West Virginia Health Insurance Guide
West Virginia Health Insurance Information, Health Organizations and Resources and access to online health insurance quotes
When you live in West Virginia you can choose from a variety of private health insurance plans including plans for individuals and group plans provided by an employer. Depending on your income or employment status, you may also be eligible for West Virginia State-funded affordable health insurance for individuals and families, and federal programs such as Medicaid and COBRA.
West Virginia is not a guarantee issue state with one exception. HMOs with at least 50,000 enrollees that have been operating in the state for more than five years are required to guarantee issue individuals policies during an annual 30-day open enrollment period. Otherwise, private insurance companies that sell individual policies can medically underwrite them and can turn you down if you do not meet their criteria. In West Virginia, insurers are permitted a 12-month exclusionary period and a 24-month look-back period for pre-existing conditions. There is no requirement to provide credit for prior coverage, except as covered by federal HIPAA laws. West Virginia also permits health insurance providers to issue Elimination Riders that exclude coverage for specific health conditions. If you file a claim during the first two years that your policy is in effect, your insurer reserves the right to another 24-month look-back at your medical records to determine if you should have listed that condition as a pre-existing condition, and to deny benefits in that case. Insurers in West Virginia can base premiums for individual policies based on your health, your age and lifestyle factors. However, individual policy rates are banded and can vary plus or minus 30% of the state’s individual index rate. West Virginia does not require insurers to offer standardized policies for individuals.
West Virginia is a guarantee issue state for group health plans issued to small businesses. If your West Virginia health insurance is provided through your employer, your coverage cannot be denied because of your past or current health. The insurer can impose a 12-month exclusionary period and a six-month look-back period for pre-existing medical conditions, but must give credit for qualifying prior creditable coverage. Your employer may impose a waiting period for eligibility for new hires, but it must be applied equally to all new hires. Premiums for small group health insurance may be underwritten and the insurer can charge a premium not to exceed 30% of its index rate if your group has a history of unfavorable health.
West Virginia is a guaranteed renewal state. Regardless of your health, your insurer must renew your individual health insurance policy as long as you’ve paid your premiums on time and haven’t defrauded the company, or in the case of some HMOs, as long as you haven’t moved out of the service area. However, your premiums can be increased to reflect your current health status. Your policy can be canceled if your insurer discontinues a plan or no longer sells insurance in the state.
West Virginia Mandated Health Benefits
West Virginia laws require private health insurance policies to cover several state-mandated benefits. These currently include:
- Alcoholism
- Breast Reconstruction
- Cervical Cancer and HPV Screening
- Clinical Trials
- Colorectal Cancer Screening
- Contraceptives
- Diabetes Supplies
- Emergency Services
- In Vitro Fertilization and Other Fertility Services
- Kidney Disease
- Long-Term Care
- Mammography
- Mastectomy Stays
- Maternity Stays
- General and Parity Mental Health
- Newborn Hearing Screening
- Prostate Cancer Screening
- Rehabilitation Services
- Second Surgical Opinions
- TMJ Disorders
- Well-Child Care
- Coverage for newborns under their parent's policy
- Coverage for adopted children under their parent's policy
- Coverage for continuation/dependents under their guardian’s policy
- Coverage for conversion to non-group
- Coverage for continuation/employees
- Coverage for domestic partners
Types Health Insurance Plans Available in West Virginia
The following major medical health insurance plans are generally available in West Virginia. Major medical plans cover illness and injury, hospitalization, prescription drugs and office visits, as well as the mandated services stated above.
Indemnity plans - Typically the most flexible and therefore highest priced choice, an indemnity plan lets you select your health providers and facilities. Depending on your plan, you will have to pay a deductible or co-insurance.
Preferred provider organization plans (PPOs) - You select from a network of preferred health care providers and facilities, and receive services at an agreed-upon discounted rate. You also have the option of going outside the network, but typically at a higher cost. You do not need a referral from a primary care physician to see a specialist. Premiums may be less than an indemnity plan but more than an HMO. You will have to pay a deductible or co-insurance.
Health maintenance organizations (HMOs) - HMOs plans require you to select a primary care physician from a prescribed network of providers, who must issue a referral before you can see a specialist. Services and covered costs are typically more comprehensive than those provided by a PPO. HMOs offer the advantage of affordable premiums and low out-of-pocket costs, with an emphasis on preventive care. Non-emergency services out of network are usually not reimbursed.
Point of Service plans (POS) - Similar to a PPO in that you will receive reimbursement for out-of-network care, but with an HMO’s requirement for a primary care physician who must provide referrals to specialists. Premiums, co-pays and co-insurance are typically higher than what you’d pay with an HMO.
Alternative Health Programs in West Virginia
AccessWV
This is the state-sponsored high-risk pool that offers health insurance if you are unable to obtain it from other sources because of your health or pre-existing medical conditions. Other eligibility requirements apply. One PPO plan is offered, with various deductibles based on whether you want individual or family coverage. Co-pays and maximum out-of-pocket vary depending on your plan. Premiums are based on age, income, where you live and number of people to be covered, but are capped at 125% to 150% of the average rate charged for similar coverage in West Virginia. Enrollment is open. There may be a six-month exclusionary period for pre-existing conditions, but this is waived under certain circumstances.
West Virginia Children’s Health Insurance Program
WVCHIP provides comprehensive low-cost health care for resident children up to age 18, whose families meet income requirements and other eligibility requirements. Premiums are based on income and family size. There are no deductibles or coinsurance, but there are two different, modest co-pay levels depending on family size and income, however no co-pays are charged for most preventive services. There may be a six-month waiting period but it can be waived in certain circumstances. Enrollment is open but is subject to review and renewal every 12 months.
Regulating Agency
The West Virginia Office of the Insurance Commissioner is responsible for regulating West Virginia’s health insurance industry.
Get access to West Virginia health insurance quotes from http://www.einsurance.com/health-insurance.
West Virginia Offices of the Insurance Commissioner
PO Box 50540
Charleston, WV 25305-0540
(304) 558-3386
http://www.wvinsurance.gov/defaulth.aspx
AccessWV
http://www.wvinsurance.gov/accesswv
West Virginia Children’s Health Insurance Program
(877) WVA-CHIP
wvchip@wvchip.org
http://www.wvchip.org
(NAIC) National Association of Insurance Commissioners
The National Association of Insurance Commissioners (NAIC) is the organization of insurance regulators from the 50 states, the District of Columbia and the five U.S. territories. The NAIC provides a forum for the development of uniform policy when uniformity is appropriate. NAIC members are the elected or appointed state government officials who along with their departments and staff regulate the conduct of insurance companies and agents in their respective state or territory.
http://www.naic.org/
Insurance Information Institute (I.I.I)
The mission of the Insurance Information Institute (I.I.I.) is to improve public understanding of insurance -- what it does and how it works.
Contact info:
110 William Street
New York, NY 10038
212-346-5500
http://www.iii.org/