H. B. 4299
(By Mr. Speaker, Mr. Kiss and Delegates Martin, Compton, Leach,
Douglas, Staton and Capito)
[Introduced February 6, 1998; referred to the
Committee on Finance.]
A BILL to amend chapter five of the code of West Virginia, one
thousand nine hundred thirty-one, as amended, by adding
thereto a new article, designated article sixteen-b; to
amend and reenact section two-b, article four-a, chapter
nine of said code; and to further amend said article four-a
by adding thereto a new section, designated section three,
creating a children's health insurance program; expanding
availability of insurance coverage to certain eligible
children; requiring reporting; creating a children's health
insurance program board, specifying membership and
qualifications of members, compensation and expenses;
providing for employment of an executive director and
providing powers and duties; authorizing contracts;
providing for powers and duties of the board, including
duties to provide fiscal stability for the children's health
insurance program; providing for preparation of state plan
through interagency cooperation; creating a special revolving fund known as the West Virginia CHIP fund;
providing guidelines to be considered by the board and
executive director in developing and planning administration
of the children's health insurance program; providing for
termination and reauthorization; expanding medicaid coverage
to certain eligible children; and creating a special
revolving fund known as the West Virginia mini-CHIP fund.
Be it enacted by the Legislature of West Virginia:
That chapter five of the code of West Virginia, one thousand
nine hundred thirty-one, as amended, be amended by adding thereto
a new article, designated article sixteen-b; that section two-b,
article four-a
, chapter nine of said code be amended and
reenacted; and that said article four-a be further amended by
adding thereto a new section, designated section three, all to
read as follows:
CHAPTER 5. GENERAL POWERS AND AUTHORITY OF THE GOVERNOR,
SECRETARY OF STATE AND ATTORNEY GENERAL; BOARD
OF PUBLIC WORKS; MISCELLANEOUS AGENCIES, COMMISSIONS,
OFFICES, PROGRAMS, ETC.
ARTICLE 16B. WEST VIRGINIA CHILDREN'S HEALTH INSURANCE PROGRAM.
§5-16B-1. Expansion of health insurance coverage to children.
(a) It is the intent of the Legislature to expand health
insurance coverage to eligible children and to pay for this
coverage by utilizing federal funds. To achieve this intention,
the West Virginia children's health insurance program is hereby
created.
(b) The children's health insurance program created in
this article is subject to the following requirements:
(1) Program design and administration is subject to the
provisions of the children's health insurance program created by
federal law under Title XXI of the Social Security Act of 1997,
including but not limited to the cost-sharing and benefit rules
established in federal law. In the event that this article
conflicts with the requirements of federal law, federal law shall
govern.
(2) The population covered under the program is limited to
children to age nineteen, who are not covered under any health
insurance plan, who are not eligible for coverage under a group
health insurance plan available to a parent or guardian, and who
are not medicaid-eligible. For purposes of eligibility
determination, a COBRA policy, as defined in chapter thirty-three
of this code, is not a group-sponsored plan available to a parent
or guardian.
(c) The program created in this article may be made
available to families of eligible children subject to eligibility
criteria and processes to be established in a state children's
health insurance plan to be developed pursuant to this article
and shall not create an entitlement to coverage in any person.
Nothing in this article may be construed to require any
appropriation of state general revenue funds for the payment of
any benefit provided for in this article.
(d) Implementation of the children's health insurance program shall be reported to the legislative oversight commission
on health and human resources accountability regarding the
program provided for in this article. The report shall include,
but not be limited to, the number of covered children, by age,
served, statistical profiles of the families served, health
status indicators of covered children, the average annual cost
of coverage per child and the total cost of all children served
by provider type.
§5-16B-2. Definitions.
As used in this article, unless the context clearly requires
a different meaning:
(a) "Board" means the children's health insurance program
board;
(b) "Executive director" means the executive director of
the children's health insurance program;
(c) "Benchmark plan" means the insurance benefit plan
currently offered within the state that meets requirements of
applicable federal law and is identified by the board as the
benefit plan that will be used in determining the minimum
aggregate actuarial value and targeted maximum actuarial value
for benefits provided under a children's health insurance program
in this state. The "benchmark plan" may also serve to set the
minimum level of pharmacy, mental health or other specified
services that may under applicable federal law be provided under
a children's health insurance program. Selection of a benefit
plan as the "benchmark plan" does not serve as an indicator of who will be awarded contracts or participate in administering a
children's health insurance program.
(d) "Benchmark-equivalent plan" means the benefit plan,
designed to serve the unique health care needs of children, that
is at least actuarially equivalent to the plan selected by the
board as the benchmark plan, that the board develops and approves
after considering the
goals and objectives for a children's
health insurance program
presented by the governor and the
guidelines for a children's health insurance program set forth in
this article.
§5-16B-3. Children's health insurance program board created;
qualifications and removal of members; quorum; compensation
and expenses.
(a) There is hereby created the West Virginia children's
health insurance program board, which shall consist of the
executive director of the children's health insurance program,
the director of the public employees insurance agency, the
secretary of the department of health and human resources or his
or her designee, the insurance commissioner, and five citizen
members appointed by the governor, to assume the duties of the
office immediately upon appointment pending the advice and
consent of the senate. The five citizen members shall have at
least a bachelor's degree and experience in the administration or
design of public or private employee or group benefit programs.
No more than three citizen members may be members of the same
political party. A lobbyist registered pursuant to chapter six-b of this code, a person representing the interests of a health
care network or private insurer reasonably expected to compete
for contracts under this article, or a private provider of health
care services reasonably expected to receive reimbursement for
health care services pursuant to this article may not serve on
the board. All members of the board shall assume the duties of
the office immediately upon the appointment and shall meet at the
call of the chair not later than the thirtieth day of April, one
thousand nine hundred ninety-eight. No member may be removed
from office by the governor except for official misconduct,
incompetence, neglect of duty, neglect of fiduciary duty or other
specific responsibility imposed by this article, or gross
immorality. Vacancies in the board shall be filled in the same
manner as the original appointment.
(b) The director of the public employees insurance agency
shall serve as chairperson of the board until such time as an
executive director of the children's health insurance program
assumes the duties of the office pursuant to section four of this
article, when the executive director shall take a seat on the
board and assume the duties of the chair. The board shall meet
at such time and place as shall be specified by the call of the
chairperson or upon the written request to the chairperson of at
least two members. Notice of each meeting shall be given in
writing to each member by the chairperson at least three days in
advance of the meeting. Five members shall constitute a quorum.
The board shall pay each of the citizen members appointed by the governor the same compensation and expense reimbursement as is
paid to members of the Legislature for their interim duties as
recommended by the citizens legislative compensation commission
and authorized by law for each day or portion thereof engaged in
the discharge of official duties.
§5-16B-4. Executive director of the children's health insurance
program; powers and duties.
The board shall employ an executive director with at least
a bachelor's degree and at least three years experience in health
insurance administration to serve at the will and pleasure of the
board. The executive director shall employ such administrative,
technical and clerical employees as are required for the proper
administration of the program provided for in this article:
Provided, That to the extent practicable, the work of the
children's health insurance program created in this article shall
be accomplished by employees of the public employees insurance
agency, the department of health and human resources and other
agencies of the state through interagency cooperation or pursuant
to section five of this article. The executive director shall
perform such duties as are required of him or her under the
provisions of this article and is the chief administrative
officer of the children's health insurance program.
(c) The executive director shall provide administrative
support for the work of the board and shall present
recommendations and alternatives for the design of a children's
health insurance program, the initial and annual plans, and other actions undertaken by the board in furtherance of this article.
The executive director is responsible for the administration and
management of the program provided for in this article and in
connection with his or her responsibility shall have the power
and authority to make all rules necessary to effectuate the
provisions of this article. Nothing in this article shall limit
the executive director's ability to manage on a day-to-day basis
the program required or authorized by this article, including,
but not limited to, administrative contracting, studies, analyses
and audits, utilization management provisions and incentives,
provider negotiations, provider contracting and payment,
designation of covered and noncovered services, offering of
additional coverage options or cost containment incentives,
pursuit of coordination of benefits and subrogation, or any other
actions which would serve to implement the plan or plans designed
by the board.
§5-16B-5. Authorization to execute contracts.
(a) The executive director is hereby given exclusive
authorization to execute such contract or contracts as are
necessary to carry out the provisions of this article, including
contracts with insurers or health care networks that meet
standards and qualifications approved by the board.
(b) The provisions of article three, chapter five-a of this
code, relating to the division of purchases of the department of
finance and administration, shall not apply to any contracts for
any health insurance coverage, health services, or professional services authorized to be executed under the provisions of this
article. Before entering into any contract for any health
insurance coverage or health services, the executive director
shall invite competent bids from all qualified entities, and
shall deal directly with health care networks, health care
providers and insurers in presenting specifications and receiving
quotations for bid purposes. The executive director shall award
such contract or contracts on a competitive basis. In awarding
the contract or contracts the executive director shall take into
account the experience of the offering agency, corporation,
insurance company or service organization. The executive
director may consider any cost savings, administrative
efficiency, or other benefit to be gained by considering existing
contracts for services with state health plans and negotiating
modifications of those contracts to meet the needs of the
children's health insurance program. In evaluating these
factors, the executive director may employ the services of
impartial, professional insurance analysts or actuaries or both.
(c) The executive director may issue requests for proposals
for community mental health centers, school health clinics,
primary care centers or rural health clinics to provide defined
portions of services under the children's health plan regionally
or statewide, and may require provider networks contracting to
provide benefits under the plan to contract with community mental
health centers, school health clinics, primary care centers or
rural health clinics, and other safety net county or community facilities as may be defined by the board.
(d) The executive director may authorize the carrier with
whom a primary contract is executed to reinsure portions of such
contract with other carriers which elect to be a reinsurer and
who are legally qualified to enter into a reinsurance agreement
under the laws of this state.
(e) The executive director may at the end of any contract
period discontinue any contract or contracts it has executed with
any carrier and replace the same with a contract or contracts
with any other carrier or carriers meeting the requirements of
this article.
§5-16B-6. Purpose, powers and duties of the board; initial
financial plan; financial plan for following year; and
annual financial plans.
(a) The purpose of the children's health insurance program
board created by this article is to bring fiscal stability to the
children's health insurance program through development of an
annual financial plan designed to meet the agency's estimated
total financial requirements, taking into account all funding
projected to be made available to the agency.
(b) The board, by the executive director, shall contract for
actuarial services. The professional actuary retained by the
public insurance agency finance board to estimate the total
financial requirements of the public employees insurance agency
for each fiscal year and to review and render written
professional opinions as to financial plans proposed by the public employees insurance agency finance board may also serve as
actuary to the children's health insurance program board to
perform the services required in this section and to perform such
other services as may be requested by the board. All reasonable
fees and expenses for actuarial services shall be paid by the
children's health insurance program.
(c) Beginning with state fiscal year two thousand, any
financial plan or modifications to a financial plan approved or
proposed by the board pursuant to this section shall be submitted
to and reviewed by an actuary, and may not be finally approved
and submitted to the governor and to the Legislature without the
actuary's written professional opinion that all estimated program
and administrative costs of the agency under the plan, excluding
incurred but unreported claims, will not exceed ninety percent of
the funding available to the children's health insurance program
for the fiscal year for which the plan is proposed. The
actuary's opinion on the financial plan for any fiscal year shall
allow for no more than thirty days of accounts payable to be
carried over into the next fiscal year. The actuary's opinion
for any fiscal year shall not include a requirement for
establishment of a reserve fund.
(d) All financial plans required by this section shall
include the design of a benefit plan or plans. All financial
plans shall establish:
(1) Maximum levels of reimbursement to categories of health
care providers;
(2) Any necessary cost containment measures for
implementation by the director;
(3) The types and levels of cost to families of covered
children. To the extent compatible with simplicity of
administration, fiscal stability and other goals of the program
established in this article, the financial plans may provide for
different levels of costs based on ability to pay.
(e) Initial plan. -- The chairperson shall convene the first
meeting of the board no later than the thirtieth day of April,
one thousand nine hundred ninety-eight. For presentation by the
chairperson at the first meeting, the governor shall prepare (1)
a statement of goals and objectives of the children's health
insurance program and (2) an estimate of the total amount of
general and special revenues which the state has or will have
available to fund the children's health insurance program for the
fiscal year ending on the thirtieth day of June, one thousand
nine hundred ninety-nine. The initial plan is subject to the
following guidelines:
(1) Plan design and administration is subject to the
provisions of the children's health insurance program created by
federal law under Title XXI of the Social Security Act of 1997,
including but not limited to the cost-sharing and benefit rules
established in federal law.
(2) In order to implement health insurance coverage at the
earliest feasible date, the initial plan may offer the same
benefit package as that offered to children of state employees insured through the public employees insurance agency, or another
benchmark plan meeting the requirements of federal law and
selected by the board.
(3) The initial plan may pay providers of health care
services under the same fee schedule applicable for services
provided to dependents of covered state employees, or the fee
schedule applicable to another benchmark plan meeting the
requirements of federal law and selected by the board
.
(4) The initial plan shall make available to children to
age nineteen whose custodial parents or guardians have income
equal to or less than one hundred thirty five percent of federal
poverty as determined according to eligibility standards and
other criteria approved by the board: Provided, That the initial
plan may make available to children to age nineteen whose
custodial parents or guardians have income equal to a higher
percentage of federal poverty established by the board, not to
exceed two hundred percent of federal poverty, to the extent it
reasonably estimates, based on assumptions that may be
recommended by its actuary, that
all estimated program and
administrative costs of the agency under the plan, excluding
incurred but unreported claims, will not exceed eighty-five
percent of the funding available to the children's health
insurance program for the state fiscal year one thousand nine
hundred ninety-nine
. Coverage under the plan is not an
entitlement for any person.
(5) The board shall establish a target date for implementation of the children's health insurance program during
the state fiscal year one thousand nine hundred ninety-nine.
(6) The board shall afford interested and affected persons
an opportunity to offer comment on the plan at a public meeting
of the board and in developing any proposed plan under this
article shall solicit comments in writing from interested and
affected persons.
(f) Annual plans. -- The board shall review implementation
of its initial or current financial plan in light of actual
experience
and shall prepare an annual financial plan for fiscal
year two thousand and each fiscal year thereafter during which
the board remains in existence. For each such fiscal year, the
governor shall provide his or her estimate of requested
appropriations and total available funding to the board no later
than the first day of July of the preceding fiscal year. The
board shall submit its final, approved financial plan, after
obtaining the necessary actuary's opinion and conducting one or
more public hearings in each congressional district, to the
governor and to the Legislature no later than the first day of
January preceding the fiscal year. The financial plan for a
fiscal year shall become effective and shall be implemented by
the director on the first day of July of such fiscal year.
Annual plans developed pursuant to this subsection are subject to
the provisions of subsections (c) and (d) of this section and the
following guidelines:
(1) Plan design and administration is subject to the provisions of the children's health insurance program created by
federal law under Title XXI of the Social Security Act of 1997,
including but not limited to the cost-sharing and benefit rules
established in federal law.
(2) The board may develop and offer a benchmark-equivalent
benefit package that differs from the benefits offered in the
benchmark plan selected by the board, so long as the total
benefit package is at least actuarially equivalent to the
benchmark plan.
(3) The plan may determine a plan for payment of providers
of health care services that differs from the same fee schedule
applicable for services provided to dependents of covered state
employees.
(4) The plan shall make available to children to age
nineteen whose custodial parents or guardians have income equal
to or less than a percentage of federal poverty established by
the board, not to exceed two hundred percent of federal poverty
as determined according to eligibility standards and other
criteria approved by the board. Coverage under the plan is not
an entitlement for any person.
(g) The provisions of chapter twenty-nine-a of this code do
not apply to the preparation, approval and implementation of the
financial plans required by this section.
(h) The board shall meet on at least a quarterly basis to
review implementation of its current financial plan in light of
the actual experience of the children's health insurance program. The board shall review actual costs incurred, any revised cost
estimates provided by the actuary, expenditures, and any other
factors affecting the fiscal stability of the plan, and may make
any additional modifications to the plan necessary to ensure that
the total financial requirements of the agency for the current
fiscal year are met. The board may not increase the types and
levels of cost to families of covered children during its
quarterly review except in the event of a true emergency. The
board may not expand the population of children to whom the
program is made available except in its annual plan.
(i) For any fiscal year in which legislative appropriations
differ from the governor's estimate of general and special
revenues available to the agency, the board shall, within thirty
days after passage of the budget bill, make any modifications to
the plan necessary to ensure that the total financial
requirements of the agency for the current fiscal year are met.
§5-16B-7. Preparation of state plan; interagency cooperation.
Upon the effective date of this article, the secretary of
the department of health and human resources shall make available
to the children's health insurance program staff of the
department to prepare at the direction of the children's health
insurance program board, and in the name of the board, the state
Title XXI plan required by applicable federal law, to include
those descriptions, procedures and proposals for implementation
under this article and article four-a, chapter nine of this code,
that will serve to qualify the state's program for children's health insurance for approval by federal authorities.
§5-16B-8. West Virginia CHIP fund.
(a) There is hereby created in the state treasury a special
revolving fund known as the "West Virginia CHIP Fund". All moneys
deposited or accrued in this fund shall be used exclusively:
(1) To provide the state's share of the federal children's
health insurance program funds, established and maintained to
purchase health services for uninsured, low-income children; and
(2) To cover administrative costs incurred by the children's
health insurance program board associated with the children's
health insurance program and this fund, which may not exceed ten
percent of the annual appropriation.
(b) Moneys from the following sources may be placed into the
fund:
(1) All public funds appropriated by the Legislature or
transferred by any public agency to the children's health
insurance program for deposit in the fund as contemplated or
permitted by applicable federal program laws;
(2) All private moneys contributed by corporations,
individuals or other entities to the fund as contemplated and
permitted by applicable federal and state laws;
(3) Any accrued interest; and
(4) Federal financial participation matching the amounts
referred to in subdivisions (1), (2) and (3) of this subsection,
in accordance with Section 1902 (a) (2) of the Social Security
Act.
(c) Any balance remaining in the children's health insurance
program fund at the end of any state fiscal year shall not revert
to the state treasury but shall remain in this fund and shall be
used only in a manner consistent with this article.
(e) The fund shall be administered by the children's health
insurance program by its executive director, or, until such time
as the executive director assumes the duties of the office, by
the director of the public employees insurance agency. Moneys
shall be disbursed from the fund on a quarterly basis. The
secretary of the department of health and human resources, in the
name of the board, shall submit and receive approval of the
state's children's health insurance plan in accordance with the
provisions of Title XXI of the Social Security Act of 1997 prior
to the receipt of any transfer or contribution from any public or
private source.
(f) All moneys expended from the fund after receipt of
federal financial participation shall be allocated to
reimbursement for health services provided in accordance with the
approved plan and the administrative costs as set forth in this
article. Expenditures from this fund for any other purposes are
void.
§5-16B-9. Guidelines for a children's health benefit package.
In developing a benefit package for a children's health
insurance program designed to serve the unique health care needs
of children, the board may consider as guidelines the following:
(a) The development of an affordable children's health benefit package designed to serve the needs of uninsured children
whose families are not financially eligible to purchase
children's health insurance at a subsidized cost
is a priority.
The board may consider allowing families not eligible for
coverage at a subsidized cost to purchase coverage at the full
premium rate, and the board may consider small employer buy-ins
to the extent these may be designed to be compatible with
"crowd-out" provisions of applicable federal law that prohibit
creating a program that substitutes for group coverage.
Therefore, design of the benefit package should be dollar-driven,
and the aggregate actuarial value of the plan established as a
benchmark plan should be considered as a targeted maximum or
limitation in developing the benefits package.
(b) In balancing the state's interest in expanding coverage
to as many children as possible against the state's interest in
providing enhanced levels of coverage, until such time as
coverage is available to all children at less than two hundred
percent of the federal poverty level, the state's interest in
providing coverage to more children takes precedence.
(c) In order to include in the benefit package additional
coverages especially necessary or beneficial to children, and in
order to remain within the cost sharing limitations of applicable
federal law, the board may adopt limitations more restrictive
than those limitations applicable to the benchmark plan
,
including, by way of illustration, limitations on inpatient days,
units of covered services, or dollar limitations,.
(d) Basic coverages may include:
(1) Those minimum coverages required by applicable federal law;
(2) Additional coverages necessary to protect the public
health, which may include, by way of illustration, medical
treatments for specific infectious diseases that pose a grave
threat to the public health, triage and crisis services for
grave mental illnesses that endanger individuals and the public,
and specified services for families of children affected by
domestic violence.
(3) An additional package of preventative services designed
with attention to those most essential services that promote
success in school and growing up healthy, which may include, by
way of illustration, vision, hearing and dental screening and
examination, dental cleaning and fluoride treatments for
children, one pair of glasses each year, and hearing aids.
(4) Services to assist in the management of specific chronic
conditions, which may include juvenile diabetes and asthma, which
if unmanaged and untreated, pose a grave threat to the health of
children.
(5) An additional package of medically necessary services
available to handicapped and disabled children with a high level
of need, which, for specified services, may be limited by
billable units of service.
(6) Comfort care for terminally ill children and the most
necessary services to families caring for those children.
(e) The benefit package shall be designed to exclude
services that are not medically necessary or, to a reasonable
degree of medical probability, are unlikely to improve the
outcome, benefit the child, restore function, or improve the quality of life for the child.
(f) Except as specifically provided in this section, and
within the limits provided by applicable federal law, the board
shall consider limiting benefits and levels of coverage provided
in a children's health insurance program to those benefits
through private health insurance
generally available, as
determined by the insurance commissioner
, to employees of
employers in this state employing fifty or fewer employees.
(g) The board may consider exempting from copay
requirements, in addition to those specific preventative benefits
required to be exempted by federal law, additional services that
it determines should be fully utilized to protect the health of
children, including, by way of illustration, services to families
of children affected by domestic violence and dental fluoride
treatments.
(h) The board may consider exempting from copay
requirements those specific pharmaceuticals used to treat
diagnosed chronic conditions for which compliance with
prescribed drug therapy is essential and most often problematic.
By way of illustration, the board may exempt copays for a drug
prescribed to manage juvenile diabetes or a psychotropic drug to
treat a grave mental illness that endangers a child or the
public.
(i) Design of the children's health insurance program
created in this article shall reflect the most essential health
care needs of children and, notwithstanding any other provision
of this code to the contrary, is exempt from the minimum benefits
and coverage requirements of articles fifteen and sixteen, chapter thirty-three of this code.
§5-16B-10 . Guidelines for administration of a children's health
insurance program.
In developing a children's health program that operates with
the highest degree of simplicity and governmental efficiency, the
board shall avoid duplicating functions available in existing
agencies and shall consider as guidelines for administration the
following:
(a) The executive director may negotiate and enter into
interagency agreements with agencies of the state, which
contracts shall require the performing of specific tasks or
duties at a specific or maximum contract price, in furthering the
purposes of this article. Administrative expense may be paid to
the other agencies by interdepartmental transfer. By way of
illustration and not by way of limitation, the executive director
may contract with the department of education for outreach
services; with the department of health and human services for
eligibility determination; the bureau of public health for
maternal and child health services; and the insurance
commissioner for preparation of requirements and standards for
case management and quality and utilization monitoring.
(b) The executive director
may negotiate and contract with
public or private entities, which contracts shall require the
performing of specific administrative tasks or duties at a
specific or maximum contract price, in furthering the purposes of
this article. Administrative expense may be paid out of funds
appropriated for this purpose to the children's health insurance
program.
(c) The executive director
may contract with insurers and
health care networks to provide an established set of benefits at
a set fee. Insurers and health care networks must be able to
meet specific case management, data collection, quality control
and utilization review standards. If the executive director
contracts with more than one insurer or network in a defined
geographic area, the parent or guardian of a covered child
residing in that area may choose between available plans.
(d) The application process and eligibility standards shall
be designed to provide the highest possible degree of
administrative simplicity, in obtaining identifying information;
in determining income status; in developing a statistical profile
of the population served;
and in obtaining such other information
required by applicable federal law or determined to be essential.
The board may consider adopting the maximum period of continuous
eligibility permitted by applicable federal law
, regardless of
changes in a family's economic status, so long as other group
insurance does not become available to a covered child. The
board may consider limiting enrollment to specified open
enrollment periods. The board may consider adopting one or more
alternate single standards for financial eligibility, which may
include, by way of illustration, a determination of eligibility
for free or reduced school lunch, a copy of the previously filed
state or federal income tax return showing gross income below a
specified level or other standards set by the board.
(e) The executive director may cooperate with the
department of health and human resources in the modification of
the streamlined application form for children's medicaid benefits, so that the same application form may be used to
determine eligibility for the children's health insurance program
established in this article and, when appropriate, serve as a
referral and application for medicaid coverage.
(f) In the event the board determines that cost-sharing
under the plan will include the payment of a premium, in order to
provide the highest possible degree of administrative simplicity
and avoid the necessity of additional income determinations and
verifications
, the board may consider imposing a flat premium
less than or equal to fifteen dollars per month per family, the
minimum premium permitted under section 1916(b)(1) of the Social
Security Act, or an equivalent sum calculated to cover a
specified benefit period,
for all families that are to pay a
premium under the plan, and, unless premiums are required to be
prepaid for the entire benefit period, may require families of
enrolled children to preauthorize direct payment of premiums.
(g) In determining levels of copays in accordance with
applicable federal law, in order to provide the highest possible
degree of administrative simplicity
and avoid the necessity of
additional income determinations and verifications
, the board may
consider imposing flat copays equal to the minimum copay
permissible under applicable federal law for all families that
are to pay copays under the plan.
(h) The executive director
may enter into agreements with
entities permitted by applicable federal law to determine
eligibility for the program created in this article, which may
include, by way of illustration and not by way of limitation, the
primary care centers, rural health clinics, the department of education, and school-based health centers.
§5-16B-11. Termination and reauthorization.
(a)The children's health insurance program established in
this article abrogates and is of no further force and effect,
without any further action by the Legislature, upon the earliest
of the following dates:
(1) The date upon which a reduction in the level of federal
funds becomes effective
for children's health insurance programs
created by federal law under Title XXI of the Social Security Act
of 1997
, below amounts allocated to the state
in the year one
thousand nine hundred ninety-nine and below future year
reductions contained in the original enactment by the Congress
of
Title XXI of the Social Security Act of 1997
: Provided, That if
an act reducing such funds specifies a date later
than the
effective date of the legislation on which the reduction of funds
takes effect, that later date controls.
(2) The date upon which a judgment or order of a court of
competent jurisdiction becomes final disallowing the state plan
for a children's health insurance program established by the
board under this article.
(3) The date upon which any federal administrative rule or
regulation promulgated in conformity with federal law becomes
effective which negates the effect or purposes of this article:
Provided, That if such rule or regulation specifies a later date
on which the prohibition takes effect, that later effective date
controls.
(b) Pursuant to the provisions of article ten, chapter four
of this code, the board shall terminate on the first day of July,
two thousand four, unless extended by legislation enacted before
the termination date.
(c) Upon termination of the board and notwithstanding any
provisions in this article to the contrary, the executive
director of the children's health insurance program is authorized
to change the types and levels of costs to the families of
enrollees, within the limits permitted by applicable federal law,
only in accordance with this subsection. Any assessments or
changes in costs imposed pursuant to this subsection shall be
implemented by rules of the director proposed to the legislature
pursuant to the provisions of chapter twenty-nine-a of this code.
Any costs authorized by the board shall remain in effect until
amended by rule of the director promulgated pursuant to this
subsection.
CHAPTER 9. HUMAN SERVICES.
ARTICLE 4A. MEDICAID UNCOMPENSATED CARE FUND.
§9-4A-2b. Expansion of coverage to children and terminally ill;
West Virginia children's health insurance plan.
(a) It is the intent of the Legislature that steps be taken
to expand coverage to children and the terminally ill and to pay
for this coverage by fully utilizing federal funds. To achieve
this intention, the department of health and human resources
shall undertake the following:
(1) Effective the first day of July, one thousand nine hundred ninety-four ninety-eight, the department shall initiate
a streamlined application form, which shall be no longer than two
pages, for all families applying only for medicaid medical
coverage for children under any of the programs set forth in this
section. (2) Effective the first day of July, one thousand nine
hundred ninety-four, the department shall initiate the option of
hospice care to terminally ill West Virginians who otherwise
qualify for medicaid. On or before the first day of January, one
thousand nine hundred ninety-five, and periodically thereafter,
the The department shall report report quarterly to the
legislative task force on uncompensated health care and medicaid
expenditures oversight commission on health and human resources
accountability created pursuant to section four, article
twenty-nine-c twenty-nine-e, chapter sixteen of this code
regarding the program initiation provided for in this
subdivision. The report shall include, but not be limited to,
the total number, by age, of newly eligible clients served as a
result of the initiation of the program pursuant to this
subdivision, the average annual cost of coverage per client, and
the total cost, by provider type, to serve all clients.
(3) Effective the first day of July, one thousand nine
hundred ninety-four, the department shall accelerate the medicaid
option for coverage of medicaid to all West Virginia children
whose family income is below one hundred percent of the federal
poverty level. On or before the first day of January, one
thousand nine hundred ninety-five, and periodically thereafter, the The department shall report provide quarterly reports to the
legislative task force on uncompensated health care and medicaid
expenditures oversight commission on health and human resources
accountability regarding the program acceleration provided for in
this subdivision. The report shall include, but not be limited
to, the number of newly eligible clients, by age, served as a
result of the acceleration, the average annual cost of coverage
per client and the total cost of all clients served by provider
type.
(4) Effective the first day of July, one thousand nine
hundred ninety-five ninety-eight, the department may initiate the
medicaid option to shall expand medicaid coverage
of medicaid to
all for only those West Virginia children below the age of six
years whose family income is below one hundred thirty-three fifty
percent of the federal poverty level. This program will be known
as "mini-CHIP" and administered in accordance with the applicable
provisions contained in Titles XIX and XXI of the Social Security
Act. The department shall coordinate the eligibility
determination, outreach efforts, purchasing strategies, service
delivery system and reporting requirements with the "CHIP"
program created pursuant to provisions of article sixteen-b,
chapter five of this code. To prepare for program expansion the
department shall submit a report to the governor and the
Legislature on the first day of January, one thousand nine
hundred ninety-five, regarding the feasibility of the expansion.
The report is to include, but not be limited to, the number of eligible clients participating in the programs specified in this
section, the average annual cost of coverage per client, the
percentage of expected participation for the expansion, the
projected cost of the expansion, the medical services trust fund
balance and the future disproportionate share
moneys expected to
be deposited in the medical services trust fund pursuant to
section two-a of this article . The department shall continually
update the additional information required to be provided to the
governor and the Legislature regarding this expansion and
periodically report the information to the legislative task force
on uncompensated health care and medicaid expenditures created
pursuant to section four, article twenty-nine-c, chapter sixteen
of this code.
(5) Effective the first day of July, one thousand nine
hundred ninety-six, the department may initiate the medicaid
option to expand coverage of medicaid to all West Virginia
children whose family income is below one hundred fifty percent
of the federal poverty level. To prepare for program expansion,
the department shall submit a report to the governor and the
Legislature on the first day of January, one thousand nine
hundred ninety-six, regarding the feasibility of the expansion.
Additionally, the report is to include, but not be limited to,
the number of clients who would be newly eligible to participate
in the program, the average annual cost of coverage per client,
by age, the percentage of expected participation for the
expansion and the projected cost of the expansion, the balance of the medical services trust fund and the future disproportionate
share moneys expected to be deposited in the medical services
trust fund pursuant to section two-a of this article. The
department shall periodically update and report to the
legislative task force on uncompensated health care and medicaid
expenditures created pursuant to section four, article twenty- nine-c, chapter sixteen of this code regarding the additional
information required to be submitted to the governor and the
Legislature.
(b) Notwithstanding the provisions of section two-a of this
article, the accruing interest in the medical services trust fund
may be utilized to pay for the programs specified in subdivisions
(2) and (3) of subsection (a) of this section: Provided, That to
the extent the accrued interest is not sufficient to fully fund
the specified programs, the disproportionate share hospital funds
paid into the medical services trust fund after the thirtieth day
of June, one thousand nine hundred ninety-four, may be applied to
cover the cost of the specified programs. Provided, however,
That in fiscal year one thousand nine hundred ninety-five, the
amount of funds applied from the disproportionate share funds,
not including accrued interest, shall not exceed ten million
dollars: Provided further, That in the interest of fiscal
responsibility, the department shall terminate the program
specified in subdivisions (4) and (5) of subsection (a) of this
section, if the future moneys deposited from disproportionate
share payments in the medical services trust fund are insufficient to cover the cost of the expanded program.
(c) On the first day of January, one thousand nine hundred
ninety-five and annually thereafter, the department shall report
to the governor and to the Legislature information regarding the
number of children and elderly covered by the program programs in
subdivisions (2) and (3) of subsection (a), the cost of services
by type of service provided, a cost-benefit analysis of the
acceleration and expansion on other insurers and the reduction of
uncompensated care in hospitals as a result of the programs.
(d) On the first day of January, one thousand nine hundred
ninety-nine and annually thereafter, the department shall report
to the governor and to the Legislature information regarding the
number of children enrolled in the medicaid program resulting
from the "outreach program"; the number of children enrolled in
"mini-CHIP"; the estimated number of children eligible for
enrollment in either program; the cost of services by type of
service provided in both programs; an analysis of the impact of
the programs on other insurers; and the reduction of
uncompensated care in hospitals as a result of the programs. The
annual report filed by the department shall also include
information relating to any proposed expansion of the population
to be served under the state's medicaid program, other than the
expansions specifically authorized in this section, and any
expansion in the population to be served may not be implemented
until sixty days following the filing of the report required in
this subsection.
The department shall make quarterly reports to the legislative oversight commission on health and human
resources accountability, established pursuant to section four,
article twenty-nine-e, chapter sixteen of this code regarding the
development, implementation and monitoring of the program.
(d) The health care cost review authority established by
section five, article twenty-nine-b of this chapter shall
consider in its rate review that uncompensated care and charity
care are reduced by the programs specified in subsection (a) of
this section and shall take the reduction into account when
determining rates. This determination shall be undertaken in
each hospital's next rate review and shall be determined
prospectively.
(e) On the first day of January, one thousand nine hundred
ninety-five, and annually thereafter, the health care cost review
authority shall present to the governor and to the Legislature a
report concerning the reduction in cost shift created by the
operation of the provisions of this article.
(f) The department shall review the additional utilization
by behavioral health centers as a result of the acceleration and
expansion for a period of eighteen months from the enactment of
this article: Provided, That during the eighteen-month study
period the department shall not issue additional behavioral
health licenses: Provided, however, That this license provision
does not apply to facilities filing for renewal applications or
to any health care facility which has a certificate of need in
effect or an application pending on the first day of March, one thousand nine hundred ninety-four: Provided further, That this
licensure prohibition shall not apply to behavioral health
services provided pursuant to any agreement for state owned
psychiatric hospitals which are approved by the federal health
care finance administration.
§9-4A-3. West Virginia mini-CHIP fund.
(a) There is hereby created in the state treasury a special
revolving fund to be known as the "West Virginia mini-CHIP Fund",
which shall be an interest-bearing account established and
maintained to purchase health services for low-income children.
(b) Funds paid into this account shall be derived from the
following sources:
(1) Any appropriations by the Legislature;
(2 All public funds transferred by any public agency as
permitted by applicable federal law;
(3) Any private funds contributed, donated or bequeathed by
corporations, individuals or other entities to the fund as
contemplated and permitted by applicable federal law; and
(4) All interest or return on investments accruing to the
fund.
(b) Moneys from this fund shall be used exclusively for the
following purposes:
(1) To purchase health care services for the program
defined in subdivision (4), subsection (a) of this section,
associated administrative costs, outreach activities and
eligibility determination costs; and
(2) To provide the state's share of the enhanced federal
medical assistance percentage funds.
(c) Notwithstanding the provisions of section two, article
two, chapter twelve of this code, moneys with the mini-CHIP
program may not be redesignated for any purpose other than those
set forth in this subsection.
NOTE: This bill creates a children's health insurance
program (CHIP) and a children's health program board and
authorizes the employment of an executive director. The bill
requires that the program be designed to fall within available
funding and provides non-mandatory guidelines for program design.
A medicaid expansion (mini-CHIP) for children up to 150% of
federal poverty to age 6 is authorized.
Strike-throughs indicate language that would be stricken
from the present law, and underscoring indicates new language
that would be added. Article 16B and section 9-4A-3 are new;
therefore, strike-throughs and underscoring have been omitted.