W. Va. Code R. § 114-64-3

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 114-64-3 - Mental Health Parity and Required Coverage

3.1. An insurer or carrier is required to provide coverage for the prevention of, screening for, and treatment of behavioral health, mental health, and substance use disorders that is no less extensive that the medical/surgical benefits or coverage provided for any physical illness and that complies with the requirements of this rule and with W.Va. Code §§ 33-15-4u, 33-16-3f f, 33-24-7u, 33-25-8r, or 33-25A-8u, whichever is applicable.

3.2. Screening for behavioral health, mental health, and substance use disorders shall include, but are not limited to, unhealthy alcohol use for adults, substance use for adults and adolescents, and depression screening for adults and adolescents.

3.3. An insurer or carrier that provides coverage for an annual physical examination shall include coverage for behavioral health screenings using a validated screening tool for behavioral health, which coverage and reimbursement is no less extensive than the coverage and reimbursement for the annual physical examination.

3.4. An insurer or carrier is required to establish procedures to authorize treatment with a non-participating provider if a covered service is not available within established time and distance standards as set forth in 114CSR100 and within a reasonable period after service is requested, and with the same coinsurance, deductible, or copayment requirements as would apply if the service were provided at a participating provider, and at no greater cost to the covered person than if the services were obtained at, or from a participating provider.

3.5. If a covered person obtains a covered service from a nonparticipating provider because the covered service is not available within the established time and distance standards as set forth in 114CSR100, an insurer or carrier is required to reimburse treatment or services for behavioral health, mental health, or substance use disorders that are provided by a non-participating provider using the same methodology that the insurer or carrier uses to reimburse covered medical/surgical services provided by non-participating providers and, upon request, provide evidence of the methodology to the person or provider.

3.6. An insurer or carrier offering a plan that does not cover services provided by an out-of-network provider may provide that the benefits required herein are covered benefits if the services are rendered by a provider who is designated by or affiliated with the insurer's or carrier's plan only if the same requirement applies for medical/surgical benefits or services. A carrier is not required to cover out-of-network care at one hundred percent (100%) or without any cost share to the covered person.

3.7. Subject to the limitation set forth in 3.8, nothing herein prohibits an insurer or carrier from using appropriate disease management or utilization review protocols for behavioral health, mental health, and substance use disorders, as long as the protocols are no more stringent or restrictive than medical/surgical disease management or utilization review protocols.

3.8. An insurer or carrier shall not impose any prior authorization or prospective utilization management requirements on any prescription medication on the insurer's or carrier's formulary that is used to treat substance use disorder when the medication is determined to be medically necessary by the covered person's provider.

3.9. If a health benefit plan, or health insurance coverage offered in connection with a plan, applies different levels of financial requirements to different tiers of prescription drug benefits based on reasonable factors determined in accordance with requirements for non-quantitative treatment limitations, and without regard to whether a drug is generally prescribed with respect to medical/surgical benefits or with respect to behavioral, mental health, or substance use disorder benefits, the plan or carrier satisfies the parity requirements with respect to prescription drug benefits. Reasonable factors may include, but are not limited to, cost, efficacy, generic versus brand name, and mail order versus pharmacy pick-up.

W. Va. Code R. § 114-64-3