COMMITTEE SUBSTITUTE
FOR
Senate Bill No. 408
(By Senators Minard, Jenkins, Stollings and Kessler)
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[Originating in the Committee on Banking and Insurance;
reported March 27, 2009.]
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A BILL to repeal §33-48-11 of the Code of West Virginia, 1931, as
amended; to amend said code by adding thereto a new section,
designated §33-48-7b; and to amend and reenact §33-48-8 of
said code, all relating to the model health plan for
uninsurable individuals; removing obsolete sunset provision;
authorizing the use of surplus funds in the plan fund to
subsidize premiums of certain enrollees; and permitting the
board to propose legislative rules to propose additional
classes of individuals to which the preexisting condition
exclusion may not apply.
Be it enacted by the Legislature of West Virginia:
That §33-48-11 of the Code of West Virginia, 1931, as amended,
be repealed; that said code be amended by adding thereto a new
section, designated §33-48-7b ; and that §33-48-8 of said code be
amended and reenacted, all to read as follows:
ARTICLE 48. MODEL HEALTH PLAN FOR UNINSURABLE INDIVIDUALS ACT.
§33-48-7b. Surplus available to subsidize premiums.
Whenever the board determines that the account created
pursuant to section seven-a of this article contains a surplus
above those amounts necessary to provide fully for the expected
costs of claims and other expenses listed in subsection (a),
section seven of this article, the plan may use such surpluses to
subsidize the premium of certain low income enrollees whose
eligibility shall be established by legislative rule. The board
shall propose rules for legislative approval in accordance with the
provisions of article three, chapter twenty-nine-a of this code to
establish criteria for enrollees with low income eligible for
premium subsidy pursuant to this section.
§33-48-8. Benefits.
(a) The plan shall offer health care coverage consistent with
comprehensive coverage to every eligible person who is not eligible
for medicare. The coverage to be issued by the plan, its schedule
of benefits, exclusions and other limitations shall be established
by the board and subject to the approval of the commissioner.
(b) In establishing the plan coverage, the board shall take
into consideration the levels of health insurance coverage provided
in the state and medical economic factors as may be deemed
appropriate; and promulgate benefit levels, deductibles,
coinsurance factors, exclusions and limitations determined to be
generally reflective of and commensurate with health insurance
coverage provided through a representative number of large
employers in the state.
(c) The board may adjust any deductibles and coinsurance
factors annually according to the medical component of the consumer
price index.
(d) Preexisting conditions. --
(1) Plan coverage shall exclude charges or expenses incurred
during the first six months following the effective date of
coverage as to any condition for which medical advice, care or
treatment was recommended or received as to such conditions during
the six-month period immediately preceding the effective date of
coverage, except that no preexisting condition exclusion shall be
applied to a federally defined eligible individual. The board may
propose rules for legislative approval in accordance with the
provisions of article three, chapter twenty-nine-a of this code to
propose any other additional class of eligible individuals to which
the preexisting condition exclusion may not apply.
(2) Subject to subdivision (1) of this subsection, the
preexisting condition exclusions shall be waived to the extent that
similar exclusions, if any, have been satisfied under any prior
health insurance coverage which was involuntarily terminated:
Provided, That:
(A) Application for pool coverage is made not later than
sixty-three days following such involuntary termination and, in
such case, coverage in the plan shall be effective from the date on
which such prior coverage was terminated; and
(B) The applicant is not eligible for continuation or
conversion rights that would provide coverage substantially similar to plan coverage.
(e) Nonduplication of benefits. --
(1) The plan shall be payer of last resort of benefits
whenever any other benefit or source of third-party payment is
available. Benefits otherwise payable under plan coverage shall be
reduced by all amounts paid or payable through any other health
insurance coverage and by all hospital and medical expense benefits
paid or payable under any workers' compensation coverage,
automobile medical payment or liability insurance, whether provided
on the basis of fault or nonfault, and by any hospital or medical
benefits paid or payable under or provided pursuant to any state or
federal law or program.
(2) The plan shall have a cause of action against an eligible
person for the recovery of the amount of benefits paid that are not
for covered expenses. Benefits due from the plan may be reduced or
refused as a set-off against any amount recoverable under this
subdivision.
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(NOTE: The purpose of this bill is to permit the Insurance
Commissioner to waive the waiting period for eligibility for
coverage under the state's high risk health insurance plan and to
use surpluses in the program to subsidize premiums of certain low
income persons.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.
§33-48-7b is new; therefore, underscoring and strike-throughs
have been omitted.)