The national Group Health Insurance guide covers how group plans work: eligibility, the master contract and certificates, federal COBRA, HIPAA and coordination of benefits. This guide covers the West Virginia rules for group accident and sickness policies (W. Va. Code 33-16-3), continuation after layoff, small employers and mass-marketed group coverage.

Required group policy provisions (33-16-3)

• Statements: applicants' statements are representations. None can void coverage or reduce benefits unless it is in a written application (33-16-3(a)).
• Certificates: the insurer gives the policyholder a certificate for each covered employee or member describing the coverage. With dependent coverage, one certificate per family is enough (33-16-3(b)).
• New members: new employees or members in eligible classes are added under the policy's terms (33-16-3(c)).

Continuation after layoff (33-16-3(e))

A group member who is involuntarily laid off may keep the same coverage by paying premiums at the group rate, for up to 18 months.

Small employers (33-16D-2)

• A small employer averaged at least two and no more than 50 eligible employees in the previous calendar year.
• Affiliated companies, or companies that may file a combined state tax return, count as one employer.

Medicaid

Group health plans, insurers, HMOs and service corporations may not consider a person's Medicaid eligibility in deciding eligibility or paying claims (33-16-14).

Mass-marketed and out-of-state groups (33-6-35)

• Mass-marketed life or health coverage can't be sold until the Commissioner finds the charges reasonable in relation to the benefits. This includes group or blanket policies issued outside West Virginia to residents.
• Insurers offering coverage under out-of-state group or blanket policies must follow West Virginia's advertising and claim-settlement rules.
• Direct response solicitation lets a person apply on the basis of the offer. It doesn't include employee benefit plan or creditor credit-insurance solicitations.

Common exam traps

• Laid-off members may continue at the group rate for up to 18 months.
• A West Virginia small employer has 2 to 50 employees, and affiliates count as one.
• Statements can't reduce benefits unless they are in a written application.
• One certificate per family is enough when dependents are covered.
• Out-of-state group coverage sold to residents still follows West Virginia's advertising and claims rules.