PEIA Story Archives - West Virginia Public Broadcasting

Appeals Court: Medicaid Program Must Cover Gender-Affirming Care

The Fourth U.S. Circuit Court of Appeals in Richmond, Virginia, upheld a lower court ruling Monday on a vote of 8 to 6 that the state’s Medicaid exclusion violated federal law.

A federal appeals court has ruled that West Virginia’s Medicaid program must cover gender-affirming surgeries.

The Fourth U.S. Circuit Court of Appeals in Richmond, Virginia, upheld a lower court ruling Monday on a vote of 8 to 6 that the state’s Medicaid exclusion violated federal law.

The Fourth Circuit ruling also applies to North Carolina’s health insurance program for state employees.

The states had argued that cost, rather than bias against transgender beneficiaries, was behind excluding gender-affirming surgeries. West Virginia’s Medicaid program does cover hormone therapy, office visits, counseling and lab work.

The court’s majority found that the states’ exclusion did not apply to the same procedures, such as mastectomies or breast reductions, for patients with cancer or excess breast tissue who are not transgender.

Attorney General Patrick Morrisey, a candidate for governor in the state’s Republican primary, said he’d appeal the case to the U.S. Supreme Court.

“Our state should have the ability to determine how to spend our resources to care for the vital medical needs of our citizens,” Morrisey said in a statement.

The West Virginia lawsuit, filed in 2020 in the U.S. District Court for the Southern District of West Virginia, named the former Department of Health and Human Resources and its former secretary, Bill Crouch, as defendants.

The suit also covered PEIA, the state employees’ health insurance program.

District Judge Robert Chambers ruled against the exclusions in 2022. Morrisey appealed to the Fourth Circuit.

Taiwan Partnership, First Responder Mental Health Highlight House Happenings

Global partnerships and international politics took center stage in the House of Delegates Thursday, along with a continuing legislative effort to address the mental health crisis among the state’s first responders.

West Virginia And Taiwan

Stepping down from his podium, Speaker of the House Roger Hanshaw, R-Clay, read House Resolution 9, reaffirming the longstanding sisterhood partnership between West Virginia and Taiwan. The state and the embattled Asian nation have worked together as trade and cultural partners since 1980.

Taiwan delegation member Robin Chang spoke of the strong West Virginia/Taiwan relationship through trade, economic ties and cooperation in education and related fields, including a united stand supporting global democracy.

“Even as our democracy thrives, the people of Taiwan continue to face harassment and aggression from our neighbor across the Taiwan Strait,” Chang said. “That is why it has been so encouraging and important for the 23 million Taiwanese people to have received the strong support of our friends here in West Virginia, and the United States.”

Delegates back from a recent mission to Taiwan talked about Taiwan’s hill and hollow topography being similar to West Virginia. However, they said they were getting 5G broadband everywhere. Delegates said Taiwan’s tunnel, bridge and rail infrastructure was exemplary. Now, legislators are studying Taiwan’s related laws and regulations to see how West Virginia can match up.

Hanshaw said it’s a win-win situation to maintain strong relations with a country fighting to remain independent and free.

“Taiwan is a democratic country,” Hanshaw said. “When we talk about growing and cultivating export markets for West Virginia’s businesses and creating new opportunities to grow our state’s economy, we know that the export markets are how we’re going to do that. And if we want to do business in Asia, we want to do business with people whose values are aligned with ours outright.”

First Responder Mental Health

House Bill 5241 requires the Insurance Commissioner to audit PEIA claims for the treatment of PTSD of first responders. The commissioner is also charged with filing an annual report.

The state EMS Department is among many working to address a mental health crisis among first responders.

Del. Heather Tully, R-Nicholas, sponsored the audit bill. She said first responders from her county and elsewhere told her their PEIA insurance mental health claims were consistently rejected.

“A lot of times in PEIA, they were seen to be denied or they were delayed,” Tully said. “As a result of this, we wanted to make sure the insurance commissioner had no oversight over PEIA claims related to this whatsoever, unlike the insurance commissioner being able to audit private insurance. The end goal is to really see how we can work forward and see if we can’t get coverage for our first responders.”

The first responder PTSD audit bill passed the House 90-0 Wednesday evening and was sent to the Senate.

PEIA Director: Agency Making Strides In Controlling Prescription Costs, Advancing Wellness

Brian Cunningham said whenever he’s out in public, he’s bombarded with questions on when PEIA will cover the new anti-obesity drugs, including Wegovy.

West Virginia’s Public Employees Insurance Agency (PEIA) Director Brian Cunningham said he’s working on several fronts to reduce the latest round of premium increases that were approved last week.

Speaking to the interim Joint Standing Committee on Insurance and PEIA on Monday, Cunningham said the agency is seeking some initial prescription cost reducing opportunities around diabetes, weight management and migraine medications.

“We’re taking an incremental approach to comparative effectiveness to minimize provider and member disruption,” Cunningham said.

Cunningham told lawmakers PEIA is leveraging the 340B Drug Pricing Program. He explained it allows Federally Qualified Health Centers (FQHC) to buy medications at a savings.

“(Getting entities such as) disproportionate share hospitals, critical access hospitals, community behavioral health centers, and other covered entities to buy at a very low cost,” Cunningham said. “For example, an AWP (Average Wholesale Price) at minus 50, 60, and even 70 percent in some cases,

Cunningham said the agency is also consolidating a number of wellness programs under a cost saving single management structure with one vendor.

“We’re targeting diabetes, weight management and behavioral health,” Cunningham said. “All problems that we face here in the state of West Virginia.”

Cunningham said a number of expanding PEIA online wellness programs also target weight loss and controlling diabetes.

“That is a bit of a shared savings model,” Cunningham said. “I believe one online program is called Cecelia, one is called DayTwo, both for weight loss. We’ve got a face to face diabetes program that is managed at local pharmacies. And then we have a host of other programs.”

Cunningham answered a question about the PEIA CapitalRX vendor and their “diabetes guarantee,” intended to protect against the spiraling cost of diabetes drugs.

“Think of the Ozempics of the world,” he said. “Which is certainly a cost driver for PEIA right now. If the target cost of those drugs is exceeded, the guarantee kicks in and PEIA is paid back for some of the cost of those drugs.”

Cunningham said whenever he’s out in public, he’s bombarded with questions on when PEIA will cover the new anti-obesity drugs, including Wegovy.

“The reason we have such tight controls and a limited prescribing network for those weight loss drugs, is, in part, because of the cost to plan,” Cunningham said. “If we just opened up, Wegovy for example, and let anybody prescribe it, instead of a 10 and a half percent premium increase, I’d be standing before you here saying it’s a 15 percent premium increase or more.”

Cunningham said later those numbers were an estimate. He told lawmakers he understands that people who have been on Ozempic, for example, may benefit from continuing to remain on Ozempic. He said those are things that PEIA is “looking at and studying right now internally.”

PEIA Health Insurance Premiums Increase Under Review

The PEIA Finance Board is evaluating higher premiums for state and local employees to comply with an 80-20 employer/employee cost split passed by the Legislature this year.

The Public Employees Insurance Agency (PEIA) is considering another increase in premiums next year.

The PEIA Finance Board is evaluating higher premiums for state and local employees to comply with an 80-20 employer/employee cost split passed by the West Virginia Legislature this year.

Senate Bill 268 took effect on July 1 and increased the amount of reimbursement to providers to a minimum of 110 percent of Medicare’s rate. It also included a 24 percent increase in premiums for state employees and a 15.6 percent increase for the non-state employees.

The board met Thursday during the West Virginia Legislature’s October interim meetings and is now considering a 10.5 percent premium increase for state employees who sign up for the insurance, but there would be no change to their benefits. It is also weighing a 13 percent premium increase for employees of local governments that opt into PEIA, and an additional surcharge of approximately $147 for eligible spouses.

Retirees eligible for Medicare would not see any changes in their premiums or benefits. Employees who meet the age requirement for retirement, but not Medicare, would see a 10 percent premium increase with no changes to their benefits.

The PEIA board will hold a series of public hearings next month before making a final decision on possible premium increases.

The public meetings will be held on Nov. 6 at the Highlands Event Center in Wheeling, Nov. 7 at the Holiday Inn in Martinsburg, Nov. 9 at the Holiday Inn – University Place in Morgantown, Nov. 13 at the Culture Center in Charleston and Nov. 14 at the Bluefield State College in Bluefield.

A virtual town hall is scheduled on Nov. 16.

Testimony On East Palestine Train Crash And PEIA Sees New Director, This West Virginia Morning

On this West Virginia Morning, we have a new story from The Allegheny Front – a public radio program based in Pittsburgh that reports on environmental issues in the region. This latest story explores the East Palestine train crash and recent testimony questioning the need to burn the train cars.

On this West Virginia Morning, we have a new story from The Allegheny Front – a public radio program based in Pittsburgh that reports on environmental issues in the region. This latest story explores the East Palestine train crash and recent testimony questioning the need to burn the train cars.

Also, in this show, in an administrative briefing Wednesday, Gov. Jim Justice announced the new director of the state’s Public Employee Insurance Agency (PEIA). Emily Rice has the story.

West Virginia Morning is a production of West Virginia Public Broadcasting which is solely responsible for its content.

Support for our news bureaus comes from Concord University and Shepherd University.

Caroline MacGregor is our assistant news director and produced this episode.

Teresa Wills is our host.

Listen to West Virginia Morning weekdays at 7:43 a.m. on WVPB Radio or subscribe to the podcast and never miss an episode. #WVMorning

Cunningham Named Director Of PEIA

Gov. Jim Justice announced Brian Cunningham as the new director of the state’s Public Employee Insurance Agency Wednesday.

Cunningham grew up in Ivydale, West Virginia, and graduated from Clay County High School. He earned his bachelor’s degree from West Virginia University and moved to Charleston to work with community health centers.

Most recently, he served as a consultant to the West Virginia Medicaid Managed Care program and as the Director of WV PATH.

WV PATH, or People’s Access To Help aids West Virginians in signing up for state benefits.

Justice said he is confident in Cunningham’s appointment as director.

“Brian has spent his career working with community health centers and, and nonprofits, and he’s most recently, he was the director of the West Virginia PATH program, and a consultant to the Medicaid management or managed care program,” Justice said. “Naturally, I’m really excited to bring Brian on as our director of PEIA. It’s a big job.”

Appalachia Health News is a project of West Virginia Public Broadcasting with support from Charleston Area Medical Center and Marshall Health.