W. Va. Code R. § 114-64-8

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

Section 114-64-8 - Comparative Analysis Reporting for Non-Quantitative Treatment Limitations

8.1. An insurer or carrier shall provide annually to the Commissioner a comparative analysis demonstrating that, for any non-quantitative treatment limitation, including medical necessity criteria, as written and in operation, the processes, strategies, evidentiary standards, or other factors used in applying the medical necessity criteria and each non-quantitative treatment limitation to benefits for behavioral, mental health, and substance use disorders within each classification of benefits are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the medical necessity criteria and each non-quantitative treatment limitation to medical and surgical benefits within the corresponding classification of benefits.

8.2. An insurer or carrier shall provide these comparative analyses results to the Commissioner, showing the following, at a minimum:

8.2.1. Identification of any factors used to determine whether a non-quantitative treatment limitation will apply to a benefit, including any factors considered but rejected;

8.2.2. Identify and define the specific evidentiary standards used to define the factors and any other evidence relied on in designing each non-quantitative treatment limitation;

8.2.3. Provide the comparative analyses, including any results of the analyses, performed to determine that the processes and strategies used to design each non-quantitative treatment limitation, as written, and the written processes and strategies used to apply to each nonquantitative treatment limitation for benefits for behavioral, mental health, and substance use disorders are comparable to, and are applied no more stringently than, the processes and strategies used to design and apply to each non-quantitative treatment limitation, as written, and the written processes and strategies used to apply to each non-quantitative treatment limitation for medical and surgical benefits;

8.2.4. Provide the comparative analyses, including the results of the analyses, performed to determine that the processes and strategies used to apply to each non-quantitative treatment limitation, in operation, for benefits for behavioral, mental health, and substance use disorders are comparable to, and are applied no more stringently than, the processes and strategies used to apply to each non-quantitative treatment limitation, in operation, for medical and surgical benefits; and

8.2.5. Disclose the specific findings and conclusions reached by the insurer or carrier that the results of the analyses indicate that each health benefit plan offered by the insurer or carrier complies with W.Va. Code §§ 33-15-4u, 33-16-3f f, 33-24-7u, 33-25-8r or 33-25A-8u, whichever is applicable, and this rule.

8.3. The insurer or carrier shall provide the commissioner with its comparative analysis annually at the same time, and in conjunction with, the insurer's or carrier's response to the annual mental health parity data call refereed to in section 7 of this rule.

W. Va. Code R. § 114-64-8