Key Takeaways
- West Virginia uses the federal HealthCare.gov marketplace
- Offices of the Insurance Commissioner (OIC) regulates health insurance
- Pre-existing condition exclusions are prohibited in ACA-compliant plans
- West Virginia expanded Medicaid under the ACA
- Essential health benefits are required in all qualified plans
Last updated: January 2026
West Virginia Health Insurance Policy Requirements
West Virginia has comprehensive health insurance regulations administered by the Offices of the Insurance Commissioner (OIC).
Regulatory Structure
West Virginia health coverage is regulated by:
| Agency | Responsibility |
|---|---|
| Offices of the Insurance Commissioner (OIC) | Primary insurance regulator |
| Department of Health and Human Resources | Medicaid and public health |
| Federal HealthCare.gov | Individual marketplace enrollment |
Offices of the Insurance Commissioner
The OIC:
- Reviews and approves policy forms and rates
- Licenses insurance producers and companies
- Handles consumer complaints
- Enforces insurance laws and regulations
Health Insurance Marketplace
West Virginia uses the federal HealthCare.gov marketplace:
Key Features
- Federal marketplace platform
- Premium tax credits available based on income
- Qualified Health Plans (QHPs) certified by federal standards
- West Virginia-specific plan options
Enrollment Periods
- Annual open enrollment each fall
- Special enrollment for qualifying life events
- Financial assistance based on income
Medicaid Expansion
West Virginia expanded Medicaid under the ACA:
Eligibility
- Adults with income up to 138% of federal poverty level (FPL)
- Children covered at higher income levels
- Pregnant women have expanded eligibility
Required Coverage
West Virginia ACA-compliant plans must cover Essential Health Benefits:
Essential Health Benefits
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
Pre-Existing Condition Protections
West Virginia follows ACA rules on pre-existing conditions:
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual | Prohibited |
| Small Group | Prohibited |
| Large Group | Prohibited |
Exam Tip: West Virginia prohibits pre-existing condition exclusions in all ACA-compliant plans.
Guaranteed Issue and Renewal
West Virginia requires:
Guaranteed Issue
- Insurers must accept all applicants during open enrollment
- Cannot deny coverage based on health status
Guaranteed Renewal
- Cannot cancel coverage except for non-payment or fraud
- Plan discontinuation requires advance notice
Mental Health Parity
West Virginia requires mental health parity:
- Mental health benefits must equal medical benefits
- Same copays, deductibles, and limits
- Coverage for substance use disorders required
Test Your Knowledge
Which marketplace does West Virginia use for individual health insurance enrollment?
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D
Test Your Knowledge
Did West Virginia expand Medicaid under the ACA?
A
B
C
D