W. Va. Code R. § 114-64-7

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

Section 114-64-7 - Annual Reporting to the Commissioner

7.1. As part of their annual health benefit plan filings, insurers or carriers shall provide an attestation to the commissioner that:

7.1.1. The plan applies the same deductible for medical/surgical and behavioral, mental health, and substance use disorders and does not otherwise apply any cumulative financial requirement for behavioral health, mental health, and substance use disorders in a classification that accumulates separately from any established for medical/surgical benefits in the same classification;

7.1.2. The plan applies the same out-of-pocket for medical/surgical and behavioral, mental health, and substance use disorders and does not otherwise apply any cumulative financial requirement for behavioral health, mental health, and substance use disorders in a classification that accumulates separately from any established for medical/surgical benefits in the same classification;

7.1.3. The plan uses the same benefits for emergency room benefits, including all ancillary services provided as part of the emergency room benefits, for medical/surgical and behavioral, mental health, and substance use disorders;

7.1.4. The plan utilizes the same copayment, coinsurance or deductible structure for prescription drug benefits for medical/surgical and behavioral, mental health, and substance use disorders;

7.1.5. The carrier utilizes the same penalties for failure to obtain prior authorization for behavioral, mental health, and substance use disorders as it does for medical/surgical procedures within the same classification of benefits.

7.2. The attestation shall be signed by responsible representative of the insurer or carrier, including but not limited to the president, vice president, assistant vice president, chief executive officer, chief financial officer, chief operating officer, general counsel or other person that has been appointed by the board of directors. The commissioner may develop an attestation form that the health carrier is required to use if he or she determines the attestation provided by the carrier is deficient or otherwise incomplete.

7.3. Data Reporting

7.3.1. Beginning on or after July 1, 2021, the commissioner shall issue annually a mandatory data call to all insurers or carriers subject to this rule to collect the following information for the commissioner's annual report on mental health parity to the Joint Committee on Government and Finance as required by the provisions of W.Va. Code §§ 33-15-4u, 33-16-3f f, 33-24-7u, 33-25-8r or 33-25A-8u.

7.3.2. The commissioner will develop a mechanism to accept the data from carriers electronically and securely. The insurers or carriers shall provide data for the twelve (12) month period immediately preceding the data call and shall only provide data regarding fully adjudicated claims, including any denied claims or adverse determinations.

7.3.3. The data call will, at a minimum, require the insurers or carriers to provide the following information and/or analysis to the commissioner.

7.3.3.a. Information regarding financial requirements and non-quantitative treatment limitations including data regarding:

7.3.3.a.1. Medical Management Evaluation;

7.3.3.a.2. Non-Quantitative Treatment Limitations;

7.3.3.a.3. Quantitative Treatment Limitation Classifications; and

7.3.3.a.4. Parity Compliance for Adverse Determinations, including the total number of adverse determinations of such claims.

7.3.3.b. Information regarding other non-quantitative treatment limitations including data regarding:

7.3.3.b.1. Inpatient In-Network;

7.3.3.b.2. Inpatient Out-of-Network;

7.3.3.b.3. Outpatient In-Network;

7.3.3.b.4. Outpatient Out-of-Network;

7.3.3.b.5. Emergency Room Services; and/or

7.3.3.b.6. Pharmacy Services.

7.4. Insurers or carriers may also be asked to provide specific information regarding processes for the development of medical necessity criteria or standards, eligibility criteria, concurrent review standards, non-quantitative treatment limitations or restrictions imposed upon obtaining covered services or benefits, processes, strategies and evidentiary standards, penalties that may be imposed for failure to obtain prior authorization for medical/surgical benefits compared to behavioral, mental health, and substance use disorder benefits.

7.5. The commissioner may ask that a qualified actuary certify that the calculations of the insurer or carrier are accurate and true to the best of the actuary's knowledge and have been appropriately calculated in accordance with Actuarial Standards of Practice.

W. Va. Code R. § 114-64-7