COMMITTEE SUBSTITUTE

FOR

Senate Bill No. 366

(By Senators Ferns, Stollings,

Walters and D. Hall)

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[Originating in the Committee on

Banking and Insurance;

reported February 24, 2015.]

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A BILL to amend the Code of West Virginia, 1931, as amended, by adding thereto a new article, designated §33-50-l, §33-50-2 and §33-50-3, all relating to the West Virginia Health Benefit Exchange; providing for publishing online information to assist consumers in making informed decisions concerning the purchase of a qualified health plan; and permitting rule-making.

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 §33-50-l, §33-50-2 and §33-50-3, all to read as follows:

ARTICLE 50. PATIENT PROTECTION AND TRANSPARENCY ACT.

§33-50-l. Definitions.

            For the purposes of this article, the following words and terms mean the following:

            (1) “Commissioner” means the West Virginia Insurance Commissioner.

            (2) “Consumer” means an individual or family purchasing insurance coverage through the exchange.

            (3) “Exchange” means the West Virginia Health Benefit Exchange or an exchange website operated by the federal government.

            (4) “Health care provider” means a provider of medical or health services and any other person or organization who furnishes, bills or is paid for health care in the normal course of business.

            (5) “Health carrier” means an entity subject to the insurance laws of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital and health service corporation or any other entity providing a plan of health insurance, health benefits or health services.

            (6) “Network” means a group of health care providers that have contracted with a health plan to provide care at a discounted rate.

            (7) “Qualified health plan” means a health plan certified to be offered for sale through the exchange.

            (8) “West Virginia Health Benefit Exchange” means the government-regulated marketplace of qualified health plans with multiple levels of coverage established pursuant to article sixteen-g of this chapter.

§33-50-2. Information available to the public and disclosures required of health carriers.

            (a) The commissioner shall on his or her website provide information regarding the qualified health plans being offered for sale through the exchange in a format easily found by a consumer on such website. Information may be provided through links to specific information, including through links to the website of each health carrier offering a qualified health plan for sale through the exchange.

            (b) Information to be made available to consumers for each qualified health plan offered for sale through the exchange include:

            (1) The names of the physicians, hospitals and other health care providers that are in network;

            (2) A list of the types of specialists that are in network;

            (3) Exclusions from coverage by category of benefits;

            (4) Restrictions on use or quantity of covered items and services by category of benefits;

            (5) The dollar amount of copayments;

            (6) The percentage of coinsurance by item and service;

            (7) Required cost-sharing;

            (8) Information sufficient to determine whether a specific drug is available on formulary;

            (9) Clinical prerequisites or authorization requirements for coverage of specific drugs;

            (10) A description of how medications will be included in or excluded from the deductible;

            (11) A description of out-of-pocket costs that may not apply to the deductible for a medication;

            (12) Information sufficient to determine whether a specific drug is covered when furnished by a physician or clinic;

            (13) An explanation of the amount of coverage for out-of-network providers or noncovered services;

            (14) The process for a patient to appeal a health plan decision; and

            (15) Contact information for the qualified health plan.

            (c)The commissioner may require a qualified health plan to make the information listed in subsection (b) of this section available, including for website usage, and to provide for the reasonable updating of such information.

            (d) The commissioner’s website should provide general information concerning the exchange, qualified health plans, health insurance terminology and other information consumers may need to assist them in making informed decisions concerning the purchase of a qualified health plan through the exchange.

§33-50-3. Rule-making authority.

            The commissioner may propose rules for legislative approval in accordance with the provisions of article three, chapter twenty-nine-a of this code to implement the provisions of this article.

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            (NOTE: The purpose of this bill is to enact the Patient Protection and Transparency Act which requires information to be made available online to persons who purchase or are interested in purchasing insurance through the West Virginia Health Benefit Exchange or an exchange website operated by the federal government.

            This article is new, therefore, strike-throughs and underscoring have been omitted.)