Title 113 W. Va. C.S.R.

Health Insurance Plan Health Insurance Plan

Series 01 Premium Subsidy

W. Va. Code R. § 113-1-1 General

1.1. Scope. -- The purpose of this rule is to establish criteria for certain individuals to obtain a premium subsidy with the West Virginia Health Insurance Plan.

1.2. Authority. -- W. Va. Code §33-48-7b.

1.3. Filing Date. -- April 20, 2012.

1.4. Effective Date. -- April 20, 2012.

W. Va. Code R. § 113-1-2 Definitions

2.1. Average annual household income means the Total Income reported on the prior years federal tax return for all individuals in the applicants or members household, plus any other Income received by any household member, including but not limited to non-taxed Social Security income, child support, disability payments, veterans benefits, and public assistance.

2.2. Board means the Board of Directors of the Plan.

2.3. Low-income eligible individuals means those persons having an annual household income at or below 400% of the federal poverty level who are otherwise eligible for coverage under the Plan as provided in W. Va. Code §33-48-4.

2.4. Plan means the West Virginia Health Insurance Plan as created in W. Va. Code §33-48-2.

2.5. Plan Administrator means the administrator of the Plan selected by the Board pursuant to W. Va. Code §33-48-6.

2.6. Premium subsidy means the difference between the amount of periodic payment the Plan Administrator makes to the Plan on behalf of the low-income eligible individual plus the administrative cost to the Plan of providing the Plan to that low-income eligible individual, and the amount determined by the Board to be the low-income eligible individuals premium responsibility.

2.7. Surplus means funds being held in the West Virginia Health Insurance Plan Fund pursuant to W. Va. Code §33-48-7a that are above those amounts necessary to provide fully for the expected costs of claims and other expenses listed in W. Va. Code §33-48-7(a).

W. Va. Code R. § 113-1-3 Determination of Surplus

3.1. The Board shall periodically, but no less than annually, determine if a surplus exists.

3.2. In making a determination concerning the existence of a surplus, the Board may consider an actuarial analysis and any other information developed by or presented to the Board that demonstrates the status of a surplus.

W. Va. Code R. § 113-1-4 Eligibility for Premium Subsidy

4.1. In the event the Board determines that a surplus exists, the Board shall create a schedule of premium subsidies that varies with income to assist low income eligible individuals in paying the premium costs of the Plan. The Board may adopt as many income categories within the premium subsidy schedule as it finds necessary and practical.

4.2. For the purposes of determining the eligibility of a person for a premium subsidy, the Board may consider information obtained from any state or federal agency. The eligibility of low income eligible individuals who receive a premium subsidy shall be reassessed annually by the Board.

4.3. No person shall be eligible for a premium subsidy if that persons premium is paid by a third party who is not a family member of the person.

4.4. Whenever the Board finds that there is a significant possibility that premium subsidies may result in an over-expenditure of the surplus, the Board may discontinue the use of the surplus to subsidize premiums until the Board determines that the possibility for over-expenditure no longer exists. The Board shall give low income eligible individuals who are receiving a premium subsidy thirty days notice prior to such a discontinuance.

W. Va. Code R. § 113-1-5 Delegation of Authority to Plan Administrator

5.1. The Board may delegate or assign any of its authority or duties set forth in this rule to the Plan Administrator.

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Series 02 Pre-existing Conditions Exclusion

W. Va. Code R. § 113-2-1 General

1.1. Scope. -- The purpose of this rule is to provide additional classes of individuals to which the waiting period for pre-existing condition exclusions does not apply.

1.2. Authority. -- W. Va. Code §§33-2-10 and 33-48-8(d)(1).

1.3. Filing Date. -- April 14, 2010.

1.4. Effective Date. -- April 14, 2010.

W. Va. Code R. § 113-2-2 Definitions

2.1. Creditable coverage, Plan and significant break in coverage have the same meanings assigned to them in W. Va. Code §33-48-1(d).

2.2. Pre-existing condition exclusion means the exclusion of charges or expenses incurred during the first six months following the effective date of coverage as to any condition for which medical advice, diagnosis, care or treatment was recommended or received as to such condition during the six-month period immediately preceding the effective date of coverage.

W. Va. Code R. § 113-2-3 Persons not Subject to the Pre-existing Condition Exclusion Period

3.1. In addition to federally defined eligible individuals and those persons to whom W. Va. Code §33-48-8(d)(2) applies, the Board may approve the waiver of the pre-existing exclusion for one or more of the following classes of enrollees if the Board finds, on the basis of actuarial review or otherwise, that the addition of such class or classes will not have an undue adverse effect on the overall operation of the Plan.

3.1.a. A person, without a significant break in coverage, who had prior creditable coverage of eighteen months or more, regardless of whether that coverage was terminated voluntarily or involuntarily.

3.1.b. A person who was previously enrolled in Medicaid, Medicare, the State Childrens Health Insurance Program or any other public health insurance program that does not impose a waiting period before treatment for a pre-existing condition and who is enrolling in the Plan without a significant break in coverage: Provided, That with respect to any person who was enrolled in such a program for less than six months prior to enrollment in the Plan, the Board may decide that any such person will be deemed to have satisfied a portion of the six-month waiting period imposed by W. Va. Code §33-48-8(d)(1) equal to the previous enrollment period of such program;

3.1.c. A person who was previously covered under another states high-risk plan: Provided, That with respect to any such person who had not satisfied the other states high-risk plans pre-existing condition waiting period, if any, the Board may decide that any such person will be deemed to have satisfied a portion of the six-month waiting period imposed by W. Va. Code §33-48-8(d)(1) equal to the waiting period such person had satisfied under such previous coverage. or

3.1.d. A person who was previously covered under an individual health insurance policy and who is enrolling in the Plan because premiums for the previous coverage were in excess of those charged under the Plan for similar coverage: Provided, That with respect to any such person who had not satisfied the prior health plans pre-existing condition waiting period, if any, the Board may decide that any such person will be deemed to have satisfied a portion of the six-month waiting period imposed by W. Va. Code §33-48-8(d)(1) equal to the waiting period such person had satisfied under such previous coverage.

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