The proposed bill seeks to amend the Code of West Virginia by establishing the Mental Health and Substance Use Disorders Insurance Coverage Protection Act. This legislation mandates that certain insurance policies provide coverage for medically necessary treatment of mental health and substance use disorders, effective for policies issued or renewed on or after January 1, 2026. Key provisions include the requirement for insurers to adhere to generally accepted standards for determining medical necessity, ensuring access to out-of-network services when in-network options are unavailable, and prohibiting coverage denials based on the assumption that services could be covered by public entitlement programs. The bill also imposes civil penalties for violations and mandates education and training for insurers on clinical review criteria.

Additionally, the bill introduces a new provision allowing insurers to include a clause in their contracts that informs insured individuals about the application of contract terms in routine operations, such as decisions related to eligibility and benefits. Importantly, this provision is designed to ensure that it does not lead to a deferential standard of review by courts when decisions are challenged. The bill also includes a deletion of certain existing legal language, although specific details of the deletions are not provided. Overall, the legislation aims to enhance transparency in insurance practices concerning mental health and substance use disorder coverage, ensuring that individuals are well-informed about the management of their claims and benefits.

Statutes affected:
Introduced Version: 5-16-15a, 33-15-4y, 33-16-3ii, 33-24-7z, 33-25-8w, 33-25A-8z, 33-57A-1, 33-57A-2, 33-57A-3, 33-57A-4, 33-57A-5