Terms Used In West Virginia Code > Chapter 5A > Article 1 - Department of Administration

• Actuarial certification: means a written statement by an actuary, or other individual acceptable to the commissioner, that a small employer carrier is in compliance with the provisions of section five of this article, based upon that person'. See West Virginia Code 33-16D-2
• Adverse determination: means a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other healthcare service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier'. See West Virginia Code 33-16H-1
• Advice and consent: Under the Constitution, presidential nominations for executive and judicial posts take effect only when confirmed by the Senate, and international treaties become effective only when the Senate approves them by a two-thirds vote.
• Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
• Annuity: A periodic (usually annual) payment of a fixed sum of money for either the life of the recipient or for a fixed number of years. A series of payments under a contract from an insurance company, a trust company, or an individual. Annuity payments are made at regular intervals over a period of more than one full year.
• Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
• Appropriation: The provision of funds, through an annual appropriations act or a permanent law, for federal agencies to make payments out of the Treasury for specified purposes. The formal federal spending process consists of two sequential steps: authorization
• Articles of incorporation: includes , but is not limited to, amended and restated articles of incorporation and articles of merger. See West Virginia Code 31E-1-150
• Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
• Attachment: A procedure by which a person's property is seized to pay judgments levied by the court.
• Bankruptcy: Refers to statutes and judicial proceedings involving persons or businesses that cannot pay their debts and seek the assistance of the court in getting a fresh start. Under the protection of the bankruptcy court, debtors may discharge their debts, perhaps by paying a portion of each debt. Bankruptcy judges preside over these proceedings.
• Base premium rate: means , for each class of business as to a rating period, the lowest premium rate charged or which could have been charged under a rating system for that class of business by the small employer carrier to small employers with similar case characteristics for health benefit plans with the same or similar coverage. See West Virginia Code 33-16D-2
• Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. ^{Source: OCC}
• board of directors: means the group of persons vested with management of the affairs of the corporation irrespective of the name by which the group is designated. See West Virginia Code 31E-1-150
• Bona fide association: means an association which has been actively in existence for at least five years. See West Virginia Code 33-16-1a
• Bona fide association: has the meaning set forth in section one-a, article sixteen of this chapter. See West Virginia Code 33-16D-2
• carrier: means any health insurer, as defined in section one-a, article sixteen of this chapter, which offers health benefit plans covering the employees of a small employer situate within the State of West Virginia. See West Virginia Code 33-16D-2
• Class of business: means all or any distinct grouping of small employers as shown on the records of the small employer carrier, which shall be subject to the following requirements:

  (1) A distinct grouping may only be established by the small employer carrier on the basis that the applicable health benefit plans:

  (A) Are marketed and sold through individuals and organizations which are not participating in the marketing or sale of other distinct groupings of small employers for such small employer carrier. See West Virginia Code 33-16D-2

• Commissioner: means the commissioner of insurance. See West Virginia Code 33-16-1a
• Commissioner: means the Insurance Commissioner of West Virginia. See West Virginia Code 33-16D-2
• Contract: A legal written agreement that becomes binding when signed.
• Conviction: A judgement of guilt against a criminal defendant.
• Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
• Creditable coverage: means , with respect to an individual, coverage of the individual after June 30, 1996, under any of the following, other than coverage consisting solely of excepted benefits:

  (1) A group health plan. See West Virginia Code 33-16-1a

• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Deed: The legal instrument used to transfer title in real property from one person to another.
• delivery: means any method of delivery used in conventional commercial practice, including, but not limited to, delivery by hand, mail, commercial delivery and electronic transmission. See West Virginia Code 31E-1-150
• Dependent: means an eligible employee'. See West Virginia Code 33-16-1a
• Dependent: has the meaning set forth in section one-a, article sixteen of this chapter. See West Virginia Code 33-16D-2
• Dependent: A person dependent for support upon another.
• Distribution: means a direct or indirect transfer of money or other property or incurrence of indebtedness by a corporation to or for the benefit of its members in respect of any of its membership interests or to or for the benefit of its officers or directors: Provided, That the payment of reasonable compensation for services rendered, the reimbursement of reasonable expenses, the granting of benefits to members in conformity with the corporation'. See West Virginia Code 31E-1-150
• domestic corporation: means a corporation without capital stock or shares, which is not a foreign corporation, incorporated under the laws of this state: Provided, That "corporation" or "domestic corporation" does not include towns, cities, boroughs or any municipal corporation or any department or any town, city, borough or municipal corporation. See West Virginia Code 31E-1-150
• electronically transmitted: means any process of communication not directly involving the physical transfer of paper that is suitable for the retention, retrieval and reproduction of information by the recipient. See West Virginia Code 31E-1-150
• Employee: includes an officer and may include a director: Provided, That the director has accepted duties that make him or her also an employee. See West Virginia Code 31E-1-150
• Entitlement: A Federal program or provision of law that requires payments to any person or unit of government that meets the eligibility criteria established by law. Entitlements constitute a binding obligation on the part of the Federal Government, and eligible recipients have legal recourse if the obligation is not fulfilled. Social Security and veterans' compensation and pensions are examples of entitlement programs.
• Entity: includes corporation and foreign corporations. See West Virginia Code 31E-1-150
• Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
• Ex officio: Literally, by virtue of one's office.
• Excepted benefits: means :

  (1) Any policy of liability insurance or contract supplemental thereto. See West Virginia Code 33-16-1a

• External review: means a review of a final adverse determination by an independent review organization. See West Virginia Code 33-16H-1
• Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
• Forbearance: A means of handling a delinquent loan. A
• Foreign corporation: means any nonprofit corporation which is incorporated under a law other than the laws of this state. See West Virginia Code 31E-1-150
• Fraud: Intentional deception resulting in injury to another.
• Group health plan: means an employee welfare benefit plan, including a church plan or a governmental plan, all as defined in section three of the Employee Retirement Income Security Act of 1974, 29 U. See West Virginia Code 33-16-1a
• Group health plan: has the meaning set forth in section one-a, article sixteen of this chapter. See West Virginia Code 33-16D-2
• Health benefit plan: means benefits consisting of medical care provided directly, through insurance or reimbursement, or indirectly, including items and services paid for as medical care, under any hospital or medical expense incurred policy or certificate. See West Virginia Code 33-16-1a
• Health benefit plan: has the meaning set forth in section one-a, article sixteen of this chapter. See West Virginia Code 33-16D-2
• Health benefit plan: means a policy, contract, certificate or agreement entered into, offered or issued by an issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including short-term and catastrophic health insurance policies and policies that pay on a cost-incurred basis, but excludes the excepted benefits defined in 42 U. See West Virginia Code 33-16H-1
• Health insurer: means an entity licensed by the commissioner to transact accident and sickness in this state and subject to this chapter. See West Virginia Code 33-16-1a
• Health status-related factor: means an individual'. See West Virginia Code 33-16-1a
• Health status-related factor: has the meaning set forth in section one-a, article sixteen of this chapter. See West Virginia Code 33-16D-2
• in writing: includes any representation of words, letters, or figures, whether by printing, engraving, writing, or otherwise. See West Virginia Code 2-2-10
• Indemnification: In general, a collateral contract or assurance under which one person agrees to secure another person against either anticipated financial losses or potential adverse legal consequences. ^{Source: FDIC}
• Independent review organization: means an entity approved by the commissioner to conduct external reviews of final adverse determinations. See West Virginia Code 33-16H-1
• Index rate: means for each class of business for small employers with similar case characteristics the arithmetic average of the applicable base premium rate and the corresponding highest premium rate. See West Virginia Code 33-16D-2
• Individual: includes , but is not limited to, the estate of an incompetent or deceased individual. See West Virginia Code 31E-1-150
• issuer: means an entity required to be licensed under this chapter that contracts, or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefit plan, including accident and sickness insurers, nonprofit hospital service corporations, medical service corporations and dental service organizations, prepaid limited health service organizations, health maintenance organizations, preferred provider organizations, provider sponsored network, and any pharmacy benefit manager that administers a fully-funded or self-funded plan. See West Virginia Code 33-16-3aa
• issuer: means an entity required to be licensed under this chapter that contracts, or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefit plan, including an accident and sickness insurance company, a health maintenance corporation, a health care corporation, a health or hospital service corporation, and a fraternal benefit society. See West Virginia Code 33-16H-1
• Joint committee: Committees including membership from both houses of teh legislature. Joint committees are usually established with narrow jurisdictions and normally lack authority to report legislation.
• Joint meeting: An occasion, often ceremonial, when the House and Senate each adopt a unanimous consent agreement
• Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
• Legislative session: That part of a chamber's daily session in which it considers legislative business (bills, resolutions, and actions related thereto).
• Medical care: means amounts paid for, or paid for insurance covering, the diagnosis, cure, mitigation, treatment or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body, including amounts paid for transportation primarily for and essential to such care. See West Virginia Code 33-16-1a
• Member: means a person having membership rights in a corporation in accordance with the provisions of its certificate of incorporation or bylaws. See West Virginia Code 31E-1-150
• Network plan: means a health benefit plan under which the financing and delivery of medical care are provided, in whole or in part, through a defined set of providers under contract with the health insurer. See West Virginia Code 33-16-1a
• Network plan: has the meaning set forth in section one-a, article sixteen of this chapter. See West Virginia Code 33-16D-2
• New business premium rate: means , for each class of business as to a rating period, the premium rate charged or offered by the small employer carrier to small employers with similar case characteristics for newly issued health benefit plans with the same or similar coverage. See West Virginia Code 33-16D-2
• Nonprofit corporation: means a corporation which may not make distributions to its members, directors or officers. See West Virginia Code 31E-1-150
• oath: shall be deemed to include an affirmation and the word "swear" or "sworn" to be complied with if the person referred to make solemn affirmation. See West Virginia Code 2-2-7
• Oath: A promise to tell the truth.
• Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
• Oversight: Committee review of the activities of a Federal agency or program.
• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• Person: includes , but is not limited to, an individual and an entity. See West Virginia Code 31E-1-150
• Preexisting condition exclusion: means , with respect to a health benefit plan, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the enrollment date for such coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before the enrollment date. See West Virginia Code 33-16-1a
• Principal office: means the office so designated in the return required pursuant to section three, article twelve-c, chapter . See West Virginia Code 31E-1-150
• Proceeding: includes , but is not limited to, civil suits and criminal, administrative and investigatory actions. See West Virginia Code 31E-1-150
• Public law: A public bill or joint resolution that has passed both chambers and been enacted into law. Public laws have general applicability nationwide.
• Rating period: means the calendar period of at least twelve months for which premium rates established by a small employer carrier are assumed to be in effect, as determined by the small employer carrier. See West Virginia Code 33-16D-2
• Real property: Land, and all immovable fixtures erected on, growing on, or affixed to the land.
• real property: include lands, tenements and hereditaments, all rights thereto and interests therein, except chattel interests. See West Virginia Code 2-2-10
• Record date: means the date established under article six or seven of this chapter on which a corporation determines the identity of its members and their interests. See West Virginia Code 31E-1-150
• Registered agent: means the agent identified by the corporation pursuant to section five hundred one, article five of this chapter. See West Virginia Code 31E-1-150
• Registered office: means the address of the registered agent for the corporation, as provided in section five hundred one, article five of this chapter. See West Virginia Code 31E-1-150
• Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
• Secretary: means the corporate officer to whom the board of directors has delegated responsibility under subsection (c), section eight hundred forty, article eight of this chapter for custody of the minutes of the meetings of the board of directors and the meetings of the members and for authenticating records of the corporation. See West Virginia Code 31E-1-150
• Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
• signature: includes , but is not limited to, any manual, facsimile, conformed or electronic signature with means to identify a record by a signature, mark or other symbol, with intent to authenticate it. See West Virginia Code 31E-1-150
• Small employer: means any person, firm, corporation, partnership or association actively engaged in business in the State of West Virginia who, during the preceding calendar year, employed an average of no more than fifty but not fewer than two eligible employees and employs at least two employees on the first day of its group health plan year. See West Virginia Code 33-16D-2
• State: when applied to a part of the United States and not restricted by the context, includes the District of Columbia and the several territories, and the words "United States" also include the said district and territories. See West Virginia Code 2-2-10
• Statute: A law passed by a legislature.
• Step therapy override determination: means a determination as to whether a step therapy protocol should apply in a particular situation, or whether the step therapy protocol should be overridden in favor of immediate coverage of the health care provider&rsquo. See West Virginia Code 33-16-3aa
• Step therapy protocol: means a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition, and medically appropriate for a particular patient, are covered by a health plan issuer or health benefit plan. See West Virginia Code 33-16-3aa
• Town: includes a city, village or town, and the word "council" any body or board, whether composed of one or more branches, which is authorized to make ordinances for the government of a city, town, or village. See West Virginia Code 2-2-10
• Trustee: A person or institution holding and administering property in trust.
• United States: includes , but is not limited to, districts, authorities, bureaus, commissions, departments and any other agency of the United States. See West Virginia Code 31E-1-150
• Uphold: The decision of an appellate court not to reverse a lower court decision.
• Utilization review: means a system for the evaluation of the necessity, appropriateness and efficiency of the use of health care services, procedure and facilities. See West Virginia Code 33-16H-1
• Utilization review organization: means an entity that conducts utilization review, other than a health plan issuer performing utilization review for its own health benefit plan. See West Virginia Code 33-16-3aa
• Venue: The geographical location in which a case is tried.
• West Virginia affordable health care plan: means a health insurance plan approved under this article. See West Virginia Code 33-16F-2