W. Va. Code R. § 114-12-5

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-12-5 - Minimum Standards for Benefits

5.1. General. -- The following minimum standards for benefits are prescribed for the categories of coverage noted in this section. No policy or certificate subject to this rule may be delivered or issued for delivery in this State which does not meet the required minimum standards for the specified categories, unless the Commissioner finds that policies or certificates 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. Nothing in this section precludes the issuance of any policy combining two (2) or more categories of coverage set forth in W. Va. Code '33-28-5(a)(1) through (6), inclusive.

a. An insurer providing inpatient benefits in connection with childbirth must meet all requirements of W. Va. Code '33-15-4e with respect to both the mother and her newborn.

b. A "noncancellable,@ "guaranteed renewable" or "noncancellable and guaranteed renewable" policy may not provide for termination of coverage of the spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than nonpayment of premium. The policy shall provide that in the event of the insured's death, the spouse of the insured, if covered under the policy, shall become the insured.

c. The terms "noncancellable,@ "guaranteed renewable,@ or "noncancellable and guaranteed renewable" may not be used without further explanatory language in accordance with the disclosure requirements of subsection 6.1 of this rule. The terms "noncancellable" or "noncancellable and guaranteed renewable" may be used only in a policy which the insured has the right to continue in force by the timely payment of premiums set forth in the policy until the age of sixty-five (65) or to eligibility for Medicare, during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force. Except as provided in this subdivision, the term "guaranteed renewable" may be used only in a policy which the insured has the right to continue in force by the timely payment of premiums until the age of sixty-five (65) or to eligibility for Medicare, during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force, except that the insurer may make changes in premium rates by classes.

d. In a family policy covering both husband and wife, the age of the younger spouse shall be used as the basis for meeting the age and durational requirements of the definitions of "noncancellable" and "guaranteed renewable." However, this requirement may not prevent termination of coverage of the older spouse upon attainment of the stated age limit, e.g., age sixty-five (65), so long as the policy may be continued in force as to the younger spouse to the age or for the durational period as specified in the definition.

e. When accidental death and dismemberment coverage is part of the insurance coverage offered under the policy, the insured shall have the option to include all insureds under the policy and not just the principal insured.

f. 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.

g. In the event the insurer cancels or refuses to renew, policies providing pregnancy benefits 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.

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

i. 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 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 chiefly dependent on the policyholder for support and maintenance. The policy may require that within thirty-one (31) days of such date, the insurer 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.

j. 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.

k. 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.

l. 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 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.

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

n. Termination of the policy by the insurer 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 insured or limited to the duration of the policy benefit period, if any, or payment of the maximum benefits.

5.2. "Basic Hospital Expense Coverage" is a policy of accident and sickness insurance which provides coverage for a period of not less than thirty-one (31) days during any continuous hospital confinement for each person insured under the policy, for expenses incurred for necessary treatment and services rendered as a result of accident or sickness for at least the following:

a. Daily hospital room and board in an amount not less than the lesser of the average semi-private room rate of the confining hospital or thirty dollars ($30) per day;

b. Miscellaneous hospital service for expenses incurred for the charges made by the hospital for services and supplies which are customarily rendered by the hospital and provided for use only during the period of confinement in an amount not less than either eighty percent (80%) of the charges incurred up to at least one thousand dollars ($1,000) or ten (10) times the daily hospital room and board benefits; and

c. Hospital outpatient services in an amount not less than fifty dollars ($50) for hospital services rendered to an insured as an outpatient for any one accident or sickness.

d. Benefits provided under subdivisions a and b of this subsection may be provided subject to a combined deductible amount not in excess of one hundred dollars ($100).

5.3. "Basic Medical-Surgical Expense Coverage" is a policy of accident and sickness insurance which provides coverage for each person insured under the policy for the expenses incurred for the necessary services rendered by a physician for treatment of an injury or sickness for at least the following:

a. Surgical services:

1. In amounts not less than those provided on a fee schedule based on an acceptable relative value scale of surgical procedures, up to a maximum of at least five hundred dollars ($500) for any one procedure; or

2. Not less than eighty percent (80%) of the reasonable charges.

b. Anesthesia services, consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical services rendered by a physician other than the physician (or his or her assistant) performing the surgical services:

1. In an amount not less than eighty percent (80%) of the reasonable charges; or

2. Fifteen percent (15%) of the surgical service benefit.

c. 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 call, one (1) call per day, for at least twenty-one (21) such calls during one (1) period of confinement.

5.4. "Hospital Confinement Indemnity Coverage" is a policy of accident and sickness insurance 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.

5.5. "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 basis not to exceed five per cent (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 a single operation shall be reasonably related to the maximum amount stated in this subdivision 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 therein 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 call, one (1) call per day, for at least twenty-one (21) calls during one period 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.

5.6. "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 thereof that:

a. 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).

b. Contains an elimination period no greater than:

1. Ninety (90) days in the case of coverage providing a benefit of one (1) year or less;

2. 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

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

c. Has a maximum period of time for which it is payable during disability of at least six (6) months except in the case of a policy covering disability arising out of pregnancy, childbirth or miscarriage in which case the period for the disability may be one (1) month. No reduction in benefits may be put into effect because of an increase in Social Security or similar benefits during a benefit period.

d. This subsection does not apply to those disability income protection policies providing business buy-out coverage.

5.7. "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 such a policy shall be at least one thousand dollars ($1,000), and a single dismemberment amount shall be at least five hundred dollars ($500).

5.8. "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 subdivisions c, d and e of this subsection. Insurance covering specified disease(s) other than cancer shall meet the standards of subdivisions b or e of this subsection.

a. General Rules. -- 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 shall 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:

1. 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.

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

3. 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).

4. Policies containing specified disease coverage shall be at least guaranteed renewable.

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

6. 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 insurer may require the applicant's signature.

7. 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.

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

9. After the effective date of the coverage (or applicable waiting period, if any), 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.

b. The following minimum benefits standards apply to noncancer coverages:

1. 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:

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

B. Treatment by a legally qualified physician or surgeon;

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

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

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

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

G. Drugs and medicines prescribed by a physician;

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

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; and

K. Any other expenses necessarily incurred in the treatment of the disease.

2. 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.

c. 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:

1. Treatment by, or under the direction of, a legally qualified physician or surgeon;

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

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

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

5. Drugs and medicines prescribed by a physician;

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

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

8. Any other expenses necessarily incurred in the treatment of the disease: Provided, That paragraphs 1, 2, 4, 5 and 7 of this subdivision 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;

9. Braces, crutches and wheelchairs as are considered 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. 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. 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 such 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 such charges or costs would be covered under the policy if provided to the insured on an in-patient basis.

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

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

14. Prosthetic devices including wigs and artificial breasts; and

15. Nursing home care for noncustodial services.

d. The following minimum benefits standards apply to cancer coverages written on a per diem indemnity basis. Such coverages shall offer covered persons:

1. 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.

2. A fixed-sum payment equal to one-half of the hospital inpatient benefit for each day of hospital or nonhospital outpatient surgery, chemotherapy and radiation therapy, for at least three hundred sixty-five (365) days of treatment.

3. 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 shall 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 inpatient 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 such 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.

e. The following minimum benefits standards apply to lump-sum indemnity coverage of any specified disease(s):

1. The coverage 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 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).

2. 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 treatments costs, lesser amounts may be payable so long as the policy clearly differentiates that subtype and its benefits.

5.9. "Specified accident coverage" is an accident insurance policy which provides coverage for a specifically identified kind of accident (or accidents) for each person insured under the policy for accidental death or accidental death and dismemberment combined, with a benefit amount not less than one thousand dollars ($1,000) for accidental death, one thousand dollars ($1,000) for double dismemberment, and five hundred dollars ($500) for single dismemberment.

5.10. "Limited benefits insurance coverage" is any policy, other than a policy covering only a specified disease or diseases, which provides benefits that are less than the minimum standards for benefits required under subsections 5.2, 5.3, 5.4, 5.5, 5.7, 5.8 and 5.9 of this rule. A policy covering a single specified disease or combination of diseases shall meet the requirements of subsection 5.8 of this rule and shall not be offered for sale as a limited benefits policy.

W. Va. Code R. § 114-12-5