Mandated Coverage for Substance Use Disorder

All group health insurance policies issued or renewed on or after Jan. 1, 2019, that provide hospital or medical expense benefits must provide coverage for inpatient and outpatient treatment of substance use disorder at in-network facilities at the same level as other medical services offered by the group policy. While federal law requires small employer plans to provide coverage for the treatment of substance use disorder, there is not a similar requirement for large employer plans. The mental health parity regulations require equal treatment between medical and substance use disorder benefits if the large plan is already providing coverage for substance use disorder. This law will require all insured plans issued in West Virginia to provide such coverage.

Further, a facility shall notify the insurer of the insured’s admission and initial treatment within 48 hours. If there is no in-network facility immediately available, the policy shall provide necessary exceptions to its network for treatment. If an insured is being treated at an out-of-network facility and an in-network facility becomes available, the insurer may require transfer to the in-network facility.

The benefits for the first five days of intensive outpatient or partial hospitalization services shall be paid without retroactive review of medical necessity by the plan. The insured’s health provider shall determine medical necessity. Coverage for day six and every subsequent six-day period shall be subject to the insurer’s concurrent review for medical necessity.

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