H. B. 4485

(By Delegates Compton, Prunty, Miller, Amores, Hunt, Hutchins, and L. White)
[Introduced February 19, 1998; referred to the
Committee on Banking and Insurance.]

A BILL to amend chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty-one, as amended, by adding thereto a new article, designated article forty- two, relating to insurance coverage for serious mental illness.

Be it enacted by the Legislature of West Virginia:
That chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended by adding thereto a new article, designated article forty-two, to read as follows:
§33-42-1. Coverage for serious mental illness required.
Every health care insurer shall provide coverage for the medical treatment of serious mental illness under the same terms and conditions as such coverage is provided for other illnesses and diseases. Insurance coverage offered pursuant to this statute shall include the same durational limits, amount limits, deductibles and coinsurance factors for serious mental illness as for other illnesses and diseases.
§33-42-2. Definitions.
(a) "Health insurers" means all persons, firms, corporations or other organizations offering and assuring health services on a prepaid or primarily expense-incurred basis, including, but not limited to: Policies of accident or sickness insurance, as defined in this chapter; nonprofit hospital or medical service plans, whether organized under this chapter or under any public law or by special act of the Legislature; health maintenance organizations; or any other entity which insures or reimburses for diagnostic, therapeutic or preventative services to a determined population on the basis of a periodic premium, except for supplemental policies which only provide coverage for specified diseases.
(b) "Serious mental illness" means any mental disorder that current medical science affirms is caused by a biological disorder of the brain and that substantially limits the life activities of the person with the illness, including, but not limited to, schizophrenia, schizoaffective disorder, delusional disorder, bipolar affective disorders, major depression and obsessive compulsive disorder.
(c) "Medical coverage" means inpatient hospitalization and outpatient medication visits.
§33-42-3. Medical necessity and appropriateness of treatment.
Upon request of the reimbursing health insurers, all providers of treatment of serious mental illness shall furnish medical records or other necessary data which substantiates that initial or continued treatment is at all times medically necessary and appropriate. When the provider cannot so establish medical necessity or appropriateness of the treatment modality provided, neither the health insurer nor the patient shall be obligated to reimburse for that period or type of care which was not so established. The provider shall inform the patient of the substance of this section in advance of providing treatment. After the patient is informed that medical necessity or appropriateness is not established, the patient may agree in writing to continue receiving treatment at his or her own expense. The health insurers shall make determinations of medical necessity and appropriateness in a manner consistent with that used to make the determination for treatment of other diseases or injuries covered under the health insurance policy or agreement.
§33-42-4. Limitation of coverage.
The health care benefits set forth in this article apply only to services delivered within this state. Inpatient coverage in cases where continuous hospitalization is medically necessary is limited to ninety consecutive days.

NOTE: The purpose of this bill is to require insurance coverage for the treatment of serious mental illness.

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