W. Va. Code R. § 114-64-2

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

Section 114-64-2 - Definitions

2.1. "Aggregate lifetime dollar limit" means, for the purposes of this rule, a dollar limitation on the total amount of specified benefits that may be paid under a health benefit plan, or health insurance coverage offered in connection with such a plan, for any coverage unit. Coverage unit refers to the way in which a plan, or health insurance coverage, groups individuals for purposes of determining benefits or premiums contributions, including family plans, employee with spouse plans, or individual plans.

2.2. "Annual dollar limit" means, for the purposes of this rule, a dollar limitation on the total amount of specified benefits that may be paid in a 12-month period under a health benefit plan.

2.3. "Autism spectrum disorder" shall have the same meaning as defined at W.Va. Code §§ 33-16-3v, 33-24-7k, and 33-25A-8j, and includes any pervasive developmental disorder, including autistic disorder, Asperger's Syndrome, Rett syndrome, childhood disintegrative disorder, or Pervasive Development Disorder as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.

2.4. "Behavioral, mental health, and substance use disorder" shall have the same meaning as defined at W.Va. Code §§ 33-15-4u, 33-16-3f f, 33-24-7u, 33-25-8r, and 33-25A-8u, and shall mean a condition or disorder, regardless of etiology, that may be the result of a combination of genetic and environmental factors and that falls under any of the diagnostic categories listed in the mental disorders section of the most recent version of the International Statistical Classification of Diseases and Related Health Problems, the Diagnostic and Statistical Manual of Mental Disorders, or the Diagnostic Classification of Mental Health and Development Disorders of Infancy and Early Childhood; and includes Autism Spectrum Disorder.

2.5. "Behavioral, mental health, and substance use disorder benefits" means, for the purposes of this rule, the benefits supplied for items or services for behavioral, mental health or substance use disorder conditions.

2.6. "Carrier" shall mean any insurer offering an accident and sickness insurance policy, contract, plan or agreement subject to Articles 15, 16, 24, 25, or 25A of Chapter 33 of the West Virginia Code.

2.7. "Commissioner" means the West Virginia Insurance Commissioner.

2.8. "Concurrent review" means inpatient care is reviewed as it is provided.

2.9. "Financial requirements" means, for the purposes of this rule, the deductibles, copayments, coinsurance, or out-of-pocket maximums imposed under a health benefit plan. Financial requirements do not include aggregate lifetime or annual dollar limits.

2.10. "Health benefit plan" or "plan," as defined in W.Va. Code § 33-16-1a(h), means benefits consisting of medical care provided directly, through insurance or reimbursement, or indirectly, including items and services paid for as medical care, under any hospital or medical expense incurred policy or certificate, hospital, medical or health service corporation contract, health maintenance organization contract, or plan provided by a multiple-employer trust or multiple-employer welfare arrangement. "Health benefit plan" does not include excepted benefits as defined by W. Va. Code § 33-16-1a(f).

2.11. "Insurer" or "health insurer" means an insurer licensed to transact accident and sickness insurance in this state, and a health maintenance organization to whom a certificate of authority has been issued by the Commissioner and is subject to the provisions of Articles 15, 16, 24, 25, or 25A of Chapter 33 of the West Virginia Code, and is subject to the provisions of W.Va. Code §§ 33-15-4u, 33-16-3f f, 33-24-7u, 33-25-8r or 33-25A-8u.

2.12. "Medical/surgical benefits" means, for the purposes of this rule, the benefits supplied for items or services for medical conditions or surgical procedures, as defined under the terms of the plan or health insurance coverage and in accordance with applicable federal and state law, but does not include behavioral, mental health, and substance use disorder benefits.

2.13. "Prior authorization" means obtaining advance approval from a carrier or insurer about the coverage of a benefit, service or medication.

2.14. "Substance use disorder" means the same as that term is defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders and shall include substance use withdrawal.

2.15. "Substance use disorder benefits" means, for the purposes of this rule, the benefits supplied for items or services used to treat substance use disorders, including substance use withdrawal.

2.16. "Treatment limitations" means, for the purposes of this rule, the limits applied based on the frequency of treatment, number of visits, days of coverage, days in a waiting period, or other limits on the scope or duration of treatment. Treatment limitations include both quantitative treatment limitations, which are expressed numerically, and non-quantitative treatment limitations, which otherwise limit the scope or duration of benefits for treatment under a plan or coverage. This term does not include any permanent exclusion of all benefits for a particular condition or disorder.

W. Va. Code R. § 114-64-2