W. Va. Code R. § 114-18-3

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

Section 114-18-3 - Coverage Requirements

3.01. Availability - Any insurance policy, contract or certificate specified in Section 2.01 of this regulation which is delivered or issued for delivery in West Virginia on or after the first day of April, 1984, shall make available to the policyholder, subscriber or certificateholder supplemental insurance coverage for continuum, of care services consistent with the provisions of this regulation. Any insurance policy, contract or certificate specified in Section 2.01 of this regulation which was delivered or issued for delivery in West Virginia before the first day of April, 1984, shall make available to the policyholder, subscriber, or certifi-cateholder, in the manner hereinafter prescribed, supplemental insurance coverage for continuum of care services consistent with the provisions of this regulation. The policyholder, subscriber or certificateholder shall be notified in writing not less than thirty (30) calendar days prior to the first anniversary renewal date of the policy, contract or certificate immediately subsequent to April 1, 1984, that such supplemental insurance coverage is available without underwriting qualification if the supplemental insurance coverage is elected no later than thirty (30) calendar days immediately subsequent to the renewal date. Underwriting qualification may be required if the supplemental insurance coverage is elected at any subsequent anniversary renewal; provided, however, any underwriting criteria shall not be unfairly discriminatory.

3.02. Minimum Benefit Standards - Supplemental insurance coverage for continuiim of care services shall include the following minimum benefits:

(A) Benefits for services determined to be necessary and appropriate by the case manager or responsible member of the comprehensive hospice care program, in accordance with the case management system or comprehensive hospice care program established by the West Virginia Continuum of Care Board pursuant to the provisions of Chapter 16, Article 5D of the Code of West Virginia of 1931, as amended.

(1) Provided, however, that benefits for counsel ing services may be limited as follows:

(a) Counseling benefits in general for the policyholder, subscriber-or certificate- , holder and his immediate family, including his spouse, children, parentsr siblings and children of his spouse, may be limited to a maximum of twelve sessions collectively at a total benefit payment not to exceed one thousand dollars ($1,000.00) during each twelve (12) month period.

(i) There shall be no requirement that any immediate family member be a named insured under the policy, contract or certificate as a prerequisite to receipt of counseling benefits.

(ii) There shall be no deductible or coinsurance requirement in regard to the counseling benefits either for the policyholder,'subscriber or certificateholder or his immediate family members.

(b) Bereavement counseling benefits for immediate family members of the policyholder, subscriber.or certificateholder, including his spouse, children, parents, siblings and children of his spouse, may be limited to a maximum of eight (8) sessions collectively at a total benefit payment not to exceed seven hundred and fifty dollars ($750.00) during a six (6) month-period commencing within 6 months subsequent to the death of the policyholder, subscriber or certificateholder.

(i) There shall be no requirement that any immediate family member be a named insured under the insurance policy, contract or certificate as a prerequisite to receipt of bereavement counseling benefits.

(ii) Bereavement counseling benefits shall not be denied immediate family members on the basis that the insurance policy, contract or certificate terminated upon or following the death of the policyholder, subscriber or certificate-holder nor shall a premium be assessed of an immediate family member in regard to bereavement counseling benefits.

(iii) There shall be no deductible or coinsurance requirement in regard to bereavem.ent counselings benefits, (2) There shall be no provisions in the supplemental insurance policy, contract or certificate which limits coverage ofr continuum of care services to medical care or in any manner attempts to exclude coverage for palliative or supportive care.

(B) Benefit payments for continuum of care services under a. supplemental insurance policy, contract or certificate shall not preclude or be in lieu of hospital or medical/surgical benefit payments under the basic policy, contract or certificate. Provided, however, that duplicative payment for a specific expense shall not be required.

W. Va. Code R. § 114-18-3