The proposed bill introduces the Mental Health and Substance Use Disorders Insurance Coverage Protection Act, which mandates that all insurance policies issued or renewed on or after January 1, 2027, must cover medically necessary treatment for mental health and substance use disorders. It establishes new sections within the Code of West Virginia that outline insurance coverage requirements, definitions of key terms, and standards for determining medical necessity. The bill prohibits discretionary clauses in insurance contracts that could undermine these requirements and ensures that insurers adhere to generally accepted standards of care when making medical necessity determinations. It also requires insurers to provide out-of-network services without imposing higher costs if in-network services are unavailable and outlines penalties for non-compliance.

Additionally, the bill allows insurers to include a clause in their contracts that informs insured individuals about the routine application of contract terms in decision-making processes, such as eligibility determinations and claims handling. However, this provision is crafted to ensure it does not create a deferential standard of review by courts, thus safeguarding the rights of insured individuals. The bill also includes specific legal language changes, including the insertion of a new clause that clarifies the permissible scope of contract provisions related to decision-making processes, promoting transparency and accountability in insurance practices concerning mental health and substance use disorder coverage.

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