Source: http://www.legis.state.wv.us/WVCODE/code.cfm?chap=33&art=16&section=3Q
Timestamp: 2016-10-21 20:45:06
Document Index: 587813359

Matched Legal Cases: ['§33', '§1395', '§1396', '§2504', '§1003', '§33', '§33', '§1395', '§1395', '§33', '§33', 'art 1', 'art 1', 'art 6', '§33', '§33', '§33', '§607', '§1167', '§33', '§33', '§33', '§33', '§33', '§33', '§33', '§33', '§33', '§33', '§33', '§33', '§651', '§669', '§33', '§33', '§33', '§1167', '§1396', '§33', '§33', '§33']

Chapter 33 Entire Code ‹ Chapter 32B
| Chapter 34 › Printer Friendly Versions
Chapter 33 | Article 33 - 16
| Section 3Q
5 - ORGANIZATION AND PROCEDURES OF 6 - THE INSURANCE POLICY
6A - CANCELLATION OR NONRENEWAL OF 6B - DECLINATION OF AUTOMOBILE LIAB
33 - 16 - 1 33 - 16 - 1 A 33 - 16 - 1 B 33 - 16 - 2 33 - 16 - 3 33 - 16 - 3 A 33 - 16 - 3 B 33 - 16 - 3 C 33 - 16 - 3 D 33 - 16 - 3 E 33 - 16 - 3 F 33 - 16 - 3 G 33 - 16 - 3 H 33 - 16 - 3 I 33 - 16 - 3 J 33 - 16 - 3 K 33 - 16 - 3 L 33 - 16 - 3 M 33 - 16 - 3 N 33 - 16 - 3 O 33 - 16 - 3 P 33 - 16 - 3 Q 33 - 16 - 3 R 33 - 16 - 3 S 33 - 16 - 3 T 33 - 16 - 3 U 33 - 16 - 3 V 33 - 16 - 3 W 33 - 16 - 3 X 33 - 16 - 3 Y 33 - 16 - 3 Z 33 - 16 - 4 33 - 16 - 5 33 - 16 - 6 33 - 16 - 7 33 - 16 - 8 33 - 16 - 9 33 - 16 - 10 33 - 16 - 11 33 - 16 - 12 33 - 16 - 13 33 - 16 - 14 33 - 16 - 15 33 - 16 - 16 33 - 16 - 17 16A - GROUP HEALTH INSURANCE CONVE
16C - EMPLOYER GROUP ACCIDENT AND 16D - MARKETING AND RATE PRACTICES
31A - SPONSORED CAPTIVE INSURANCE 32 - RISK RETENTION ACT
40 - RISK-BASED CAPITAL (RBC) FOR 40A - RISKED-BASED CAPITAL FOR HEA
47 - INTERSTATE INSURANCE PRODUCT 48 - MODEL HEALTH PLAN FOR UNINSUR
WVC 33 - CHAPTER 33. INSURANCE.
WVC 33 - 16 - ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
WVC 33 - 16 - 1 §33-16-1. Scope of article.
(a) Nothing in this article shall apply to or affect any
policy of liability or workers' compensation insurance, or any
policy of individual accident and sickness insurance issued in
accordance with article fifteen of this chapter, or any policy
issued by a fraternal benefit society.
(b) Nothing in this article shall apply to or in any way
affect life insurance, endowment or annuity contracts or contracts
supplemental thereto which contain no provisions relating to
accident or sickness insurance except (a) such as provide
additional benefits in case of death by accidental means and except
(b) such as operate to safeguard such contracts against lapse, or
to give a special surrender value or special benefit or an annuity
in the event that the insured or annuitant shall become totally and
permanently disabled as defined by the contract or supplemental
(c) No accident and sickness policy or certificate shall be
delivered or issued for delivery in this state insuring more than
one individual (subject to the same exceptions provided for group
life insurance in section one of article fourteen of this chapter)
unless to one of the groups set forth in section two of this
article and unless otherwise in compliance with this article.
WVC 33 - 16 - 1 A
(a) "Bona fide association" means an association which has
been actively in existence for at least five years; has been formed
and maintained in good faith for purposes other than obtaining
insurance; does not condition membership in the association on any
health status-related factor relating to an individual; makes
accident and sickness insurance offered through the association
available to all members regardless of any health status-related
factor relating to members or individuals eligible for coverage
through a member; does not make accident and sickness insurance
coverage offered through the association available other than in
connection with a member of the association; and meets any
additional requirements as may be set forth in this chapter or by
(c) "Creditable coverage" means, with respect to an
individual, coverage of the individual after the thirtieth day of
June, one thousand nine hundred ninety-six, under any of the
following, other than coverage consisting solely of excepted
(3) Medicare Part A or Part B, 42 U. S. C. §1395 et seq.;
Medicaid, 42 U. S. C. §1396a et seq. (other than coverage consisting solely of benefits under Section 1928 of the Social
Security Act); Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS), 10 U. S. C., Chapter 55; and a medical care
program of the Indian Health Service or of a tribal organization;
(4) A health benefits risk pool sponsored by any state of the
United States or by the District of Columbia; a health plan offered
under 5 U. S. C., chapter 89; a public health plan as defined in
regulations promulgated by the federal secretary of health and
human services; or a health benefit plan as defined in the Peace
Corps Act, 22 U. S. C. §2504(e).
(d) "Dependent" means an eligible employee's spouse or any
unmarried child or stepchild under the age of twenty-five if that
child or stepchild meets the definition of a "qualifying child" or
a "qualifying relative" in section 152 of the Internal Revenue
Code. (e) "Eligible employee" means an employee, including an
individual who either works or resides in this state, who meets all
requirements for enrollment in a health benefit plan.
(1) Any policy of liability insurance or contract supplemental
thereto; coverage only for accident or disability income insurance
or any combination thereof; automobile medical payment insurance;
credit-only insurance; coverage for on-site medical clinics;
workers' compensation insurance; or other similar insurance under
which benefits for medical care are secondary or incidental to other insurance benefits; or
(2) If offered separately, a policy providing benefits for
long-term care, nursing home care, home health care,
community-based care or any combination thereof, dental or vision
benefits or other similar, limited benefits; or
(3) If offered as independent, noncoordinated benefits under
separate policies or certificates, specified disease or illness
coverage, hospital indemnity or other fixed indemnity insurance, or
coverage, such as medicare supplement insurance, supplemental to a
group health plan; or
(4) A policy of accident and sickness insurance covering a
period of less than one year.
(g) "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. S. C. §1003, to the extent that the plan
provides medical care.
(h) "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; hospital, medical or health service corporation
contract; health maintenance organization contract; or plan
provided by a multiple-employer trust or a multiple-employer
welfare arrangement. "Health benefit plan" does not include excepted benefits.
(i) "Health insurer" means an entity licensed by the
commissioner to transact accident and sickness in this state and
subject to this chapter. "Health insurer" does not include a group
(j) "Health status-related factor" means an individual's
health status, medical condition (including both physical and
mental illnesses), claims experience, receipt of health care,
medical history, genetic information, evidence of insurability
(including conditions arising out of acts of domestic violence) or
(k) "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.
(l) "Mental health benefits" means benefits with respect to
mental health services, as defined under the terms of a group
health plan or a health benefit plan offered in connection with the
group health plan.
(m) "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
(n) "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.
WVC 33 - 16 - 1 B
(a) The provisions of this article which generally require
policies of group accident and sickness insurance to cover specific
conditions or treatments, but which are not expressly made
applicable to the following types of policies,
do not apply to:
(1) Coverage only for accident, or disability income insurance
or any combination thereof;
(3) Liability insurance, including general liability insurance
and automobile liability insurance;
(8) Other similar insurance coverage, which may be specified
by rule, under which benefits for medical care are secondary or
incidental to other insurance benefits.
(b) The requirements of sections two-b, two-d, two-e and
two-f, article fifteen of this chapter and the provisions of this
article which generally require policies of group accident and
sickness insurance to cover specific conditions or treatments, but
which are not expressly made applicable to the following types of
policies, do not apply to the following if provided under a
separate policy, certificate, or contract of insurance:
(2) Benefits for long-term care, nursing home care, home
health care, community-based care, or any combination thereof;
(5) Medicare supplement insurance (as defined under section
1882(g)(1) of the Social Security Act), coverage supplemental to
the coverage provided under chapter 55 of title 10, United States
Code, and similar supplemental coverage provided to coverage under
group accident and sickness insurance; and
WVC 33 - 16 - 2 §33-16-2. Eligible groups.
Any insurer licensed to transact accident and sickness
insurance in this state may issue group accident and sickness
policies coming within any of the following classifications:
(1) A policy issued to an employer, who shall be considered
the policyholder, insuring at least two employees of the employer,
for the benefit of persons other than the employer, and conforming
to the following requirements:
(A) If the premium is paid by the employer the group shall
comprise all employees or all of any class or classes thereof
determined by conditions pertaining to the employment; or
(B) If the premium is paid by the employer and the employees
jointly, or by the employees, there shall be no employee
participation requirement. The term "employee" as used herein is
considered to include the officers, managers and employees of the
employer, the partners, if the employer is a partnership, the
officers, managers and employees of subsidiary or affiliated
corporations of a corporate employer, and the individual
proprietors, partners and employees of individuals and firms, the
business of which is controlled by the insured employer through
stock ownership, contract or otherwise. The term "employer" as
used herein may include any municipal or governmental corporation,
unit, agency or department and the proper officers of any
unincorporated municipality or department, as well as private
individuals, partnerships and corporations.
(2) A policy issued to an association or to a trust or to the
trustees of a fund established, created or maintained for the
benefit of members of one or more associations. The association or
associations shall have at the issuance of the policy a minimum of
one hundred persons and have been organized and maintained in good
faith for purposes other than that of obtaining insurance; shall
have been in active existence for at least one year; and shall have
a constitution and bylaws that provide that: The association or
associations hold regular meetings not less than annually to
further the purposes of the members; except for credit unions, the
association or associations collect dues or solicit contributions
from members; and the members have voting privileges and
representation on the governing board and committees. The policy
is subject to the following requirements:
(A) The policy may insure members of the association or
associations, employees thereof or employees of members or one or
more of the preceding or all of any class or classes for the
benefit of persons other than the employee's employer.
(iii) Funds contributed by both covered employer members and
the association or associations;
(C) Except as provided in paragraph (D) of this subdivision,
a policy on which no part of the premium is to be derived from
funds contributed by the covered persons specifically for their
insurance must insure all eligible persons, except those who reject
coverage in writing.
(D) An insurer may exclude or limit the coverage on any person
as to whom evidence of individual insurability is not satisfactory
(E) A small employer, as defined in subdivision (r), section
two, article sixteen-d of this chapter, insured under an eligible
group policy provided in this subdivision shall also be subject to
the marketing and rate practices provisions in article sixteen-d of
(4) A policy issued to a college, school or other institution
of learning or to the head or principal thereof, insuring at least
ten students, or students and employees, of the institution;
(5) A policy issued to or in the name of any volunteer fire
department, insuring all of the members of the department or all of
any class or classes thereof against any one or more of the hazards
to which they are exposed by reason of the membership but in each
case not less than ten members;
(6) A policy issued to any person or organization to which a
policy of group life insurance may be issued or delivered in this state, to insure any class or classes of individuals that could be
insured under the group life policy; and
(7) A policy issued to cover any other substantially similar
group which in the discretion of the commissioner may be subject to
the issuance of a group accident and sickness policy or contract.
WVC 33 - 16 - 3 §33-16-3. Required policy provisions.
Each such policy hereafter delivered or issued for delivery in
this state shall contain in substance the following provisions:
(a) A provision that the policy, the application of the
policyholder, a copy of which shall be attached to such policy, and
the individual applications, if any, submitted in connection with
such policy by the employees or members, shall constitute the
entire contract between the parties, and that all statements made
by any applicant or applicants shall be deemed representations and
not warranties, and that no such statement shall void the insurance
or reduce benefits thereunder unless contained in a written
(b) A provision that the insurer will furnish to the
policyholder, for delivery to each employee or member of the
insured group, an individual certificate setting forth in substance
the essential features of the insurance coverage of such employee
or member and to whom benefits thereunder are payable. If
dependents are included in the coverage, only one certificate need
be issued for each family unit.
(c) A provision that all new employees or members, as the case
may be, in the groups or classes eligible for insurance, shall from
time to time be added to such groups or classes eligible to obtain
such insurance in accordance with the terms of the policy.
(d) No provision relative to notice or proof of loss or the
time for paying benefits or the time within which suit may be
brought upon the policy shall be less favorable to the insured than
would be permitted in the case of an individual policy by the provisions set forth in article fifteen of this chapter.
(e) A provision that all members in groups or classes eligible
for insurance provided through an employee's group plan shall be
permitted to pay the premiums at the same group rate and receive
the same coverages for a period not to exceed eighteen months when
they are involuntarily laid off from work.
(f) Such further provisions establishing group accident and
sickness minimum policy coverage standards as the commissioner
shall promulgate by rule pursuant to chapter twenty-nine-a of this
WVC 33 - 16 - 3 A
(a) (1) Notwithstanding the requirements of subsection (b) of
this section, any health benefits plan described in this article
that is delivered, issued or renewed in this state shall provide
benefits to all individual subscribers and members and to all group
members for expenses arising from treatment of serious mental
illness. The expenses do not include custodial care, residential
or subclassifications of: (A) Schizophrenia and other psychotic
disorders; (B) bipolar disorders; (C) depressive disorders; (D)
disorders and nicotine-related disorders; (E) anxiety disorders;
and (F) anorexia and bulimia.
(2) Notwithstanding any other provision in this section to the
contrary, in the event that an insurer can demonstrate actuarially
to the Insurance Commissioner that its total anticipated costs for
treatment for mental illness, for any plan will exceed or have
exceeded two percent of the total costs for such plan in any
experience period, then the insurer may apply whatever cost
containment measures may be necessary, including, but not limited
to, limitations on inpatient and outpatient benefits, to maintain
costs below two percent of the total costs for the plan: Provided, That for any plan year beginning on or after October 3, 2009, an
insurer providing a "group health plan," as defined in section
one-a of this article, with an average of more than fifty employees
on business days during the preceding calendar year, may not apply
cost containment measures as provided in this subdivision unless
the insurer can demonstrate that the application of this section
results in an increase of two percent of the actual total costs of
coverage for the plan year involved with respect to
medical-surgical benefits and mental health benefits under the
plan: Provided, however, That such cost containment measures
implemented are applicable only for the plan year following
approval of the request to implement cost containment measures.
(3) The insurer shall not discriminate between
medical-surgical benefits and mental health benefits in the
administration of its plan. With regard to both medical-surgical
and mental health benefits, it may make determinations of medical
necessity and appropriateness, and it may use recognized health
care quality and cost management tools, including, but not limited
to, utilization review, use of provider networks, implementation of
cost containment measures, preauthorization for certain treatments,
setting coverage levels including the number of visits in a given
time period, using capitated benefit arrangements, using
fee-for-service arrangements, using third-party administrators, and
using patient cost sharing in the form of copayments, deductibles
and coinsurance.
(4) The amendments to this subsection enacted during the
regular session of the Legislature in the year 2009 shall apply
with respect to group health plans for plan years beginning on or
after October 3, 2009.
(b) With respect to mental health benefits furnished to an
enrollee of a health benefit plan offered in connection with a
group health plan, for a plan year beginning on or after January 1,
1998, the following requirements shall apply to aggregate lifetime
limits and annual limits.
(A) If the health benefit plan does not include an aggregate
lifetime limit on substantially all medical and surgical benefits,
as defined under the terms of the plan but not including mental
health benefits, the plan may not impose any aggregate lifetime
limit on mental health benefits;
(B) If the health benefit plan limits the total amount that
may be paid with respect to an individual or other coverage unit
for substantially all medical and surgical benefits (in this
paragraph, "applicable lifetime limit"), the plan shall either
apply the applicable lifetime limit to medical and surgical
benefits to which it would otherwise apply and to mental health
benefits, as defined under the terms of the plan, and not
distinguish in the application of the limit between medical and
surgical benefits and mental health benefits, or not include any
aggregate lifetime limit on mental health benefits that is less than the applicable lifetime limit;
(C) If a health benefit plan not previously described in this
subdivision includes no or different aggregate lifetime limits on
different categories of medical and surgical benefits, the
commissioner shall propose rules for legislative approval in
twenty-nine-a of this code under which paragraph (B) of this
subdivision shall apply, substituting an average aggregate lifetime
limit for the applicable lifetime limit.
(A) If a health benefit plan does not include an annual limit
on substantially all medical and surgical benefits, as defined
under the terms of the plan but not including mental health
benefits, the plan may not impose any annual limit on mental health
benefits, as defined under the terms of the plan;
may be paid in a twelve-month period with respect to an individual
or other coverage unit for substantially all medical and surgical
benefits (in this paragraph, "applicable annual limit"), the plan
shall either apply the applicable annual limit to medical and
surgical benefits to which it would otherwise apply and to mental
health benefits, as defined under the terms of the plan, and not
annual limit on mental health benefits that is less than the applicable annual limit;
subdivision includes no or different annual limits on different
categories of medical and surgical benefits, the commissioner shall
propose rules for legislative approval in accordance with the
provisions of article three, chapter twenty-nine-a of this code
under which paragraph (B) of this subdivision shall apply,
substituting an average annual limit for the applicable annual
(3) If a group health plan or a health insurer offers a
participant or beneficiary two or more benefit package options,
this subsection shall apply separately with respect to coverage
under each option.
WVC 33 - 16 - 3 B
(a) Any insurer who, on or after the first day of January, one
thousand nine hundred eighty-one, delivers or issues for delivery
in this state group basic hospital expense or major medical expense
coverage under this article shall make available to the
policyholder home health care coverage consistent with the
provisions of this section. For purposes of this section, "home
health care" means health services provided by a home health agency
certified in the state in which the home health services are
delivered or under Title XVIII of the Social Security Act.
(1) Services provided by a registered nurse or a licensed
practical nurse;
(2) Health services provided by physical, occupational,
respiratory and speech therapists;
(3) Health services provided by a home health aide to the
extent that such services would be covered if provided to the
insured on an inpatient basis;
(4) Medical supplies, drugs, medicines and laboratory services
to the extent that they would be covered if provided to the insured
on an inpatient basis; and
(5) Services provided by a licensed midwife or a licensed
nurse midwife as these occupations are defined in section one,
article fifteen of the code.
(1) Services provided on the written order of a licensed
physician, provided such order is renewed at least every sixty days;
(2) Services provided, directly or through contractual
agreements, by a home health agency certified in the state in which
the home health services are rendered or under Title XVIII of the
Social Security Act; and
(3) Services as set forth in subsection (b) of this section
without which the insured would have to be hospitalized.
(d) Coverage under this section shall be provided for at least
one hundred home visits per insured per policy year, with each home
visit by a member of a home health care team to be considered as
one home health care visit including up to four hours of home
(e) No such policy need provide such coverage to persons
eligible for medicare.
WVC 33 - 16 - 3 C
WVC 33 - 16 - 3 D
(1) "Applicant" means, in the case of a group Medicare
supplement policy or subscriber contract, the proposed certificate
(2) "Certificate" means, for the purposes of this section, any
certificate issued under a group Medicare supplement policy, which
policy has been delivered or issued for delivery in this state.
(3) "Medicare supplement policy" means a group or individual
policy of accident and sickness insurance or a subscriber contract
of hospital and medical service corporations or health maintenance
organizations, other than a policy issued pursuant to a contract
under Section 1876 of the federal Social Security Act (42 U.S.C.
§1395, et seq.) or an issued policy under a demonstration project
specified pursuant to amendments to the federal Social Security Act
in 42 U.S.C. §1395ss(g)(1), which is advertised, marketed or
designed primarily as a supplement to reimbursements under Medicare
for the hospital, medical or surgical expenses of persons eligible
for Medicare. Such term does not include:
(A) A policy or contract of one or more employers or labor
organizations, or of the trustees of a fund established by one or
more employers or labor organizations, or a combination thereof,
for employees or former employees, or combination thereof, or for
members or former members, or combination thereof, of the labor
(B) Medicare advantage plans established under Medicare Part
C, outpatient prescription drug plans established under Medicare
Part D, or any health care prepayment plan (HCPP) that provides
benefits pursuant to an agreement under Section 1833(a)(1)(A) of
the Social Security Act.
(4) "Medicare" means the Health Insurance for the Aged Act,
Title XVIII of the Social Security Amendments of 1965, as then
constituted or later amended.
(1) The commissioner shall issue reasonable rules to establish
specific standards for policy provisions of Medicare supplement
policies. Such standards shall be in addition to and in accordance
with the applicable laws of this state and may cover, but shall not
be limited to:
(2) The commissioner may issue reasonable rules that specify
prohibited policy provisions not otherwise specifically authorized by statute which, in the opinion of the commissioner, are unjust,
unfair or unfairly discriminatory to any person insured or proposed
for coverage under a Medicare supplement policy.
(3) Notwithstanding any other provisions of the law, a
Medicare supplement policy may not deny a claim for losses incurred
more than six months from the effective date of coverage for a
preexisting condition. The policy may not define a preexisting
condition more restrictively than a condition for which medical
advice was given or treatment was recommended by or received from
a physician within six months before the effective date of
(c) Minimum standards for benefits. -- The commissioner shall
issue reasonable rules to establish minimum standards for benefits
under Medicare supplement policies.
(d) Loss ratio standards. -- Medicare supplement policies
shall be expected to return to policyholders benefits which are
reasonable in relation to the premium charge. The commissioner
shall issue reasonable rules to establish minimum standards for
loss ratios and for Medicare supplement policies on the basis of
incurred claims experience and earned premiums for the entire
period for which rates are computed to provide coverage and in
accordance with accepted actuarial principles and practices. For
purposes of rules issued pursuant to this subsection, Medicare
supplement policies issued as a result of solicitations of
individuals through the mail or mass media advertising, including both print and broadcast advertising, shall be treated as
individual policies.
(1) In order to provide for full and fair disclosure in the
sale of accident and sickness policies, to persons eligible for
Medicare, the commissioner may require by rule that no policy of
accident and sickness insurance may be issued for delivery in this
state and no certificate may be delivered pursuant to such a policy
unless an outline of coverage is delivered to the applicant at the
time application is made.
(2) The commissioner shall prescribe the format and content of
the outline of coverage required by subdivision (1) above. For
purposes of this subdivision, "format" means style, arrangements
and overall appearance, including such items as size, color and
prominence of type and the arrangement of text and captions. Such
outline of coverage shall include:
(A) A description of the principal benefits and coverage
provided in the policy;
(B) A statement of the exceptions, reductions and limitations
contained in the policy;
(C) A statement of the renewal provisions including any
reservation by the insurer of the right to change premiums and
disclosure of the existence of any automatic renewal premium
increases based on the policyholder's age;
(D) A statement that the outline of coverage is a summary of the policy issued or applied for and that the policy should be
consulted to determine governing contractual provisions.
(3) The commissioner may prescribe by rule a standard form and
the contents of an informational brochure for persons eligible for
Medicare, which is intended to improve the buyer's ability to
select the most appropriate coverage and improve the buyer's
understanding of Medicare. Except in the case of direct response
insurance policies, the commissioner may require by rule that the
information brochure be provided to any prospective insureds
eligible for Medicare concurrently with delivery of the outline of
coverage. With respect to direct response insurance policies, the
commissioner may require by rule that the prescribed brochure be
provided upon request to any prospective insureds eligible for
Medicare, but in no event later than the time of policy delivery.
(4) The commissioner may further promulgate reasonable rules
to govern the full and fair disclosure of the information in
connection with the replacement of accident and sickness policies,
subscriber contracts or certificates by persons eligible for
(f) Notice of free examination. -- Medicare supplement
policies or certificates, other than those issued pursuant to
direct response solicitation, shall have a notice prominently
printed on the first page of the policy or attached thereto stating
in substance that the applicant shall have the right to return the
policy or certificate within thirty days from its delivery and have the premium refunded if, after examination of the policy or
certificate, the applicant is not satisfied for any reason. Any
refund made pursuant to this section shall be paid directly to the
applicant by the issuer in a timely manner. Medicare supplement
policies or certificates issued pursuant to a direct response
solicitation to persons eligible for Medicare shall have a notice
prominently printed on the first page or attached thereto stating
policy or certificate within thirty days of its delivery and to
have the premium refunded if, after examination, the applicant is
not satisfied for any reason. Any refund made pursuant to this
section shall be paid directly to the applicant by the issuer in a
(g) Administrative procedures. -- Rules promulgated pursuant
to this section shall be subject to the provisions of chapter
twenty-nine-a (the West Virginia Administrative Procedures Act) of
(h) Severability. -- If any provision of this section or the
application thereof to any person or circumstance is for any reason
held to be invalid, the remainder of the section and the
application of such provision to other persons or circumstances
shall not be affected thereby.
WVC 33 - 16 - 3 E
thousand nine hundred eighty-four, delivers or issues a policy of
group accident and sickness insurance in this state under the
provisions of this article shall make available as benefits to all
subscribers and members coverage for primary health care nursing
services as defined in section four-b, article fifteen of this
chapter, if such services are currently being reimbursed when
rendered by any other duly licensed health care practitioner. No
insurer may be required to pay for duplicative health care services
actually provided by both a registered professional nurse or
licensed midwife and other health providers.
(b) Nothing in this section may be construed to permit any
registered professional nurse licensee or midwife licensee to
perform professional services beyond such individual's areas of
professional competence as established by education, training and
WVC 33 - 16 - 3 F
§33-16-3f. Required policy provisions -- Treatment of
temporomandibular joint disorder and
craniomandibular disorder.
(a) The Legislature hereby finds that there is a need to
provide guidelines regarding the coverage of temporomandibular
joint disorder and craniomandibular disorder in policies issued
pursuant to this article and article fifteen of this chapter, in
order to provide for the health of our citizens. The purpose of
this section is to require the insurance commissioner to develop
standards regarding temporomandibular joint disorder and
craniomandibular disorder and to require that all insurers writing
accident and sickness policies which are covered by this article or
article fifteen of this chapter, and the public employees insurance
agency as set forth in article sixteen of chapter five make
available this coverage to the policyholder or sponsor of each such
policy. For purposes of this section, the public employees
insurance agency is the policyholder.
(b) The insurance commissioner shall promulgate rules and
regulations regarding the diagnosis and treatment for
temporomandibular joint disorder and craniomandibular disorder
coverage in accident and sickness policies covered by this article
and article fifteen of this chapter. Such regulations shall
prescribe the manner by which such coverage shall be offered to the
policyholder or sponsor; that benefits shall apply whether
administered by a physician or dentist, and findings regarding the
projected actuarial costs of implementing said regulations.
(c) The regulations shall be developed by the insurance commissioner with the advice of a six-member panel to be appointed
by the commissioner. Such panel shall consist of a general
practicing dentist who shall be recommended by the West Virginia
Dental Association, an oral and maxillofacial surgeon who shall be
recommended by the West Virginia Society for Oral and Maxillofacial
Dentists, a physician who shall be recommended by the West Virginia
State Medical Association, a member from a Health Services
Corporation who shall be recommended by the Health Services
Corporation in this state, a member representing commercial health
insurers who shall be recommended by the association representing
accident and sickness insurance, and a representative of the Public
Employees Insurance Association.
The insurance commissioner shall make his appointments to the
panel based solely upon said recommendations thirty days after this
section takes effect.
(d) This section shall only apply to policies of insurance
which provide hospital, surgical or major medical expense insurance
or any combination of these coverages.
WVC 33 - 16 - 3 G
§33-16-3g. Third party reimbursement for mammography, pap smear
or human papilloma virus testing.
Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, whenever
reimbursement or indemnity for laboratory or X-ray services are
covered, reimbursement or indemnification shall not be denied for any of the following when performed for cancer screening or
diagnostic purposes, at the direction of a person licensed to
practice medicine and surgery by the board of medicine:
age eighteen or over; and
(3) A test for the human papilloma virus (HPV)for women age
Gynecologists for women age eighteen and over.
A policy, provision, contract, plan or agreement may apply to
mammograms, pap smears or human papilloma virus (HPV) test the same
deductibles, coinsurance and other limitations as apply to other covered services.
WVC 33 - 16 - 3 H
contract, plan or agreement to which this article applies, any
entity regulated by this article shall, on or after the first day
of July, one thousand nine hundred ninety-one, provide as benefits
to all subscribers and members coverage for rehabilitation services
as hereinafter set forth, unless rejected by the insured.
(b) For purposes of this article and section, "rehabilitation
services" includes those services which are designed to remediate
patient's condition or restore patients to their optimal physical,
medical, psychological, social, emotional, vocational and economic
status. Rehabilitative services include by illustration and not
limitation diagnostic testing, assessment, monitoring or treatment
of the following conditions individually or in a combination:
(9) Neurological disorders, including, but not limited to,
multiple sclerosis, motor neuron diseases, polyneuropathy, muscular
dystrophy and Parkinson's disease;
(10) Cardiac disorders, including, but not limited to, acute
myocardial infarction, angina pectoris, coronary arterial insufficiency, angioplasty, heart transplantation, chronic
arrhythmias, congestive heart failure, valvular heart disease;
(c) Rehabilitative services includes care rendered by any of
(1) A hospital duly licensed by the state of West Virginia
that meets the requirements for rehabilitation hospitals as
described in Section 2803.2 of the Medicare Provider Reimbursement
Manual, Part 1, as published by the U.S. Health Care Financing
(2) A distinct part rehabilitation unit in a hospital duly
licensed by the state of West Virginia. The distinct part unit
must meet the requirements of Section 2803.61 of the Medicare
Provider Reimbursement Manual, Part 1, as published by the U.S.
Health Care Financing Administration;
(3) A hospital duly licensed by the state of West Virginia
which meets the requirements for cardiac rehabilitation as
described in Section 35-25, Transmittal 41, dated August, 1989, as
promulgated by the U.S. Health Care Financing Administration.
(d) Rehabilitation services do not include services for mental
health, chemical dependency, vocational rehabilitation, long-term
maintenance or custodial services.
(e) A policy, provision, contract, plan or agreement may apply
to rehabilitation services the same deductibles, coinsurance and
other limitations as apply to other covered services.
WVC 33 - 16 - 3 I
entity regulated by this article shall provide as benefits to all
subscribers and members coverage for emergency services. A policy,
provision, contract, plan or agreement may apply to emergency
services the same deductibles, coinsurance and other limitations as
apply to other covered services: Provided, That preauthorization
or precertification shall not be required.
ninety-eight, the following provisions apply:
(1) Every insurer shall provide coverage for emergency medical
services, including prehospital services, to the extent necessary
to screen and to stabilize an emergency medical condition. The
insurer shall not require prior authorization of the screening
if an emergency medical condition exists. Payment of claims for
emergency services shall be based on the retrospective review of
the presenting history and symptoms of the covered person.
(2) An insurer that has given prior authorization for
emergency services shall cover the services and shall not retract
the authorization after the services have been provided unless the
authorization was based on a material misrepresentation about the covered person's health condition made by the referring provider,
the provider of the emergency services or the covered person.
(3) Coverage of emergency services shall be subject to
coinsurance, copayments and deductibles applicable under the health
(4) The emergency department and the insurer shall make a good
faith effort to communicate with each other in a timely fashion to
expedite postevaluation or poststabilization services in order to
avoid material deterioration of the covered person's condition.
(A) "Emergency medical services" means those services required
to screen for or treat an emergency medical condition until the
condition is stabilized, including prehospital care;
(B) "Prudent layperson" means a person who is without medical
(D) "Stabilize" means with respect to an emergency medical
otherwise delay the transportation required for a higher level of
care than that possible at the treating facility;
medical condition exists; and
(F) "Emergency medical condition" means a condition that
WVC 33 - 16 - 3 J
(a) Nothing in this section shall be construed to require a
mother to give birth in a hospital or to stay in the hospital for
a fixed period of time following the birth of her child, but if a
health benefit plan, for plan years beginning on or after the first
day of January, one thousand nine hundred ninety-eight, provides
inpatient benefits in connection with childbirth for a mother or
her newborn child:
(1) The plan may not restrict benefits for any hospital stay
following a normal vaginal delivery to less than forty-eight hours
or following a cesarean section to less than ninety-six hours, or
require a provider to obtain authorization for such length hospital
(2) The plan must cover maternity and pediatric care in
accordance with guidelines established by the American College of
Obstetricians and Gynecologists, the American Academy of Pediatrics
or other established professional medical association; and
(3) The mother and her newborn child may be discharged prior
to the expiration of the minimum length of stay required under this
section only in those cases in which the decision to discharge is
made by an attending provider in consultation with the mother.
(b) Benefits provided for under this section may be made
subject to deductibles, coinsurance or other cost-sharing if such
cost-sharing is no greater than cost-sharing for any preceding
portion of the mother's or newborn child's hospital stay.
health insurer from negotiating with a provider the level and type
of reimbursement for inpatient maternity or newborn care provided
under a health benefit plan.
WVC 33 - 16 - 3 K
(a) (1) For plan years beginning after the thirtieth day of
June, one thousand nine hundred ninety-seven, a health benefit plan
issued in connection with a group health plan may not impose a
preexisting condition exclusion with respect to an employee or a
dependent of an employee for losses incurred by the employee or
dependent more than twelve months (or eighteen months for a late
enrollee) after the earlier of the individual's date of enrollment
in the health benefit plan or the first day of a waiting period for
enrollment in the plan. Genetic information may not be treated as
a condition for which a preexisting condition exclusion may be
imposed absent a diagnosis of the condition related to the genetic
(2) A health benefit plan may impose a preexisting condition
exclusion only if such condition relates to a physical or mental
condition, regardless of its cause, for which medical advice,
diagnosis, care or treatment was recommended or received within the
six-month period ending on the enrollee's enrollment date.
(3) A health benefit plan may impose no preexisting condition
exclusion relating to pregnancy or in the case of a newborn covered
under creditable coverage within thirty days of birth or a child
adopted before the age of eighteen and covered under creditable
coverage within thirty days of adoption or placement for adoption.
(b) A health maintenance organization that does not impose apreexisting condition exclusion allowed under subsection (a) of
this section with respect to any particular coverage option may:
(1) Impose an affiliation period for that coverage option if
the affiliation period is applied uniformly without regard to any
health status-related factors and does not exceed two months (three
months for a late enrollee). For purposes of this article,
"affiliation period" means a period that begins on an employee's or
dependent's enrollment date, runs concurrently with any waiting
period under the group health plan, must expire before coverage is
effective and during which the health maintenance organization need
not provide medical care and may not charge any premium to the
employee or dependent; or
(2) Use other alternatives approved by the commissioner to
address adverse selection.
(c) Any preexisting condition exclusion period, including any
waiting period or affiliation period prior to the effective date of
coverage, shall be reduced by the aggregate of the periods of
creditable coverage applicable to the enrollee as of the enrollment
WVC 33 - 16 - 3 L
(a) A health insurer may refuse to renew a health benefit plan
issued in connection with a group health plan after complying with
all applicable provisions of this chapter and only for one of the
(1) The policyholder's failure to pay premiums or the
carrier's failure to receive timely premium payments;
(2) Fraud or intentional misrepresentation of material fact by
the policyholder;
(3) The policyholder's failure to comply with a material plan
provision relating to contribution or group participation rules;
(4) The health insurer elects to discontinue offering health
benefit plans:
(A) Of a particular type, if the health insurer gives notice
to each policyholder of such plan and to all covered employees or
members and dependents at least ninety days before the date such
coverage is discontinued: Provided, That a health insurer electing
to discontinue health benefit plans to small employers shall comply
with the requirements of section seven, article sixteen-d of this
chapter. The health insurer shall offer each such policyholder the
option to purchase any other health benefit plan offered by the
health insurer to employers. In electing to discontinue health
benefit plans of a particular type and in offering coverage under
the preceding sentence, the health insurer shall act uniformly without regard to policyholders' claims experience or any health
status-related factor relating to any covered employee, member or
dependent or new employees, members or dependents who may become
eligible for coverage; or
(B) Of all types, if the health insurer gives notice to the
commissioner and to each policyholder and all covered employees or
members and dependents at least one hundred eighty days before the
date plans are discontinued: Provided, That a health insurer
electing to discontinue health benefit plans to small employers
shall comply with the requirements of section seven, article
sixteen-d of this chapter. The health insurer shall discontinue
all, and not renew any, health benefit plans issued pursuant to
this article. The health insurer may not issue any health benefit
plan pursuant to this article for a five-year period beginning on
the date the last discontinued health benefit plan is not renewed;
(5) For a health insurer offering coverage under a network
plan, the health insurer no longer has any enrollees of the network
plan who live, reside or work in the plan's service area; or
(6) For health benefit plans offered only through a bona fide
association, an employer ceases to be a member of the bona fide
association, if coverage is terminated uniformly without respect to
any health status-related factor relating to any covered employee,
association member or dependent. With respect to coverage provided
to an employer, a reference to "policyholder" or "plan sponsor" is
deemed to include a reference to the employer.
(b) Subject to other requirements of this chapter, a health
insurer may modify a health benefit plan issued in connection with
a group health plan when the health benefit plan is renewed.
(a)(1) A health insurer shall certify an enrollee's creditable
coverage at the time an enrollee:
(A) Ceases to be covered under a health benefit plan issued
in connection with a group health plan, including coverage under a
COBRA continuation provision. For purposes of this article, "COBRA
continuation provision" means any of the following:
(i) Section 4980B of the Internal Revenue Code of 1986, other
than subsection (f)(1) of such section insofar as it relates to
pediatric vaccines;
(ii) Part 6 of subtitle B of Title I of the Employee
Retirement Income Security Act of 1974, other than Section 609 of
such act; or
(B) Ceases to be covered under a COBRA continuation provision;
(C) Requests certification, but no later than twenty-four
months after cessation of coverage under the health benefit plan.
(2) The health insurer shall provide the enrollee a written
certification of:
(A) The period of creditable coverage under the health benefit
plan, including coverage, if any, under a COBRA continuation
provision; and
(B) The waiting period, if any, and affiliation period, if
applicable, for any coverage under the health benefit plan.
(b) For purposes of reducing an enrollee's preexisting
condition exclusion period, creditable coverage shall not be
counted if, after such period and before an employee's or
dependent's enrollment in a health benefit plan issued in
connection with a group health plan, there was a period of
sixty-three days or more during all of which the individual was not
covered under any creditable coverage. For purposes of this
subsection, a sixty-three-day period may not include any waiting
period or affiliation period prior to the effective date of an
individual's coverage.
(c) For purposes of reducing an enrollee's preexisting
condition exclusion period, a health insurer:
(1) Shall count a period of creditable coverage without regard
to specific benefits covered during the period; or
(2) May elect to apply creditable coverage based upon each of
several classes or categories of benefits in accordance with rules
promulgated by the commissioner. A health insurer shall make such
an election on a uniform basis for all enrollees and shall count a
period of creditable coverage with respect to any class or category
of benefits if any level of benefits is covered within such class
or category.
WVC 33 - 16 - 3 N
contract, plan or agreement to which this article applies, a health
insurer offering coverage in connection with a group health plan
may not, for plan years beginning after the thirtieth day of June,
one thousand nine hundred ninety-seven, establish rules for
eligibility, including continued eligibility, of any employee or
dependent to enroll under a health benefit plan based on a health
status-related factor.
(b) For plan years beginning after the thirtieth day of June,
one thousand nine hundred ninety-seven, a health benefit plan
offered in connection with a group health plan shall provide that
an employee or dependent of an employee who is eligible, but not
enrolled, under terms of a health benefit plan may enroll under
terms of the plan if the employee or dependent:
(1) Was covered under other creditable coverage when coverage
was previously offered to the employee or dependent and, if
required by the insurer, the employee stated in writing that the
existence of other creditable coverage was the reason for declining
enrollment under the health benefit plan;
(2) Lost coverage under the other creditable coverage because
of legal separation, divorce, death, termination of employment,
reduction in the number of hours of employment, exhaustion of COBRA
continuation coverage or termination of the employer's
contributions towards the other creditable coverage; and
(3) The employee requests enrollment no more than thirty days
after loss of the other creditable coverage.
(c) For plan years beginning after the thirtieth day of June,
one thousand nine hundred ninety-seven, if a health benefit plan
makes coverage available to an employee's dependents, the plan
shall provide that if an employee is enrolled under the plan or has
met any waiting period requirement and is eligible for enrollment
but for a failure to enroll during a previous enrollment period:
(1) The employee or a person who becomes a dependent of the
employee through marriage, birth, adoption or placement for
adoption may be enrolled under the plan, and in the case of the
birth or adoption of a child, the employee's spouse who is
otherwise eligible for coverage may be enrolled as a dependent,
during a period of at least thirty days beginning on the later of
the date dependent coverage is made available or the date of the
marriage, birth, adoption or placement for adoption; and
(2) If the employee requests enrollment of a dependent during
the first thirty days that dependent coverage is available, the
dependent's coverage shall become effective:
(A) In the case of marriage, no later than the first day of
the first month after the date the completed enrollment request is
received; or
(B) In the case of a dependent's birth, adoption or placement
for adoption, as of the date of birth, adoption or placement for
WVC 33 - 16 - 3 O
§33-16-3o. Third party reimbursement for colorectal cancer
examination and laboratory testing.
or X-ray services are covered under the policy and are performed
(b) A symptomatic person is defined as: (i) An individual who experiences a change in bowel habits, rectal bleeding or stomach
cramps that are persistent; or (ii) an individual who poses a
higher than average risk for colorectal cancer because he or she
has had colorectal cancer or polyps, inflammatory bowel disease, or
an immediate family history of such conditions.
provision, contract, plan or agreement of the covered person may
apply to colorectal cancer examinations and laboratory testing.
WVC 33 - 16 - 3 P
§33-16-3p. Required coverage for reconstruction surgery following
(a) Any policy of insurance described in this article which provides medical and surgical benefits with respect to a mastectomy
shall provide, in a case of a participant or beneficiary who is
receiving benefits in connection with a mastectomy and who elects
breast reconstruction in connection with such mastectomy, coverage
the attending physician and the patient. Coverage shall be
provided for a minimum stay in the hospital of not less than
forty-eight hours for a patient following a radical or modified
mastectomy and not less than twenty-four hours of inpatient care
following a total mastectomy or partial mastectomy with lymph node
dissection for the treatment of breast cancer. Nothing in this
section shall be construed as requiring inpatient coverage where
inpatient coverage is not medically necessary or where the
attending physician in consultation with the patient determines that a shorter period of hospital stay is appropriate. Such
coverage may be subject to annual deductibles and coinsurance
provisions as may be deemed appropriate and as are consistent with
those established for other benefits under the health benefit plan
policy or coverage. Written notice of the availability of such
coverage shall be delivered to the participant upon enrollment and
(b) A health benefit plan policy, and a health insurer
providing health insurance coverage in connection with a health
benefit plan policy, shall provide notice to each participant and
beneficiary under such plan regarding the coverage required by this
section. Such notice shall be in writing and prominently
positioned in any literature or correspondence made available or
distributed by the issuer of the health benefit plan policy.
(c) A health benefit plan policy and a health insurer offering
health insurance coverage in connection with a health benefit plan
policy, may not:
otherwise) to an attending provider, to induce such provider to provide care to an individual participant or beneficiary in a
(d) Nothing in this section shall be construed to prevent a
(e) The provisions of this section shall be included under any
WVC 33 - 16 - 3 Q
(a) An insurer issuing group accident and sickness policies in
this state pursuant to the provisions of this article may not
require any person covered under a contract which provides coverage
for prescription drugs to obtain the prescription drugs from a
mail-order pharmacy in order to obtain benefits for the drugs.
(b) An insurer may not violate the provisions of subsection
(a) of this section through the use of an agent or contractor or
through the action of an administrator of prescription drug
(c) The insurance commissioner may propose rules for
legislative approval in accordance with the provisions of article
three, chapter twenty-nine-a of this code to implement and enforce
WVC 33 - 16 - 3 R
The provisions relating to clinical trials established in
article twenty-five-f of this chapter shall apply to the health
benefit plans regulated by this article.
WVC 33 - 16 - 3 S
reimbursement or indemnification for annual kidney disease
screening and laboratory testing as recommended by the National
Kidney Foundation may not be denied for any person when
covered under the policy and are performed for kidney disease
screening or diagnostic purposes at the direction of a person
licensed to practice medicine and surgery by the board of medicine. The tests are as follows: Any combination of blood pressure
testing, urine albumin or urine protein testing and serum
creatinine testing.
(b) The same deductibles, coinsurance, network restrictions
apply to kidney disease screening and laboratory testing.
WVC 33 - 16 - 3 T
entity regulated by this article shall, on or after July 1, 2009,
provide as benefits to all subscribers and members coverage for
dental anesthesia services as hereinafter set forth.
(b) For purposes of this article and section, "dental
anesthesia services" means general anesthesia for dental procedures
and associated outpatient hospital or ambulatory facility charges
conjunction with dental care provided to an enrollee or insured if
the enrollee or insured is:
(1) Seven years of age or younger or is developmentally
condition of the enrollee or insured and for whom a superior result
can be expected from dental care provided under general anesthesia;
(2) A child who is twelve years of age or younger with
dental morbidity and for whom a successful result cannot be expected from dental care provided under local anesthesia because
(c) Prior authorization. -- An entity subject to this section
may require prior authorization for general anesthesia and
associated outpatient hospital or ambulatory facility charges for
dental care in the same manner that prior authorization is required
for these benefits in connection with other covered medical care.
(d) An entity subject to this section may restrict coverage
for general anesthesia and associated outpatient hospital or
ambulatory facility charges unless the dental care is provided by:
(2) A fully accredited specialist in oral and maxillofacial
(e) Dental care coverage not required. -- The provisions of
this section may not be construed to require coverage for the
dental care for which the general anesthesia is provided.
(f) Temporal mandibular joint disorders. -- The provisions of
this section do not apply to dental care rendered for temporal
mandibular joint disorders.
(g) A policy, provision, contract, plan or agreement may apply
to dental anesthesia services the same deductibles, coinsurance and
WVC 33 - 16 - 3 U
§33-16-3u. Special enrollment period under the American Recovery
and Reinvestment Act of 2009.
(a) The Legislature finds that recent attempts to assist
unemployed persons during the economic downturn beginning at the
end of 2008 included a federal initiative to provide subsidies to
certain persons who have lost their employer-sponsored health
insurance coverage. As part of the American Recovery and
Reinvestment Act of 2009, certain involuntarily terminated
employees and their dependents were given an second opportunity to
elect subsidized COBRA coverage. This federal initiative also
included relief to certain persons not covered by the federal COBRA
laws, but access to such relief was made dependent on the states
acting to require that such persons be given notice of their right
to elect such coverage. Therefore, the Legislature intends that
this section be interpreted in such a manner as to maximize the
opportunity of West Virginians to obtain these much needed
(1) "Assistance eligible individual" means any qualified
beneficiary who was eligible for continuation coverage between
September 1, 2008, and February 17, 2009, due to a covered
employee's termination from employment during this period and who
elected such coverage.
(2) "Continuation coverage" means accident and sickness
insurance coverage offered to persons pursuant to policy provisions required by subsection (e), section three of this article.
(3) "Covered employee" means a person who was involuntarily
terminated by a small employer between September 1, 2008, and
February 16, 2009, and at the time of his or her termination
either: (i) Was eligible for but did not elect to enroll in
continuation coverage; or (ii) enrolled but subsequently
discontinued enrollment in continuation coverage.
(4) "Qualified beneficiary" has the same meaning as that term
is defined in §607(3) of the Employee Retirement Income Security
Act of 1974, 29 U.S.C. §1167(3).
(5) "Small employer" means any employer that had fewer than
twenty (20) employees during fifty percent (50%) or more of its
typical business days in the previous calendar year.
(c) An individual who does not have an election of
continuation coverage in effect on February 17, 2009, but who would
be an assistance eligible individual if such election were in
effect, may elect continuation coverage pursuant to this section. Such election shall be made no later than sixty days after the date
the administrator of the group health plan (or other entity
involved) provides the notice required by Section 3001(a)(7) of the
American Recovery and Reinvestment Act of 2009. The administrator
of the group health plan (or other entity involved) shall provide
such individuals with additional notice of the right to elect
coverage pursuant to this subsection prior to April 18, 2009.
(d) Continuation coverage elected pursuant to subsection (c) of this section shall commence with the first period of coverage
beginning on or after February 17, 2009: Provided, That
continuation coverage elected pursuant to this subsection shall not
extend beyond the maximum eighteen-month period provided for by
subsection (e), section three of this article.
(e) With respect to an individual who elects continuation
coverage pursuant to subsection (b) of this section, the period
beginning on the date of the involuntary termination and ending on
the date of the first period of coverage on or after February 17,
2009, shall be disregarded for purposes of determining the
sixty-three day period referred to in subsection (b), section
three-m of this article.
WVC 33 - 16 - 3 V
§33-16-3v. Required coverage for treatment of autism spectrum
(a) Any insurer who, on or after January 1, 2012, delivers,
renews or issues a policy of group accident and sickness insurance
in this state under the provisions of this article shall include
coverage for diagnosis, evaluation and treatment of autism spectrum
disorder in individuals ages eighteen months to eighteen years. To
be eligible for coverage and benefits under this section, the
individual must be diagnosed with autism spectrum disorder at age
eight or younger. Such policy shall provide coverage for
treatments that are medically necessary and ordered or prescribed
by a licensed physician or licensed psychologist and in accordance
with a treatment plan developed from a comprehensive evaluation by
a certified behavior analyst for an individual diagnosed with
(b) Coverage shall include, but not be limited to, applied
behavior analysis. Applied behavior analysis shall be provided or
supervised by a certified behavior analyst. The annual maximum
benefit for applied behavior analysis required by this subsection
shall be in an amount not to exceed $30,000 per individual, for
three consecutive years from the date treatment commences. At the
conclusion of the third year, required coverage shall be in an
amount not to exceed $2,000 per month, until the individual reaches
eighteen years of age, as long as the treatment is medically
necessary and in accordance with a treatment plan developed by a
certified behavior analyst pursuant to a comprehensive evaluation
or reevaluation of the individual. This section shall not be construed as limiting, replacing or affecting any obligation to
Disabilities Education Act, 20 U.S.C. 1400 et seq., as amended from
time to time or other publicly funded programs. Nothing in this
section shall be construed as requiring reimbursement for services
provided by public school personnel.
with the insurer semiannually. In order for treatment to continue,
the insurer must receive objective evidence or a clinically
(1) The individual's condition is improving in response to
treatment; and
(3) There is an expectation that the anticipated improvement
(1) "Applied Behavior Analysis" means the design,
implementation, and evaluation of environmental modifications using
behavioral stimuli and consequences, to produce socially
significant improvement in human behavior, including the use of
direct observation, measurement, and functional analysis of the
(2) "Autism spectrum disorder" means any pervasive
developmental disorder, including autistic disorder, Asperger's
Syndrome, Rett syndrome, childhood disintegrative disorder, or
Pervasive Development Disorder as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental
(3) "Certified behavior analyst" means an individual who is
(4) "Objective evidence" means standardized patient assessment
instruments, outcome measurements tools or measurable assessments
of functional outcome. Use of objective measures at the beginning
of treatment, during and after treatment is recommended to quantify
progress and support justifications for continued treatment. The
tools are not required, but their use will enhance the
justification for continued treatment.
(e) The provisions of this section do not apply to small
employers. For purposes of this section a 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
twenty-five eligible employees.
(f) To the extent that the application of this section for
of actual total costs of coverage for the plan year the insurer may
(g) To the extent that the provisions of this section require
benefits that exceed the essential health benefits specified under
section 1302(b) of the Patient Protection and Affordable Care Act,
Pub. L. No. 111-148, as amended, the specific benefits that exceed
the specified essential health benefits shall not be required of a health benefit plan when the plan is offered by a health care
insurer in this state.
WVC 33 - 16 - 3 W
contract, plan or agreement applicable to this article, any health
insurance policy subject to this article, issued or renewed on or
after January 1, 2014, which provides health insurance coverage for
maternity services, shall provide coverage for maternity services
for all persons participating in, or receiving coverage under the
policy. To the extent that the provisions of this section require
the specified essential health benefits are not required of a
health benefit plan when the plan is offered by a health care
insurer in this state. Coverage required under this section may
not be subject to exclusions or limitations which are not applied
to other maternity coverage under the policy.
WVC 33 - 16 - 3 X
§33-16-3x. Deductibles, copayments and coinsurance for anti-cancer
(a) Any group accident and sickness insurance policy issued by
an insurer pursuant to this article that covers anti-cancer
medications that are injected or intravenously administered by a
health care provider and patient administered anti-cancer
medications, including, but not limited to, those medications
orally administered or self-injected, may not require a less
favorable basis for a copayment, deductible or coinsurance amount
for patient administered anti-cancer medications than it requires
for injected or intravenously administered anti-cancer medications,
regardless of the formulation or benefit category determination by
the policy or plan.
(b) A group accident and sickness insurance policy may not
comply with subsection (a) of this section by:
(1) Increasing the copayment, deductible or coinsurance amount
required for injected or intravenously administered anti-cancer
medications that are covered under the policy or plan; or
(2) Reclassifying benefits with respect to anti-cancer
(c) As used in this section, "anti-cancer medication" means a
FDA approved medication prescribed by a treating physician who
determines that the medication is medically necessary to kill or
slow the growth of cancerous cells in a manner consistent with
nationally accepted standards of practice.
(d) This section is effective for policy and plan years
beginning on or after January 1, 2016. This section applies to all
group accident and sickness insurance policies and plans subject to
this article that are delivered, executed, issued, amended,
adjusted or renewed in this state, on and after the effective date
(e) Notwithstanding any other provision in this section to the
any plan to comply with this section will exceed or have exceeded
two percent of the total costs for such plan in any experience
period, then the insurer may apply whatever cost containment
measures may be necessary to maintain costs below two percent of
the total costs for the plan: Provided, That such cost containment
measures implemented are applicable only for the plan year
following approval of the request to implement cost containment
(f) For any enrollee that is enrolled in a catastrophic plan
as defined in Section 1302(e) of the Affordable Care Act or in a
plan that, but for this requirement, would be a High Deductible
Health Plan as defined in section 223(c)(2)(A) of the Internal
Revenue Code of 1986, and that, in connection with every
enrollment, opens and maintains for each enrollee a Health Savings
Account as that term is defined in section 223(d) of the Internal
Revenue Code of 1986, the cost-sharing limit outlined in subsection (a) of this section shall be applicable only after the minimum
annual deductible specified in section 223(c)(2)(A) of the Internal
Revenue Code of 1986 is reached. In all other cases, this limit
shall be applicable at any point in the benefit design, including
before and after any applicable deductible is reached.
WVC 33-16-3Y
§33-16-3y. Eye drop prescription refills. An insurance policy issued by an insurer pursuant to this article for prescription topical eye medication may not deny coverage for the refilling of a prescription for topical eye medication when: (1) The medication is to treat a chronic condition of the eye; (2) The refill is requested by the insured prior to the last day of the prescribed dosage period and after at least 70% of the predicted days of use; and (3) A person licensed under chapter thirty and authorized to prescribe topical eye medication indicates on the original prescription that refills are permitted and that the early refills requested by the insured do not exceed the total number of refills prescribed. WVC 33-16-3Z
§33-16-3z. Deductibles, copayments and coinsurance for abuse-deterrent opioid analgesic drugs. (a) As used in this section: (1) “Abuse-deterrent opioid analgesic drug product” means a brand name or generic opioid analgesic drug product approved by the United States Food and Drug Administration with abuse-deterrent labeling that indicates its abuse-deterrent properties are expected to deter or reduce its abuse; (2) “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible or other out-of-pocket expense requirements; (3) “Opioid analgesic drug product” means a drug product that contains an opioid agonist and is indicated by the United States Food and Drug Administration for the treatment of pain, regardless of whether the drug product: (A) Is in immediate release or extended release form; or (B) Contains other drug substances. (b) Notwithstanding any provision of any group accident and sickness insurance policy issued by an insurer pursuant to this article, on or after January 1, 2017: (1) Coverage shall be provided for at least one abuse-deterrent opioid analgesic drug product for each active opioid analgesic ingredient; (2) Cost-sharing for brand name abuse-deterrent opioid analgesic drug products shall not exceed the lowest tier for brand name prescription drugs on the entity’s formulary for prescription drug coverage; (3) Cost-sharing for generic abuse-deterrent opioid analgesic drug products covered pursuant to this section shall not exceed the lowest cost-sharing level applied to generic prescription drugs covered under the applicable health plan or policy; and (4) An entity subject to this section may not require an insured or enrollee to first use an opioid analgesic drug product without abuse-deterrent labeling before providing coverage for an abuse-deterrent opioid analgesic drug product covered on the entity's formulary for prescription drug coverage. (c) Notwithstanding subdivision (3), subsection (b) of this section, an entity subject to this section may undertake utilization review, including preauthorization, for an abuse-deterrent opioid analgesic drug product covered by the entity, if the same utilization review requirements are applied to nonabuse-deterrent opioid analgesic drug products and with the same type of drug release, immediate or extended. (d) For purposes of subsection (b) of this section, the lowest tier and the lowest cost-sharing level shall not mean the cost-sharing tier applicable to preventive care services which are required to be provided at no cost-sharing under the Patient Protection and Affordable Care Act. WVC 33 - 16 - 4 §33-16-4. Size of type. Every printed portion of every such policy shall be plainly
printed in type of which the face shall be not smaller than ten-point, and the exceptions shall be printed with the same
prominence as the benefits to which they apply.
WVC 33 - 16 - 5 §33-16-5. Contingencies for which benefits or reimbursement of
expenses permitted. Any such policy may provide, in addition to such other
indemnities, if any, as are provided in the policy on account of
sickness or bodily injury or death of insured employees or
members by accident, for the payment of benefits or reimbursement
for expenses with respect to any one or more of the following
contingencies: Hospitalization, nursing care, medical or
surgical examination or treatment, or ambulance transportation,
of insured employees or members, or of their spouses or children,
or of dependents living with them.
WVC 33 - 16 - 6 §33-16-6. Rider changing individual policy to group policy
prohibited. No endorsement or rider shall hereafter be used in this
state to transform an individual policy issued under article
fifteen of this chapter into a group policy.
WVC 33 - 16 - 7 §33-16-7. Hospital indemnity policies not to exclude coverage
for confinement in government hospital. No policy providing hospital indemnity coverage may exclude
coverage because of confinement in a hospital operated by the
federal or state government.
WVC 33 - 16 - 8 §33-16-8. Continuum of care services.
Any insurer which, on or after the first day of July, one
thousand nine hundred eighty-six, delivers or issues for delivery
in this state any policy of group accident and sickness insurance
under the provisions of this article, shall make available for
purchase, at a reasonable rate, supplemental insurance coverage for
continuum of care services pursuant to article five-d, chapter
sixteen of this code: Provided, That any insurance carrier
required to provide supplemental insurance coverage for continuum
of care services hereunder shall not be required to expend funds
for underwriting such supplemental coverage until the continuum of
care board, in cooperation with the West Virginia state insurance
commissioner, shall have completed a written master plan related to
insurance coverage as set forth in section five, article five-d,
chapter sixteen of the code of West Virginia, one thousand nine
hundred thirty-one, as amended, including, but not limited to, the
specific standards and coverages to be provided in such
supplemental coverage: Provided, however, That a public hearing
shall be held pursuant to the provisions of chapter twenty-nine-a
of this code applicable to such proceedings prior to the
considerations of the aforesaid plan by said board. The rates for
continuum of care coverage shall accurately reflect the cost of
such coverage and shall not be subsidized by the rate structure for
any other coverage.
WVC 33 - 16 - 9 §33-16-9. Policies not to terminate coverage because of diagnosis
or treatment of acquired immune deficiency syndrome.
No insurer may cancel or nonrenew the accident and sickness
insurance policy of any insured because of diagnosis or treatment
of acquired immune deficiency syndrome.
WVC 33 - 16 - 10 §33-16-10. Policies discriminating among health care providers.
Notwithstanding any other provisions of law, when any health
insurance policy, health care services plan or other contract
provides for the payment of medical expenses, benefits or
procedures, such policy, plan or contract shall be construed to
include payment to all health care providers including medical
physicians, osteopathic physicians, podiatric physicians,
chiropractic physicians, midwives and nurse practitioners who
provide medical services, benefits or procedures which are within
the scope of each respective provider's license. Any limitation or
condition placed upon services, diagnoses or treatment by, or
payment to any particular type of licensed provider shall apply
equally to all types of licensed providers without unfair
discrimination as to the usual and customary treatment procedures
of any of the aforesaid providers.
WVC 33 - 16 - 11 §33-16-11. Group policies not to exclude insured's children from
coverage; required services; coordination with other
this state shall provide coverage for the child or children of
each employee or member of the insured group without regard to the
amount of child support ordered to be paid or actually paid by such
employee or member, if any, and without regard to the fact that the
employee or member may not have legal custody of the child or
children or that the child or children may not be residing in the
home of the employee or member.
(b) An insurer issuing group accident and sickness policies in
this state shall provide benefits to dependent children placed with
participants or beneficiaries for adoption under the same terms and
conditions as apply to natural, dependent children of participants
and beneficiaries, irrespective of whether the adoption has become
(c) An insurer shall not deny enrollment of a child under the
health plan of the child's parent on the grounds that:
(2) The child is not claimed as a dependent on the parent's
(3) The child does not reside with the parent or in the
insurer's service area.
(d) Where a child has health coverage through an insurer of
a noncustodial parent the insurer shall:
(2) Permit the custodial parent, or the provider, with the
custodial parent's approval, to submit claims for covered services
without the approval of the noncustodial parent; and
(3) Make payments on claims submitted in accordance with
subdivision (2) of this subsection directly to the custodial
parent, the provider or the state medicaid agency: Provided,
upon payment to the custodial parent, the provider or the state
medicaid agency the insurer's obligation to the noncustodial parent
under the policy with respect to the covered child's claims shall
be fully satisfied.
(e) Where a parent is required by court or administrative
order to provide health coverage for a child, and the parent is
eligible for family health coverage, the insurer shall:
(1) Permit the parent to enroll, under the family coverage,
a child who is otherwise eligible for the coverage without regard
to any enrollment season restrictions;
(2) If the parent is enrolled but fails to make application to
obtain coverage for the child, enroll the child under family
coverage upon application of the child's other parent, the state
agency administering the medicaid program or the state agency
administering 42 U.S.C. §651 through §669, the child support
enforcement program; and
(3) Not disenroll or eliminate coverage of the child unless
the insurer is provided satisfactory written evidence that:
(A) The court or administrative order is no longer in effect;
(B) The child is or will be enrolled in comparable health
coverage through another insurer which will take effect not later
than the effective date of disenrollment.
WVC 33 - 16 - 12 §33-16-12. Child immunization services coverage.
All policies issued pursuant to this article shall cover the
cost of child immunization services as described in section five,
article three, chapter sixteen of this code, including the cost of
the vaccine, if incurred by the health care provider, and all costs
of vaccine administration. These services shall be exempt from any
deductible, per-visit charge and/or copayment provisions which may
be in force in these policies or contracts. This section does not
require that other health care services provided at the time of
immunization be exempt from any deductible and/or copayment
WVC 33 - 16 - 13 §33-16-13. Equal treatment of state agency.
An insurer may not impose requirements on a state agency,
which has been assigned the rights of an individual eligible for
medical assistance under medicaid and covered for health benefits
from the insurer, that are different from requirements applicable
to an agent or assignee of any other individual so covered.
WVC 33 - 16 - 14 §33-16-14. Coordination of benefits with medicaid.
Any health insurer, including a group health plan, as defined
in 29 U.S.C. §1167, Section 607(1) of the Employee Retirement
Income Security Act of 1974, health maintenance organization as
defined in article twenty-five-a of this chapter or hospital and
medical service corporations as defined in article twenty-four of
this chapter is prohibited from considering the availability or
eligibility for medical assistance in this or any other state under
42 U.S.C. §1396a, Section 1902 of the Social Security Act herein
referred to as medicaid, when considering eligibility for coverage
or making payments under its plan for eligible enrollees,
subscribers, policyholders or certificateholders.
WVC 33 - 16 - 15 §33-16-15. Individual medical savings accounts; definitions; ownership; contributions; trustees; regulations.
(a) Any insurer issuing group accident and sickness policies
in this state, the public employees insurance agency and any
employer offering a health benefit plan pursuant to the Employee
Retirement Income Security Act of 1974, as amended, may offer a
benefit plan including deductibles or copayments combined with
employee self-insurance through the establishment of individual
medical savings accounts. An insurer offering a benefit plan
consisting of deductibles or copayments combined with employee
self-insurance and individual medical savings accounts shall not be
deemed to be an insurer offering individual accident and sickness
insurance coverage solely because the insurer offers such a benefit
plan. Notwithstanding any provision of this section, an employer
may not compel an employee as a condition of employment to
contribute any amount to an individual medical savings account
which has been established for the employee, or to accept
contributions to an individual medical savings account in lieu of
other compensation or benefits. An employer may not charge an
employee a fee, by any name whatsoever, in return for establishing
an individual medical savings account for the employee: Provided,
That a reasonable fee may be charged for any necessary services
rendered in the establishment of the individual medical savings
account and which fee is fully disclosed to the employee or account
holder: Provided, however, That any qualified person serving astrustee of an individual medical savings account established for
any employee or account holder], may impose reasonable fees,
charges and expenses for administration.
An employee establishing an individual medical savings
account, or for whom an account is established by an employer, may
designate a percentage of the employee's contributions, if any, to
that account that may be withdrawn by the employee if not needed
for the payment of medical expenses: Provided, That any amount
remaining in an individual medical savings account on the earlier
of the date of retirement, at the age of fifty-nine and one-half
years or more, of the employee or the date of death of the
employee, may be withdrawn by the employee or by his or her
personal representative for a purpose other than the payment of
medical expenses: Provided, however, That no withdrawal pursuant
to this subsection shall be subject to the additional twenty
percent tax as provided in subsection (d) of this section. As used
in this section, "individual medical savings account" means a trust
that meets the definition of "medical savings account" set forth in
paragraph (1), subsection (d), section 220 of the Internal Revenue
Code of 1986, as amended, when that definition is applied without
regard to sub-subparagraph (ii), subparagraph (A) of that
paragraph. "Medical expenses" means expenses that fall within the
definition of "qualified medical expenses" set forth in paragraph
(2), subsection (d), Section 220 of the Internal Revenue Code of
1986, as amended, when that definition is applied without regard tosubparagraph (C) of that paragraph.
(b) A benefit plan established pursuant to this section shall
provide that medical expenses included within deductible or
copayment provisions of the group accident and sickness policy and
therefore not payable under the group policy for the employee or
for his or her covered dependents be paid by the trustee, either
directly or as reimbursement to an employee who has previously paid
medical expenses, from the individual medical savings account. A
benefit plan may limit payment of medical expenses until the group
plan annual deductible is met from the medical savings account to
expenses which are covered services under the group policy. Combined plans are subject to the protections afforded by article
twenty-six-a of this chapter. (c) Within one hundred eighty days of the passage of this
legislation, the tax commissioner may promulgate emergency rules as
to the keeping of records, the content and form of returns and
statements, and the filing of copies of income tax returns and
determination by trustees of individual medical savings accounts
and by employees establishing those accounts or for whom those
accounts are established: Provided, That for purposes of sections
fifteen, fifteen-a and fifteen-b, article three, chapter
twenty-nine-a of this code, a sufficient emergency to justify the
promulgation of those rules shall be deemed to exist. The power
granted by this subsection shall be in addition to the rule-making
power granted to the tax commissioner elsewhere in this code.
(d) If any amount distributed out of an individual medical
savings account is used for any purpose other than to defray
medical expenses, except as specifically provided in subsection (a)
of this section or except for a distribution of account assets
pursuant to order of a federal bankruptcy court, the West Virginia
personal income tax of the employee establishing the account or for
whom the account is established, for the taxable year in which the
distribution is made shall be increased by an amount equal to
twenty percent of the distribution.
WVC 33 - 16 - 16 §33-16-16. Insurance for diabetics.
(a) Except as provided in section six, article fifteen of this
chapter, any policy which provides major medical or similar
comprehensive-type medical coverage shall include coverage for the
following equipment and supplies for the treatment and/or
management of diabetes for both insulin dependent and noninsulin
dependent persons with diabetes and those with gestational
diabetes, if medically necessary and prescribed by a licensed
physician: Blood glucose monitors, monitor supplies, insulin,
injection aids, syringes, insulin infusion devices, pharmacological
agents for controlling blood sugar, orthotics and any additional
items as promulgated by rule, pursuant to the provisions of chapter
twenty-nine-a of this code, by the insurance commissioner, with the
advice of the commissioner of the bureau of public health.
(b) All policies affected by the provisions of this section
shall also include coverage for diabetes self-management education
to ensure that persons with diabetes are educated as to the proper
self-management and treatment of their diabetes, including
information on proper diets. Coverage for self-management
education and education relating to diet and prescribed by a
licensed physician shall be limited to: (1) Visits medically
necessary upon the diagnosis of diabetes; (2) visits under
circumstances whereby a physician identifies or diagnoses asignificant change in the patient's symptoms or conditions that
necessitates changes in a patient's self-management; and (3) where
a new medication or therapeutic process relating to the person's
treatment and/or management of diabetes has been identified as
medically necessary by a licensed physician: Provided, That
coverage for reeducation or refresher education shall be limited to
one hundred dollars annually.
(c) The education may be provided by the physician as part of
an office visit for diabetes diagnosis or treatment, or by a
certified diabetes educator certified by a national diabetes
educator certification program, or registered dietitian registered
by a nationally recognized professional association of dietitians
upon the referral of a physician: Provided, That such national
diabetes education certification program or nationally recognized
professional association of dieticians has been certified to the
commissioner of insurance by the commissioner of the bureau of
(d) Any deductible or coinsurance billed for any service as
provided in this section shall apply on an equal basis with all
other coverages provided by the insurer but not included in this
WVC 33 - 16 - 17 §33-16-17. Commissioner to propose rules.
Pursuant to chapter twenty-nine-a of this code, the
commissioner shall have the power to propose rules, subject to
legislative approval, necessary to implement the provisions of this