing an accident and sickness insurance policy pursuant to W.Va. Code § 33-15-1et seq. of this code, an insurer issuing an accident and sickness group policy pursuant to W.Va. Code § 33-16-1et seq. of this code, a hospital medical and dental corporation licensed pursuant to W.Va. Code § 33-24-1et seq. of this code, a health care corporation licensed pursuant to W.Va. Code § 33-25-1et seq. of this code, or a health maintenance organization licensed pursuant to W.Va. Code § 33-25A-1et seq. of this code. For purposes of this rule, the term "health carrier" or "carrier" does not include insurers or managed care organizations with respect to their Medicaid or CHIP plans or contracts which are reviewed and approved by the Department of Health and Human Resources Bureau for Medical Services.

2.12. "Limited scope dental plan" means a plan that provides coverage, substantially all of which is for treatment of the mouth, including any organ or structure within the mouth, which is provided under a separate policy, certificate, or contract of insurance or is otherwise not an integral part of a group benefit plan.

2.13. "Limited scope vision plan" means a plan that provides coverage, substantially all of which is for treatment of the eye, that is provided under a separate policy, certificate, or contract of insurance or is otherwise not an integral part of a group benefit plan.

2.14. "Material change" means changes in the health carrier's network of providers or type of providers available in the network to provide health care services or specialty health care services to covered persons that may render the carrier's network non-compliant with one or more network adequacy standards. Types of changes that could be considered material include:

2.14.1. A significant reduction in the number of primary or specialty care physicians available in a network;

2.14.2. A reduction in a specific type of provider such that a specific covered service is no longer available;

2.14.3. A change to the tiered, multi-tiered, layered or multi-level network plan structure; and

2.14.4. A change in inclusion of a major health system that causes the network to be significantly different from what the covered person initially purchased.

2.15. "Network" means the group or groups of participating providers providing services under a network plan.

2.16. "Network plan" means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with or employed by the health carrier.

2.17. "Participating provider" means a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier.

2.18. "Pediatric" means the specialty of medical science concerned with the physical, mental, and social health of children from birth up to the age of nineteen.

2.19. "Primary care" means health care services for a range of common physical, mental, or behavioral health conditions provided by a physician or nonphysician primary care professional.

2.20. "Primary care professional" means a participating health care professional designated by the health carrier to supervise, coordinate, or provide initial care or continuing care to a covered person, and who may be required by the health carrier to initiate a referral for specialty care and maintain supervision of health care services rendered to the covered person.

2.21. "SERFF" means the National Association of Insurance Commissioners' System for Electronic Rate and Form Filing.

2.22. "Specialist" means a physician or non-physician health care professional, including a subspecialist who has additional training and recognition above and beyond his or her specialty training, who:

2.22.1. Focuses on a specific area of physical, mental, or behavioral health or a group of patients; and

2.22.2. Has successfully completed required training and is recognized by the state in which he or she practices to provide specialty care.

2.23. "Specialty care" means advanced medically necessary care and treatment of specific physical, mental, or behavioral health conditions or those health conditions which may manifest in particular ages or subpopulations, that are provided by a specialist, preferably in coordination with a primary care professional or other health care professional.

2.24. "Telemedicine" or "telehealth" means health care services provided through telecommunications technology by a health care professional who is at a location other than where the covered person is located.

2.25. "Tiered network" means a network that identifies and groups some or all types of providers and facilities into specific groups to which different provider reimbursement, covered person cost-sharing, or provider access requirements, or any combination thereof, apply for the same services.

W. Va. Code R. § 114-100-2