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This page lists some of the action toward parity compliance undertaken by West Virginia regulatory agencies since 2008.

Are we missing any actions taken by state regulatory agencies? Let us know at info@paritytrack.org.

Action in the Regulatory Arena

The West Virginia Offices of the Insurance Commissioner (OIC) requires plans to complete and submit a document whenever they apply to use “cost containment measures,” which allow plans to limit inpatient and outpatient behavioral health services if their costs increase by 2% due to covering behavioral health services (for small employer fully-insured plans it is 2% in “anticipated costs”; for large employer fully-insured plans it is “actual costs”).

This document requires plans to detail their behavioral health costs and overall costs for 4 consecutive years to show that costs did in fact increase or are expected to increase by at least 2%. It then requires them to describe which “cost containment measures” they will use and what their expected impact is on costs. Examples of “cost containment measures” could be inpatient day limits or outpatient visit limits, for example (ParityTrack has used that example because it is specifically mentioned in the relevant section of the state insurance law, which is summarized at the bottom of this page under “West Virginia Parity Law,” “Behavioral Health Coverage for Group Plans”).

This document is available as a Word document at this OIC link. It is at the very bottom of the page under “Rates and Forms” as “Mental Health Parity Cost Containment Measures Application.”

Primary Focus: Mandated Benefit: Provider
Agency: Insurance Commissioner
Title/Description: Providing Benefits for Serious Mental Illness
Citation: W. Va. Code R. § 114-64-3
Summary: Each health benefit plan issued by an insurer shall provide benefits to all individual subscribers and members and to all group members for expenses arising from the treatment of serious mental illness.  The expenses may not include custodial care, residential care or schooling.  An insurer may not apply cost-sharing requirements (e.g. deductibles, co-payments, co-insurance) and treatment limits (e.g. limitations on frequency of treatment and number of visits) to mental health benefits that are more restrictive than those applied to medical and surgical benefits or otherwise discriminate between medical-surgical benefits and mental health benefits in the administration of its plan.
Effective Date: None listed.
Notes: N/A

1/2011

On page 130 of this annual report (pdf | Get Adobe® Reader®), it states that the West Virginia Offices of the Insurance Commissioner (OIC) fined insurance plans $550,311.50 for numerous violations of the state insurance law, including a section about parity (bottom of page 130). On page 131, it states that $115,305.79 in restitution was collected for consumers because of disciplinary actions taken by OIC related to a section of the state insurance law about parity (top of page 131). These actions were the result of market conduct examinations and collaborative market conduct actions with other states.

6/2011

Among many other things, this market conduct examination (pdf | Get Adobe® Reader®) of The Health Plan of the Upper Ohio Valley Inc., conducted by the West Virginia Offices of the Insurance Commissioner (OIC), found two issues of potential non-compliance with state-parity provisions. It found that the company had not complied with a section of the mental health parity regulation issued by OIC that requires plans to receive approval before they implement cost containment procedures. It also found that the company needed revise its “forms, policies, and procedures” to ensure that enrollees receive coverage for substance use disorders, anorexia, and bulimia, as required by state law. The company agreed to comply with these recommendations (both of these recommendations and company responses can be found on page 13 of the document; page 13 as determined by a PDF viewer, not as written on the pages of the report).

6/2011

Among many other things, this market conduct examination (pdf | Get Adobe® Reader®) of THP Insurance Company, conducted by the West Virginia Offices of the Insurance Commissioner (OIC), found two issues of potential non-compliance with state-parity provisions. It found that the company had not complied with a section of the mental health parity regulation issued by OIC that requires plans to receive approval before they implement cost containment procedures. It also found that the company needed revise its “forms, policies, and procedures” to ensure that enrollees receive coverage for substance use disorders, anorexia, and bulimia, as required by state law. The company agreed to comply with these recommendations (both of these recommendations and company responses can be found on page 13 of the document; page 13 as determined by a PDF viewer, not as written on the pages of the report).

4/2010

The West Virginia Insurance Commissioner updated the regulation regarding parity. Here are the specific updates made:

  • Clarified that one of the purposes of the regulation was to provide parity regarding treatment limitations and financial requirements that “meet or exceed” what the Federal Parity Law requires
  • Clarified that in order to qualify to use “cost containment measures,” which allow plans to limit inpatient and outpatient behavioral health coverage, large employer fully-insured plans must show that “actual costs” increased by 2%, not “anticipated costs”
  • Defined “group health plans” to include employe welfare plans, church-sponsored plans, and government plans, as defined in ERISA
  • Specified that plans must not “discriminate between medical-surgical benefits” and behavioral health benefits in terms of treatment limitations and financial requirements.
  • Described the actuarial reporting requirements needed for a plan to prove its costs increased by 2% in a given year
  • Eliminated some cost-sharing language that became obsolete after changes to the state insurance law

Click here for the final version of the updated regulation and click here to see the version that shows the changes that were made.

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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