Introduced Version
House Bill 2383 History
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Key: Green = existing Code. Red = new code to be enacted
H. B. 2383
(By Delegates Perdue and Moore)
[Introduced February 13, 2013; referred to the
Committee on Banking and Insurance then the Judiciary.]
A BILL to amend and reenact §5-16-7 of the Code of West Virginia,
1931, as amended; to amend said code by adding thereto a new
section, designated §33-15-4k; to amend said code by adding
thereto a new section, designated §33-16-3w; to amend and
reenact §33-16E-2 of said code; to amend said code by adding
thereto a new section, designated §33-24-7l; to amend said
code by adding thereto a new section, designated §33-25-8i;
and to amend said code by adding thereto a new section,
designated §33-25A-8k, all relating to requiring all insurers,
health care organizations, hospital medical corporations and
health maintenance organizations that offer maternity coverage
in their health care plans to provide that maternity coverage
to all persons receiving coverage under the plans; and
requiring health insurance plans that include a prescription
drug plan to cover contraceptive services
for all individuals participating in or receiving coverage under that plan.
Be it enacted by the Legislature of West Virginia:
That §5-16-7 of the Code of West Virginia, 1931, as amended,
be amended and reenacted; that said code be amended by adding
thereto a new section, designated §33-15-4k; that said code be
amended by adding thereto a new section, designated §33-16-3w; to
amend and reenact §33-16E-2
of said code;
that said code be amended
by adding thereto a new section, designated §33-24-7l; that said
code be amended by adding thereto a new section, designated
§33-25-8i; and that said code be amended by adding thereto a new
section, designated §33-25A-8k,
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 these 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 when medically appropriate and
consistent with current guidelines from the United States
Preventive Services Task Force; pap smears, either conventional or
liquid-based cytology, whichever is medically appropriate and
consistent with the current guidelines from either the United
States Preventive Services Task Force or The American College of
Obstetricians and Gynecologists; and a test for the human papilloma
virus (HPV) when medically appropriate and consistent with current
guidelines from either the United States Preventive Services Task
Force or The American College of Obstetricians and Gynecologists,
when performed for cancer screening or diagnostic services on a
woman age eighteen or over;
(2) Annual checkups for prostate cancer in men age fifty and
over;
(3) Annual screening for kidney disease as determined to be
medically necessary by a physician using any combination of blood pressure testing, urine albumin or urine protein testing and serum
creatinine testing as recommended by the National Kidney
Foundation;
(4) 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 considers medically necessary for the mother or
her newly born child: Provided, That no plan may deny payment for
a mother or her newborn 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 considers
discharge medically inappropriate;
(5) For 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 (4)
of this subsection if 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 any other inpatient and outpatient services and
expenses considered appropriate and desirable by the agency; and
(6) Coverage for treatment of serious mental illness.
(A) The coverage does not include custodial care, residential
care or schooling. For purposes of this section, "serious mental
illness" means an illness included in the American Psychiatric Association's diagnostic and statistical manual of mental
disorders, as periodically revised, under the diagnostic categories
or subclassifications of: (i) Schizophrenia and other psychotic
disorders; (ii) bipolar disorders; (iii) depressive disorders; (iv)
substance-related disorders with the exception of caffeine-related
disorders and nicotine-related disorders; (v) anxiety disorders;
and (vi) anorexia and bulimia. With regard to any covered
individual who has not yet attained the age of nineteen years,
"serious mental illness" also includes attention deficit
hyperactivity disorder, separation anxiety disorder and conduct
disorder.
(B) Notwithstanding any other provision in this section to the
contrary, in the event that the agency can demonstrate that its
total costs for the treatment of mental illness for any plan
exceeded two percent of the total costs for such plan in any
experience period, then the agency may apply whatever additional
cost-containment measures may be necessary, including, but not
limited to, limitations on inpatient and outpatient benefits, to
maintain costs below two percent of the total costs for the plan
for the next experience period.
(C) The agency shall not discriminate between medical-surgical
benefits and mental health benefits in the administration of its
plan. With regard to both medical-surgical and mental health
benefits, it may make determinations of medical necessity and appropriateness, and it may use recognized health care quality and
cost management tools, including, but not limited to, limitations
on inpatient and outpatient benefits, utilization review,
implementation of cost-containment measures, preauthorization for
certain treatments, setting coverage levels, setting maximum number
of visits within certain time periods, using capitated benefit
arrangements, using fee-for-service arrangements, using third-party
administrators, using provider networks and using patient cost
sharing in the form of copayments, deductibles and coinsurance.
(7) Coverage for general anesthesia for dental procedures and
associated outpatient hospital or ambulatory facility charges
provided by appropriately licensed health care individuals in
conjunction with dental care if the covered person is:
(A) Seven years of age or younger or is developmentally
disabled, and is an individual for whom a successful result cannot
be expected from dental care provided under local anesthesia
because of a physical, intellectual or other medically compromising
condition of the individual and for whom a superior result can be
expected from dental care provided under general anesthesia;
(B) A child who is twelve years of age or younger with
documented phobias, or with documented mental illness, and with
dental needs of such magnitude that treatment should not be delayed
or deferred and for whom lack of treatment can be expected to
result in infection, loss of teeth or other increased oral or dental morbidity and for whom a successful result cannot be
expected from dental care provided under local anesthesia because
of such condition and for whom a superior result can be expected
from dental care provided under general anesthesia.
(8) (A) Any plan issued or renewed on or after January 1,
2012, shall include coverage for diagnosis, evaluation and
treatment of autism spectrum disorder in individuals ages eighteen
months to eighteen years. To be eligible for coverage and benefits
under this subdivision, the individual must be diagnosed with
autism spectrum disorder at age eight or younger. Such policy
shall provide coverage for treatments that are medically necessary
and ordered or prescribed by a licensed physician or licensed
psychologist and in accordance with a treatment plan developed from
a comprehensive evaluation by a certified behavior analyst for an
individual diagnosed with autism spectrum disorder.
(B) The coverage shall include, but not be limited to, applied
behavior analysis. Applied behavior analysis shall be provided or
supervised by a certified behavior analyst. The annual maximum
benefit for applied behavior analysis required by this subdivision
shall be in an amount not to exceed $30,000 per individual, for
three consecutive years from the date treatment commences. At the
conclusion of the third year, coverage for applied behavior
analysis required by this subdivision shall be in an amount not to
exceed $2,000 per month, until the individual reaches eighteen years of age, as long as the treatment is medically necessary and
in accordance with a treatment plan developed by a certified
behavior analyst pursuant to a comprehensive evaluation or
reevaluation of the individual. This subdivision shall not be
construed as limiting, replacing or affecting any obligation to
provide services to an individual under the Individuals with
Disabilities Education Act, 20 U.S.C. 1400 et seq., as amended from
time to time or other publicly funded programs. Nothing in this
subdivision shall be construed as requiring reimbursement for
services provided by public school personnel.
(C) The certified behavior analyst shall file progress reports
with the agency semiannually. In order for treatment to continue,
the agency must receive objective evidence or a clinically
supportable statement of expectation that:
(i) The individual's condition is improving in response to
treatment; and
(ii) A maximum improvement is yet to be attained; and
(iii) There is an expectation that the anticipated improvement
is attainable in a reasonable and generally predictable period of
time.
(D) On or before January 1 each year, the agency shall file an
annual report with the Joint Committee on Government and Finance
describing its implementation of the coverage provided pursuant to
this subdivision. The report shall include, but shall not be limited to, the number of individuals in the plan utilizing the
coverage required by this subdivision, the fiscal and
administrative impact of the implementation, and any
recommendations the agency may have as to changes in law or policy
related to the coverage provided under this subdivision. In
addition, the agency shall provide such other information as may be
required by the Joint Committee on Government and Finance as it may
from time to time request.
(E) For purposes of this subdivision, the term:
(i) "Applied Behavior Analysis" means the design,
implementation, and evaluation of environmental modifications using
behavioral stimuli and consequences, to produce socially
significant improvement in human behavior, including the use of
direct observation, measurement, and functional analysis of the
relationship between environment and behavior.
(ii) "Autism spectrum disorder" means any pervasive
developmental disorder, including autistic disorder, Asperger's
Syndrome, Rett Syndrome, childhood disintegrative disorder, or
Pervasive Development Disorder as defined in the most recent
edition of the Diagnostic and Statistical Manual of Mental
Disorders of the American Psychiatric Association.
(iii) "Certified behavior analyst" means an individual who is
certified by the Behavior Analyst Certification Board or certified
by a similar nationally recognized organization.
(iv) "Objective evidence" means standardized patient
assessment instruments, outcome measurements tools or measurable
assessments of functional outcome. Use of objective measures at
the beginning of treatment, during and after treatment is
recommended to quantify progress and support justifications for
continued treatment. The tools are not required, but their use
will enhance the justification for continued treatment.
(F) To the extent that the application of this subdivision for
autism spectrum disorder causes an increase of at least one percent
of actual total costs of coverage for the plan year the agency may
apply additional cost containment measures.
(G) To the extent that the provisions of this subdivision
require benefits that exceed the essential health benefits
specified under section 1302(b) of the Patient Protection and
Affordable Care Act, Pub. L. No. 111-148, as amended, the specific
benefits that exceed the specified essential health benefits shall
not be required of insurance plans offered by the Public Employees
Insurance Agency.
(9) For plans that include maternity benefits, coverage for
those maternity benefits shall include all individuals
participating in or receiving insurance coverage under insurance
plans that are issued or renewed on or after July 1, 2013.
(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 state public
institutions of higher education and county boards of education;
(3) All nonteaching employees of the Higher Education Policy
Commission, West Virginia Council for Community and Technical
College Education and county boards of education; or
(4) Any other categorization which would ensure the stability
of the overall program.
(d) The agency shall maintain the medical and prescription
drug coverage for Medicare-eligible retirees by providing coverage
through one of the existing plans or by enrolling the
Medicare-eligible retired employees into a Medicare-specific plan,
including, but not limited to, the Medicare/Advantage Prescription
Drug Plan. In the event that a Medicare specific plan would no
longer be available or advantageous for the agency and the retirees, the retirees shall remain eligible for coverage through
the agency.
CHAPTER 33. INSURANCE.
ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.
§33-15-4k. Maternity coverage.
_____Notwithstanding any policy, provision, contract, plan or
agreement applicable to this article, any health insurance policy
subject to this article that provides health insurance coverage for
maternity services shall, on or after July 1, 2013, provide
coverage for maternity services for all persons participating in,
or receiving coverage under the policy. Coverage required under
this section may not be subject to exclusions or limitations which
are not applied to other maternity coverage under the policy.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-3w. Maternity coverage.
_____Notwithstanding any policy, provision, contract, plan or
agreement applicable to this article, any health insurance policy
subject to this article that provides health insurance coverage for
maternity services shall, on or after July 1, 2013, provide
coverage for maternity services for all persons participating in,
or receiving coverage under the policy. Coverage required under
this section may not be subject to exclusions or limitations which
are not applied to other maternity coverage under the policy.
ARTICLE 16E. CONTRACEPTIVE COVERAGE.
§33-16E-2. Definitions.
For the purposes of this article, these definitions are
applicable unless a different meaning clearly appears from the
context.
(1) "Contraceptives" means drugs or devices approved by the
food and drug administration to prevent maternity.
(2) "Covered person" means the policyholder, subscriber,
certificate holder, enrollee or other individual who is
participating in, or receiving coverage under a health insurance
plan. For the purposes of this article, covered person does not
include a dependent child.
(3) "Health insurance plan" means benefits consisting of
medical care provided directly, through insurance or reimbursement,
or indirectly, including items and services paid for as medical
care, under any hospital or medical expense incurred policy or
certificate; hospital, medical or health service corporation
contract; health maintenance organization contract; fraternal
benefit society contract; plan provided by a multiple-employer
trust or a multiple-employer welfare arrangement; or plan provided
by the West Virginia Public Employees Insurance Agency pursuant to
article sixteen, chapter five of this code.
(4) "Outpatient contraceptive services" means consultations,
examinations, procedures and medical services, provided on an outpatient basis and related to the use of prescription
contraceptive drugs and devices to prevent maternity issued under
a health insurance plan that provides benefits for prescription
drugs or prescription devices in a prescription drug plan.
(5) "Religious employer" is an entity whose sincerely held
religious beliefs or sincerely held moral convictions are central
to the employer's operating principles, and the entity is an
organization listed under 26 U.S.C. §501(c)(3), 26 U.S.C. §3121, or
listed in the Official Catholic Directory published by P.J. Kennedy
and Sons.
ARTICLE 24. HOSPITAL MEDICAL AND DENTAL CORPORATIONS.
§33-24-7l. Maternity coverage.
_____Notwithstanding any policy, provision, contract, plan or
agreement applicable to this article, any health insurance policy
subject to this article that provides health insurance coverage for
maternity services shall, on or after July 1, 2013, provide
coverage for maternity services for all persons participating in,
or receiving coverage under the policy. Coverage required under
this section may not be subject to exclusions or limitations which
are not applied to other maternity coverage under the policy.
ARTICLE 25. HEALTH CARE CORPORATION.
§33-25-8i. Maternity coverage.
_____Notwithstanding any policy, provision, contract, plan or agreement applicable to this article, any health insurance policy
subject to this article that provides health insurance coverage for
maternity services shall, on or after July 1, 2013, provide
coverage for maternity services for all persons participating in,
or receiving coverage under the policy. Coverage required under
this section may not be subject to exclusions or limitations which
are not applied to other maternity coverage under the policy.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-8k. Maternity coverage.
_____Notwithstanding any policy, provision, contract, plan or
agreement applicable to this article, any health insurance policy
subject to this article that provides health insurance coverage for
maternity services shall, on or after July 1, 2013, provide
coverage for maternity services for all persons participating in,
or receiving coverage under the policy. Coverage required under
this section may not be subject to exclusions or limitations which
are not applied to other maternity coverage under the policy.
NOTE: The purpose of this bill is to require health insurers
that offer maternity service coverage to cover all individuals who
are participating in or receiving coverage under a policyholder's
health insurance plan. The bill changes the current law that
excludes contraceptive services for dependents of policyholders if
the policy includes a prescription drug plan to cover contraceptive
services.
§33-15-4k, §33-16-3w, §33-24-7l, §33-25-8i, and §33-25A-8k
are new; therefore, they have been completely underscored.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.