SB407 H JUD AM 3-8 #1 

    The Committee on the Judiciary moves to amend the bill on page two, following the enacting clause, by striking out the remainder of the bill and inserting in lieu thereof the following language:

    “That the Code of West Virginia, 1931, as amended, be amended by adding thereto a new section, designated §33-15F-1 and §33-15F-2, all to read as follows:

ARTICLE 15F. ADOPTION AND STATE ENFORCEMENT OF FEDERAL MANDATES AND PROHIBITIONS PURSUANT TO THE REFORMS EFFECTED BY THE PATIENT PROTECTION AND AFFORDABLE CARE ACT.

§33-15F-1. Insurance Commissioner to adopt and enforce the federal              mandates and prohibitions promulgated by the  Affordable Care Act.

    (a) For the purposes of this section, “Federal Act” means the Federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any amendments thereto, or regulations or guidance issued thereunder.

    (b) The West Virginia Legislature hereby authorizes and directs the Insurance Commissioner to adopt, incorporate and enforce the prohibitions and mandates required by federal insurance reforms promulgated by the Federal Act. The Insurance Commissioner shall incorporate such federal mandates and prohibitions into its rules by the promulgation of appropriate emergency rules and legislative rules.

    (c) In the event any portion of the Federal Act or of any regulation or other guidance issued thereunder is legislatively or judicially invalidated and rendered of no effect in this state, the corresponding provisions of such act, regulation or guidance as set forth in this article or in emergency or legislative rules shall likewise be considered to be of no further effect, and the commissioner shall immediately issue a bulletin setting forth its legal opinion as to the effect of such legislative or judicial action on the legal status of the corresponding provisions of such act, regulation or guidance as set forth in this article or in rules promulgated hereunder; the commissioner shall also issue recommendations to the Legislature for amendments to this article necessitated by such judicial or legislative action.

    §33-15F-2. Review and appeal rights.

    (a) The commissioner shall adopt emergency and legislative rules to set forth minimum requirements for utilization review and management, grievance and external review processes to be adopted by health benefit plans.

    (b) Every health benefit plan shall have in effect provisions ensuring for appropriate grievance and external review procedures to apply to adverse determinations.

    (c)For the purposes of this section:

    (1) “Adverse determination” means:

    (A) A determination by a health carrier or its designee utilization review organization that, based upon the information provided, a request for a benefit under the health carrier’s health benefit plan upon application of any utilization review technique does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness or is determined to be experimental or investigational and the requested benefit is therefore denied, reduced or terminated or payment is not provided or made, in whole or in part, for the benefit;

    (B) The denial, reduction, termination or failure to provide or make payment, in whole or in part, for a benefit based on a determination by a health carrier or its designee utilization review organization of a covered person’s eligibility to participate in the health carrier's health benefit plan; or

    (C) Any prospective review or retrospective review determination that denies, reduces or terminates or fails to provide or make payment, in whole or in part, for a benefit.

    (D) Adverse determination includes a rescission of coverage determination.”