W. Va. Code R. § 114-54-1

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

Section 114-54-1 - General

1.1. Scope and applicability. -- This rule applies to health benefit plans issued in connection with a group health plan by insurance companies; fraternal benefit societies; hospital, medical, dental and health service corporations and health care corporations; and health maintenance organizations, and delivered or issued for delivery in this state on and after the effective date hereof for group health plan years beginning after June 30, 1997, or as otherwise provided in this rule. This rule does not apply to:

a. Individual policies or contracts issued pursuant to a conversion privilege under a policy or contract of group insurance;

b. Individual policies or contracts issued to eligible individuals, as defined in W. Va. Code '33-15-2a(e);

c. A health benefit plan for any group health plan year if, on the first day of the group health plan year, the group health plan has fewer than two participants who are current employees;

d. Coverage under the West Virginia Public Employees Insurance Act (W. Va. Code '5-16-1 et seq.): Provided, That this rule applies to a health benefit plan issued by a health insurer to provide medical care under the West Virginia Public Employees Insurance Act;

e. Coverage under Medicare or Medicaid: Provided, That this rule applies to a health benefit plan issued by a health insurer to provide medical care under Medicare or Medicaid;

f. Coverage that consists solely of excepted benefits;

g. Coverage under health benefit plans issued to or through bona fide associations, if such coverage is not related to a group health plan;

h. Accident and sickness insurance contracts covering members of fraternal benefit societies organized pursuant to West Virginia Code ''33-23-1 et seq., if not issued in connection with a group health plan;

i. Credit accident and sickness insurance subject to WV 114CSR6 "Regulation of Credit Life Insurance and Credit Accident and Sickness Insurance;"

j. Medicare supplement insurance policies subject to WV 114CSR24 "Medicare Supplement Insurance;"

k. Long-term care insurance policies subject to WV 114CSR32 "Long-Term Care Insurance;"

l. Individual limited benefits policies subject to the requirements of W. Va. Code '33-16E-1 et seq.

The requirements contained in this rule are in addition to WV 114CSR39 "Group Accident and Sickness Insurance Minimum Policy Coverage Standards" and any other applicable rules previously adopted.

1.2. A health insurer may provide greater rights to policyholders, persons covered under a health benefit plan and their dependents than the minimum standards set forth in this rule.

1.3. Authority. -- W. Va. Code ''33-2-10, 33-16-3(f) and 33-16D-6.

1.4. Filing Date. -- April 30, 1999.

1.5. Effective Date. -- April 30, 1999.

1.6. Purpose. -- The purpose of this legislative rule is to provide for implementation of state standards meeting federal requirements under the Health Insurance Portability and Accountability Act of 1996 ( P.L. 104-191 ) and to facilitate public understanding of these standards.

W. Va. Code R. § 114-54-1