COMMITTEE SUBSTITUTE
FOR
H. B. 2090
(By Delegates Compton, Fleischauer, Manuel, Pulliam and Warner)
(Originating in the Committee on Finance)
[March 14, 1997]
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 and
reenact sections four-c and fifteen, article fifteen, chapter
thirty-three of said code; to further amend said article by
adding thereto a new section, designated section four-e; to
amend and reenact section three-g, article sixteen of said
chapter; to further amend said article by adding thereto a new
section, designated section three-j; to amend and reenact
section four, article sixteen-c of said chapter; to amend and
reenact section seven-b, article twenty-four of said chapter;
to further amend said article by adding thereto a new section,
designated section seven-f; to amend and reenact section
eight-a, article twenty-five of said chapter; to further amend
said article by adding thereto a new section, designated
section eight-e; to amend and reenact section eight-a, article twenty-five-a of said chapter; to further amend said article
by adding thereto a new section, designated section eight-e;
and to amend and reenact section five, article twenty-eight of
said chapter, all relating to health insurance; mandating
certain benefits for public employees insurance agency plans,
individual and group insurance policies, health service
corporation plans, health care corporation plans and health
maintenance organization plans; requiring coverage of prostate
screenings under specified plans; requiring coverage of
inpatient care for mothers and newborn infants during
specified time periods following childbirth; requiring
coverage of mastectomy surgery and medically necessary
reconstructive surgery; prohibiting discharge of mastectomy or
reconstructive surgery patients prior to forty-eight hours
after surgery; prohibiting discharge of prostate surgery
patients prior to forty-eight hours after surgery; 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 sections four-c and
fifteen, article fifteen, chapter thirty-three of said code be
amended and reenacted; that said article be further amended by
adding thereto a new section, designated section four-e; that section three-g, article sixteen of said chapter be amended
reenacted; that said article be further 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
section seven-b, article twenty-four of said chapter be amended and
reenacted; that said article be further amended by adding thereto
a new section, designated section seven-f; that section eight-a,
article twenty-five of said chapter be amended and reenacted; that
said article be further amended by adding thereto a new section,
designated section eight-e; that section eight-a, article twenty- five-a of said chapter be amended and reenacted; that said article
be further 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 pursuant to this article, and to
establish and promulgate rules for the administration of such the
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;
(3) For plans that include maternity benefits:
(A) Coverage for inpatient care for a mother and her newborn child for at least forty-eight hours following a normal vaginal
delivery, and at least ninety-six hours following a caesarean
section delivery;
(B) Subject to the provisions of paragraph (A) of this
subdivision, coverage for inpatient care in a duly licensed health
care facility for a mother and her newborn infant for the length of
time which the attending physician, after consultation with the
mother, determines is medically necessary for the mother or her
newborn child;
(C) Coverage for maternity and pediatric care in accordance
with guidelines established by the American College of
Obstetricians and Gynecologists, the American Academy of Pediatrics
or other established professional medical associations;
(D) For purposes of this subsection, the term "attending
physician" means the obstetrician, pediatrician, other physician or
certified nurse-midwife attending the mother or her newborn child;
(4) For plans which provide coverages for post-delivery care
to a mother and her newly born newborn 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 as
determined by the agency.; and
(5) For plans which provide coverage for any degree of
mastectomy or breast reconstructive surgery; or prostate surgery:
(A) Coverage for inpatient mastectomy surgery and, when
determined to be medically necessary by the attending physician,
coverage for reconstruction of the breast on which surgery has been
performed and reconstruction of the other breast to produce a
symmetrical appearance in a manner chosen by the patient and the
attending physician; and
(B) Coverage for the mastectomy surgery or breast
reconstructive surgery in a duly licensed health care facility for
the length of time which the attending physician determines is
medically necessary for the patient. No plan may require discharge
for a patient prior to forty-eight hours following the surgery if
the attending physician determines that the discharge medically
inappropriate.
(C) Coverage for the prostate surgery in a duly licensed
health care facility for the length of time which the attending
physician determines is medically necessary for the patient. No
plan may require discharge for a patient prior to forty-eight hours
following the surgery if the attending physician determines that
the discharge medically inappropriate.
(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 any 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 shall 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 in this
section 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 in this section 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 purchasing 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 by this article, said 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. 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 may be paid to any individual or agent;: Provided,
That but this does not preclude an underwriting insurance company
or companies, at their own expense, is not precluded from
appointing , at their own expense 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, 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 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 under this article 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 the
employee, his or her spouse and his or her dependents are entitled
thereunder under the contract, 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 for a mother and her newborn child for at
least forty-eight hours following a normal vaginal delivery, and
at least ninety-six hours following a caesarean section delivery;
(2) Subject to the provisions of subdivision (1) of this
subsection, inpatient care in a duly licensed health care facility
for a mother and her newborn infant for the length of time which
the attending physician, after consultation with the mother,
determines is medically necessary for the mother or her newborn
child;
(3) Maternity and pediatric care in accordance with
guidelines established by the American College of Obstetricians and
Gynecologists, the American Academy of Pediatrics or other
established professional medical associations;
(4) For plans which provide coverages for post-delivery care
to a mother and her newborn child in the home, 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;
(5) For purposes of this subsection, the term "attending
physician" means the obstetrician, pediatrician, other physician or
certified nurse-midwife attending the mother or her newborn child.
(k) The director shall provide, by contract or contracts
entered into pursuant to the provisions of this article and which
include benefits for mastectomy or breast reconstructive surgery,
or prostate surgery, the cost of coverage for:
(1) Inpatient mastectomy surgery and, when determined to be
medically necessary by the attending physician, reconstruction of
the breast on which surgery has been performed and reconstruction
of the other breast to produce a symmetrical appearance in a manner
chosen by the patient and the attending physician; and
(2) Inpatient mastectomy surgery or reconstructive surgery in
a duly licensed health care facility for the length of time which
the attending physician determines is medically necessary for the
patient. No plan may require discharge for a patient prior to
forty-eight hours following the surgery if the attending physician
determines that the discharge is medically inappropriate; and
(3) Inpatient prostate surgery in a duly licensed health care
facility for the length of time which the attending physician determines is medically necessary for the patient. No plan may
require discharge for a patient prior to forty-eight hours
following the surgery if the attending physician determines that
the discharge is medically inappropriate.
CHAPTER 33. INSURANCE.
ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.
§33-15-4c. Required policy provisions for mammography or pap
smear testing and mastectomy and reconstructive
surgery.
(a) 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
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. For
purposes of this subsection, the term "mammograms and pap smears"
includes, but is not limited to:
(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; and
(4) A pap smear annually or more frequently based on the woman's physician's recommendation for women age eighteen or over.
(b) 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
annual cancer screenings in men age fifty and over for prostate
cancer, at the direction of a person licensed to practice medicine
and surgery by the board of medicine.
(c) A policy, provision, contract, plan or agreement may
apply to mammograms or pap smears, the same deductibles,
coinsurance and other limitations as apply to other covered
services.
(d) Notwithstanding any other provision of a policy, any
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
which provides coverage for any degree of mastectomy or
reconstructive surgery or prostate surgery shall provide to all
subscribers and members:
(1) Coverage for inpatient mastectomy surgery and, when
determined to be medically necessary by the attending physician,
coverage for reconstruction of the breast on which surgery has been
performed and reconstruction of the other breast to produce a
symmetrical appearance in a manner chosen by the patient and the
attending physician;
(2) Coverage for the mastectomy surgery or breast
reconstructive surgery in a duly licensed health care facility for
the length of time which the attending physician determines is
medically necessary for the patient. No policy, provision,
contract, plan or agreement may require discharge for a patient
prior to forty-eight hours following the surgery if the attending
physician determines that the is discharge medically inappropriate;
and
(3) Coverage for prostate surgery in a duly licensed health
care facility for the length of time which the attending physician
determines is medically necessary for the patient. No policy,
provision, contract, plan or agreement may require discharge for a
patient prior to forty-eight hours following the surgery if the
attending physician determines that the is discharge medically
inappropriate.
§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) Coverage for inpatient care for a mother and her newborn
child for at least forty-eight hours following a normal vaginal
delivery, and at least ninety-six hours following a caesarean section delivery;
(2) Subject to the provisions of subdivision onesubdivision (1) of this
subsection, coverage for inpatient care in a duly licensed health
care facility for a mother and her newborn infant for the length of
time which the attending physician, after consultation with the
mother, determines is medically necessary for the mother or her
newborn child;
(3) Coverage for maternity and pediatric care in accordance
with guidelines established by the American college of
obstetricians and gynecologists, the American academy of pediatrics
or other established professional medical associations; and
(4) For policies which provide coverages for post-delivery
care to a mother and her newborn child in the home, coverage for
inpatient care following childbirth as provided in subdivision onesubdivision (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
certified nurse-midwife attending the mother or the 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 for a mother and her newborn
child for at least forty-eight hours following a normal
vaginal delivery, and at least ninety-six hours following a
caesarean section delivery;
(C) Subject to the provisions of paragraph (B) of this
subdivision, coverage for inpatient care in a duly licensed health care facility for a mother and her newborn infant for the
length of time which the attending physician, after consultation
with the mother, determines is medically necessary for the
mother or her newborn child;
(D) Coverage for maternity and pediatric care in
accordance with guidelines established by the American College
of Obstetricians and Gynecologists, the American Academy of
Pediatrics or other established professional medical
associations;
(E) For policies which provide coverage for post-delivery
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;
(F) For purposes of this subsection, the term "attending
physician" means the obstetrician, pediatrician, other physician
or certified nurse-midwife attending the mother or her newborn
child;
(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;
(10) Coverage for inpatient mastectomy surgery and, when
determined medically necessary by the attending physician,
coverage for reconstruction of the breast on which surgery has
been performed and reconstruction of the other breast to produce a symmetrical appearance in a manner chosen by the patient and
the attending physician;
(11) Coverage for the mastectomy surgery or breast
reconstructive surgery in a duly licensed health care facility
for the length of time which the attending physician determines
is medically necessary for the patient. No policy may require
discharge for a patient prior to forty-eight hours following the
surgery if the attending physician determines that the
discharge is medically inappropriate; and
(12) Coverage for prostate surgery in a duly licensed
health care facility for the length of time which the attending
physician determines is medically necessary for the patient. No
policy may require discharge for a patient prior to forty-eight
hours following the surgery if the attending physician
determines that the discharge is medically inappropriate.
(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 article three, 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.
§33-16-3g. Required policy provisions for mammography or pap
smear testing and mastectomy and reconstructive
surgery.
(a) 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 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. For purposes of this subsection, the term
"mammograms and pap smears" includes, but is not limited to:
(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;
and
(4) A pap smear annually or more frequently based on the
woman's physician's recommendation for women age eighteen or
over.
(b) A policy, provision, contract, plan or agreement may
apply to mammograms or pap smears, the same deductibles,
coinsurance and other limitations as apply to other covered
services.
(c) 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 annual prostate cancer screenings in men over fifty at the direction of a person licensed to practice medicine
and surgery by the board of medicine.
(d) 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 which provides coverage for any degree of mastectomy or
breast reconstructive surgery, or prostate surgery shall provide
to all subscribers and members:
(1) Coverage for inpatient mastectomy surgery, and, when
determined to be medically necessary by the attending physician,
coverage for reconstruction of the breast on which surgery has
been performed and reconstruction of the other breast to produce
a symmetrical appearance in a manner chosen by the patient and
the attending physician;
(2) Coverage for the mastectomy surgery or reconstructive
surgery in a duly licensed health care facility for the length
of time which the attending physician determines medically
necessary for the patient. No policy, provision, contract, plan
or agreement may require discharge for a patient prior to forty- eight hours following the surgery if the attending physician
determines that the discharge is medically inappropriate; and
(3) Coverage for prostate surgery in a duly licensed
health care facility for the length of time which the attending
physician determines medically necessary for the patient. No policy, provision, contract, plan or agreement may require
discharge for a patient prior to forty-eight hours following the
surgery if the attending physician determines that the discharge
is medically inappropriate.
§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 and pursuant to
the provisions of this article shall make available to all
subscribers and members coverage for the following maternity
benefits:
(1) Coverage for inpatient care for a mother and her
newborn child for at least forty-eight hours following a normal
vaginal delivery, and at least ninety-six hours following a
caesarean section delivery;
(2) Subject to the provisions of subdivision onesubdivision (1) of this
subsection, coverage for inpatient care in a duly licensed
health care facility for a mother and her newborn infant for the
length of time which the attending physician, after consultation
with the mother, determines is medically necessary for the
mother or her newborn child;
(3) Coverage for maternity and pediatric care in
accordance with guidelines established by the American College
of Obstetricians and Gynecologists, the American Academy of
Pediatrics or other established professional medical
associations; and
(4) For policies which provide coverages for post-delivery
care to a mother and her newborn child in the home, coverage for
inpatient care following childbirth as provided in subdivision
onesubdivision
(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 certified nurse-midwife attending the mother or the 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.
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) Coverage for inpatient care for a mother and her
newborn child for at least forty-eight hours following a normal
vaginal delivery, and at least ninety-six hours following a
caesarean section delivery;
(C) Subject to the provisions of paragraph (B) of this
subdivision, coverage for inpatient care in a duly licensed
health care facility for a mother and her newborn infant for the
length of time which the attending physician, after consultation
with the mother, determines is medically necessary for the
mother or her newborn child;
(D) Coverage for maternity and pediatric care in accordance
with guidelines established by the American College of
Obstetricians and Gynecologists, the American Academy of
Pediatrics or other established professional medical
associations; and
(E) For policies 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 paragraph
(B) of this subdivision if inpatient care is determined to be
medically necessary by the attending physician;
(F) For purposes of this subdivision, the term "attending
physician" means the obstetrician, pediatrician, other physician
or certified nurse-midwife attending the mother or her newborn
child;
(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;
(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;
(10) Coverage for inpatient mastectomy surgery and, when
determined medically necessary by the attending physician,
reconstruction of the breast on which surgery has been performed
and reconstruction of the other breast to produce a symmetrical
appearance in a manner chosen by the patient and the attending
physician;
(11) Coverage for the mastectomy surgery or breast
reconstructive surgery in a duly licensed health care facility
for the length of time which the attending physician determines
is medically necessary for the patient. No policy or plan may
require discharge for a patient prior to forty-eight hours
following the surgery if the attending physician determines that
the discharge is medically inappropriate; and
(12) Coverage for the prostate surgery in a duly licensed
health care facility for the length of time which the attending
physician determines is medically necessary for the patient. No policy or plan may require discharge for a patient prior to
forty-eight hours following the surgery if the attending
physician determines that the discharge is medically
inappropriate.
ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE
CORPORATIONS, DENTAL SERVICE CORPORATIONS AND
HEALTH SERVICE CORPORATIONS.
§33-24-7b. Required policy provisions for mammography, pap
smear testing or other cancer screening and
mastectomy surgery, reconstructive breast surgery
or prostate surgery.
(a) 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 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. For purposes of this subsection, the term
"mammograms and pap smears" includes, but is not limited to:
(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; and
(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 or over.
(b) A policy, provision, contract, plan or agreement may
apply to mammograms or pap smears, the same deductibles,
coinsurance and other limitations as apply to other covered
services.
(c) 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 annual prostate cancer screenings in men over
fifty at the direction of a person licensed to practice medicine
and surgery by the board of medicine.
(d) Notwithstanding any other provision of any policy, a
provision, contract, plan or agreement to which this article
applies, any policy or plan which provides converge for any
degree of mastectomy or breast reconstructive surgery or
prostate surgery shall provide to all subscribers and members:
(1) Coverage for inpatient mastectomy surgery and, when
determined medically necessary by the attending physician,
coverage for reconstruction of the breast on which surgery has
been performed and reconstruction of the other breast to produce
a symmetrical appearance in a manner chosen by the patient and
the attending physician;
(2) Coverage for the mastectomy surgery or breast
reconstructive surgery in a duly licensed health care facility
for the length of time which the attending physician determines
is medically necessary for the patient. No policy or plan may
require discharge for a patient prior to forty-eight hours
following the surgery if the attending physician determines that
the discharge is medically inappropriate; and
(3) Coverage for prostate surgery in a duly licensed health
care facility for the length of time which the attending
physician determines is medically necessary for the patient. No
policy or plan may require discharge for a patient prior to
forty-eight hours following the surgery if the attending
physician determines that the discharge is medically
inappropriate.
§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) Coverage for inpatient care for a mother and her
newborn child for at least forty-eight hours following a normal
vaginal delivery, and at least ninety-six hours following a
caesarean section delivery;
(2) Subject to the provisions of subdivision (1) of this
subsection, coverage for inpatient care in a duly licensed
health care facility for a mother and her newborn infant for the
length of time which the attending physician, after consultation
with the mother, determines is medically necessary for the
mother or her newborn child;
(3) Coverage for maternity and pediatric care in accordance
with guidelines established by the American College of
Obstetricians and Gynecologists, the American Academy of
Pediatrics or other established professional medical
associations; and
(4) For policies or plans which provide coverages for
post-delivery care to a mother and her newborn child in the
home, coverage for inpatient care following childbirth as
provided in subdivision onesubdivision (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 or newborn 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.
§33-25-8a. Required policy provisions for mammography, pap
smear testing, prostate screening, mastectomy and
breast reconstructive surgery, and prostate
surgery.
(a) 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 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. For purposes of this subsection, the term "mammograms
and pap smears" includes, but is not limited to:
(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;
and
(4) A pap smear annually or more frequently based on the
woman's physician's recommendation for women age eighteen or
over.
(b) A policy, provision, contract, plan or agreement may
apply to mammograms or pap smears, the same deductibles, coinsurance and other limitations as apply to other covered
services.
(c) 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 annual prostate cancer screenings in men
age fifty or over, at the direction of a person licensed to
practice medicine and surgery by the board of medicine.
(d) Notwithstanding any other provision of any policy,
provision, contract, plan or agreement to which this article
applies, any policy or plan which provides coverage for any
degree of mastectomy or breast reconstructive surgery or
prostate surgery shall provide to all subscribers and members:
(1) Coverage for inpatient mastectomy surgery and, when
determined to be medically necessary by the attending physician,
coverage for reconstruction of the breast on which surgery has
been performed and reconstruction of the other breast to produce
a symmetrical appearance in a manner chosen by the patient and
the attending physician;
(2) Coverage for the mastectomy surgery or breast
reconstructive surgery in a duly licensed health care facility
for the length of time which the attending physician determines
is medically necessary for the patient. No policy or plan may
require discharge for a patient prior to forty-eight hours following the surgery if the attending physician determines that
the discharge is medically inappropriate; and
(3) Coverage for prostate surgery in a duly licensed health
care facility for the length of time which the attending
physician determines is medically necessary for the patient. No
policy or plan may require discharge for a patient prior to
forty-eight hours following the surgery if the attending
physician determines that the discharge is medically
inappropriate.
§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) Coverage for inpatient care for a mother and her
newborn child for at least forty-eight hours following a normal
vaginal delivery, and at least ninety-six hours following a
caesarean section delivery;
(2) Subject to the provisions of subdivision onesubdivision (1) of this
subsection, coverage for inpatient care in a duly licensed
health care facility for a mother and her newborn infant for the
length of time which the attending physician, after consultation
with the mother, determines is medically necessary for the mother or her newborn child;
(3) Coverage for maternity and pediatric care in accordance
with guidelines established by the American College of
Obstetricians and Gynecologists, the American Academy of
Pediatrics or other established professional medical
associations; and
(4) For policies 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 onesubdivision (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-8a. Required policy provisions for mammography and pap
smear testing and mastectomy and reconstructive
surgery.
(a)
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 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. For purposes of this subsection, the term
"mammograms and pap smears" includes, but is not limited to:
(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;
and
(4) A pap smear annually or more frequently based on the
woman's physician's recommendation for women age eighteen or
over.
(b) A policy, provision, contract, plan or agreement may
apply to mammograms or pap smears, the same deductibles,
coinsurance and other limitations as apply to other covered
services.
(c) 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 annual prostate cancer screenings in men age fifty
or older, at the direction of a person licensed to practice
medicine and surgery by the board of medicine.
(d) Notwithstanding any other provision of any policy,
provision, contract, plan or agreement to which this article
applies, any policy or plan which provides converge for any
degree of mastectomy or breast reconstructive surgery, or
prostate surgery shall provide to all subscribers and members:
(1) Coverage for inpatient mastectomy surgery and, when
determined to be medically necessary by the attending physician,
coverage for reconstruction of the breast on which surgery has
been performed and reconstruction of the other breast to produce
a symmetrical appearance in a manner chosen by the patient and
the attending physician;
(2) Coverage for the mastectomy surgery or breast
reconstructive surgery in a duly licensed health care facility
for the length of time which the attending physician determines
is medically necessary for the patient. No policy or plan may
require discharge for a patient prior to forty-eight hours
following the surgery if the attending physician determines that
the discharge is medically inappropriate; and
(3) Coverage for the prostate surgery in a duly licensed
health care facility for the length of time which the attending
physician determines is medically necessary for the patient. No
policy or plan may require discharge for a patient prior to forty-eight hours following the surgery if the attending
physician determines that the discharge is medically
inappropriate.
§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) Coverage for inpatient care for a mother and her
newborn child for at least forty-eight hours following a normal
vaginal delivery, and at least ninety-six hours following a
caesarean section delivery;
(2) Subject to the provisions of subdivision onesubdivision (1) of this
subsection, coverage for inpatient care in a duly licensed
health care facility for a mother and her newborn infant for the
length of time which the attending physician, after consultation
with the mother, determines is medically necessary for the
mother or her newborn child;
(3) Coverage for maternity and pediatric care in accordance
with guidelines established by the American College of
Obstetricians and Gynecologists, the American Academy of
Pediatrics or other established professional medical associations; and
(4) For policies or 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 onesubdivision (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 article three, 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) Coverage for inpatient care for a mother and her
newborn child for at least forty-eight hours following a normal
vaginal delivery, and at least ninety-six hours following a
caesarean section delivery;
(B) Subject to the provisions of paragraph (A) of this
subdivision, coverage for inpatient care in a duly licensed
health care facility for a mother and her newborn infant for the
length of time which the attending physician, after consultation
with the mother, determines is medically necessary for the
mother or her newborn child;
(C) Coverage for maternity and pediatric care in accordance
with guidelines established by the American college of
obstetricians and gynecologists, the American academy of
pediatrics or other established professional medical
associations; and
(D) For policies 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 paragraph
(A) of this subdivision, if inpatient care is determined to be
medically necessary by the attending physician;
(E) For purposes of this subsection, the term "attending physician" means the obstetrician, pediatrician, other physician
or certified nurse-midwife attending the mother or her newborn
child;
(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;
(9) Coverage for inpatient mastectomy surgery and, when
deemed medically necessary by the attending physician, coverage
for reconstruction of the breast on which surgery has been
performed and reconstruction of the other breast to produce a
symmetrical appearance in a manner chosen by the patient and the
attending physician;
(10) Coverage for the mastectomy surgery or reconstructive
surgery in a duly licensed health care facility for the length
of time which the attending physician determines is medically
necessary for the patient. No policy may require discharge for
a patient prior to forty-eight hours following the surgery if
the attending physician determines that the discharge is
medically inappropriate; and
(11) Coverage for prostate surgery in a duly licensed
health care facility for the length of time which the attending
physician determines is medically necessary for the patient. No
policy may require discharge for a patient prior to forty-eight
hours following the surgery if the attending physician determines that the discharge is medically inappropriate.
(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) (10) 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.