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SB164 SUB2 Senate Bill 164 History

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Key: Green = existing Code. Red = new code to be enacted
COMMITTEE SUBSTITUTE

FOR

COMMITTEE SUBSTITUTE

FOR

Senate Bill No. 164

(By Senators Tomblin, Mr. President, and Sprouse,

By Request of the Executive)

____________

[Originating in the Committee on Banking and Insurance;

reported January 25, 2006.]

____________


A BILL to amend the Code of West Virginia, 1931, as amended, by adding thereto a new article, designated §16-2J-1, §16-2J-2, §16-2J-3, §16-2J-4, §16-2J-5, §16-2J-6, §16-2J-7, §16-2J-8 and §16-2J-9, all relating to a pilot program authorizing participating health care clinics and private medical practitioners to provide primary and preventive health services for a prepaid fee; declaring legislative intent; authorizing approval of participants based on guidelines by the Health Care Authority and the Insurance Commissioner; requiring licensure by the Health Care Authority; authorizing the Insurance Commissioner to approve fees, marketing materials and forms and to certify financial soundness; authorizing study of the program by the Health Care Authority; providing for legislative rules; mandating a Health Care Authority report to the Legislative Oversight Commission on Health and Human Resources Accountability; setting grounds for revocation, suspension and failure to renew licenses; and creating penalties.

Be it enacted by the Legislature of West Virginia:
That the Code of West Virginia, 1931, as amended, be amended by adding thereto a new article, designated §16-2J-1, §16-2J-2, §16-2J-3, §16-2J-4, §16-2J-5, §16-2J-6, §16-2J-7, §16-2J-8 and §16- 2J-9, all to read as follows:
ARTICLE 2J. PREVENTIVE CARE PILOT PROGRAM.
§16-2J-1. Legislative findings and statement of purpose.
(a) The Legislature finds that a program that would allow health clinics and private medical practitioners to provide primary and preventive health services for a prepaid fee would enable more West Virginians to gain access to affordable health care and to establish a medical home for purposes of receiving primary and preventive health care services. By establishing a pilot project for clinic based health care, the Legislature intends to enable state health and insurance officials to study this method of delivering health services, to encourage all West Virginians to establish a medical home and to determine the success, continued need and feasibility of expanding such a program and allowing similar programs to operate on a statewide basis.
(b) In carrying out this pilot program, it is the intent of the Legislature to eliminate legal, statutory and regulatory barriers to the establishment of pilot programs providing preventive and primary care services for a prepaid fee; to encourage residents of this state to establish and use a medical home; to expand preventive and primary care services for the uninsured; and to exempt health providers participating in the pilot program from regulation as an insurer, the operation of insurance laws of the state and all other laws inconsistent with the purposes of this article.
§16-2J-2. Definitions.
For the purposes of this article, the following definitions apply:
(1) "Dependent" has the same meaning set forth in subsection (d), section one-a, article sixteen, chapter thirty-three of this code;
(2) "Family" means an subscriber and his or her dependents; (3) "Medical home" means a clinic, hospital or other health care facility where a patient has an established relationship, has his or her routine medical care or treatment and where his or her medical records are maintained.
(4) "Participating provider" means a provider under this article that has been granted a license under this article to operate as part of the pilot program;
(5) "Primary care" means basic or general health care which emphasizes the point when the patient first seeks assistance from the medical care system and the care of the simpler and more common illnesses;
(6)"Provider" has the same meaning as "ambulatory health care facility" set forth in subsection (b), section two, article two-d of this chapter or "private office practice" as set forth in subdivision (1), subsection (a), section four of said article;
(7)"Qualifying event" means loss of coverage due to: (i) Emancipation and resultant loss of coverage under a parent or guardian's plan; (ii) divorce and loss of coverage under the former spouse's plan; (iii) termination of employment and resultant loss of coverage under an employer group plan: Provided, That any rights of coverage under a COBRA continuation plan as that term is defined in section three-m, article sixteen, chapter thirty-three of this code shall not be considered coverage under an employer group health plan; (iv) involuntary termination of coverage under a group health benefit plan except for termination due to nonpayment of premiums or fraud by the insured; or (v) exhaustion of COBRA benefits; and
(8) "Subscriber" means any individual who subscribes to a prepaid program approved and operated in accordance with the provisions of this article, including an employee of any employer that has purchased a group enrollment on behalf of its employees.
§16-2J-3. Authorization of preventive care pilot program; number of participants and sites; Health Care Authority considerations in selection of participating providers; funding.

(a) The Health Care Authority shall, in consultation with the Insurance Commissioner, develop and implement during the fiscal year beginning the first day of July, two thousand six, a pilot program that permits no more than eight providers to market and sell prepaid memberships entitling subscribers to obtain preventive and primary health care from the participating providers. Participating providers shall not be allowed to offer their qualifying services at more than three separate sites. The pilot program will be three years in length.
(b) Subject to the provisions of this article, the Health Care Authority is vested with discretion to select providers using diversity in practice organization, geographical diversity and other criteria it deems appropriate. The Health Care Authority also shall give consideration to providers located in rural areas or serving a high percentage or large numbers of uninsured.
© In furtherance of the objectives of this article, the Health Care Authority is authorized to accept any and all gifts, grants and matching funds whether in the form of money or services: Provided, That no gifts, grants and matching funds shall be provided to the Health Care Authority by the State of West Virginia to further the objectives of this article.
§16-2J-4. License for preventive care pilot program.
(a) No provider may participate in the pilot program without first obtaining a preventive care pilot program license from the Health Care Authority.
(b) The Health Care Authority shall determine the eligibility of providers to obtain licenses on the basis of applications filed by providers on forms developed by the Health Care Authority.
© Upon approval of the application, the participating provider shall be granted a license to market and sell prepaid health services under such terms as may be established in guidelines developed by the Health Care Authority or the Insurance Commissioner.
§16-2J-5. Insurance Commissioner approval of fees, marketing materials and forms and certification of financial condition; statement of services.

(a) The Insurance Commissioner shall develop guidelines for all forms, marketing materials and fees proposed by program applicants and participating providers under the same criteria generally applicable to accident and sickness insurance policies.
(b) All fees, marketing materials and forms proposed to be used by any program applicant or participating provider are subject to prior approval of the Insurance Commissioner, which the Insurance Commissioner shall communicate to the Health Care Authority. Fees may not be excessive, inadequate or unfairly discriminatory.
© The Insurance Commissioner must certify whether a program applicant or, upon the request of the Health Care Authority, an already participating provider is in a sound financial condition and capable of operating in a manner that is not hazardous to its prospective subscribers or the people of West Virginia.
(d) Every subscriber is entitled to evidence of program membership that shall contain a clear, concise and complete statement of the services provided by the participating provider and the benefits, if any, to which the subscriber is entitled; any exclusions or limitations on the service, kind of service, benefits, or kind of benefits, to be provided, including any copayments; and where and in what manner information is available as to how a service may be obtained. (e) Fees paid to participating providers are not subject to premium taxes and surcharges imposed on insurance companies.
(f) Notwithstanding the provisions of chapter thirty-three of this code to the contrary, participation by providers in the preventive care clinic-based pilot program created and authorized pursuant to this article is not to be considered as providing insurance or as offering insurance services. Such providers and services are specifically excluded from the definitions of "insurer" and "insurance" as defined in article one, chapter thirty-three of this code and are not subject to regulation by the Insurance Commissioner except to the extent set forth in this article, nor are participating providers unauthorized insurers pursuant to section four, article forty-four, chapter thirty-three of this code.
§16-2J-6. Rule-making authority.
The Health Care Authority and the Insurance Commissioner shall promulgate rules as necessary to implement the provisions of this article, including emergency rules promulgated pursuant to chapter twenty-nine-a of this code.
§16-2J-7. Participating provider plan requirements: primary care services; prior coverage restrictions; notice of discontinuance or reduction of benefits.

In addition to the provisions of this article and any guidelines established by the Health Care Authority and Insurance Commissioner, the plans offered pursuant to this article shall be subject to the following:
(1) Each participating provider and site must offer a minimum set of preventive and primary care services as established by the Health Care Authority.
(2) No participating provider may offer: (i) An individual plan to any individual who currently has a health benefit plan or who was covered by a health benefit plan within the preceding twelve months unless said coverage was lost due to a qualifying event; (ii) a family plan to any family that includes an adult to be covered who currently has a health benefit plan or who was covered by a health benefit plan within the preceding twelve months unless said coverage was lost due to a qualifying event; or (iii) an employee group plan to any employer that currently has a group health benefit plan or had a group health benefit plan covering its employees within the preceding twelve months.
(3) The Health Care Authority and the Insurance Commissioner may, by legislative rule, permit participation by an employer with a comprehensive high deductible plan if such employer is able to demonstrate that such participation will not negatively impact the coverage currently offered by such employer.
(4) A participating provider must provide subscribers and, where applicable, subscribers' employers with a minimum of thirty days' notice of discontinuance or reduction of subscriber benefits.
§16-2J-8. Guidelines for evaluation of the pilot program; report to Legislative Oversight Commission on Health and Human Resources Accountability.

(a) The Health Care Authority shall establish by guidelines criteria to evaluate the pilot program and may require participating providers to submit such data and other information related to the pilot program as may be required by the Health Care Authority.
(b) No later than the first day of December, two thousand seven, and annually thereafter during the operation of the pilot program, the Health Care Authority must submit a report to the Legislative Oversight Commission of Health and Human Resources Accountability as established in article twenty-nine-e of this chapter on progress made by the pilot project including suggested legislation, necessary changes to the pilot program and suggested expansion of the pilot program.
§16-2J-9. Grounds for refusal to renew; revocation and suspension of pilot program license; penalties; termination of suspension, reissuance and renewal of license.

(a) The Health Care Authority may, after notice and hearing, refuse to renew, or may revoke or suspend, the license of a participating provider, in addition to other grounds therefor in this
article, if the participating provider:

(1) Violates any provision of this article; (2) Fails to comply with any lawful rule or order of the Health Care Authority; (3) Is operating in an illegal, improper or unjust manner; (4) Is found by the Insurance Commissioner to be in an unsound condition or in such condition as to render its further operation in West Virginia hazardous to its subscribers or to the people of West Virginia; (5) Compels subscribers under its contract to accept less service than due them or to bring suit against it to secure full service when it has no substantial defense; (6) Refuses to be examined or to produce its accounts, records and files for examination by the Insurance Commissioner when requested to do so pursuant to section five of this article; (7) Fails to pay any final judgment rendered against it in West Virginia within thirty days after the judgment became final or time for appeal expired, whichever is later; (8) Fails to pay when due to the State of West Virginia any taxes, fees, charges or penalties.
(b) In addition to or in lieu of refusing to renew, revoking or suspending the license of a participating provider in any case, the Health Care Authority may, by order, require the participating provider to pay to the State of West Virginia a penalty in a sum not exceeding five thousand dollars for each violation. Upon the failure of the provider to pay such penalty within thirty days after notice thereof, the Health Care Authority shall revoke or suspend the license of such participating provider. © When any license has been revoked or suspended or renewal thereof refused, the Health Care Authority may reissue, terminate the suspension of or renew such license when it is determined that the conditions causing such revocation, suspension or refusal to renew have ceased to exist and are unlikely to recur.
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(NOTE: The purpose of this bill is to establish a pilot program overseen by the health care authority authorizing participating health care providers and private medical practitioners to provide primary and preventive health services to subscribers for a prepaid fee.
This is a new article; therefore, underscoring and strike- throughs have been omitted.
)
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