West Virginia Code of State Rules Agency 113 - Health Insurance Plan
West Virginia Code of State Rules – Agency 113: Public Employees Insurance Agency (PEIA)
(Also referred to as "Health Insurance Plan")
Overview:
Agency 113 of the West Virginia Code of State Rules (CSR) contains the rules established by the Public Employees Insurance Agency (PEIA), which administers health insurance benefits for eligible public employees, retirees, and their dependents in West Virginia.
PEIA is responsible for managing health, life, and optional benefits under a self-insured plan or through contracts with third-party providers. The agency's authority comes from West Virginia Code §5-16.
Primary Functions of Agency 113 / PEIA:
Administering Health and Life Insurance Plans
Oversees the benefits and policies for state employees, public school employees, and certain local governments and retirees.
Offers multiple plan options (e.g., PPB Plans, managed care).
Premiums and Contributions
Sets premium rates and employer/employee contributions.
Adjusts based on salary tiers, family size, tobacco use, and spousal coverage.
Benefit Design
Specifies coverage for medical, prescription drug, dental, vision, and wellness benefits.
Defines in-network vs. out-of-network coverage, copays, deductibles, and coinsurance.
Eligibility and Enrollment
Establishes rules for initial enrollment, qualifying life events, and open enrollment periods.
Manages retiree health benefits and dependent eligibility requirements.
Appeals and Grievances
Provides processes for members to appeal claims denials, eligibility issues, and benefit disputes.
Wellness and Incentive Programs
Offers financial incentives and premium reductions for participation in wellness screenings and programs.
Key CSR Sections Under Agency 113 Include:
CSR §113-1 – General Administration of the Public Employees Insurance Program
Definitions, eligibility, plan administration, and employer responsibilities.
CSR §113-2 – Benefits and Premium Structure
Details benefit levels, premium rates, employer/employee cost-sharing, and rate-setting procedures.
CSR §113-3 – Grievance and Appeals Procedures
Steps for filing and resolving member appeals regarding coverage or claim issues.
CSR §113-5 – Managed Care and Third-Party Administration
Describes contracts with providers and network rules.
Legal Authority:
West Virginia Code §5-16 – Public Employees Insurance Act
Grants PEIA authority to create, amend, and enforce rules necessary to manage the public employee insurance programs.
Covered Populations:
State employees
County and municipal employees (if participating)
Public school employees
Retirees
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