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Islets of Hope state diabetes insurance coverage laws |
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Important Disclaimer Information for this article was compiled and edited by Lahle A. Wolfe, Islets of Hope. Important Disclaimer This information for general information purposes only. It is not intended to be used a recommendation or endorse- ment of any program or entity This information is not intended to serve as any form of medical or legal advice. Article Sources National Conference of State Legislatures Government Accountability Office (GAO) report number GAO-05-210 entitled "Managing Diabetes: Health Plan Coverage of Services and Supplies;" released on March 28, 2005.
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West Virginia - State Diabetes Insurance Coverage Laws
Hock's offers 30-50% discounted prices on diabetes supplies. We cannot specifically recommend or endorse any company but we have been listing Hock's in our resource directory for over a year as one of the two cheapest online companies to purchase from. We recently affiliated with Hock's because our own experience with them has been so positive. If you do place an order through our site, they will contribute financially towards our cause and you will get reasonable prices for diabetes supplies. West Virginia has mandated coverage for diabetes care. For additional laws mandating insurance coverage in West Virginia, see §33-16-16 (major medical) - 1996 law. Requires health insurance policies to provide coverage for specified medically necessary equipment and supplies.; includes education in self-management diet. West Virginia Managed Care Regulations (HMOs) Access - W. Va. Code Ann. §§ 33-42-1 – 33-42-7 – OB/GYNs – direct access at least annually to a women’s health care provider. Complaints/UR W. Va. Code Ann. § 33-25A-12 – grievances – HMO must designate grievance coordinator and establish toll-free number; each level of procedure must have some person with problem solving authority to participate; formal grievances must be processed through all phases of the procedure in a reasonable length of time, not to exceed 60 days (any grievance in which time is of the essence must be handled on an expedited basis, “such that a reasonable person would believe that a prevailing subscriber would be able to realize the full benefit of a decision in his or her favor”); the procedure must state that the subscriber has the right to appeal to the state insurance commissioner; physicians must be involved in reviewing medically related grievances; HMOs may not establish time limits of less than one year from the date of occurrence for the subscriber to file a formal grievance; copies of grievances and responses must be available to the commissioner and public for inspection for 3 years. W. Va. Code Rules §§ 114-51-2 – 114-51-4 – UR – UR programs must have written UR protocols based on reasonable medical evidence; HMOs must make review criteria available to participating physicians upon request and establish mechanisms for checking the consistency of application and updating criteria on a periodic basis; a licensed physician must conduct a review of medical appropriateness on any denial of medical services, with a physician consultant specially trained in the area available during the review process; decisions must be made in a timely manner; HMOs must establish medically appropriate timeframes for urgent, emergency and planned care cases; in case of denial, a written notice must be sent immediately to all involved parties, and must include the reason for denial and an explanation of the appeal process; HMOs must have mechanisms to evaluate the effects of the program. Disclosure - W. Va. Code Ann. § 33-25C-3 – disclosure – all managed care plans (HMOs and prepaid plans) must give subscribers notice of certain rights including: the ability to pursue grievance and hearing procedures without reprisal, the right to privacy and confidentiality, the right to be informed of plan policies and any charges; the ability to obtain evidence of medical credentials of providers, the right to have coverage denials reviewed by appropriate medical professionals. Emergency Care - W. Va. Code Ann. §§ 33-25A-8d (HMOs), 33-15-21, 33-16-3i (insurers), 33-24-7e (corporations) – emergency care – prudent layperson standard for emergency medical condition; preauthorization or precertification may not be required for emergency services (stabilization); excludes employer-sponsored plans. (applies through 6/30/2000) Nondiscrimination - W. Va. Code Ann. § 33-25A-14 – discrimination – HMOs may not discriminate in enrollment policies or quality of services on the basis of health status, among other things, subject to proviso that differences in rates based on valid actuarial distinctions will not be considered discrimination. Prohibition of Incentives - W. Va. Code of Reg. § 114-53 – incentives – payments as an inducement to deny medically necessary services are prohibited. Consumer Participation - W. Va. Code Ann. § 33-25A-6 – policy and operation – HMO enrollees must be afforded an opportunity to participate in matters of policy and operation. Selected Benefit Mandates - W. Va. Code Ann. §§ 33-15C-1, 33-16-16 – diabetes – standard provision. |
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