COMMITTEE SUBSTITUTE
FOR
Senate Bill No. 477
(By Senators Prezioso, Oliverio, Jenkins, Dempsey, Hunter,
Foster, Kessler, Minear and Unger)
____________
[Originating in the Committee on Health and Human Resources;
reported February 17, 2006.]
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A BILL to amend and reenact §5-16-7 and §5-16-9 of the Code of West
Virginia, 1931, as amended; to amend and reenact §33-15-4c of
said code; to amend and reenact §33-16-3g of said code; to
amend and reenact §33-24-7b of said code; to amend and reenact
§33-25-8a of said code; and to amend and reenact §33-25A-8a of
said code, all relating to insurance coverage for mammograms,
pap smears and human papillomavirus.
Be it enacted by the Legislature of West Virginia:
That §5-16-7 and §5-16-9 of the Code of West Virginia, 1931,
as amended, be amended and reenacted; that §33-15-4c of said code
be amended and reenacted; that §33-16-3g of said code be amended
and reenacted; that §33-24-7b of said code be amended and
reenacted; that §33-25-8a of said code be amended and reenacted;
and that §33-25A-8a of said code be amended and reenacted, all to
read as follows:
ARTICLE 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.
§5-16-7. Authorization to establish group hospital and surgical
insurance plan, group major medical insurance plan,
group prescription drug plan and group life and
accidental death insurance plan; rules for
administration of plans; mandated benefits; what plans
may provide; optional plans; separate rating for
claims experience purposes.
(a) The agency shall establish a group hospital and surgical
insurance plan or plans, a group prescription drug insurance plan
or plans, a group major medical insurance plan or plans and a group
life and accidental death insurance plan or plans for those
employees herein made eligible, and to establish and promulgate
rules for the administration of these plans, subject to the
limitations contained in this article. Those plans shall include:
(1) Coverages and benefits for X ray and laboratory services
in connection with mammograms,
and pap smears
, either conventional
or liquid-based cytology, whichever is medically appropriate in the
opinion of the woman's physician, and an annual test for human
papillomavirus when performed for cancer screening or diagnostic
services;
(2) Annual checkups for prostate cancer in men age fifty and
over;
(3) For plans that include maternity benefits, coverage for
inpatient care in a duly licensed health care facility for a mother and her newly born infant for the length of time which the
attending physician considers medically necessary for the mother or
her newly born child:
Provided, That no plan may deny payment for
a mother or her newborn child prior to forty-eight hours following
a vaginal delivery, or prior to ninety-six hours following a
caesarean section delivery, if the attending physician considers
discharge medically inappropriate;
(4) For plans which provide coverages for post-delivery care
to a mother and her newly born child in the home, coverage for
inpatient care following childbirth as provided in subdivision (3)
of this subsection if inpatient care is determined to be medically
necessary by the attending physician. Those plans may also
include, among other things, medicines, medical equipment,
prosthetic appliances, and any other inpatient and outpatient
services and expenses considered appropriate and desirable by the
agency; and
(5) Coverage for treatment of serious mental illness.
(A) The coverage does not include custodial care, residential
care or schooling. For purposes of this section, "serious mental
illness" means an illness included in the American psychiatric
association's diagnostic and statistical manual of mental
disorders, as periodically revised, under the diagnostic categories
or subclassifications of: (i) Schizophrenia and other psychotic
disorders; (ii) bipolar disorders; (iii) depressive disorders; (iv)
substance-related disorders with the exception of caffeine-related
disorders and nicotine-related disorders; (v) anxiety disorders; and (vi) anorexia and bulimia. With regard to any covered
individual who has not yet attained the age of nineteen years,
"serious mental illness" also includes attention deficit
hyperactivity disorder, separation anxiety disorder and conduct
disorder.
(B) Notwithstanding any other provision in this section to the
contrary, in the event that the agency can demonstrate actuarially
that its total anticipated costs for the treatment of mental
illness for any plan will exceed or have exceeded two percent of
the total costs for such plan in any experience period, then the
agency may apply whatever cost containment measures may be
necessary, including, but not limited to, limitations on inpatient
and outpatient benefits, to maintain costs below two percent of the
total costs for the plan.
(C) The agency shall not discriminate between medical-surgical
benefits and mental health benefits in the administration of its
plan. With regard to both medical-surgical and mental health
benefits, it may make determinations of medical necessity and
appropriateness, and it may use recognized health care quality and
cost management tools, including, but not limited to, limitations
on inpatient and outpatient benefits, utilization review,
implementation of cost containment measures, preauthorization for
certain treatments, setting coverage levels, setting maximum number
of visits within certain time periods, using capitated benefit
arrangements, using fee-for-service arrangements, using third-party
administrators, using provider networks and using patient cost sharing in the form of copayments, deductibles and coinsurance.
(b) The agency shall make available to each eligible employee,
at full cost to the employee, the opportunity to purchase optional
group life and accidental death insurance as established under the
rules of the agency. In addition, each employee is entitled to
have his or her spouse and dependents, as defined by the rules of
the agency, included in the optional coverage, at full cost to the
employee, for each eligible dependent; and with full authorization
to the agency to make the optional coverage available and provide
an opportunity of purchase to each employee.
(c) The finance board may cause to be separately rated for
claims experience purposes: (1) All employees of the state of West
Virginia; (2) all teaching and professional employees of state
public institutions of higher education and county boards of
education; (3) all nonteaching employees of the university of West
Virginia board of trustees or the board of directors of the state
college system and county boards of education; or (4) any other
categorization which would ensure the stability of the overall
program.
§5-16-9. Authorization to execute contracts for group hospital
and surgical insurance, group major medical insurance, group
prescription drug insurance, group life and accidental death
insurance and other accidental death insurance; mandated
benefits; limitations; awarding of contracts; reinsurance;
certificates for covered employees; discontinuance of contracts.
(a) The director is hereby given exclusive authorization to
execute such contract or contracts as are necessary to carry out
the provisions of this article and to provide the plan or plans of
group hospital and surgical insurance coverage, group major medical
insurance coverage, group prescription drug insurance coverage and
group life and accidental death insurance coverage selected in
accordance with the provisions of this article, such contract or
contracts to be executed with one or more agencies, corporations,
insurance companies or service organizations licensed to sell group
hospital and surgical insurance, group major medical insurance,
group prescription drug insurance and group life and accidental
death insurance in this state.
(b) The group hospital or surgical insurance coverage and
group major medical insurance coverage herein provided for shall
include coverages and benefits for X-ray and laboratory services in
connection with mammogram and pap smears when performed for cancer
screening or diagnostic services and annual checkups for prostate
cancer in men age fifty and over. Such benefits shall include, but
not be limited to, the following:
(1) Baseline or other recommended mammograms for women age
thirty-five to thirty-nine, inclusive;
(2) Mammograms recommended or required for women age forty to
forty-nine, inclusive, every two years or as needed;
(3) A mammogram every year for women age fifty and over;
(4) A pap smear
, either conventional or liquid-based cytology, whichever is medically appropriate in the opinion of the woman's
physician annually or more frequently based on the woman's
physician's recommendation for women age eighteen and over;
and
(5) A human papillomavirus (HPV), annually or more frequently
based on the woman's physician's recommendation for women aged
eighteen or over.
(5) (6) A checkup for prostate cancer annually for men age
fifty or over.
(c) The group life and accidental death insurance herein
provided for shall be in the amount of ten thousand dollars for
every employee. The amount of the group life and accidental death
insurance to which an employee would otherwise be entitled shall be
reduced to five thousand dollars upon such employee attaining age
sixty-five.
(d) All of the insurance coverage to be provided for under
this article may be included in one or more similar contracts
issued by the same or different carriers.
(e) 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 insurance coverage or professional services authorized to be
executed under the provisions of this article. Before entering
into any contract for any insurance coverage, as authorized in this
article, the director shall invite competent bids from all
qualified and licensed insurance companies or carriers, who may
wish to offer plans for the insurance coverage desired:
Provided, That the director shall negotiate and contract directly with health
care providers and other entities, organizations and vendors in
order to secure competitive premiums, prices and other financial
advantages. The director shall deal directly with insurers or
health care providers and other entities, organizations and vendors
in presenting specifications and receiving quotations for bid
purposes. No commission or finder's fee, or any combination
thereof, shall be paid to any individual or agent; but this shall
not preclude an underwriting insurance company or companies, at
their own expense, from appointing a licensed resident agent,
within this state, to service the companies' contracts awarded
under the provisions of this article. Commissions reasonably
related to actual service rendered for the agent or agents may be
paid by the underwriting company or companies:
Provided, however,
That in no event shall payment be made to any agent or agents when
no actual services are rendered or performed. The director shall
award the contract or contracts on a competitive basis. In
awarding the contract or contracts the director shall take into
account the experience of the offering agency, corporation,
insurance company or service organization in the group hospital and
surgical insurance field, group major medical insurance field,
group prescription drug field and group life and accidental death
insurance field, and its facilities for the handling of claims. In
evaluating these factors, the director may employ the services of
impartial, professional insurance analysts or actuaries or both.
Any contract executed by the director with a selected carrier shall be a contract to govern all eligible employees subject to the
provisions of this article. Nothing contained in this article
shall prohibit any insurance carrier from soliciting employees
covered hereunder to purchase additional hospital and surgical,
major medical or life and accidental death insurance coverage.
(f) The director may authorize the carrier with whom a primary
contract is executed to reinsure portions of the 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.
(g) Each employee who is covered under any contract or
contracts shall receive a statement of benefits to which the
employee, his or her spouse and his or her dependents are entitled
under the contract, setting forth the information as to whom the
benefits are payable, to whom claims shall be submitted, and a
summary of the provisions of the contract or contracts as they
affect the employee, his or her spouse and his or her dependents.
(h) The 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.
(i) The director shall provide by contract or contracts
entered into under the provisions of this article the cost for
coverage of children's immunization services from birth through age
sixteen years to provide immunization against the following
illnesses: Diphtheria, polio, mumps, measles, rubella, tetanus, hepatitis-b, haemophilus influenzae-b and whooping cough.
Additional immunizations may be required by the commissioner of the
bureau of public health for public health purposes. Any contract
entered into to cover these services shall require that all costs
associated with immunization, including the cost of the vaccine, if
incurred by the health care provider, and all costs of vaccine
administration, be exempt from any deductible, per visit charge
and/or copayment provisions which may be in force in these policies
or contracts. This section does not require that other health care
services provided at the time of immunization be exempt from any
deductible and/or copayment provisions.
ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.
§33-15-4c. Third party reimbursement for mammography, pap smear
or human papillomavirus
testing.
Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, whenever
reimbursement or indemnity for laboratory or X ray services are
covered, reimbursement or indemnification shall not be denied for
any of the following mammograms or pap smears when performed for
cancer screening or diagnostic purposes, at the direction of a
person licensed to practice medicine and surgery by the board of
medicine:
(1) A baseline mammogram for women age thirty-five to
thirty-nine, inclusive;
(2) A mammogram for women age forty to forty-nine, inclusive, every two years or more frequently based on the woman's physician's
recommendation;
(3) A mammogram every year for women age fifty and over;
(4) A pap smear, either conventional or liquid-based cytology,
whichever is medically appropriate in the opinion of the woman's
physician annually or more frequently based on the woman's
physician's recommendation for women age eighteen or over;
(5) A human papillomavirus (HPV
), annually or more frequently
based on the woman's physician's recommendation
for women aged
eighteen or over.
A policy, provision, contract, plan or agreement may apply to
mammograms, or pap smears or human papillomavirus (HPV
)
the same
deductibles, coinsurance and other limitations as apply to other
covered services.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-3g. Third party reimbursement for mammography, pap smear
or human papillomavirus
testing.
Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, whenever
reimbursement or indemnity for laboratory or X ray services are
covered, reimbursement or indemnification shall not be denied for
any of the following mammograms or pap smears when performed for
cancer screening or diagnostic purposes, at the direction of a
person licensed to practice medicine and surgery by the board of
medicine:
(1) A baseline mammogram for women age thirty-five to
thirty-nine, inclusive;
(2) A mammogram for women age forty to forty-nine, inclusive,
every two years or more frequently based on the woman's physician's
recommendation;
(3) A mammogram every year for women age fifty and over;
(4) A pap smear, either conventional or liquid-based cytology,
whichever is medically appropriate in the opinion of the woman's
physician annually or more frequently based on the woman's
physician's recommendation for women age eighteen or over;
(5) A human papillomavirus (HPV
), annually or more frequently
based on the woman's physician's recommendation
for women aged
eighteen or over.
A policy, provision, contract, plan or agreement may apply to
mammograms, or pap smears or human papillomavirus (HPV
)
the same
deductibles, coinsurance and other limitations as apply to other
covered services.
ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE
CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH SERVICE
CORPORATIONS.
§33-24-7b. Third party reimbursement for mammography, pap smear
or human papillomavirus
testing.
Notwithstanding any provision of any policy, provision, contract,
plan or agreement to which this article applies, whenever
reimbursement or indemnity for laboratory or X ray services are covered, reimbursement or indemnification shall not be denied for
any of the following mammograms or pap smears when performed for
cancer screening or diagnostic purposes, at the direction of a
person licensed to practice medicine and surgery by the board of
medicine:
(1) A baseline mammogram for women age thirty-five to
thirty-nine, inclusive;
(2) A mammogram for women age forty to forty-nine, inclusive,
every two years or more frequently based on the woman's physician's
recommendation;
(3) A mammogram every year for women age fifty and over;
(4) A pap smear, either conventional or liquid-based cytology,
whichever is medically appropriate in the opinion of the woman's
physician annually or more frequently based on the woman's
physician's recommendation for women age eighteen or over;
(5) A human papillomavirus (HPV
), annually or more frequently
based on the woman's physician's recommendation
for women aged
eighteen or over.
A policy, provision, contract, plan or agreement may apply to
mammograms, or pap smears or human papillomavirus (HPV
)
the same
deductibles, coinsurance and other limitations as apply to other
covered services.
ARTICLE 25. HEALTH CARE CORPORATIONS.
§33-25-8a. Third party reimbursement for mammography or pap smear
or human papillomavirus
testing.
Notwithstanding any provision of any policy, provision, contract,
plan or agreement to which this article applies, whenever
reimbursement or indemnity for laboratory or X ray services are
covered, reimbursement or indemnification shall not be denied for
any of the following mammograms or pap smears when performed for
cancer screening or diagnostic purposes, at the direction of a
person licensed to practice medicine and surgery by the board of
medicine:
(1) A baseline mammogram for women age thirty-five to
thirty-nine, inclusive;
(2) A mammogram for women age forty to forty-nine, inclusive,
every two years or more frequently based on the woman's physician's
recommendation;
(3) A mammogram every year for women age fifty and over;
(4) A pap smear, either conventional or liquid-based cytology,
whichever is medically appropriate in the opinion of the woman's
physician annually or more frequently based on the woman's
physician's recommendation for women age eighteen or over;
(5) A human papillomavirus (HPV
), annually or more frequently
based on the woman's physician's recommendation
for women aged
eighteen or over.
A policy, provision, contract, plan or agreement may apply to
mammograms, or pap smears or human papillomavirus (HPV
)
the same
deductibles, coinsurance and other limitations as apply to other
covered services.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-8a. Third party reimbursement for mammography, pap smear
or human papillomavirus
testing.
Notwithstanding any provision of any policy, provision, contract,
plan or agreement to which this article applies, whenever
reimbursement or indemnity for laboratory or X ray services are
covered, reimbursement or indemnification shall not be denied for
any of the following mammograms or pap smears when performed for
cancer screening or diagnostic purposes, at the direction of a
person licensed to practice medicine and surgery by the board of
medicine:
(1) A baseline mammogram for women age thirty-five to
thirty-nine, inclusive;
(2) A mammogram for women age forty to forty-nine, inclusive,
every two years or more frequently based on the woman's physician's
recommendation;
(3) A mammogram every year for women age fifty and over;
(4) A pap smear, either conventional or liquid-based cytology,
whichever is medically appropriate in the opinion of the woman's
physician annually or more frequently based on the woman's
physician's recommendation for women age eighteen or over;
(5) A human papillomavirus (HPV
), annually or more frequently
based on the woman's physician's recommendation
for women aged
eighteen or over.
A policy, provision, contract, plan or agreement may apply to
mammograms, or pap smears or human papillomavirus (HPV
)
the same
deductibles, coinsurance and other limitations as apply to other covered services.
NOTE: The purpose of this bill is to provide for insurance
coverage for medically indicated mammograms, pap smears and human
papillomavirus testing for cancer detection.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.
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