West Virginia Code of State Rules Agency 72 - Catastrophic Illness Commission
📘 West Virginia Code of State Rules — Agency 72: Catastrophic Illness Commission
Agency 72 establishes the rules and procedures for the West Virginia Catastrophic Illness Commission (CIC). This commission is tasked with providing financial assistance to families of children with catastrophic illnesses—conditions that are severe, long-term, and require expensive medical treatment.
The Commission operates under the authority of West Virginia Code §16-29A.
1. Purpose and Authority
Purpose: To provide assistance to families with children under 18 suffering from catastrophic illnesses when medical expenses exceed their ability to pay.
Authority: The Commission is authorized by statute to:
Accept applications
Evaluate financial and medical eligibility
Approve payments to cover medical expenses
Establish administrative procedures to govern claims and reimbursements
Goal: Protect children with severe medical conditions and relieve financial burden on their families while ensuring public funds are properly administered.
2. Eligibility and Application
A. Eligibility Criteria
To qualify for assistance, applicants must meet the following:
Child’s Age: Under 18 years of age.
Residency: Must be a resident of West Virginia or the family must maintain legal residence in the state.
Medical Condition: Child must have a catastrophic illness or injury, defined as one with:
Life-threatening potential or long-term severe disability
High cost of treatment exceeding typical insurance coverage
Financial Need: Family income must fall below thresholds established by the Commission relative to medical expenses.
B. Application Process
Submission of Forms: Families submit an application including:
Medical documentation from licensed physicians
Proof of family income
Details of expenses already incurred
Verification: The Commission verifies medical and financial eligibility.
Approval/Denial: The Commission approves applications meeting criteria and issues a written notice of the decision.
3. Types of Assistance
The Commission can provide:
Reimbursement of medical bills not covered by insurance or other programs
Payment for medications, medical supplies, therapies, and specialized equipment
Travel and lodging expenses related to treatment, if approved
Other extraordinary medical costs deemed necessary for the child’s care
Limits: Payments are subject to available funding and prioritization criteria. The Commission has discretion to approve partial funding when resources are insufficient.
4. Administrative Procedures
A. Hearings and Appeals
If an application is denied, families may request a formal hearing.
The hearing allows applicants to present:
Additional evidence
Medical opinions
Financial documentation
Decisions after a hearing can be appealed to West Virginia courts under the Administrative Procedures Act.
B. Documentation and Reporting
Families must submit receipts, invoices, or proof of payment for reimbursement.
The Commission audits claims to ensure funds are used appropriately.
C. Confidentiality
Medical and financial information provided to the Commission is confidential and protected under state law.
5. Case Law Principles
While there are few reported cases directly involving the Catastrophic Illness Commission, relevant principles can be drawn from general administrative law and public assistance case law in West Virginia:
A. Administrative Discretion
The Commission is granted broad discretion in determining eligibility and allocating funds.
Courts generally defer to the Commission’s judgment unless there is:
Arbitrary or capricious action
Clear violation of statutory authority
Denial without adequate evidence or due process
B. Due Process
Applicants are entitled to notice and an opportunity to be heard before denial of assistance becomes final.
For example, if a family submits complete documentation but the Commission denies assistance without explanation, courts can overturn the decision for lack of procedural fairness.
C. Judicial Review
Appeals from Commission decisions are governed by West Virginia’s Administrative Procedures Act.
Courts evaluate whether the Commission:
Followed statutory and procedural rules
Based its decisions on substantial evidence
Acted within the scope of authority
Example Principle: If a denial of assistance is based solely on subjective interpretation of “catastrophic illness” without supporting medical evidence, courts can require the Commission to reconsider the application.
6. Key Provisions Summary
| Topic | Key Points |
|---|---|
| Purpose | Provide financial assistance to families of children with catastrophic illnesses. |
| Eligibility | Child under 18, WV resident, catastrophic illness, financial need. |
| Application | Must submit medical documentation, income verification, and expense records. |
| Assistance | Reimbursement for medical bills, equipment, travel, and extraordinary expenses. |
| Administrative Procedures | Written decisions, hearings on denial, documentation audits, confidentiality. |
| Appeals | Judicial review under Administrative Procedures Act; decisions must be supported by evidence. |
| Case Law Principles | Courts defer to Commission discretion but require due process, substantial evidence, and adherence to statutory authority. |
7. Key Takeaways
Agency 72 ensures families of children with catastrophic illnesses can access funds for medical care they cannot otherwise afford.
The Commission has discretion in granting assistance but must follow statutory and procedural rules.
Families have rights to hearings and judicial review if applications are denied.
Case law emphasizes due process, substantial evidence, and non-arbitrary decision-making.
RELATED Blog
comments