W. Va. Code R. § 114-64-4

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

Section 114-64-4 - Financial Requirements and Quantitative Treatment Limitations

4.1. An insurer or carrier shall comply with financial requirements and quantitative treatment limitations specified in 45 CFR § 146.136(c)(2) and (c)(3), or any successor federal regulation as adopted by the Legislature through subsequent amendment to this rule.

4.2. An insurer or carrier shall not impose any financial requirement or quantitative treatment limitation on behavioral, mental health, or substance use disorder benefits that it does not impose on medical/surgical benefits.

4.3. An insurer or carrier shall not impose annual maximums on the number of visits or dollar amounts for behavioral, mental health, or substance use disorder benefits.

4.4. An insurer or carrier shall not impose any financial requirement or quantitative treatment limitation on behavioral, mental health, or substance use disorder benefits, unless the financial requirement or quantitative treatment limitation applies to substantially all of the medical/surgical benefits in a permitted benefit classification.

4.4.1. Benefit classifications may include:

4.4.1.a. Inpatient in-network;

4.4.1.b. Inpatient out-of-network;

4.4.1.c. Outpatient in-network, except that insurers or carriers may use the following sub-classifications;

4.4.1.c.1. Office visits, such as physician visits; and

4.4.1.c.2. All other outpatient services, such as outpatient surgery, day treatment centers, laboratory charges, or other medical items;

4.4.1.d. Outpatient out-of-network, except that insurers or carriers may use the following sub-classifications;

4.4.1.d.1. Office visits, such as physician visits; and

4.4.1.d.2. All other outpatient services, such as outpatient surgery, day treatment centers, laboratory charges, or other medical items;

4.4.1.e. Emergency; and

4.4.1.f. Pharmacy.

4.4.2. If an insurer or carrier provides benefits through multiple tiers of in-network providers, such as an in-network tier of preferred providers with more generous cost-sharing to members than a separate in-network tier of participating providers, the insurer or carrier may divide its benefits furnished on an in-network basis into sub-classifications that reflect network tiers, if the tiering is based on reasonable factors determined in accordance with the requirements in Section 5 of this rule and without regard to whether a provider provides services with respect to medical/surgical benefits or behavioral, mental health, and substance use disorder benefits.

4.4.3. After sub-classifications are established, the insurer or carrier shall not impose any financial requirement or treatment limitation on behavioral, mental health, and substance use disorder benefits in any sub-classification that is more restrictive than the predominant financial requirement or treatment limitation that applies to substantially all medical/surgical benefits in the sub-classification using the methodology as required by sections 4.9 and 4.10 of this rule.

4.4.4. An insurer or carrier shall not use any other type of sub-classification, including but not limited to intermediate services, intensive care or any other sub-classification.

4.4.5. An insurer or carrier shall not sub-classify between primary care providers and specialists in the outpatient classifications.

4.5. An insurer or carrier shall not impose any financial requirement or quantitative treatment limitation on behavioral, mental health, or substance use disorder benefits that it does not impose on medical/surgical benefits.

4.6. An insurer or carrier shall not impose any financial requirement or quantitative treatment limitation on behavioral, mental health, or substance use disorder benefits, unless the financial requirement or quantitative treatment limitation applies to substantially all of the medical/surgical benefits in a permitted benefit classification, as shown in section 4.4 of this rule.

4.7. An insurer or carrier shall not impose a level of financial requirement or quantitative treatment limitation on behavioral, mental health, or substance use disorder benefits, unless the level of financial requirement or treatment limitation predominantly applies to medical/surgical benefits, as shown in Sections 4.9 and 4.10 of this rule.

4.8. Calculation of Substantially All and Predominant Level Tests

4.8.1. An insurer or carrier shall use a reasonable and verifiable method to determine the claims costs associated with the medical/surgical benefits that are subject to a financial requirement or quantitative treatment limitation. The method utilized by the carrier shall conform with Actuarial Standards of Practice.

4.8.2. An insurer or carrier shall not consider claims costs associated with behavioral, mental health, or substance use disorder benefits in the calculation.

4.8.3. An insurer or carrier shall consider all claims applying to the deductible and out-of-pocket maximum when calculating the deductible and out-of-pocket applicability in determining if the deductible and out-of-pocket apply to substantially all of the claims.

4.9. An insurer or carrier shall not use any financial requirement unless the insurer or carrier can provide verification that the following conditions have been met:

4.9.1. An insurer or carrier shall not apply any type of financial requirement or quantitative treatment limitation to behavioral, mental health, or substance use disorder benefits unless the financial requirement applies to "substantially all" medical/surgical benefits in a permitted classification, which consists of no less than two-thirds (2/3) of the expected medical/surgical claims for any given classification of benefits.

4.9.2. Once an insurer or carrier has determined that the financial requirement or quantitative treatment limitation applies to at least two-thirds (2/3) of the benefits, it shall not apply any specific level of financial requirement or quantitative treatment limitation to any behavioral, mental health, or substance use disorder benefit unless the financial requirement applies to more than one-half (1/2) of the expected claims for any given classification of benefits.

4.10. If, with respect to a financial requirement or quantitative treatment limitation that applies to at least two-thirds (2/3) of all medical/surgical benefits in a classification, an insurer or carrier determines that no one specific level of financial requirement or quantitative treatment level applies to more than one-half (1/2) of the expected claims for the classification, the carrier may combine levels until the combination of levels applies to more than one-half (1/2) of the medical/surgical benefits subject to the financial requirement or quantitative treatment limitation in the classification. The carrier must use the least restrictive (lowest) amount that makes up one-half (1/2) of the expected claims.

4.11. An insurer or carrier shall use a combined deductible for behavioral, mental health, and substance use disorder and medical/surgical benefits.

4.12. An insurer or carrier shall use a combined out-of-pocket maximum for behavioral, mental health, and substance use disorder and medical/surgical benefits.

4.13. Nothing herein shall prohibit an insurer or carrier from providing some benefits that are subject to the deductible and other benefits that are not subject to the deductible within the same classification or from applying, separately, a deductible or out-of-pocket maximum that differs between the in-network and out-of-network benefit levels, as long as the same deductible or out-of-pocket applies to behavioral, mental health, or substance use disorder benefits that applies to medical/surgical benefits.

W. Va. Code R. § 114-64-4