West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-39 - Group Accident And Sickness Insurance Minimum Policy Coverage Standards
Section 114-39-5 - Minimum Standards for Benefits

Universal Citation: 114 WV Code of State Rules 114-39-5

Current through Register Vol. XLI, No. 38, September 20, 2024

5.1. General. -- The following minimum standards for benefits are prescribed for the categories of coverage noted in the following subdivisions. No health insurer may deliver or issue for delivery in this state a policy which does not meet the required minimum standards of subdivisions a and b of this subsection, if applicable. Except for coverage under policies issued to employers of fifty-one (51) or more employees, under which the coverage is negotiated by the policyholder, no health insurer may deliver or issue for delivery in this state a policy which does not meet the required minimum standards of subdivisions c through k of this subsection unless the commissioner finds that policies containing less than the prescribed minimum standards for benefits, which are filed for approval, will be in the public interest and otherwise meet the requirements set forth in W. Va. Code § 33-6-9. The benefits described in a certificate issued under a policy subject to this rule shall be consistent with the benefits contained in the policy and shall be no less than those required under this section.

a. A health benefit plan issued in connection with a group health plan and providing inpatient benefits in connection with childbirth must meet all requirements of W. Va. Code § 33-16-3 j with respect to both the mother and her newborn.

b. A health benefit plan issued in connection with a group health plan and providing mental health benefits must meet all requirements of W. Va. Code § 33-16-3 a: Provided, That W. Va. Code § 33-16-3 a(d) does not apply to any health benefit plan for any group health plan year of a small employer.

c. If a policy contains a status-type military service exclusion which suspends coverage during military service, the policy shall provide, upon receipt of written request, for refund of premiums as applicable to an insured in military service on a pro rata basis.

d. If a health insurer terminates coverage under a policy providing pregnancy coverage, such policy shall provide for an extension of benefits as to pregnancy commencing while the policy is in force and for which benefits would have been payable had the policy remained in force, provided that this subsection shall not apply when termination of coverage is due to fraud, nonpayment of premium or any breach of the terms of the policy for which termination is authorized under chapter 33 of the W. Va. Code.

e. Policies providing convalescent or extended care benefits following hospitalization may not condition the benefits upon admission to the convalescent or extended care facility within a period of less than fourteen (14) days after discharge from the hospital.

f. Any policy which provides coverage of a dependent child may not terminate coverage for the dependent child if upon attainment of any limiting age set forth in the policy, the child is and continues to be both:
(1) incapable of self-sustaining employment due to mental retardation or physical handicap on the date that the child's coverage would otherwise terminate under the policy due to the attainment of the specified limiting age; and

(2) chiefly dependent on the policyholder for support and maintenance. The policy may require that within thirty-one (31) days of the termination date, the health insurer must receive due proof of the incapacity in order for the insured to elect to continue the policy in force with respect to the dependent child. As an alternative to this requirement, a separate converted policy may be issued to the child at the option of the insured or policyholder.

g. Any policy providing coverage for the recipient in a transplant operation shall also provide for the reimbursement of any medical expenses of a live donor to the extent that benefits remain and are available under the recipient's policy, after benefits for the recipient's own expenses have been paid provided such benefits may be limited to those expenses directly relating to the organ donation.

h. A policy may contain a provision relating to recurrent disabilities: Provided, That no such provision may specify that a recurrent disability be separated by a period greater than six (6) months from the last previous occurrence of the disability.

i. Accidental death and dismemberment benefits shall be payable if the loss occurs within ninety (90) days from the date of the accident, irrespective of total disability. Disability income benefits, if provided, may not require the loss to commence less than thirty (30) days after the date of accident, nor may any policy which the health insurer cancels or refuses to renew require that it be in force at the time disability commences if the accident occurred while the policy was in force.

j. Specific dismemberment benefits may not be in lieu of other benefits unless the specific benefit exceeds the other benefits.

k. Termination of coverage under a policy shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period the policy was in force may be predicated upon the continuous disability of the individual covered under the policy or limited to the duration of the policy benefit period if any: Provided, That this subdivision shall not apply when termination of coverage is due to fraud, nonpayment of premium or any breach of the terms of the policy for which refusal to renew the policy is authorized under W. Va. Code, chapter thirty-three.

5.2. Hospital Confinement Indemnity Coverage. -- "Hospital confinement indemnity coverage" is a policy which provides daily benefits for hospital confinement on an indemnity basis in an amount not less than thirty dollars ($30) per day and for a period of not less than thirty-one (31) days during any one (1) period of confinement for each person insured under the policy.

5.3. Major Medical Expense Coverage. -- "Major medical expense coverage" is a policy which provides hospital, medical and surgical expense coverage, to an aggregate maximum of not less than ten thousand dollars ($10,000); copayment by the covered person not to exceed twenty-five percent (25%) of covered charges; and a deductible stated on a per person, per family, per illness, per benefit period, or per year basis, or a combination of such bases not to exceed five percent (5%) of the aggregate maximum limit under the policy, unless the policy is written to complement underlying hospital and medical insurance in which case the deductible may be increased by the amount of the benefits provided by the underlying insurance, for each covered person for at least:

a. Daily hospital room and board expenses for not less than fifty dollars ($50) daily (or in lieu thereof the average daily cost of the semi-private room rate in the area where the insured resides) for a period of not less than thirty-one (31) days during continuous hospital confinement;

b. Miscellaneous hospital services for an aggregate maximum of not less than four thousand five hundred dollars ($4,500) or fifteen (15) times the daily room and board rate if specified in dollar amounts;

c. Surgical services to a maximum of not less than six hundred dollars ($600) for the most expensive surgical procedure when two or more medically necessary surgical procedures are performed during the course of a single operation. Amounts paid for the second and each additional surgical procedure during such single operation shall be reasonably related to the above-stated maximum amount for the first surgical procedure.

d. Anesthesia services for a maximum of not less than fifteen (15%) percent of the covered surgical fees or, alternatively, if the surgical schedule is based on relative values, not less than the amount provided in the surgical schedule for anesthesia services at the same unit value as used for the surgical schedule;

e. In-hospital medical services, consisting of physicians' services rendered to a person who is a bed patient in a hospital for treatment of sickness or injury other than that for which surgical care is required, in an amount not less than eighty percent (80%) of the reasonable charges, or five dollars ($5) per hospital call, one (1) call per day, for at least twenty-one (21) calls during one period of confinement.

f. Out-of-hospital care, consisting of physicians' services rendered on an ambulatory basis where coverage is not provided elsewhere in the policy for diagnosis and treatment of sickness or injury, and diagnostic X-ray, laboratory services, radiation therapy and hemodialysis order by a physician; and

g. Prosthetic appliances, meaning artificial limbs or other prosthetic appliances (except replacements thereof) and rental of durable medical equipment required for therapeutic use.

5.4. Disability Income Protection Coverage.

a. "Disability income protection coverage" is a policy which provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or injury or a combination of sickness or injury that:
1. Provides that periodic payments which are payable at ages after sixty-two (62) and reduced solely on the basis of age are at least fifty percent (50%) of amounts payable immediately prior to age sixty-two (62).

2. Contains an elimination period no greater than:
A. Ninety (90) days in the case of coverage providing a benefit of one (1) year or less;

B. One hundred eighty (180) days in the case of coverage providing a benefit of more than one year but not greater than two (2) years; or

C. Three hundred sixty-five (365) days in all other cases during the continuance of disability resulting from sickness or injury; and

3. Has a maximum period of time for which it is payable during disability of at least six (6) months. No reduction in benefits may be put into effect because of an increase in Social Security or similar benefits during a benefit period.

b. Subsection 5.4 of this rule does not apply to those disability income protection policies providing business buy-out coverage.

5.5. Accident-Only Coverage. "Accident-only coverage" is a policy of accident insurance which provides coverage, singly or in combination, for death, dismemberment, disability or hospital and medical care caused by accident. Accidental death and double dismemberment amounts under an accident-only policy shall be at least one thousand dollars ($1,000), and a single dismemberment amount shall be at least five hundred dollars ($500).

5.6. Specified Disease and Specified Accident Coverage.

a. "Specified disease coverage" pays benefits for the diagnosis and treatment of a specifically named disease or diseases. Any such policy shall meet the following rules and one of the following sets of minimum standards for benefits. Such insurance covering cancer -- whether cancer only, or in conjunction with other conditions(s) or disease(s) -- shall meet the standards of paragraphs 3, 4 and 5 of this subdivision. Insurance covering specified disease(s) other than cancer shall meet the standards of paragraph 2 of this subdivision.
1. Except for cancer coverage provided on an expense-incurred basis, either as cancer-only coverage or in combination with one or more other specified diseases, the following provisions apply to specified disease coverages in addition to all other requirements imposed by this rule. In cases of conflict between the following and other provisions, the following provisions shall govern:
A. Policies covering a single specified disease or combination of specified diseases may not be sold or offered for sale other than as specified disease coverage under this section.

B. Any policy issued pursuant to this section which conditions payment upon pathological diagnosis of a covered disease shall also provide that if such a pathological diagnosis is medically inappropriate, a clinical diagnosis will be accepted in lieu thereof.

C. Notwithstanding any other provision of this rule, specified disease policies shall provide benefits to any covered person not only for the specified disease(s) but also for any other conditions(s) or disease(s) directly caused or aggravated by the specified diseases(s) or the treatment of the specified disease(s).

D. No policy issued pursuant to this section may contain a waiting or probationary period greater than thirty (30) days.

E. Any application for specified disease coverage shall contain a statement above the signature of the applicant that no person to be covered for specified disease is also covered by any Title XIX program such as Medicaid. The statement may be combined with any other statement for which the health insurer may require the applicant's signature.

F. Payments may be conditioned upon a covered person receiving medically necessary care, given in a medically appropriate location, under a medically accepted course of diagnosis or treatment.

G. Except for the uniform provision regarding other insurance with this health insurer, benefits for specified disease coverage shall be paid regardless of other coverage available through other individual health insurance.

H. After the effective date of the coverage or applicable waiting period, benefits shall begin with the first day of care or confinement if the care or confinement is for a covered disease even though the diagnosis is made at some later date. The retroactive application of the coverage may not be less than ninety (90) days prior to the diagnosis.

2. The following minimum benefits standards apply to non-cancer coverages:
A. Coverage for each person insured under the policy for a specifically named disease or diseases with a deductible amount not in excess of two hundred fifty dollars ($250) and an overall aggregate benefit limit of not less than five thousand dollars ($5,000) and a benefit period of not less than two (2) years for at least the following incurred expenses:
1. Hospital room and board and any other hospital-furnished medical services or supplies;

2. Treatment by a legally qualified physician or surgeon;

3. Private duty services of a registered nurse (R.N.);

4. X-ray, radium and other therapy procedures used in diagnosis and treatment;

5. Professional ambulance for local service to or from a local hospital;

6. Blood transfusions, including expenses incurred for blood donors;

7. Drugs and medicines prescribed by a physician;

8. Rental of a mechanical ventilator or similar mechanical apparatus;

9. Braces, crutches and wheelchairs as are deemed necessary by the attending physician for the treatment of the disease;

10. Emergency transportation if, in the opinion of the attending physician, it is necessary to transport the insured to another locality for treatment of the disease; and

11. Any other expenses necessarily incurred in the treatment of the disease; and

B. Coverage for each person insured under the policy for a specifically named disease or diseases with no deductible amount, and an overall aggregate benefit limit of not less than twenty-five thousand dollars ($25,000) payable at the rate of not less than fifty dollars ($50) a day while confined in a hospital and a benefit period of not less than five hundred (500) days.

3. A policy which provides coverage for each person insured under the policy for cancer-only coverage or in combination with one or more other specified diseases on an expense-incurred basis for services, supplies, care and treatment of cancer, in amounts not in excess of the usual and customary charges, with a deductible amount not in excess of two hundred fifty dollars ($250), and an overall aggregate benefit limit of not less than ten thousand dollars ($10,000) and a benefit period of not less than three (3) years for at least the following:
A. Treatment by, or under the direction of, a properly licensed and/or certified physician or surgeon;

B. X-ray, radium, chemotherapy and other therapy procedures used in diagnosis and treatment;

C. Hospital room and board and any other hospital-furnished medical services or supplies;

D. Blood transfusions, and the administration thereof, including expenses incurred for blood donors;

E. Drugs and medicines prescribed by a physician;

F. Professional ambulance for local service to or from a local hospital;

G. Private duty services of a registered nurse (R.N.) provided in a hospital;

H. Any other expenses necessarily incurred in the treatment of the disease: Provided, That subparagraphs A, B, D, E and G of this paragraph, plus at least the following shall also be included, but may be subject to copayment by the covered person not to exceed twenty percent (20%) of covered charges when rendered on an out-patient basis:

I. Braces, crutches and wheelchairs as are considered necessary by the attending physician for the treatment of the disease;

J. Emergency transportation if, in the opinion of the attending physician, it is necessary to transport the insured to another locality for treatment of the disease;

K. Home health care that is necessary care and treatment provided at the covered person's residence by a home health care agency or by others under arrangements made with a home health care agency. The program of care and treatment shall be ordered in writing by the covered person's attending physician, who shall approve the program prior to its start and renew the order for such care and treatment at least every sixty (60) days. The physician shall certify that hospital confinement would be otherwise required.
1. Home health care coverages shall include:
(a) Services provided by a registered nurse (R.N.) or a licensed practical nurse (L.P.N.);

(b) Home health aide services to the extent that the services would be covered if provided to the insured on an in-patient basis;

(c) Health services provided by physical, occupational, respiratory, or speech and hearing therapists; and

(d) Medical supplies, drugs and medicines prescribed by a physician and related pharmaceutical services, and laboratory services to the extent the charges or costs would be covered under the policy if provided to the insured on an in-patient basis.

L. Physical, respiratory, speech, hearing and occupational therapy;

M. Special equipment including hospital beds, toilettes, pulleys, wheelchairs, aspirators, chux, oxygen, surgical dressings, rubber shields, and colostomy and ileostomy appliances;

N. Prosthetic devices including wigs and artificial breasts; and

O. Nursing home care for noncustodial services.

4. The following minimum benefits standards apply to cancer coverages written on a per diem indemnity basis. The coverages shall offer covered persons:
A. A fixed-sum payment of at least one hundred dollars ($100) for each day of hospital confinement for at least three hundred sixty-five (365) days.

B. A fixed-sum payment equal to one half of the hospital in-patient benefit for each day of hospital or non-hospital out-patient surgery, chemotherapy and radiation therapy, for at least three hundred sixty-five (365) days of treatment.

5. The following minimum benefits standards apply to cancer coverages written on a per diem indemnity basis. Benefits tied to confinement in a skilled nursing home or to receipt of home health care are optional. If a policy offers these benefits, they must equal the following:
A. A fixed-sum payment equal to one-fourth of the hospital in-patient benefit for each day of skilled nursing home confinement for at least one hundred (100) days;

B. A fixed-sum payment equal to one-fourth of the hospital in-patient benefit for each day of home health care for at least one hundred (100) days;

C. Benefit payments shall begin with the first day of care or confinement after the effective date of coverage if the care or confinement is for a covered disease, even though the diagnosis of a covered disease is made at some later date (but not retroactive more than thirty (30) days from the date of diagnosis) if the initial care or confinement was for diagnosis or treatment of the covered disease;

D. Notwithstanding any other provision of this rule, any restriction or limitation applied to the benefits in subparagraphs A and B of this paragraph, whether by definition or otherwise, shall be no more restrictive than those under Medicare.

6. The following minimum benefits standards apply to lump-sum indemnity coverage of any specified disease(s):
A. The coverages shall pay indemnity benefits on behalf of covered persons for a specifically named disease or diseases. The benefits are payable as a fixed, one-time payment made within thirty (30) days of submission to the health insurer of proof of diagnosis of the specified disease(s). Dollar benefits shall be offered for sale only in even increments of one thousand dollars ($1,000); and

B. Where coverage is advertised or otherwise represented to offer generic coverage of a disease or diseases, the same dollar amounts shall be payable regardless of the particular subtype of the disease with one exception. In the case of clearly identifiable subtypes with significantly lower treatment costs, lesser amounts may be payable so long as the policy clearly differentiates that subtype and its benefits.

5.7. Specified disease coverage. -- A policy covering a single specified disease or combination of diseases shall meet the requirements of subsection 5.6 of this rule and shall not be offered for sale as a policy that limits benefits in a manner contrary to subsection 5.6 of this rule.

Disclaimer: These regulations may not be the most recent version. West Virginia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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