H. B. 2087
(By Delegates Walters, Harrison, Sprouse,
Greear and Pulliam)
[Introduced January 19, 1995; referred to the Committee
on Health and Human Resources then Finance.]
A BILL to amend chapter nine of the code of West Virginia, one
thousand nine hundred thirty-one, as amended, by adding
thereto a new article, designated article two-a, relating to
providing access to private health insurance for recipients
of medicaid by using medicaid funds to pay for private
health insurance premiums; defining certain terms;
establishing a purpose; setting eligibility criteria;
providing for issuance of eligibility forms; requests for
reimbursement for policy and contract offers; standards for
insurance contracts and policies; reimbursement of insurers
by the department of health and human resources;
responsibilities of the secretary of health and human
resources including rule-making authority; establishing a
board to set reimbursement rates for family and individual coverage; creating a medicaid access fund to be used only to
reimburse insurers for health care policies and contracts;
prohibiting employers from refusing coverage solely for the
purpose of making the employee eligible to receive medicaid
funded health insurance; allowing employers to purchase the
remaining term of a new employees medicaid coverage; and
establishing a high-risk pool.
Be it enacted by the Legislature of West Virginia:
That chapter nine of the code of West Virginia, one thousand
nine hundred thirty-one, as amended, be amended by adding thereto
a new article, designated article two-a, to read as follows:
ARTICLE 2A. ACCESS TO PRIVATE HEALTH INSURANCE FOR MEDICAID
RECIPIENTS.
§9-2A-1. Title.
This article is known and may be cited as the "Access To
Medicaid Act."
§9-2A-2. Definitions.
As used in this article:
"Insurer" means any insurance company authorized by the laws
of this state to conduct sickness and accident insurance business
and any state authorized health maintenance organization.
"Secretary" means the secretary of health and human resources.
§9-2A-3. Purpose.
The "Access to Medicaid Act" is hereby enacted for the
purpose of providing a publicly financed voucher program to
provide access to privately delivered health insurance coverage
for residents of this state who qualify for medicaid funded
private health insurance coverage as provided under the
provisions of section four of this article.
§9-2A-4. Eligibility requirements.
The following persons are eligible for coverage under the
program:
(a) Any person who is a recipient of aid to families with
dependent children (AFDC);
(b) Any person whose income is equal to or less than one
hundred percent of the federal poverty level and who is not
covered under an employer-provided health care plan; and
(c) Any person not covered by an employer-provided health
care plan whose income is equal to or greater than one hundred
percent of the federal poverty level, but not more than one
hundred fifty percent of the federal poverty level: Provided,
That a person eligible under this subdivision shall be required to pay ten percent of the reimbursable premium amount determined
by the director of health and human resources.
§9-2A-5. Issuance of proof of eligibility forms.
If the department of health and human resources determines
that a person meets the eligibility requirements set forth in
section four of this article, the department shall issue that
person a proof of eligibility form, which entitles the person to
coverage under any health insurance or health care policy or
contract, offered in accordance with this article, in the amount
of the premium indicated on the form and for a policy or contract
period of one year.
§9-2A-6. Reimbursement of premiums.
If coverage is issued to the individual, policyholder or
contract holder, the insurer shall submit the proof of
eligibility forms and a request for reimbursement of premium to
the department of health and human resources.
§9-2A-7. Standards applicable to the policies and contracts.
The health insurance or health care policies and contracts
for which insurers are eligible shall be provided in accordance
with the following conditions:
(a) The cost of the policies and contracts shall not exceed the reimbursable premium amount indicated on the proof of
eligibility form;
(b) The policies and contracts are not subject to any
previous state mandatory benefits;
(c) Each policy and contract shall include the following:
(1) All nine of the federal medicaid mandates; (2) thirty days
in-patient care coverage for mental health, mental retardation
and substance abuse; (3) prescription drugs; (4) prenatal care
coverage; and (5) lifestyle incentives with preventive education:
Provided, That no contract may cover any abortion, except an
abortion that is necessary to save the life of the mother;
(d) The nine federal medicaid mandates as referred in
subsection (c) of this section consist of the following: (1)
In-patient and out-patient hospital services; (2) rural health
clinic services; (3) other laboratory and X ray services; (4)
nurse practitioners' services; (5) nursing facility services and
home health services for individuals twenty-one years of age and
older; (6) early and periodic screening, diagnosis and treatment
for individuals under twenty-one years of age; (7) family
planning services and supplies; (8) physicians' services; and (9)
nurse-midwife services;
(e) The insurer may not impose any waiting period for
benefits, or otherwise reduce or restrict benefits, for any claim
that is the result of a high risk condition;
(f) The insurer shall refund to the insured, in accordance
with the program established by the secretary, a portion of the
premium for coverage of an eligible person if the total amount of
claims submitted by the person is less than the amount of the
premium paid; and
(g) The insurer shall refund to the insured, in accordance
with the program established by the secretary, a portion of the
premium for coverage of an eligible person if the person locates
any item or service listed on a billing statement, which item or
services was not received by, or rendered to, the person. The
insurance company may collect this amount from the health care
provider.
§9-2A-8. Reimbursement of insurers.
Within thirty days after receipt of a valid proof of
eligibility form and request for reimbursement from an insurer,
the department shall issue payment to the insurer in the amount
of the premium indicated on the form.
§9-2A-9. Duties of secretary; rule-making authority.
Within ninety days after the effective date of this article,
the secretary shall adopt rules that provide for the fair,
reasonable and equitable administration of this program,
including provisions relative to procedures for determining
eligibility under the program, issuance of proof of eligibility
forms by the department, determinations of the reimbursable
premium amount and procedures for the reimbursement of insurers
that issue policies and contracts to eligible persons. Rules
adopted under this section shall also include a schedule for the
implementation of the program on an incremental basis. The
duties of the secretary include:
(a) Administrating and implementing the program;
(b) Monitoring the operation of the program;
(c) Disseminating, to insurers and to the public,
information concerning the program and the persons eligible to
receive benefits under the program;
(d) Implementing a system to provide information and
guidance to all persons eligible under the program relative to
the program's procedures and the selection of the most
appropriate benefits under a health insurance or health care
policy or contract;
(e) Implementing a program whereby a portion of the premium
for coverage, other than coverage for preventive care, of an
eligible person shall be refunded by the insurer to the person if
the total amount of claims submitted by the person for that
coverage is less than the amount of the premium paid for that
coverage;
(f) Implementing a program whereby a portion of the premium
for coverage of an eligible person shall be refunded by the
insurer to the person if the person locates any item or service
listed on a billing statement, which item or service was not
received by, or rendered to, the person; and
(g) Studying and evaluating the operation of the program,
and submitting an annual report of his or her findings and
conclusions to the Legislature.
§9-2A-10. Annual amount of reimbursable voucher.
A board composed of the secretary, the commissioner of
insurance or their designees and three citizen members appointed
by the governor, by and with the advice and consent of the Senate
shall determine on an annual basis, the premium amount that is
reimbursable by the department for individual and family
coverage. The board shall meet at least once each year and on call of the secretary who shall act as chairman of the board for
the conduct of board business. Three members shall constitute a
quorum. Citizen members shall be reimbursed for daily expenses
incurred in the actual performance of board business at the rate
members of the Legislature receive during legislative sessions.
§9-2A-11. Creation of fund; funding; uses.
(a) There is hereby created in the state treasury a medicaid
access fund, which shall consist of all of the following:
(1) Federal payments received as a result of any waiver of
requirements granted by the United States secretary of health
and human services under the health care programs, other than the
nursing facility care programs and the intermediate care facility
programs for the mentally retarded, established under Title XIX
of the "Social Security Act."
(2) State funding in an annual amount equal to the funding
appropriated for expenditure in the fiscal year in which this
article is enacted for purposes of the current state medicaid
program, other than the nursing facility care programs and the
intermediate care facility programs for the mentally retarded.
(3) All other money appropriated to the fund, interest
earned on investments or deposits, grants and gifts made to the fund from public or private sources, or moneys acquired otherwise
by the fund.
(b) The fund shall be administered by the secretary and
shall be used solely for purposes of reimbursing insurers for the
provision of health insurance of health care policies and
contracts to residents of this state who are eligible for
benefits under this article.
§9-2A-12. Prohibition against "dumping."
An employer may not fail to extend coverage to, or continue
coverage of, an employee or his dependents under any health care
coverage provided by the employer solely to render the employee
or dependent eligible to receive benefits provided under this
article.
§9-2A-13. Employer buy-in.
Employers who hire current medicaid voucher recipients shall
be permitted to provide health care coverage for the employee by
buying into the remaining term of the medicaid recipient's health
plan. The amount of employer paid premiums shall be prorated for
the number of months remaining in the current year of coverage.
The money from the employer buy-in shall be placed in the
medicaid access fund.
§9-2A-14. High-risk individuals.
Medicaid recipients who have been previously rejected by two
or more insurers due to high-risk conditions shall be placed into
the state high-risk pool developed and administered by the
insurance commissioner. The difference between the value of the
voucher and the high-risk pool premium shall be paid by the state
medicaid program.
NOTE: The purpose of this bill is to provide a voucher
program paid for by medicaid funds to provide access to privately
delivered health insurance coverage for residents of this state
who qualify for benefits under the medicaid program.
§9-2A is new; therefore, strike-throughs and underscoring
have been omitted.