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|
|Title/Description||Providing Benefits for Serious Mental Illness|
|Citation||W. Va. Code R. § 114-64-3|
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.
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.
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).
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
- West Virginia Insurance Division