West Virginia Offices of the Insurance Commissioner 2009 Annual ...

An applicant must be a resident of West Virginia for at least 30 days except in the case of the HIPAA
and HCTC eligibles, for whom there are no minimum residency requirements. Dependents of persons
eligible for AccessWV coverage are also eligible.
The following persons are not eligible for coverage through AccessWV:
Those eligible to receive employment-related group insurance coverage through their own
employment, or that of a spouse or a parent;
Those eligible for medical coverage under a federal or state program including Medicare,
Medicaid and the West Virginia Children’s Health Insurance Program; and
Residents of a public institution (i.e., federal or state correctional facility or a Veteran’s home)
unless there is HIPAA eligibility.
Coverage Plans
Access WV offers four plans — A, B , C, and D. All plans cover the same broad array of services but
differ in their premiums, deductibles and out-of-pocket maximums. Annual medical deductibles range
from $400 to $4,000 for individual coverage and $800 to $8,000 for family coverage for in-network
services. The medical deductibles are double for out-of-network services. A separate deductible,
ranging from $200 to $2,000 for individual coverage and $400 to $4000 for family coverage, applies to
prescription drugs. The annual medical benefit maximum is $200,000 for all plans and the annual
pharmacy benefit maximum is $25,000. A combined lifetime maximum of $1,000,000 for medical and
pharmaceutical benefits applies to all plans.
Covered services include hospital, physician services, outpatient services, home care, prescription
drugs, maternity, rehabilitation, outpatient therapies and other medical services. The benefit package
incorporates cost containment measures including precertification of specified inpatient admissions
and outpatient services, prior authorization of out-of-state services, medical case management, disease
management, and pharmacy benefit management, including prior authorization, quantity limits and
step therapy.
Premiums
The enabling legislation provides that AccessWV premiums be set at 125-150 percent of the standard
risk rate as determined by considering the premium rates charged by other insurers offering coverage
in the individual market in West Virginia. Premium levels are set by the Board of Directors and vary
based on geographic region, age band, gender and tier (single or family). 2009 rates were found to be
127% of the standard market rates.
Premiums adjustments were discussed by the board as sufficient actuarial experience began to
accumulate. New premiums for geographic area, region and tier were made effective January 1, 2010.
Enrollment Procedures
Interested persons may call toll free 1-866-445-8491 to request application materials. Materials may
also be downloaded from the website www.accesswv.org. Requests for information are fulfilled by the
AccessWV Program Office. The completed application and first month’s premium are returned to the
Third Party Administrator. The TPA determines eligibility and answers eligibility and benefit
questions. Since November 1, 2007, the Plan Administrator has subcontracted these functions to Wells
Fargo Third Party Administrators (TPA).
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