AccessWV - Health Care

Frequently Asked Question's

What is AccessWV?
AccessWV is a health plan created by West Virginia law to provide health insurance to West Virginians who have been unable to find health insurance in the private market because of a medical condition.
It also serves those who have guaranteed access to coverage ("portability rights") through the federal Health Insurance Portability and Accountability Act (HIPAA) as well as those who are eligible for the federal Health Coverage Tax Credit (HCTC) program.

When did AccessWV begin operations?
AccessWV began operations July 2005.

Who is eligible for AccessWV insurance coverage?
Eligible individuals must be legal residents of West Virginia for at least 30 days AND must also experience one or more of the following: • Be rejected, within the last six months, for health insurance coverage by a carrier selling health insurance in West Virginia
• Only be able to get limited coverage in the regular market or similar coverage to AccessWV at a higher rate • Have a pre-existing, severe or chronic medical condition that would make a person uninsurable as determined by the AccessWV Board of Directors • Be federally eligible through HIPAA • Be eligible for the Health Coverage Tax Credit (HCTC)
Persons who do not qualify for this plan include: •Those eligible to receive coverage under a group insurance plan offered either by their employer or union or their spouse’s employer or union •Those eligible for medical coverage under a federal or state program including Medicare, Medicaid, or WVCHIP • Residents of a public institution (i.e., a federal or state correctional institution or a Veteran’s Home)

Note: Minimum WV residency requirement does not apply to HIPAA or HCTC eligibles.

Does AccessWV guarantee coverage?
AccessWV guarantees that all West Virginia residents who meet eligibility requirements can purchase health insurance through the plan, regardless of their current and past health circumstances. The plan is offered by the State of West Virginia through the West Virginia Offices of the Insurance Commissioner.

How many different plans are available through AccessWV?
Individuals may apply for one of three benefit plans (Plan A, B or C). The plans have different premiums, deductibles and out-of-pocket maximums. An applicant may elect single or family coverage. Please see the “Summary of Benefits” at www.AccessWV.org for details on the plans and a list of covered services.

How are AccessWV premiums determined?
Premiums for AccessWV are based on the applicant's age, gender and county of residence and the kind of coverage selected (single or family). Please see the “Premiums" chart at www.AccessWV.org for current premiums.

What do the AccessWV plans cover?
All three plans cover inpatient hospital care, physician services, outpatient services, home care, prescription drugs, maternity care, rehabilitation, outpatient therapies, and other medical services. Deductibles and out-of-pocket maximums vary depending upon the plan chosen. Under all plans, in most cases there is a 6-month waiting period before AccessWV will provide coverage for services related to a pre-existing condition of a new enrollee. Health care needed for other reasons is covered according to the benefit design.

How does someone obtain AccessWV coverage?
An Application and related materials may be obtained by calling AccessWV toll-free at 1-866 445 8491. The Application may also be downloaded from the web-site www.AccessWV.org. A "Guide to Completing Your Application" is also available on the web-site. Applications must be complete and received by the fifteenth of the month to be approved for coverage as of the first of the following month.

Who manages AccessWV?
Overall direction and management of AccessWV is the responsibility of the Board of Directors and the Executive Director. The AccessWV Program Office is part of the West Virginia Offices of the Insurance Commissioner.
AccessWV contracts with the Public Employees Insurance Agency (PEIA) to perform eligibility, customer service and claims administration functions. PEIA in turn subcontracts with Wells Fargo (formerly known as Acordia National) for medical claims administration and Express Scripts for pharmacy benefit management.

Can members go to any doctor or hospital?
AccessWV reimburses providers using the Public Employees Insurance Agency (PEIA) fee schedule. As such, any West Virginia provider who accepts PEIA reimbursement is considered an AccessWV provider.

While it is not encouraged, a member may elect to receive care outside of West Virginia. As of July 1, 2007, prior authorization for out-of-state services must be received from our medical claims administrator for full out-of state benefits to apply. If a member elects to receive services out-of state without prior authorization, payment by AccessWV will be reduced as specified in our Policy.

Is out-of-state coverage available?
AccessWV is a program of the State of West Virginia for West Virginians. AccessWV strongly encourages receipt of services within West Virginia. Member cost-sharing is most favorable when services are received within the state. Services from out-of-state providers are subject to increased cost-sharing, and the required cost-sharing depends on whether the provider is "in-network" or "out-of-network". As of July 1, all out-of-state services must receive prior authorization through Wells Fargo in order to be eligible for the full out-of-state benefit. Failure to obtain prior authorization results in a penalty.

Can coverage be terminated?
Once enrolled, you will continue to be enrolled in AccessWV as long as you continue to pay your premiums and respond to our annual survey regarding your continued residency in West Virginia and other requests for information that we may make, unless one of the following occurs: • You become eligible to obtain individual coverage because your condition has improved.
• You become eligible to obtain group coverage through your employer or union or your spouse's employer or union.
• You move out of West Virginia.
• You become eligible for Medicare, Medicaid, or WVCHIP.
• You become a resident or inmate of a public institution.
• AccessWV spends $1,000,000 in lifetime benefits for your care.
• You request disenrollment in writing
• You have committed an act of fraud to circumvent the statutes or regulations of AccessWV.

Enrollees who have terminated coverage for any reason are not eligible to re-apply for 12 months. AccessWV's policies with regard to termination of dependent coverage may be found in our Policy.

Who sets the premiums charged?
By law, premiums are required to be based on the prices charged by other insurers offering comparable health insurance coverage to individuals in West Virginia and are to be set at 125 to 150 percent of the standard market. As a result, the premiums for AccessWV are somewhat higher than the premiums in the traditional market. This pricing is necessary due to the medical status of the AccessWV members. The premiums in effect for AccessWV are set by the Board of Directors.

Who are the current members of the Board?
The Board, by law, is made up of the Insurance Commissioner or his or her designated representative and six members appointed by the Governor. At least 2 members must be individuals or the parent, spouse or child of an individual who may be reasonably expected to qualify for coverage by the plan. ("consumer representatives"). At least two Board members must be representatives of insurers and at least one Board member must be a hospital administrator. Laura Phillips of Charleston and Paul Prunty of Fairmont currently serve as consumer representatives. Fred Earley of Mountain State Blue Cross Blue Shield and David Haden of David Haden Associates serve as insurer representatives. David Ramsey of Charleston Area Medical Center is the hospital representative. Christopher Plein of West Virginia University's Division of Public Administration represents the community at large. The Insurance Commissioner, Jane Cline (or her designee), serves as the chairperson and is an ex officio member of the Board.

How are operations of AccessWV financed?
AccessWV is financed through premiums paid by members of the plan and by special assessments made by all hospitals that are based in West Virginia. No public or state funds are used to support the plan. AccessWV received a federal grant of $1 million to cover development and initial operating costs through 2006.

Can employers pay premiums on behalf of employees?
No, the law specifically prohibits employers from paying premiums on behalf of enrollees. However, the federal HCTC program may pay a portion of your premium if you qualify for that program.

5/07