H. B. 2090
(By Delegates Douglas, Compton, Fleischauer,
Manuel, Pulliam and Warner)
[Introduced February 14, 1997; referred to the
Committee on Health and Human Resources then Finance.]
A BILL to amend and reenact sections seven and nine, article
sixteen, chapter five of the code of West Virginia, one
thousand nine hundred thirty-one, as amended; to amend
article fifteen, chapter thirty-three of said code by adding
thereto a new section, designated section four-e; to amend
and reenact section fifteen, article fifteen of said
chapter; to amend article sixteen of said chapter by adding
thereto a new section, designated section three-j; to amend
and reenact section four, article sixteen-c of said chapter;
to amend article twenty-four of said chapter by adding
thereto a new section, designated section seven-f; to amend
article twenty-five of said chapter by adding thereto a new
section, designated section eight-e; to amend article
twenty-five-a of said chapter by adding thereto a new
section, designated section eight-e; and to amend and reenact section five, article twenty-eight of said chapter thirty-three, all relating to health insurance; mandating
certain benefits for public employees insurance agency plans
and individual and group insurance policies; requiring
coverage of inpatient care for mothers and newly born
infants during specified time periods following childbirth;
creating exceptions; defining terms and making certain
technical changes.
Be it enacted by the Legislature of West Virginia:
That sections seven and nine, article sixteen, chapter five
of the code of West Virginia, one thousand nine hundred
thirty-one, as amended, be amended and reenacted; that article
fifteen, chapter thirty-three of said code be amended by adding
thereto a new section, designated section four-e; that section
fifteen, article fifteen of said chapter be amended and
reenacted; that article sixteen of said chapter be amended by
adding thereto a new section, designated section three-j; that
section four, article sixteen-c of said chapter be amended and
reenacted; that article twenty-four of said chapter be amended by
adding thereto a new section, designated section seven-f; that
article twenty-five of said chapter be amended by adding thereto
a new section, designated section eight-e; that article twenty
five-a of said chapter be amended by adding thereto a new
section, designated section eight-e; and that section five,
article twenty-eight of said chapter be amended and reenacted, 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 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 such 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 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 deems medically necessary for the mother or
her newly born child: Provided, That no such plan may deny
payment for a mother or her new born 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 deems discharge medically inappropriate; Provided,
however, that for purposes of this subsection, the term
"attending physician" means the obstetrician, pediatrician, other
physician or certified nurse-midwife attending the mother and
newly born child; and
(4) For plans which provide coverages for postdelivery 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 such 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 such other inpatient and outpatient
services and expenses deemed appropriate and desirable by the
agency.
(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 the
university of West Virginia board of trustees or the board of
directors of the state college system 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
the 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 mammograms and pap smears when performed for
cancer screening or diagnostic services and annual checkups for
prostate cancer in men age fifty and over. Such The 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 annually or more frequently based on the
woman's physician's recommendation for women age eighteen and
over; and
(5) 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 the 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 does 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 herein
authorized, said 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. The
director shall deal directly with insurers 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 does 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 such the agent or agents may be paid
by the underwriting company or companies: Provided, 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
such 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 such 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 such contract or
contracts shall receive a statement of benefits to which such
employee, his or her spouse and his or her dependents are
entitled thereunder, setting forth such the information as to
whom such the benefits shall be payable, to whom claims shall be
submitted, and a summary of the provisions of any such 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 pursuant to 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 hemophilus
influenza-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.
(j) The director shall provide, by contract or contracts
entered into pursuant to the provisions of this article and which
include maternity benefits, the cost of coverage for:
(1) 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 deems medically necessary for the
mother or her newly born child: Provided, That no plan may
require discharge of a mother or her newly born 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 deems discharge inappropriate: Provided,
however, That for purposes of this subsection, the term
"attending physician" means the obstetrician, pediatrician, other
physician or certified nurse midwife attending the mother and
newly born child; and
(2) For plans which provide coverages for postdelivery care
to a mother and her newly born child in the home, inpatient care
following childbirth as provided in subdivision one of this
subsection if inpatient care is determined to be medically
necessary by the attending physician.
CHAPTER 33. INSURANCE.
ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.
§33-15-4e. Required policy provisions for maternity benefits.
(a) Notwithstanding any other provision of any policy,
provision, contract, plan or agreement to which this article
applies, any policy of accident and sickness insurance delivered
or issued in this state pursuant to the provisions of this
article shall provide to all subscribers and members coverage for
maternity benefits which include, but are not limited to, the following:
(1) For policies which 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 deems medically necessary for the mother or
her newly born child: Provided, That no policy may require
discharge of a mother or her newly born 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 deems such discharge inappropriate;
(2) For policies which provide coverages for postdelivery
care to a mother and her newly born child in the home, coverage
for inpatient care following childbirth as provided in
subdivision one of this subsection if inpatient care is
determined to be medically necessary by the attending physician.
(b) For purposes of this section, the term "attending
physician" means the obstetrician, pediatrician, other physician
or certified nurse-midwife attending the mother and newly born
child.
(c) Nothing in this section shall be construed to prohibit
any insured from declining or rejecting maternity benefits
offered by any policy, provision, contract, plan or agreement to
which this article applies.
§33-15-15. Insurance commissioner to establish minimum benefits and coverages for an individual policy design;
basic policy benefits; exemptions; legislative
rules; premiums; applicability.
(a) The insurance commissioner shall establish minimum
benefits which may be included in any individual accident and
sickness insurance policy issued pursuant to this article. The
commissioner may accept bids on designs for such minimum plans
and shall compile a final basic benefit plan for use by insurers
within six months after the effective date of this article.
(b) The basic policy plan established by the insurance
commissioner may include coverage for the services of medical
physicians or surgeons, podiatrists, physician assistants,
osteopathic physicians or surgeons, chiropractors, midwives,
advanced nurse practitioners or any other professional health
care provider as deemed appropriate by the insurance
commissioner.
(c) The following shall serve as a guide to the commissioner
in the design of a basic policy issued pursuant to this article:
(1) Inpatient hospital care up to twenty days per year;
(2) Outpatient hospital care including, but not limited to,
surgery and anesthesia, preadmission testing, radiation therapy
and chemotherapy;
(3) Accident or emergency care through emergency room care
and emergency admissions to a hospital;
(4) Physician office visits for primary, preventive, well,
acute or sick care, up to four visits per year, and laboratory
fees, surgery and anesthesia, diagnostic X rays, physician care
in a hospital inpatient or outpatient setting;
(5) Prenatal care, including a minimum of one prenatal
office visit per month during the first two trimesters of
pregnancy, two office visits per month during the seventh and
eighth months of pregnancy, and one office visit per week during
the ninth month and until term. Coverage for each such visit
shall include necessary appropriate screening, including history,
physical examination, and such laboratory and diagnostic
procedures as may be deemed appropriate by the physician based
upon recognized medical criteria for the risk group of which the
patient is a member. Coverage for each office visit shall also
include such the prenatal counseling as the physician deems
appropriate;
(6) Obstetrical care, including:
(A) Physician's services, delivery room and other medically
necessary hospital services;
(B) 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 deems medically
necessary for the mother or her newly born child: Provided, That
no policy may require discharge of a mother or her newly born 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 deems discharge inappropriate:
Provided, however, That for purposes of this subsection, the term
"attending physician" means the obstetrician, pediatrician, other
physician or certified nurse-midwife attending the mother and
newly born child; and
(C) For policies which provide coverage for postdelivery
care to a mother and her newly born child in the home, coverage
for inpatient care following childbirth as provided in paragraph
(B) of this subsection if inpatient care is determined to be
medically necessary by the attending physician;
(7) X ray and laboratory services in connection with
mammograms or pap smears when performed for cancer screening or
diagnostic purposes, at the direction of a physician, including,
but not limited to, the following:
(A) Baseline or other recommended mammograms for women age
thirty-five to thirty-nine, inclusive;
(B) Mammograms recommended or required for women age forty
to forty-nine, inclusive, every two years or as needed;
(C) A mammogram every year for women age fifty and over; or
(D) A pap smear annually or more frequently based on the
woman's physician's recommendation for women age eighteen or
over. A basic policy issued pursuant to this article may apply to mammograms or pap smears the same deductibles or copayments as
apply to other covered services;
(8) Medical and laboratory services in connection with
annual checkups for prostate cancer in men age fifty and over;
and
(9) Child immunization services as described in section
five, article three, chapter sixteen of this code. This coverage
will cover all costs associated with immunization, including the
cost of the vaccine, if incurred by the health care provider, and
all costs of vaccine administration. These services shall 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 copayment provisions.
(d) Notwithstanding any other provision of this code to the
contrary, any basic policy issued pursuant to this section shall
be exempt from all statutorily and regulatorily mandated benefits
and coverages except for the minimum benefits and coverages as
established by the commissioner pursuant to subsection (a) of
this section.
(e) Nothing in this section shall preclude an insurer from
offering any other benefit or coverage under a basic policy
issued pursuant to this article, for an appropriate additional premium: Provided, That any additional benefit or coverage must
first be approved by the insurance commissioner.
(f) A basic policy issued pursuant to this section may
include deductibles, copayments and maximum benefits: Provided,
That any additional benefit must first be approved by the
insurance commissioner.
(g) The insurance commissioner shall promulgate legislative
rules pursuant to chapter twenty-nine-a of this code to implement
the provisions of this section, including, but not limited to,
rules regarding bids, forms and rates.
(h) The premiums paid for insurance provided pursuant to
this article shall be exempt from the premium tax required to be
paid pursuant to sections fourteen and fourteen-a, article three
of this chapter.
(i) A basic policy provided by this section shall be issued
only to individuals who have been without health insurance
coverage for at least one year prior to application for the same.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-3j. Required policy provisions for maternity benefits.
(a) Any insurer which delivers or issues a policy of group
accident and sickness insurance in this state pursuant to the
provisions of this article shall make available to all
subscribers and members coverage for the following maternity
benefits:
(1) 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 deems medically necessary for the mother or
her newly born child: Provided, That no plan may require
discharge of a mother or her newly born 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 deems such the discharge inappropriate.
(2) For policies which provide coverages for postdelivery
care to a mother and her newly born child in the home, coverage
for inpatient care following childbirth as provided in
subdivision (1) of this subsection, if inpatient care is
determined to be medically necessary by the attending physician.
(b) For purposes of this section, the term "attending
physician" means the obstetrician, pediatrician, other physician
or licensed nurse-midwife attending the mother and newly born
child.
(c) Nothing in this section shall be construed to prohibit
any insured from rejecting maternity benefits offered by any
policy, provision, contract, plan or agreement to which this
article applies.
ARTICLE 16C. EMPLOYER GROUP ACCIDENT AND SICKNESS INSURANCE
POLICIES.
§33-16C-4. Insurance commissioner to establish minimum benefits
and coverages; basic policy benefits.
(a) The insurance commissioner shall establish minimum
benefits which shall be included in every insurance policy issued
pursuant to this article. The commissioner may accept bids on
designs for such minimum plans and shall compile a final basic
benefit plan for use by insurers within six months after the
effective date of this article.
(b) The basic policy plan established by the insurance
commissioner may include coverage for the services of medical
physicians or surgeons, podiatrists, physician assistants,
osteopathic physicians or surgeons, chiropractors, midwives,
advanced nurse practitioners, or any other professional health
care provider as deemed appropriate by the insurance
commissioner.
(c) The following shall serve as a guide to the commissioner
in the design of a basic policy issued pursuant to this article:
(1) Inpatient hospital care up to twenty days per year;
(2) Outpatient hospital care including, but not limited to,
surgery and anesthesia, preadmission testing, radiation therapy
and chemotherapy;
(3) Accident or emergency care through emergency room care
and emergency admissions to a hospital;
(4) Physician office visits for primary, preventive, well, acute or sick care, up to four visits per year, and laboratory
fees, surgery and anesthesia, diagnostic X rays, physician care
in a hospital inpatient or outpatient setting;
(5) Prenatal care, including a minimum of one prenatal
office visit per month during the first two trimesters of
pregnancy, two office visits per month during the seventh and
eighth months of pregnancy, and one office visit per week during
the ninth month and until term. Coverage for each such visit
shall include necessary appropriate screening, including history,
physical examination, and such the laboratory and diagnostic
procedures as may be deemed appropriate by the physician based
upon recognized medical criteria for the risk group of which the
patient is a member. Coverage for each office visit shall also
include such the prenatal counseling as the physician deems
appropriate;
(6) Obstetrical care, including:
(A) Physician's services, delivery room and other medically
necessary hospital services;
(B) 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 deems medically necessary for the
mother or her newly born child: Provided, That no policy may
require discharge of a mother or her newly born 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 deems discharge inappropriate: Provided,
however, That for purposes of this subsection, the term
"attending physician" means the obstetrician, pediatrician, other
physician or certified nurse-midwife attending the mother and
newly born child; and
(C) For policies which provide coverages for postdelivery
care to a mother and her newly born child in the home, coverage
for inpatient care following childbirth as provided in paragraph
(B) of this subdivision if inpatient care is determined to be
medically necessary by the attending physician.
(7) X ray and laboratory services in connection with
mammograms or pap smears when performed for cancer screening or
diagnostic purposes, at the direction of a physician, including,
but not limited to, the following:
(A) Baseline or other recommended mammograms for women age
thirty-five to thirty-nine, inclusive;
(B) Mammograms recommended or required for women age forty
to forty-nine, inclusive, every two years or as needed;
(C) A mammogram every year for women age fifty and over; or
(D) A pap smear annually or more frequently based on the
woman's physician's recommendation for women age eighteen or
over. A basic policy issued pursuant to this article may apply
to mammograms or pap smears the same deductibles or copayments as apply to other covered services;
(8) Medical and laboratory services in connection with
annual checkups for prostate cancer in men age fifty and over;
and
(9) Child immunization services as described in section
five, article three, chapter sixteen of this code. This coverage
will cover all costs associated with immunization, including the
cost of the vaccine, if incurred by the health care provider, and
all costs of vaccine administration. These services shall 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 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE
CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH SERVICE CORPORATIONS.
§33-24-7f. Required maternity benefits.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
contract, plan or policy issued pursuant to the provisions of
this article shall provide to all subscribers and members
coverage for maternity benefits which include, but are not
limited to, the following:
(1) 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 deems medically necessary for the
mother or her newly born child: Provided, That no policy may
require discharge of a mother or her newly born 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 deems discharge inappropriate; and
(2) For policies which provide coverages for postdelivery
care to a mother and her newly born child in the home, coverage
for inpatient care following childbirth as provided in
subdivision (1) of this subsection, if inpatient care is
determined to be medically necessary by the attending physician.
(b) For purposes of this section, the term "attending
physician" means the obstetrician, pediatrician, other physician
or licensed nurse-midwife attending the mother and newly born
child.
(c) Nothing in this section shall be construed to prohibit
any insured from rejecting maternity benefits offered by any
policy, provision, contract, plan or agreement to which this
article applies.
ARTICLE 25. HEALTH CARE CORPORATIONS.
§33-25-8e. Required maternity benefits.
(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any
contract, agreement, policy or plan issued pursuant to the
provisions of this article shall provide to all subscribers and
members coverage for maternity and newborn child care benefits
which include, but are not limited to, the following:
(1) 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 deems medically necessary for the
mother or her newly born child: Provided, That no policy may
require discharge of a mother or her newly born 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 deems discharge inappropriate; and
(2) For policies which provide coverages for postdelivery
care to a mother and her newly born child in the home, coverage
for inpatient care following childbirth as provided in
subdivision (1) of this subsection, if inpatient care is
determined to be medically necessary by the attending physician.
(b) For purposes of this section, the term "attending
physician" means the obstetrician, pediatrician, other physician
or licensed nurse-midwife attending the mother and newly born
child.
(c) Nothing in this section shall be construed to prohibit
any insured from rejecting maternity care benefits offered by any policy, provision, contract, plan or agreement to which this
article applies.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-8e. Required maternity benefits.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
contract, agreement, policy or plan issued pursuant to the
provisions of this article shall provide to all subscribers and
members coverage for maternity and newborn child care benefits
which include, but are not limited to, the following:
(1) 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 deems medically necessary for the
mother or her newly born child: Provided, That no policy may
require discharge of a mother or her newly born 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 deems discharge inappropriate; and
(2) For policies which provide coverages for postdelivery
care to a mother and her newly born child in the home, coverage
for inpatient care following childbirth as provided in
subdivision (1) of this subsection, if inpatient care is
determined to be medically necessary by the attending physician.
(b) For purposes of this section, the term "attending physician" means the obstetrician, pediatrician, other physician
or licensed nurse-midwife attending the mother and newly born
child.
(c) Nothing in this section shall be construed to prohibit
any insured from rejecting maternity care benefits offered by any
policy, provision, contract, plan or agreement to which this
article applies.
ARTICLE 28. INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM
STANDARDS.
§33-28-5. Minimum standards for benefits.
(a) The commissioner shall promulgate rules and regulations,
in accordance with chapter twenty-nine-a of the code, to
establish minimum standards for benefits under each of the
following categories of coverage in individual policies of
accident and sickness insurance and subscriber contracts of
hospital, medical, dental and service corporations:
(1) Basic hospital expense coverage;
(2) Basic medical-surgical expense coverage;
(3) Hospital confinement indemnity coverage;
(4) Basic maternity benefits coverage which includes, but
is not limited to, the following, unless rejected by the insured:
(A) 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 deems medically necessary for the mother or her newly born child: Provided, That no policy may
require discharge of a mother or her newly born 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 deems discharge inappropriate: Provided,
however, That for purposes of this subsection, the term
"attending physician" means the obstetrician, pediatrician, other
physician or licensed nurse-midwife attending the mother and
newly born child;
(B) For policies which provide coverages for postdelivery
care to a mother and her newly born child in the home, coverage
for inpatient care following childbirth as provided in
subdivision (1) of this subsection, if inpatient care is
determined to be medically necessary by the attending physician;
(4) (5) Major medical expense coverage;
(5) (6) Disability income protection coverage;
(6) (7) Accident only coverage; and
(7) (8) Specified disease or specified accident coverage.
(b) Nothing in this section shall preclude the issuance of
any policy or subscriber contract which combines two or more of
the categories of coverage enumerated in subdivisions (1) through
(6) of subsection (a) of this section.
(c) No policy or subscriber contract shall be delivered or
issued for delivery in this state which does not meet the prescribed minimum standards for the categories of coverage
listed in subdivisions (1) through (7) (8) of subsection (a) of
this section unless the commissioner finds that such the policy
or subscriber contract will be in the public interest and that
such the policy or subscriber contract contains benefits which
are reasonable in relation to the premium charged.
(d) The commissioner shall prescribe the method of
identification of policies and subscriber contracts based upon
coverages provided.
NOTE: This bill mandates coverage by insurance carriers of
inpatient care for mothers and newly born infants during
specified time periods following childbirth.
Strike-throughs indicate language that would be stricken
from the present law, and underscoring indicates new language
that would be added.
§§33-15-4c, 33-16-3j, 33-24-7f, 33-25-8e, 33-25A-8e, are
new; therefore, strike-throughs and underscoring have been
omitted.