COMMITTEE SUBSTITUTE
FOR
H. B. 3022
(By Delegates Hatfield, Guthrie, Perdue, Brown,
Hunt, Skaff, Spencer, Wells, Campbell and Canterbury)
(Originating in the Committee on Finance)
[March 27, 2009]
A BILL to amend the Code of West Virginia, 1931, as amended, by
adding thereto a new article, designated §16-2L-1, §16-2L-2,
§16-2L-3, §16-2L-4, §16-2L-5, §16-2L-6 and §16-2L-7, all
relating to the creation of a medical home health care plan
for uninsured adults providing primary and preventive care;
the plan's cost would not exceed $40 per month per subscriber,
medical home participating providers would be paid a
capitation payment per member per month; funding to be
provided by the State of West Virginia if available, the
uninsured adult and his or her employer; providing the
Director of the Public Employees Insurance Agency with the
authority to develop the plan and to promulgate regulations,
policies and procedures if resources are available; providing
that an administrative fee may be charged per member per month
to cover the administrative costs if no other funding is made
available; providing for requirements for participating health
care providers; and providing the Public Employees Insurance Agency with the authority to suspend, revoke or nonrenew
participating providers' participation agreements.
Be it enacted by the Legislature of West Virginia:
That the Code of West Virginia, 1931, as amended, be amended
by adding thereto a new article, designated §16-2L-1, §16-2L-2,
§16-2L-3, §16-2L-4, §16-2L-5, §16-2L-6 and §16-2L-7, all to read as
follows:
ARTICLE 2L. UNINSURED MEDICAL HOME PLAN.
§16-2L-1. Legislative findings and statement of purpose.
(a) The Legislature finds that the high number of West
Virginia uninsured workers causes unnecessary morbidity and
mortality, increases the cost of health insurance for employers
offering health insurance and contributes to high utilization of
emergency rooms. The Legislature also finds that the medical home
concept is an effective delivery system for preventive care and a
plan that would allow health clinics and private medical
practitioners to provide medical home services including primary
care and preventive health services for a monthly fee would improve
the well-being and health status of West Virginia's uninsured
adults.
(b) In carrying out this plan, it is the intent of the
Legislature to eliminate legal, statutory and regulatory barriers
to the establishment of a plan providing preventive and primary
care services for a prepaid monthly fee, not to exceed $40 for the
first two years, and modest per visit subscriber copayment; to encourage uninsured adult residents of this state to establish and
use a medical home; to expand preventive and primary care services
for the adult uninsured; and to exempt the Uninsured Medical Home
Plan from regulation as an insurer, the operation of insurance laws
of the state and all other laws inconsistent with the purposes of
this article.
§16-2L-2. Definitions.
For the purposes of this article, the following definitions
apply:
(1) "Patient centered medical home" or "medical home" means
a health care setting that facilitates partnerships between
individual patients and their personal physicians and, when
appropriate, the patients' families and communities. A patient
centered medical home integrates patients as active participants in
their own health and well being. Patients are cared for by a
physician or physician practice that leads a multi-disciplinary
health team, which may include but is not limited to nurse
practitioners, nurses, physician's assistants, behavioral health
providers, pharmacists, social workers, physical therapists, dental
and eye care providers and dieticians to meet the needs of the
patient in all aspects of preventive, acute, chronic care and end-
of-life care using evidence-based medicine and technology.
(2) "Participating provider" means a provider under this
article that has been granted approval to participate as a medical
home for the Medical Home Plan;
(3) "Primary care" means basic or general health care which
emphasizes access to assure timely intervention with acute
problems, continuity of care for chronic conditions and monitoring
to recall to promote appropriate preventive health services.
(4) "Provider" has the same meaning as "ambulatory health care
facility" set forth in subsection (b), section two, article two-d
of this chapter or "private office practice" as set forth in
subsection (a)(1), section four of that article;
(5) "Subscriber" means any adult individual who subscribes to
the prepaid plan approved and operated in accordance with the
provisions of this article, including an employee of any employer
that has purchased a group enrollment on behalf of its employees.
(6) "Plan Advisory Group" means a group of ten individuals who
advise the Director of the Public Employees Insurance Agency (PEIA)
on regulations and significant policy and procedures related to the
implementation of the Uninsured Medical Home Plan. The members of
the group shall serve two year terms and shall be selected by the
Governor. The group's membership shall consist of two
representatives from each of the following groups: employers
participating in the plan; employees who are members of the plan;
state consumer health advocacy groups; members of the House of
Delegates or Senate Health Committees; and participating medical
homes.
§16-2L-3. Authorization of Uninsured Medical Home Plan; Health
Care Authority considerations in selection of participating providers; funding.
(a) As resources are available, PEIA shall develop and
implement a plan that entitles subscribers to obtain medical home
services from participating providers. The medical home shall
include primary care services for acute and chronic diseases and
minor injuries, preventive health services, care management
services, office laboratory, twenty-four hour telephone access to
a health care professional and assistance in obtaining free or
discounted prescription medicines through the West Virginia Rx
program, patient assistance programs offered by pharmaceutical
companies or Section 340(b) pharmaceutical programs offered by
certain community health centers and hospitals. Services may also
include, if provided by the medical home, directly or by contract,
or if provided by contract with PEIA, outpatient reference
laboratory, plain film radiology, primary behavioral health
services and limited prescriptions not otherwise available.
(b) Subject to the provisions of this article, the PEIA, with
the advice of the Medical Home Advisory Group, is vested with
authority to carry out the following functions, either directly or
by contract, to implement the Uninsured Medical Home Plan: develop
service and reporting requirements for participating medical homes
and enter into contracts with primary care providers to provide
medical home services; develop medical home capitation rates and
copayment rates, including possible variations in rate levels based
on the range of services provided through the medical homes; establish and revise quality performance measures, processes for
collecting data on quality measures and utilization and reporting
on quality measures and utilization; recruit medical home
providers; market the Uninsured Medical Home Plan to employers and
employees; manage member enrollment and disenrollment and the
billing and collection of premiums. A portion of the medical home
plan's monthly fee may be funded by the state and the remainder
shall be divided between an employer and the employee: Provided,
That an unemployed adult may participate in the plan by paying one
hundred percent of the fee after the state's share.
(c) The state's contribution to the cost of the Uninsured
Medical Home Plan, including the cost of the administration of such
a plan, may be obtained by the allocation of federal funds for
preventive health care or other appropriate Federal funds or may be
obtained by funds appropriated by the Legislature or by retaining
a percentage of the monthly per member per month fee determined
necessary by the Finance Board created in article sixteen, chapter
five of this code in consultation with the Medical Home Advisory
Board created in this article.
(d) In furtherance of the objectives of this article, the PEIA
is authorized to accept any and all gifts, grants and matching
funds whether in the form of money or services for the purpose of
implementing this article.
§16-2L-4. Director of the Public Employees Insurance Agency
approval of fees, statement of services.
(a) Every subscriber is entitled to evidence of plan
membership that shall contain a clear, concise and complete
statement of the services provided by the participating provider
and the benefits, if any, to which the subscriber is entitled; any
exclusions or limitations on the service, kind of service,
benefits, or kind of benefits, to be provided; and where and in
what manner information is available as to how a service may be
obtained.
(b) Fees paid to participating providers are not subject to
premium taxes and surcharges imposed on insurance companies.
(c) Notwithstanding the provisions of chapter thirty-three of
this code to the contrary, the Uninsured Medical Home Plan and
participating providers in the medical home plan created and
authorized pursuant to this article are not to be considered as
providing insurance or as offering insurance services. The
Uninsured Medical Home Plan and such medical home participating
providers are specifically excluded from the definitions of
"insurer" and "insurance" as defined in article one, chapter
thirty-three of this code, and are not subject to regulation by the
Insurance Commissioner except to the extent set forth in this
article, nor are participating providers unauthorized insurers
pursuant to section four, article forty-four of chapter thirty-
three of this code.
§16-2L-5. Rule-making authority.
The Director of the PEIA, with advice from the Medical Home Advisory Group, shall promulgate joint rules as necessary to
implement the provisions of this article, including emergency
rules, promulgated pursuant to, chapter twenty-nine-a of this code.
§16-2L-6. Participating provider plan requirements; primary care
services; notice of discontinuance or reduction of
benefits.
In addition to the provisions of this article and any
guidelines established by the Health Care Authority and Director of
the PEIA, the plan offered pursuant to this article is subject to
the following:
(1) Each participating provider and site must offer a minimum
set of preventive and primary care services as established by the
PEIA.
(2) No participating provider may offer: (i) An individual
plan to any individual who currently has a health benefit plan; or
(ii) an employee group plan to any employer that currently has a
group health benefit plan.
(3) The Director of PEIA may, by legislative rule, permit
participation by an employer with a comprehensive high deductible
plan if such employer is able to demonstrate that such
participation will not negatively impact the coverage currently
offered by such employer.
(4) A participating provider must provide subscribers and,
where applicable, subscribers' employers with a minimum of thirty
days' notice of discontinuance or reduction of subscriber benefits.
§16-2L-7. Guidelines for evaluation of the plan; report to
Legislative Oversight Commission on Health and Human
Resources Accountability.
(a) The PEIA shall establish by guidelines criteria to
evaluate the medical home plan and may require participating
providers to submit such data and other information related to the
plan.
(b) No later than one year after implementation of the plan,
and annually thereafter during the operation of the plan, the
Health Care Authority must submit a report to the Legislative
Oversight Commission of Health and Human Resources Accountability
as established in article twenty-nine-e of this chapter on progress
made by the medical home project including suggested changes to the
plan and suggested expansion of the plan.
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