West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-64 - Mental Health Parity › Section 114-64-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. "Aggregate lifetime
				dollar limit" means, for the purposes of this rule, a dollar limitation on the total
				amount of specified benefits that may be paid under a health benefit plan, or health
				insurance coverage offered in connection with such a plan, for any coverage unit.
				Coverage unit refers to the way in which a plan, or health insurance coverage,
				groups individuals for purposes of determining benefits or premiums contributions,
				including family plans, employee with spouse plans, or individual plans.
2.2. "Annual dollar limit" means, for the purposes
				of this rule, a dollar limitation on the total amount of specified benefits that may
				be paid in a 12-month period under a health benefit plan.
2.3. "Autism spectrum disorder" shall have the
				same meaning as defined at W.Va. Code §§
									33-16-3v,
				33-24-7k,
				and
				33-25A-8j,
				and includes 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 Disorders of the American Psychiatric
				Association.
2.4. "Behavioral, mental
				health, and substance use disorder" shall have the same meaning as defined at W.Va.
				Code §§
									33-15-4u,
				33-16-3f
				f,
				33-24-7u,
				33-25-8r,
				and
				33-25A-8u,
				and shall mean a condition or disorder, regardless of etiology, that may be the
				result of a combination of genetic and environmental factors and that falls under
				any of the diagnostic categories listed in the mental disorders section of the most
				recent version of the International Statistical Classification of Diseases and
				Related Health Problems, the Diagnostic and Statistical Manual of Mental Disorders,
				or the Diagnostic Classification of Mental Health and Development Disorders of
				Infancy and Early Childhood; and includes Autism Spectrum Disorder.
2.5. "Behavioral, mental health, and substance use
				disorder benefits" means, for the purposes of this rule, the benefits supplied for
				items or services for behavioral, mental health or substance use disorder
				conditions.
2.6. "Carrier" shall mean
				any insurer offering an accident and sickness insurance policy, contract, plan or
				agreement subject to Articles 15, 16, 24, 25, or 25A of Chapter 33 of the West
				Virginia Code.
2.7. "Commissioner" means
				the West Virginia Insurance Commissioner.
2.8. "Concurrent review" means inpatient care is
				reviewed as it is provided.
2.9.
				"Financial requirements" means, for the purposes of this rule, the deductibles,
				copayments, coinsurance, or out-of-pocket maximums imposed under a health benefit
				plan. Financial requirements do not include aggregate lifetime or annual dollar
				limits.
2.10. "Health benefit plan" or
				"plan," as defined in W.Va. Code §
									33-16-1a(h),
				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 multiple-employer welfare
				arrangement. "Health benefit plan" does not include excepted benefits as defined by
				W. Va. Code §
									33-16-1a(f).
2.11. "Insurer" or "health insurer" means an
				insurer licensed to transact accident and sickness insurance in this state, and a
				health maintenance organization to whom a certificate of authority has been issued
				by the Commissioner and is subject to the provisions of Articles 15, 16, 24, 25, or
				25A of Chapter 33 of the West Virginia Code, and is subject to the provisions of
				W.Va. Code §§
									33-15-4u,
				33-16-3f
				f,
				33-24-7u,
				33-25-8r
				or
				33-25A-8u.
2.12. "Medical/surgical benefits" means, for the
				purposes of this rule, the benefits supplied for items or services for medical
				conditions or surgical procedures, as defined under the terms of the plan or health
				insurance coverage and in accordance with applicable federal and state law, but does
				not include behavioral, mental health, and substance use disorder
				benefits.
2.13. "Prior authorization"
				means obtaining advance approval from a carrier or insurer about the coverage of a
				benefit, service or medication.
2.14.
				"Substance use disorder" means the same as that term is defined by the American
				Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders
				and shall include substance use withdrawal.
2.15. "Substance use disorder benefits" means, for
				the purposes of this rule, the benefits supplied for items or services used to treat
				substance use disorders, including substance use withdrawal.
2.16. "Treatment limitations" means, for the
				purposes of this rule, the limits applied based on the frequency of treatment,
				number of visits, days of coverage, days in a waiting period, or other limits on the
				scope or duration of treatment. Treatment limitations include both quantitative
				treatment limitations, which are expressed numerically, and non-quantitative
				treatment limitations, which otherwise limit the scope or duration of benefits for
				treatment under a plan or coverage. This term does not include any permanent
				exclusion of all benefits for a particular condition or disorder.