West Virginia Code of State Rules Agency 151 - Public Employees Insurance Agency
West Virginia Code of State Rules – Agency 151: Public Employees Insurance Agency (PEIA)
Overview:
Agency 151 of the West Virginia Code of State Rules (CSR) contains the administrative rules promulgated by the Public Employees Insurance Agency (PEIA). PEIA is responsible for managing health and life insurance benefits for eligible public employees, retirees, and their dependents across West Virginia.
The rules in this agency govern eligibility, premium contributions, plan design, coverage options, and administrative procedures for health benefit plans administered under West Virginia Code §5-16 (Public Employees Insurance Act).
Key Functions and Areas Regulated by Agency 151:
Eligibility and Enrollment
Defines who qualifies as an employee, retiree, or dependent under PEIA
Enrollment and termination procedures
Special enrollment events (e.g., marriage, birth, loss of other coverage)
Plan Options and Coverage
Rules outlining PEIA’s offered plans (PPO, HMO, high-deductible, etc.)
Covered medical services, prescription drugs, and exclusions
Mental health, maternity, and preventive care coverage
Premiums and Cost Sharing
Contribution requirements for employees, employers, and retirees
Deductibles, coinsurance, and out-of-pocket maximums
Premium assistance programs and wellness incentives
Retiree Benefits
Continued coverage for eligible retirees
Medicare coordination rules (e.g., Medicare Advantage plans)
Premium structures based on years of service or income
Appeals and Grievances
Procedures for appealing claims denials or plan coverage decisions
Timeframes, documentation requirements, and final review processes
Wellness and Cost Containment Programs
Incentive programs for smoking cessation, physical activity, and chronic condition management
Disease management services and preventive screening campaigns
Coordination of Benefits
Rules for when participants have other insurance (e.g., spouse’s plan or Medicare)
Subrogation rights and third-party recovery rules
Selected CSR Chapters under Agency 151 (Illustrative Examples):
151CSR1 – General Administration and Definitions
151CSR2 – Eligibility and Enrollment Rules
151CSR3 – Premiums, Cost-Sharing, and Contributions
151CSR4 – Claims, Appeals, and Grievance Procedures
151CSR5 – Retiree Health Coverage and Medicare Coordination
(CSR chapter numbers may vary based on updates or restructuring.)
Administering Agency:
West Virginia Public Employees Insurance Agency (PEIA)
Legal Authority:
West Virginia Code §5-16 – Public Employees Insurance Act
Related statutory amendments and budgetary requirements from the West Virginia Legislature
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