Current through Register Vol. XLI, No. 38, September 20, 2024
7.1. As part
of their annual health benefit plan filings, insurers or carriers shall provide an
attestation to the commissioner that:
7.1.1. The
plan applies the same deductible for medical/surgical and behavioral, mental health,
and substance use disorders and does not otherwise apply any cumulative financial
requirement for behavioral health, mental health, and substance use disorders in a
classification that accumulates separately from any established for medical/surgical
benefits in the same classification;
7.1.2. The plan applies the same out-of-pocket for
medical/surgical and behavioral, mental health, and substance use disorders and does
not otherwise apply any cumulative financial requirement for behavioral health,
mental health, and substance use disorders in a classification that accumulates
separately from any established for medical/surgical benefits in the same
classification;
7.1.3. The plan uses the
same benefits for emergency room benefits, including all ancillary services provided
as part of the emergency room benefits, for medical/surgical and behavioral, mental
health, and substance use disorders;
7.1.4. The plan utilizes the same copayment,
coinsurance or deductible structure for prescription drug benefits for
medical/surgical and behavioral, mental health, and substance use
disorders;
7.1.5. The carrier utilizes
the same penalties for failure to obtain prior authorization for behavioral, mental
health, and substance use disorders as it does for medical/surgical procedures
within the same classification of benefits.
7.2. The attestation shall be signed by
responsible representative of the insurer or carrier, including but not limited to
the president, vice president, assistant vice president, chief executive officer,
chief financial officer, chief operating officer, general counsel or other person
that has been appointed by the board of directors. The commissioner may develop an
attestation form that the health carrier is required to use if he or she determines
the attestation provided by the carrier is deficient or otherwise
incomplete.
7.3. Data Reporting
7.3.1. Beginning on or after July 1, 2021, the
commissioner shall issue annually a mandatory data call to all insurers or carriers
subject to this rule to collect the following information for the commissioner's
annual report on mental health parity to the Joint Committee on Government and
Finance as required by the provisions of W.Va. Code §§
33-15-4u,
33-16-3f
f,
33-24-7u,
33-25-8r
or
33-25A-8u.
7.3.2. The commissioner will develop a mechanism
to accept the data from carriers electronically and securely. The insurers or
carriers shall provide data for the twelve (12) month period immediately preceding
the data call and shall only provide data regarding fully adjudicated claims,
including any denied claims or adverse determinations.
7.3.3. The data call will, at a minimum, require
the insurers or carriers to provide the following information and/or analysis to the
commissioner.
7.3.3.a. Information regarding
financial requirements and non-quantitative treatment limitations including data
regarding:
7.3.3.a.1. Medical Management
Evaluation;
7.3.3.a.2. Non-Quantitative
Treatment Limitations;
7.3.3.a.3.
Quantitative Treatment Limitation Classifications; and
7.3.3.a.4. Parity Compliance for Adverse
Determinations, including the total number of adverse determinations of such
claims.
7.3.3.b. Information
regarding other non-quantitative treatment limitations including data regarding:
7.3.3.b.1. Inpatient In-Network;
7.3.3.b.2. Inpatient Out-of-Network;
7.3.3.b.3. Outpatient In-Network;
7.3.3.b.4. Outpatient Out-of-Network;
7.3.3.b.5. Emergency Room Services; and/or
7.3.3.b.6. Pharmacy Services.
7.4.
Insurers or carriers may also be asked to provide specific information regarding
processes for the development of medical necessity criteria or standards,
eligibility criteria, concurrent review standards, non-quantitative treatment
limitations or restrictions imposed upon obtaining covered services or benefits,
processes, strategies and evidentiary standards, penalties that may be imposed for
failure to obtain prior authorization for medical/surgical benefits compared to
behavioral, mental health, and substance use disorder benefits.
7.5. The commissioner may ask that a qualified
actuary certify that the calculations of the insurer or carrier are accurate and
true to the best of the actuary's knowledge and have been appropriately calculated
in accordance with Actuarial Standards of Practice.
