W. Va. Code R. § 114-29-4

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

Section 114-29-4 - Mandatory Coverage

4.1. All accident and sickness coverage which provides hospital, surgical, or major medical coverage or any combination of those coverages and which is offered by any of the entities set out in Section 2 of this rule shall provide benefits for the diagnosis and treatment of temporomandibular disorders (TMD) and craniomandibular disorders (CMD). This applies to both renewed coverage and new coverage. This requirement shall not apply to insurance policies or other forms of coverage which provide benefits only for specific illnesses such as "cancer policies" or "intensive care policies."

4.1.1. An insured shall be given the option of declining coverage for temporomandibular disorders (TMD) and craniomandibular disorders (CMD) and the insurer must provide an appropriate waiver form or incorporate such waiver form into the insurance policy or other evidence of coverage.

4.1.1.1. Such waiver form must clearly indicate that the prospective insured understands that coverage is available for temporomandibular disorders (TMD) and craniomandibular disorders (CMD), but that the insured does not desire such coverage; all of which shall be witnessed by the signature of the insured and the date signed.

4.1.1.2. Such waiver form shall be subject to the prior approval of the Commissioner.

4.2. If a waiver, as described in subsection 4.1.1 above, is not properly executed, coverage for temporomandibular disorders (TMD) and craniomandibular disorders (CMD) will remain as a part of the policy or other evidence of coverage.

4.3. For purposes of this rule, the PEIA is the policyholder and not an insurer. If the PEIA elects to purchase accident and sickness coverage for its participants from an insurer, then such insurer must offer to the PEIA the option of purchasing benefits for temporomandibular disorders (TMD) and craniomandibular disorders (CMD) in compliance with this rule.

4.4. For purposes of this rule, the owner or sponsor of a group insurance policy shall be deemed to be the insured and shall have the option of purchasing benefits for temporomandibular disorders (TMD) and craniomandibular disorders (CMD) in compliance with this rule.

W. Va. Code R. § 114-29-4