ENROLLED
COMMITTEE SUBSTITUTE
FOR
Senate Bill No. 18
(Senators Prezioso, Minard, Stollings, Hunter, Kessler, Sprouse and McCabe,
original sponsors)
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[Passed March 5, 2007; in effect ninety days from passage.]
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AN ACT to amend and reenact §5-16-7 and §5-16-9 of the Code of West
Virginia, 1931, as amended; to amend said code by adding
thereto a new section, designated §9-5-20; to amend said code
by adding thereto a new section, designated §33-15-4i; to
amend said code by adding thereto a new section, designated
§33-16-3s; to amend said code by adding thereto a new section,
designated §33-24-7i; to amend said code by adding thereto a
new section, designated §33-25-8g; and to amend said code by
adding thereto a new section, designated §33-25A-8h, all
relating to modifying required insurance benefits; modifying
required benefits for public employees insurance, accident and
sickness insurance, group accident and sickness insurance,
hospital service corporations, medical service corporations,
dental service corporations, health service corporations,
health care corporations and health maintenance organizations; requiring insurance policies and medical benefit plans to
include certain coverages when medically appropriate and
consistent with relevant national guidelines; requiring
coverage from Medicaid for testing for chronic kidney disease;
public education of providers on management of chronic kidney
disease; defining diagnostic criteria for chronic kidney
disease; ensuring the Public Employees Insurance Agency will
continue and maintain medical and prescription drug coverage
for Medicare-eligible retired employees; and providing that if
a Medicare/Advantage Prescription Drug Plan should fail, the
Public Employees Insurance Agency will take all Medicare-
eligible retired employees back into the existing Public
Employees Insurance Agency plan or provide another plan of
equal or better coverage.
Be it enacted by the Legislature of West Virginia:
That §5-16-7 and §5-16-9 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 §9-5-20; that said code be
amended by adding thereto a new section, designated 33-15-4i; that
said code be amended by adding thereto a new section, designated
§33-16-3s; that said code be amended by adding thereto a new
section, designated §33-24-7i; that said code be amended by adding
thereto a new section, designated §33-25-8g; and that said code be
amended by adding thereto a new section, designated §33-25A-8h, 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 (3)
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 actuarially
that its total anticipated costs for the treatment of mental
illness for any plan will exceed or have exceeded two percent of
the total costs for such plan in any experience period, then the
agency may apply whatever 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.
(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.
(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 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.
(d) The agency shall maintain the medical and prescription
drug coverage for Medicare-eligible retirees by providing that
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.
§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 coveredemployees; discontinuance of
contracts.
(a) The director is hereby given exclusive authorization to
execute such 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 contract or
contracts to 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 shall
include coverages and benefits for X-ray and laboratory services in connection with mammogram and pap smears when performed for cancer
screening or diagnostic services and annual checkups for prostate
cancer in men age fifty and over. Such benefits shall include, but
not be limited to, the following:
(1) Mammograms when medically appropriate and consistent with
the current guidelines from the United States Preventive Services
Task Force;
(2) A pap smear, either conventional or liquid-based cytology,
whichever is medically appropriate and consistent with the current
guidelines from the United States Preventative Services Task Force
or The American College of Obstetricians and Gynecologists, for
women age eighteen and over;
(3) A test for the human papilloma virus (HPV) for women age
eighteen or over, when 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 for women age eighteen and over;
(4) A checkup for prostate cancer annually for men age fifty
or over; and
(5) 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.
(c) The group life and accidental death insurance herein
provided for 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 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 Purchasing of the Department of
Finance and Administration, shall 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 authorized in this
article, 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: Provided,
That the director shall negotiate and contract directly with health
care providers and other entities, organizations and vendors in
order to secure competitive premiums, prices and other financial
advantages. The director shall deal directly with insurers or
health care providers and other entities, organizations and vendors
in presenting specifications and receiving quotations for bid
purposes. No commission or finder's fee, or any combination
thereof, shall be paid to any individual or agent; but this shall
not preclude an underwriting insurance company or companies, at
their own expense, from appointing 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 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 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 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 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 contract or
contracts shall receive a statement of benefits to which the
employee, his or her spouse and his or her dependents are entitled
under the contract, setting forth the information as to whom the
benefits are payable, to whom claims shall be submitted and a
summary of the provisions of the 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 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 influenza-b and whooping cough.
Additional immunizations may be required by the Commissioner of the
Bureau for 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.
CHAPTER 9. HUMAN SERVICES.
ARTICLE 5. MISCELLANEOUS PROVISIONS.
§9-5-20. Medicaid program; chronic kidney disease; evaluation and
classification
.
(a) Any enrollee in Medicaid who is eligible for services and
who has a diagnosis of diabetes or hypertension or, who has a family history of kidney disease, shall receive coverage for an
evaluation for chronic kidney disease through routine clinical
laboratory assessments of kidney function.
(b) Any enrollee in Medicaid who is eligible for services and
who has been diagnosed with diabetes or hypertension or who has a
family history of kidney disease and who has received a diagnosis
of kidney disease shall be classified as a chronic kidney patient.
(c) The diagnostic criteria used to define chronic kidney
disease should be those generally recognized through clinical
practice guidelines which identify chronic kidney disease or its
complications based on the presence of kidney damage and level of
kidney function.
(d) Medicaid providers shall be educated by the Bureau for
Public Health in an effort to increase the rate of evaluation and
treatment for chronic kidney disease. Providers should be made
aware of:
(i) Managing risk factors, which prolong kidney function or
delay progression to kidney replacement therapy;
(ii) Managing risk factors for bone disease and cardiovascular
disease associated with chronic kidney disease;
(iii) Improving nutritional status of chronic kidney disease
patients; and
(iv) Correcting anemia associated with chronic kidney disease.
CHAPTER 33. INSURANCE.
ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.
§33-15-4i. Third-party reimbursement for kidney disease screening.
(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement applicable to this article,
reimbursement or indemnification for annual kidney disease
screening and laboratory testing as recommended by the National
Kidney Foundation may not be denied for any person when
reimbursement or indemnity for laboratory or X-ray services are
covered under the policy and are performed for kidney disease
screening or diagnostic purposes at the direction of a person
licensed to practice medicine and surgery by the board of medicine.
The tests are as follows: Any combination of blood pressure
testing, urine albumin or urine protein testing and serum
creatinine testing.
(b) The same deductibles, coinsurance, network restrictions
and other limitations for covered services found in the policy,
provision, contract, plan or agreement of the covered person may
apply to kidney disease screening and laboratory testing.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-3s.
Third-party reimbursement for kidney disease screening.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement applicable to this article,
reimbursement or indemnification for annual kidney disease
screening and laboratory testing as recommended by the National
Kidney Foundation may not be denied for any person when
reimbursement or indemnity for laboratory or X-ray services are
covered under the policy and are performed for kidney disease
screening or diagnostic purposes at the direction of a person
licensed to practice medicine and surgery by the board of medicine.
The tests are as follows: Any combination of blood pressure testing, urine albumin or urine protein testing and serum
creatinine testing.
(b) The same deductibles, coinsurance, network restrictions
and other limitations for covered services found in the policy,
provision, contract, plan or agreement of the covered person may
apply to kidney disease screening and laboratory testing.
ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE
CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH SERVICE
CORPORATIONS.
§33-24-7i.
Third-party reimbursement for kidney disease screening.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement applicable to this article,
reimbursement or indemnification for annual kidney disease
screening and laboratory testing as recommended by the National
Kidney Foundation may not be denied for any person when
reimbursement or indemnity for laboratory or X-ray services are
covered under the policy and are performed for kidney disease
screening or diagnostic purposes at the direction of a person
licensed to practice medicine and surgery by the board of medicine.
The tests are as follows: Any combination of blood pressure
testing, urine albumin or urine protein testing and serum
creatinine testing.
(b) The same deductibles, coinsurance, network restrictions
and other limitations for covered services found in the policy,
provision, contract, plan or agreement of the covered person may
apply to kidney disease screening and laboratory testing.
ARTICLE 25. HEALTH CARE CORPORATION.
§33-25-8g. Third-party reimbursement for kidney disease screening.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement applicable to this article,
reimbursement or indemnification for annual kidney disease
screening and laboratory testing as recommended by the National
Kidney Foundation may not be denied for any person when
reimbursement or indemnity for laboratory or X-ray services are
covered under the policy and are performed for kidney disease
screening or diagnostic purposes at the direction of a person
licensed to practice medicine and surgery by the board of medicine.
The tests are as follows: Any combination of blood pressure
testing, urine albumin or urine protein testing and serum
creatinine testing.
(b) The same deductibles, coinsurance, network restrictions
and other limitations for covered services found in the policy,
provision, contract, plan or agreement of the covered person may
apply to kidney disease screening and laboratory testing.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-8h. Third-party reimbursement for kidney disease
screening.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement applicable to this article,
reimbursement or indemnification for annual kidney disease
screening and laboratory testing as recommended by the National
Kidney Foundation may not be denied for any person when
reimbursement or indemnity for laboratory or X-ray services are
covered under the policy and are performed for kidney disease
screening or diagnostic purposes at the direction of a person licensed to practice medicine and surgery by the board of medicine.
The tests are as follows: Any combination of blood pressure
testing, urine albumin or urine protein testing and serum
creatinine testing.
(b) The same deductibles, coinsurance, network restrictions
and other limitations for covered services found in the policy,
provision, contract, plan or agreement of the covered person may
apply to kidney disease screening and laboratory testing.