ENROLLED
COMMITTEE SUBSTITUTE
FOR
Senate Bill No. 312
(Senators Macnaughtan, Bowman, Blatnik, Grubb, Ross, Anderson,
Scott, Wagner, Plymale, Sharpe and Manchin, original sponsors)
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[Passed March 9, 1996; in effect ninety days from passage.]
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AN ACT 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 fifteen-c; that
article sixteen of said chapter be amended by adding thereto
a new section, designated section sixteen; to amend and
reenact section four, article twenty-four of said chapter; to
amend and reenact section six, article twenty-five of said
chapter; and to amend and reenact section twenty-four, article
twenty-five-a of said chapter, all relating to requiring
insurance companies to cover the complete treatment and
management of diabetes for their insureds to the same extent
that they provide coverage for the complete treatment of other
diseases; and relating generally to health maintenance
organizations.
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 fifteen-c; that article
sixteen of said chapter be amended by adding thereto a new section,
designated section sixteen; that section four, article twenty-four
of said chapter be amended and reenacted; that section six, article
twenty-five of said chapter be amended and reenacted; and that
section twenty-four, article twenty-five-a of said chapter be
amended and reenacted, all to read as follows:
ARTICLE 15C. DIABETES INSURANCE.
§33-15C-1. Insurance for diabetics.
(a) Except as provided in section six, article fifteen of this
chapter, any policy which provides major medical or similar
comprehensive-type medical coverage shall include coverage for the
following equipment and supplies for the treatment and/or
management of diabetes for both insulin dependent and noninsulin
dependent persons with diabetes and those with gestational
diabetes, if medically necessary and prescribed by a licensed
physician: Blood glucose monitors, monitor supplies, insulin,
injection aids, syringes, insulin infusion devices, pharmacological
agents for controlling blood sugar, orthotics and any additional
items as promulgated by rule, pursuant to the provisions of chapter
twenty-nine-a of this code, by the insurance commissioner, with the
advice of the commissioner of the bureau of public health.
(b) All policies affected by the provisions of this section
shall also include coverage for diabetes self-management education
to ensure that persons with diabetes are educated as to the proper self-management and treatment of their diabetes, including
information on proper diets. Coverage for self-management
education and education relating to diet and prescribed by a
licensed physician shall be limited to: (1) Visits medically
necessary upon the diagnosis of diabetes; (2) visits under
circumstances whereby a physician identifies or diagnoses a
significant change in the patient's symptoms or conditions that
necessitates changes in a patient's self-management; and (3) where
a new medication or therapeutic process relating to the person's
treatment and/or management of diabetes has been identified as
medically necessary by a licensed physician:
Provided, That
coverage for reeducation or refresher education shall be limited to
one hundred dollars annually.
(c) The education may be provided by the physician as part of
an office visit for diabetes diagnosis or treatment, or by a
licensed pharmacist for instructing and monitoring a patient
regarding the proper use of covered equipment, supplies and
medications prescribed by a licensed physician, or by a certified
diabetes educator certified by a national diabetes educator
certification program, or registered dietitian registered by a
nationally recognized professional association of dietitians upon
the referral of a physician:
Provided, That such national diabetes
education certification program or nationally recognized
professional association of dieticians has been certified to the
commissioner of insurance by the commissioner of the bureau of
public health.
(d) Any deductible or coinsurance billed for any service as
provided in this section shall apply on an equal basis with all
other coverages provided by the insurer but not included in this
section.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-16. Insurance for diabetics.
(a) Except as provided in section six, article fifteen of this
chapter, any policy which provides major medical or similar
comprehensive-type medical coverage shall include coverage for the
following equipment and supplies for the treatment and/or
management of diabetes for both insulin dependent and noninsulin
dependent persons with diabetes and those with gestational
diabetes, if medically necessary and prescribed by a licensed
physician: Blood glucose monitors, monitor supplies, insulin,
injection aids, syringes, insulin infusion devices, pharmacological
agents for controlling blood sugar, orthotics and any additional
items as promulgated by rule, pursuant to the provisions of chapter
twenty-nine-a of this code, by the insurance commissioner, with the
advice of the commissioner of the bureau of public health.
(b) All policies affected by the provisions of this section
shall also include coverage for diabetes self-management education
to ensure that persons with diabetes are educated as to the proper
self-management and treatment of their diabetes, including
information on proper diets. Coverage for self-management
education and education relating to diet and prescribed by a
licensed physician shall be limited to: (1) Visits medically necessary upon the diagnosis of diabetes; (2) visits under
circumstances whereby a physician identifies or diagnoses a
significant change in the patient's symptoms or conditions that
necessitates changes in a patient's self-management; and (3) where
a new medication or therapeutic process relating to the person's
treatment and/or management of diabetes has been identified as
medically necessary by a licensed physician:
Provided, That
coverage for reeducation or refresher education shall be limited to
one hundred dollars annually.
(c) The education may be provided by the physician as part of
an office visit for diabetes diagnosis or treatment, or by a
certified diabetes educator certified by a national diabetes
educator certification program, or registered dietitian registered
by a nationally recognized professional association of dietitians
upon the referral of a physician:
Provided, That such national
diabetes education certification program or nationally recognized
professional association of dieticians has been certified to the
commissioner of insurance by the commissioner of the bureau of
public health.
(d) Any deductible or coinsurance billed for any service as
provided in this section shall apply on an equal basis with all
other coverages provided by the insurer but not included in this
section.
ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE
CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH SERVICE
CORPORATIONS.
§33-24-4. Exemptions; applicability of insurance laws.
Every corporation defined in section two of this article is
hereby declared to be a scientific, nonprofit institution and
exempt from the payment of all property and other taxes. Every
corporation, to the same extent the provisions are applicable to
insurers transacting similar kinds of insurance and not
inconsistent with the provisions of this article, shall be governed
by and be subject to the provisions as hereinbelow indicated, of
the following articles of this chapter: Article two (insurance
commissioner), except that, under section nine of said article,
examinations shall be conducted at least once every four years;
article four (general provisions), except that section sixteen of
said article shall not be applicable thereto; section thirty-four,
article six (fee for form and rate filing); article six-c
(guaranteed loss ratio); article seven (assets and liabilities);
article eleven (unfair trade practices); article twelve (agents,
brokers and solicitors), except that the agent's license fee shall
be five dollars; section fourteen, article fifteen (individual
accident and sickness insurance); section sixteen, article fifteen
(coverage of children); section eighteen, article fifteen (equal
treatment of state agency); section nineteen, article fifteen
(coordination of benefits with medicaid); article fifteen-a (long-
term care insurance); article fifteen-c (diabetes insurance);
section three, article sixteen (required policy provisions);
section three-a, article sixteen (mental illness); section three-c,
article sixteen (group accident and sickness insurance); section three-d, article sixteen (medicare supplement insurance); section
three-f, article sixteen (treatment of temporomandibular joint
disorder and craniomandibular disorder); section eleven, article
sixteen (coverage of children); section thirteen, article sixteen
(equal treatment of state agency); section fourteen, article
sixteen (coordination of benefits with medicaid); section sixteen,
article sixteen (diabetes insurance); article sixteen-a (group
health insurance conversion); article sixteen-c (small employer
group policies); article sixteen-d (marketing and rate practices
for small employers); article twenty-six-a (West Virginia life and
health insurance guaranty association act), after the first day of
October, one thousand nine hundred ninety-one; article twenty-seven
(insurance holding company systems); article twenty-eight
(individual accident and sickness insurance minimum standards);
article thirty-three (annual audited financial report); article
thirty-four (administrative supervision); article thirty-four-a
(standards and commissioner's authority for companies deemed to be
in hazardous financial condition); article thirty-five (criminal
sanctions for failure to report impairment); and article thirty-
seven (managing general agents); and no other provision of this
chapter may apply to these corporations unless specifically made
applicable by the provisions of this article. If, however, the
corporation is converted into a corporation organized for a
pecuniary profit or if it transacts business without having
obtained a license as required by section five of this article, it
shall thereupon forfeit its right to these exemptions.
ARTICLE 25. HEALTH CARE CORPORATIONS.
§33-25-6. Supervision and regulation by insurance commissioner;
exemption from insurance laws.
Corporations organized under this article are subject to
supervision and regulation of the insurance commissioner. The
corporations organized under this article, to the same extent these
provisions are applicable to insurers transacting similar kinds of
insurance and not inconsistent with the provisions of this article,
shall be governed by and be subject to the provisions as
hereinbelow indicated of the following articles of this chapter:
Article four (general provisions), except that section sixteen of
said article shall not be applicable thereto; article six-c
(guaranteed loss ratio); article seven (assets and liabilities);
article eight (investments); article ten (rehabilitation and
liquidation); section fourteen, article fifteen (individual
accident and sickness insurance); section sixteen, article fifteen
(coverage of children); section eighteen, article fifteen (equal
treatment of state agency); section nineteen, article fifteen
(coordination of benefits with medicaid); article fifteen-c
(diabetes insurance); section three, article sixteen (required
policy provisions); section eleven, article sixteen (coverage of
children); section thirteen, article sixteen (equal treatment of
state agency); section fourteen, article sixteen (coordination of
benefits with medicaid); section sixteen, article sixteen (diabetes
insurance); article sixteen-a (group health insurance conversion);
article sixteen-c (small employer group policies); article sixteen-d (marketing and rate practices for small employers); article
twenty-six-a (West Virginia life and health insurance guaranty
association act); article twenty-seven (insurance holding company
systems); article thirty-three (annual audited financial report);
article thirty-four-a (standards and commissioner's authority for
companies deemed to be in hazardous financial condition); article
thirty-five (criminal sanctions for failure to report impairment);
and article thirty-seven (managing general agents); and no other
provision of this chapter may apply to these corporations unless
specifically made applicable by the provisions of this article.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-24. Statutory construction and relationship to other laws.
(a) Except as otherwise provided in this article, provisions
of the insurance laws and provisions of hospital or medical service
corporation laws are not applicable to any health maintenance
organization granted a certificate of authority under this article.
The provisions of this article shall not apply to an insurer or
hospital or medical service corporation licensed and regulated
pursuant to the insurance laws or the hospital or medical service
corporation laws of this state except with respect to its health
maintenance corporation activities authorized and regulated
pursuant to this article. The provisions of this article shall not
apply to an entity properly licensed by a reciprocal state to
provide health care services to employer groups, where residents of
West Virginia are members of an employer group, and the employer
group contract is entered into in the reciprocal state. For purposes of this subsection, a "reciprocal state" means a state
which physically borders West Virginia and which has subscriber or
enrolled hold harmless requirements substantially similar to those
set out in section seven-a of this article.
(b) Factually accurate advertising or solicitation regarding
the range of services provided, the premiums and copayments
charged, the sites of services and hours of operation, and any
other quantifiable, nonprofessional aspects of its operation by a
health maintenance organization granted a certificate of authority,
or its representative shall not be construed to violate any
provision of law relating to solicitation or advertising by health
professions:
Provided, That nothing contained in this subsection
shall be construed as authorizing any solicitation or advertising
which identifies or refers to any individual provider or makes any
qualitative judgment concerning any provider.
(c) Any health maintenance organization authorized under this
article shall not be considered to be practicing medicine and is
exempt from the provision of chapter thirty of this code, relating
to the practice of medicine.
(d) The provisions of section fifteen, article four (general
provisions); section seventeen, article six (noncomplying forms);
article six-c (guaranteed loss ratio); article seven (assets and
liabilities); article eight (investments); article nine
(administration of deposits); article twelve (agents, brokers,
solicitors and excess line); section fourteen, article fifteen
(individual accident and sickness insurance); section sixteen, article fifteen (coverage of children); section eighteen, article
fifteen (equal treatment of state agency); section nineteen,
article fifteen (coordination of benefits with medicaid); article
fifteen-b (uniform health care administration act); article
fifteen-c (diabetes insurance); section three, article sixteen
(required policy provisions); section three-f, article sixteen
(treatment of temporomandibular joint disorder and craniomandibular
disorder); section eleven, article sixteen (coverage of children);
section thirteen, article sixteen (equal treatment of state
agency); section fourteen, article sixteen (coordination of
benefits with medicaid); section sixteen, article sixteen (diabetes
insurance); article sixteen-a (group health insurance conversion);
article sixteen-c (small employer group policies); article
sixteen-d (marketing and rate practices for small employers);
article twenty-seven (insurance holding company systems); article
thirty-four-a (standards and commissioner's authority for companies
deemed to be in hazardous financial condition); article thirty-five
(criminal sanctions for failure to report impairment); article
thirty-seven (managing general agents); and article thirty-nine
(disclosure of material transactions) shall be applicable to any
health maintenance organization granted a certificate of authority
under this article. In circumstances where the code provisions
made applicable to health maintenance organizations by this
section refer to the "insurer", the "corporation" or words of
similar import, the language shall be construed to include health
maintenance organizations.
(e) Any long-term care insurance policy delivered or issued
for delivery in this state by a health maintenance organization
shall comply with the provisions of article fifteen-a of this
chapter.
(f) A health maintenance organization granted a certificate of
authority under this article shall be exempt from paying municipal
business and occupation taxes on gross income it receives from its
enrollees, or from their employers or others on their behalf, for
health care items or services provided directly or indirectly by
the health maintenance organization. This exemption applies to all
taxable years through the thirty-first day of December, one
thousand nine hundred ninety-six. The commissioner and the tax
department shall conduct a study of the appropriateness of
imposition of the municipal business and occupation tax or other
tax on health maintenance organizations, and shall report to the
regular session of the Legislature, one thousand nine hundred
ninety-seven, on their findings, conclusions and recommendations,
together with drafts of any legislation necessary to effectuate
their recommendations.