W. Va. Code R. § 114-46-6

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

Section 114-46-6 - Regulation of Marketing

6.1. After a subscriber signs an enrollment application and before the health maintenance organization may process the application changing or initiating the subscriber coverage, the health maintenance organization must verify the intent and desire of the individual to join the health maintenance organization.

a. The verification must be in writing and must be conducted by someone outside the health maintenance organization's marketing department.

b. Each verification, using the Subscriber Verification Form provided by the Insurance Commissioner, shall confirm that:

A. The subscriber intends and desires to join the health maintenance organization;

B. If the subscriber is a Medicare or Medicaid recipient, the subscriber understands that, by joining the health maintenance organization, he or she will be limited to the benefits provided by the health maintenance organization, and Medicare or Medicaid will pay the health maintenance organization for the subscriber coverage;

C. The subscriber understands the applicable restrictions of health maintenance organizations, especially that he or she must use the health maintenance organization providers and secure approval from the health maintenance organization to use health care providers outside the plan; and

D. If the subscriber is enrolled as a member of a health maintenance organization, the subscriber understands that he or she is transferring to another health maintenance organization.

6.2. The health maintenance organization shall not pay a commission, fee, money or any other form of scheduled compensation to any health insurance agent until verification from the subscriber of his or her intent and desire to enroll in the health maintenance organization has been secured and the enrollment process has been completed:

a. The health maintenance organization shall verify the subscriber's intent to enroll by a written notice to the subscriber, using the Subscriber Confirmation Form provided by the Insurance Commissioner:

A. The Subscriber Confirmation Form shall state that the subscriber has transferred from his or her existing coverage to the new health maintenance organization;

B. The Subscriber Confirmation Form shall be accompanied by printed materials explaining the nature of the health maintenance organization and any applicable restrictions and exclusions; and

C. The Subscriber Confirmation Form shall state the subscriber's enrollment date and when benefits will begin; and

b. The enrollment process shall be considered complete seven (7) days after the health maintenance organization mails the Subscriber Confirmation Form and all attachments to the subscriber.

W. Va. Code R. § 114-46-6