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Statutory Overview in West Virginia

Legislation Signed into Law

2018

Primary Focus: Mandated Benefit: Provider
Title/Description: Substance Use Disorder
Citation: W. Va. Code § 33-24-7r; W. Va. Code § 33-25-8o; W. Va. Code § 33-25A-8r; W. Va. Code § 33-15-4r; W. Va. Code § 33-16-3cc
Summary: The following plans that are delivered, issued, executed, or renewed in this state, or approved for issuance or renewal by the Insurance Commissioner, on or after January 1, 2019, shall provide benefits for inpatient and outpatient treatment of substance use disorder at in-network facilities at the same level as other medical services offered by the health benefit plan:
• A health benefit plan offered by a health plan issuer that provides hospital or medical expense benefits;
• An accident and sickness policy that provides hospital or medical expense benefits; and
• A group accident and sickness policy that provides hospital or medical expense benefits.
Effective Date for all citations: June 8, 2018
Note: Enacted through S 401 (2018 Regular Session)

2013

Primary Focus: Mandated Benefit: Provider
Title/Description: Authorization to Establish Group Hospital and Surgical Insurance Plan, Group Major Medical Insurance Plan, Group Prescription Drug Plan, and Group Life and Accidental Death Insurance Plan; Rules for Administration of Plans; Mandated Benefits; What Plans May Provide; Optional Plans; Separate Rating for Claims Experience Purposes
Citation: W. Va. Code § 5-16-7
Summary: The agency shall establish a group hospital and surgical insurance plan or plans, a group prescription drug insurance plan or plans, a group major medical insurance plan or plans and a group life and accidental death insurance plan or plans for those employees herein made eligible and establish and promulgate rules for the administration of these plans subject to the limitations contained in this article. These plans shall include coverage for treatment of serious mental illness, subject to certain limitations. The agency shall not discriminate between medical-surgical benefits and mental health benefits in the administration of its plan.
W. Va. Code § 5-16-7 continues on to discuss other covered services.
Effective Date: May 2, 2013
Notes: Amended by W.V. SB 22.

2012

HB 4260/SB 401
Introduced: 1/2012
Sponsor: Del. Fleischauer and Sen. Wills
Status: Signed into law 4/2012
Summary: This bill made minor technical changes the sections of state law about autism coverage to what they are currently (these sections are summarized at the bottom of the under “West Virginia Parity Law,” “Autism Coverage”).

2011

HB 2693/SB 218
Introduced: 1/2011
Sponsor: Del. Fleischauer and Sen. Jenkins
Status: Signed into law 5/2011
Summary: This bill added the sections of state law about autism coverage (these sections are summarized at the bottom of the under “West Virginia Parity Law,” “Autism Coverage”).

2010

SB 407
Introduced: 2/2010
Sponsor: Sen. Minard
Status: Signed into law 3/2010
Summary: Among many other things, this bill authorized the Insurance Commissioner to issue regulations regarding parity.

2009

HB 3288/SB 659
Introduced: 3/2009
Sponsor: Del. Perry and Sen. Minard
Status: Signed into law 6/2009
Summary: This bill changed sections of state law about parity so that small employer fully-insured plans with less than 25 employees can only limit inpatient days and outpatient visits if their costs rise by 2% annually. Previously it had been 1%. Also, if a large employer fully-insured plan qualifies for the 2% allowment, it may only limit inpatient days and outpatient visits for the following plan year.

West Virginia Parity Law

There are multiple sections of the state insurance law relevant to parity. They are summarized below in 4 different sections:

  • Behavioral Health Coverage for Group Plans
  • Behavioral Health Coverage for State Employee Plans
  • Mental Health Coverage for Individual plans
  • Autism Coverage

Behavioral Health Coverage for Group Plans

This section requires large employer fully-insured plans and small employer fully-insured plans to cover services for the following behavioral health conditions:

  • Schizophrenia and other psychotic disorders
  • Bipolar disorders
  • Depressive disorders
  • Substance use disorders
  • Anxiety disorders
  • Anorexia
  • Bulimia

The section makes clear that quantitative treatment limitations, financial requirements, and non-quantitative treatment limitations must be applied similarly for behavioral health services and other medical services.

Plans may use “whatever cost containment measures may be necessary,” including day and visit limits on inpatient care and outpatient care if they can prove that complying with this section of the law causes total costs to rise by at least 2%.

Plans are explicitly exempted from covering residential treatment.

Behavioral Health Coverage for State Employee Plans

This section requires state employee plans to cover services for the following behavioral health conditions:

  • Schizophrenia and other psychotic disorders
  • Bipolar disorders
  • Depressive disorders
  • Substance use disorders
  • Anxiety disorders
  • Anorexia
  • Bulimia
  • Attention deficit hyperactivity disorder through age 18
  • Separation anxiety disorder through age 18
  • Conduct disorder through age 18

The section makes clear that non-quantitative treatment limitations must be applied similarly for behavioral health services and other medical services.

Plans may use “whatever cost containment measures may be necessary,” including day and visit limits on inpatient care and outpatient care if they can prove that complying with this section of the law causes total costs to rise by at least 2%.

Plans are explicitly exempted from covering residential treatment.

Mental Health Coverage for Individual Plans

This section requires individual plans to offer optional coverage for any mental health condition that meets the following requirements:

Autism Coverage

These are the sections in the state insurance law about autism coverage:

These sections are identical except for the last two, which apply to the Children’s Health Insurance Program in West Virginia and state employee plans. The only difference in these two sections is that they requires an annual report about the number of children receiving autism coverage because of these sections, the sections’ fiscal impact, and any recommendations for changing the law or policies related to the law.

These sections require large employer fully-insured plans and small employer fully-insured plans with more than 25 employees to cover autism services for children age 18 months through 18 years of age, as long as they received a diagnosis before age 9.

Plans are required to cover an annual maximum for applied behavior analysis of $30,000 for the first 3 years of treatment after a diagnosis and $2,000 per month for every year afterwards through age 18.

The child’s provider must provide the insurance plan with a report every 6 months for coverage to continue. This report must include the following information for coverage to continue:

  • The child’s condition is improving because of treatment
  • Maximum improvement is still to come
  • This improvement is expected to occur “in a reasonable and generally predictable period of time”

Autism spectrum disorder is defined as “any pervasive developmental disorder, including autistic disorder, Asperger’s Syndrome, Rett syndrome, childhood disintegrative disorder, or Pervasive Development Disorder as defined” in the DSM.

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Common Violations

In seeking care or services, be aware of the common ways parity rights can be violated.

Common Violations

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