West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-64 - Mental Health Parity › Section 114-64-3 - Mental Health Parity and Required Coverage

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1.
				An insurer or carrier is required to provide coverage for the prevention of,
				screening for, and treatment of behavioral health, mental health, and substance use
				disorders that is no less extensive that the medical/surgical benefits or coverage
				provided for any physical illness and that complies with the requirements of this
				rule and with W.Va. Code §§
									33-15-4u,
				33-16-3f
				f,
				33-24-7u,
				33-25-8r,
				or
				33-25A-8u,
				whichever is applicable.
3.2. Screening
				for behavioral health, mental health, and substance use disorders shall include, but
				are not limited to, unhealthy alcohol use for adults, substance use for adults and
				adolescents, and depression screening for adults and adolescents.
3.3. An insurer or carrier that provides coverage
				for an annual physical examination shall include coverage for behavioral health
				screenings using a validated screening tool for behavioral health, which coverage
				and reimbursement is no less extensive than the coverage and reimbursement for the
				annual physical examination.
3.4. An
				insurer or carrier is required to establish procedures to authorize treatment with a
				non-participating provider if a covered service is not available within established
				time and distance standards as set forth in 114CSR100 and within a reasonable period
				after service is requested, and with the same coinsurance, deductible, or copayment
				requirements as would apply if the service were provided at a participating
				provider, and at no greater cost to the covered person than if the services were
				obtained at, or from a participating provider.
3.5. If a covered person obtains a covered service
				from a nonparticipating provider because the covered service is not available within
				the established time and distance standards as set forth in 114CSR100, an insurer or
				carrier is required to reimburse treatment or services for behavioral health, mental
				health, or substance use disorders that are provided by a non-participating provider
				using the same methodology that the insurer or carrier uses to reimburse covered
				medical/surgical services provided by non-participating providers and, upon request,
				provide evidence of the methodology to the person or provider.
3.6. An insurer or carrier offering a plan that
				does not cover services provided by an out-of-network provider may provide that the
				benefits required herein are covered benefits if the services are rendered by a
				provider who is designated by or affiliated with the insurer's or carrier's plan
				only if the same requirement applies for medical/surgical benefits or services. A
				carrier is not required to cover out-of-network care at one hundred percent (100%)
				or without any cost share to the covered person.
3.7. Subject to the limitation set forth in 3.8,
				nothing herein prohibits an insurer or carrier from using appropriate disease
				management or utilization review protocols for behavioral health, mental health, and
				substance use disorders, as long as the protocols are no more stringent or
				restrictive than medical/surgical disease management or utilization review
				protocols.
3.8. An insurer or carrier
				shall not impose any prior authorization or prospective utilization management
				requirements on any prescription medication on the insurer's or carrier's formulary
				that is used to treat substance use disorder when the medication is determined to be
				medically necessary by the covered person's provider.
3.9. If a health benefit plan, or health insurance
				coverage offered in connection with a plan, applies different levels of financial
				requirements to different tiers of prescription drug benefits based on reasonable
				factors determined in accordance with requirements for non-quantitative treatment
				limitations, and without regard to whether a drug is generally prescribed with
				respect to medical/surgical benefits or with respect to behavioral, mental health,
				or substance use disorder benefits, the plan or carrier satisfies the parity
				requirements with respect to prescription drug benefits. Reasonable factors may
				include, but are not limited to, cost, efficacy, generic versus brand name, and mail
				order versus pharmacy pick-up.