3.1 West Virginia Health Insurance Policy Requirements

Who Regulates Health Insurance in West Virginia

West Virginia calls health insurance accident and sickness insurance, and it is regulated by the Offices of the Insurance Commissioner (OIC) under W. Va. Code Chapter 33. On the Pearson VUE exam, roughly 30 scoreable questions test this WV-specific accident-and-sickness content; the passing score is a scaled 70. Memorize the exact numbers below — the state section rewards precise recall, not general concepts.

Common trap: an answer naming a "West Virginia Health Exchange" or "Covered West Virginia" is wrong. WV uses the federally facilitated marketplace at HealthCare.gov.

Uniform Policy Provisions

Individual accident and sickness policies must contain the mandatory provisions of the Uniform Individual Accident and Sickness Policy Provision Law. The most-tested numeric thresholds:

Worked example: A claimant suffers a covered loss on March 1. Notice should be filed by March 21 (20 days). If the insurer has not supplied claim forms by 15 days after that notice, the claimant may submit written proof in any form. Proof of loss is due within 90 days — by roughly May 30 — though late proof is excused if it was not reasonably possible to comply.

The Marketplace and Medicaid Expansion

West Virginia residents buy individual coverage through HealthCare.gov, with advance premium tax credits available based on household income. Annual open enrollment runs each fall; special enrollment periods open for qualifying life events such as marriage, birth/adoption, or loss of other coverage.

West Virginia expanded Medicaid under the ACA:

• Adults with income up to 138% of the Federal Poverty Level (FPL) qualify.
• Children qualify at higher income thresholds through Medicaid and CHIP.
• Pregnancy-related coverage extends eligibility further.

Know that 138% FPL is the adult-expansion line — a frequent distractor offers 100% or 150%.

Essential Health Benefits and Federal Protections

ACA-compliant Qualified Health Plans (QHPs) sold in West Virginia must cover the ten Essential Health Benefits (EHBs):

1. Ambulatory (outpatient) patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

A reliable exam trap drops adult dental and vision into the EHB list — those are NOT required EHBs; only pediatric dental and vision are.

Pre-Existing Conditions, Guaranteed Issue, and Renewal

ACA rules apply across market segments in West Virginia:

• Guaranteed issue: insurers must accept all applicants during open enrollment or a valid special enrollment period; coverage cannot be denied based on health status.
• Guaranteed renewability: the insurer cannot cancel an in-force ACA plan except for non-payment of premium, fraud, or material misrepresentation; product discontinuation requires advance notice (generally 90 days).
• Community rating: premiums may vary only by age (3:1 limit), geographic area, family size, and tobacco use — never by gender or health history.

Scenario: A 58-year-old applies during open enrollment after a cancer diagnosis. The insurer must issue the policy at the standard community rate with no pre-existing waiting period — guaranteed issue plus the pre-existing prohibition both apply.

Mental Health Parity and Mandated Benefits

Under federal parity and West Virginia mandates, mental health and substance use disorder benefits must be no more restrictive than medical/surgical benefits — the same deductibles, copays, visit limits, and treatment limits apply. West Virginia also mandates specific coverages in group and individual accident and sickness plans, including:

• Mammography and cervical cancer screening
• Diabetes self-management education and supplies
• Newborn and adopted-child coverage from the moment of birth/placement (notify the insurer within 31 days to continue dependent coverage)
• Maternity and minimum hospital stays after childbirth

Exam tip: the 31-day window to add a newborn mirrors the 31-day grace period for non-weekly/non-monthly modes — keep them distinct: one adds a dependent, the other keeps the policy in force.