W. Va. Code R. § 114-78-5

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

Section 114-78-5 - Eligibility

5.1. An insurer issuing limited health benefit individual health insurance policies shall, as part of the application process require the applicant to provide evidence of eligibility in a form satisfactory to the Insurance Commissioner and the insurer shall retain the evidence of eligibility as long as the policy remains in effect.

5.2. An individual limited health benefits plan may only be offered to an adult between the ages of eighteen and sixty-four, inclusive, who:

a. Has not had a health benefit plan covering him or her for at least the prior twelve consecutive months: Provided, That such a plan may not be offered to an employee of an employer that offers a health benefits plan to its employees unless that employee does not qualify for coverage under such employer plan; or

b. Has lost coverage due to a qualifying event. A qualifying event includes loss of coverage due to:

(i) emancipation and resultant loss of coverage under a parent's or guardian's plan;

(ii) divorce and loss of coverage under the former spouse's plan;

(iii) termination of employment and resultant loss of coverage under an employer group plan, except for loss of employment for gross misconduct; or

(iv) involuntary termination of coverage under a group health benefit plan, except for termination due to nonpayment of premiums or fraud by the insured.

5.3. Every individual limited health benefits plan may limit eligibility on the basis of health status. Except as provided in section three, article fifteen-d, chapter thirty-three of the Code of West Virginia, an individual who has been treated for a health condition in the prior twelve months may have that condition excluded from coverage for the first twelve months of the policy term.

W. Va. Code R. § 114-78-5