ENGROSSED
Senate Bill No. 702
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[Originating in the Committee on Finance;
reported March 3, 1999.]
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A BILL to amend and reenact sections two, four, five, nine, twelve
and twenty-four, article sixteen, chapter five of the code of West
Virginia, one thousand nine hundred thirty-one, as amended; and to
further amend said article by adding thereto two new sections,
designated sections twelve-a and twelve-b, all relating to the West
Virginia public employees insurance act; defining terms; increasing
the membership of the finance board; providing for appointment of
the new members; revising requirements regarding preparation of
annual financial plans and long-range plans; realigning duties of
the finance board and the actuary; changing time of submission for
revenue estimates; requiring submission of prospective financial
plan; removing requirement that types and levels of costs to
employers, employees and retired employees in effect remain in
effect; providing criminal penalties for knowingly obtaining
benefits, payments or anything of value to which the person is not
entitled or greater than those to which the person is entitled;
authorizing the director to refer instances of suspected or potential fraud and abuse to the insurance commissioner for
investigation and, where appropriate, prosecution; providing
penalties for violations not otherwise specifically provided;
authorizing the director to negotiate and contract directly with
health care providers; providing immunity for reporting fraudulent
activities; and limiting those retirees who are eligible for
subsidized insurance.
Be it enacted by the Legislature of West Virginia:
That sections two, four, five, nine, twelve, and twenty-four,
article sixteen, chapter five of the code of West Virginia, one
thousand nine hundred thirty-one, as amended, be amended and
reenacted; and that said article be further amended by adding
thereto a two new sections, designated sections twelve-a and twelve- b, all to read as follows:
ARTICLE 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.
§5-16-2. Definitions.
The following words and phrases as used in this article,
unless a different meaning is clearly indicated by the context,
have the following meanings:
(1) "Advisory board" means the public employees insurance agency advisory board created by this article.
(2)(1) "Agency" means the public employees insurance agency
created by this article.
(3)(2) "Director" means the director of the public employees
insurance agency created by this article.
(4)(3) "Employee" means any person, including elected
officers, who works regularly full time in the service of the state
of West Virginia and, for the purpose of this article only, the
term "employee" also means any person, including elected officers,
who works regularly full time in the service of a county board of
education; a county, city or town in the state; any separate
corporation or instrumentality established by one or more counties,
cities or towns, as permitted by law; any corporation or
instrumentality supported in most part by counties, cities or
towns; any public corporation charged by law with the performance
of a governmental function and whose jurisdiction is coextensive
with one or more counties, cities or towns; any comprehensive
community mental health center or comprehensive mental retardation
facility established, operated or licensed by the secretary of
health and human resources pursuant to section one, article two-a,
chapter twenty-seven of this code, and which is supported in part
by state, county or municipal funds; any person who works regularly full time in the service of the university of West Virginia board
of trustees or the board of directors of the state college system;
and any person who works regularly full time in the service of a
combined city-county health department created pursuant to article
two, chapter sixteen of this code. On and after the first day of
January, one thousand nine hundred ninety-four, and upon election
by a county board of education to allow elected board members to
participate in the public employees insurance program pursuant to
this article, any person elected to a county board of education
shall be deemed to be an "employee" during the term of office of
the elected member: Provided, That the elected member shall pay
the entire cost of the premium if he or she elects to be covered
under this article. Any matters of doubt as to who is an employee
within the meaning of this article shall be decided by the
director.
On or after the first day of July, one thousand nine hundred
ninety-seven, a person shall be considered an "employee" if that
person meets the following criteria:
(i) Participates in a job-sharing arrangement as defined in
section one, article one, chapter eighteen-a of this code;
(ii) Has been designated, in writing, by all other
participants in that job-sharing arrangement as the "employee" for purposes of this section; and
(iii) Works at least one third of the time required for a
full-time employee.
(5)(4) "Employer" means the state of West Virginia, its
boards, agencies, commissions, departments, institutions or
spending units; a county board of education; a county, city or town
in the state; any separate corporation or instrumentality
established by one or more counties, cities or towns, as permitted
by law; any corporation or instrumentality supported in most part
by counties, cities or towns; any public corporation charged by law
with the performance of a governmental function and whose
jurisdiction is coextensive with one or more counties, cities or
towns; any comprehensive community mental health center or
comprehensive mental retardation facility established, operated or
licensed by the secretary of health and human resources pursuant to
section one, article two-a, chapter twenty-seven of this code, and
which is supported in part by state, county or municipal funds; and
a combined city-county health department created pursuant to
article two, chapter sixteen of this code. Any matters of doubt as
to who is an "employer" within the meaning of this article shall be
decided by the director. The term "employer" does not include
within its meaning the national guard.
(6)(5) "Finance board" means the public employees insurance
agency finance board created by this article.
(7)(6) "Plan" means the medical indemnity plan or a managed
care plan option offered by the agency.
(8)(7) "Retired employee" means an employee of the state who
retired after the twenty-ninth day of April, one thousand nine
hundred seventy-one, and an employee of the university of West
Virginia board of trustees or the board of directors of the state
college system or a county board of education who retires on or
after the twenty-first day of April, one thousand nine hundred
seventy-two, and all additional eligible employees who retire on or
after the effective date of this article, and meet the minimum
eligibility requirements for their respective state retirement
system and whose last employer immediately prior to retirement
under the state retirement system is a participating employer:
Provided, That for the purposes of this article, the employees who
are not covered by a state retirement system shall, in the case of
education employees, meet the minimum eligibility requirements of
the state teachers retirement system, and in all other cases, meet
the minimum eligibility requirements of the public employees
retirement system.
§5-16-4. Public employees insurance agency finance board created; qualifications, terms and removal of members; quorum;
compensation and expenses; termination date.
(a) There is hereby created continued the public employees
insurance agency finance board, which shall consist consists of the
director and four six members appointed by the governor with the
advice and consent of the Senate for terms of four years and until
the appointment of their successors: Provided, That the members
initially appointed by the governor shall be appointed not later
than the tenth day of September, one thousand nine hundred ninety,
and may serve and may perform the duties required by this article
until such time as the Senate may convene to give its advice and
consent. Of the members first appointed, one shall be appointed
for a term of one year, one for two years, one for three years and
one for four years. of the two members added to the board by the
amendment of this section, enacted during the regular legislative
session, one thousand nine hundred ninety-nine, the at-large member
shall be appointed for an initial term of two years and the member
representing organized labor shall be appointed for a term of four
years. Members may be reappointed for successive terms. No more
than three four members (including the director) may be of the same
political party.
(b) Of the four six members appointed by the governor, one member shall represent the interests of education employees, one
shall represent the interests of public employees, one shall
represent the interests of organized labor and two three shall be
selected from the public at large. The governor shall appoint the
member representing the interests of education employees from a
list of three names submitted by the largest organization of
education employees in this state. The governor shall appoint the
member representing the interests of organized labor from a list of
three names submitted by the state's largest organization
representing labor affiliates. The two three members appointed
from the public shall each have experience in the financing,
development or management of employee benefit programs. All new
appointments made subsequent to after the first day of July, one
thousand nine hundred ninety-four, shall be selected to represent
the different geographical areas within the state and all members
shall be residents of West Virginia. No member may be removed from
office by the governor except for official misconduct,
incompetence, neglect of duty, neglect of fiduciary duty or other
specific responsibility imposed by this article, or gross
immorality.
(c) The director shall serve as chairperson of the finance
board, which shall meet at such time and place as shall be times and places specified by the call of the director or upon the
written request to the director of at least two members. Notice of
each meeting shall be given in writing to each member by the
director at least three days in advance of the meeting. Three Four
members shall constitute constitutes a quorum. The board shall pay
each member the same compensation and expense reimbursement as is
paid to members of the Legislature for their interim duties, as
recommended by the citizens legislative compensation commission and
authorized by law for each day or portion thereof of a day engaged
in the discharge of official duties.
(d) Pursuant to the provisions of article ten, chapter four of
this code, the finance board shall terminate on the first day of
July, two thousand one, unless extended by legislation enacted
before the termination date.
(e) Upon termination of the board and notwithstanding any
provisions in this article to the contrary, the director is
authorized to assess monthly employee premium contributions and to
change the types and levels of costs to employees only in
accordance with this subsection. Any assessments or changes in
costs imposed pursuant to this subsection shall be implemented by
legislative rule rules and regulations of the director promulgated
proposed by the director for promulgation pursuant to the provisions of article three, chapter twenty-nine-a of this code;
any employee assessments or costs previously authorized by the
finance board shall then remain in effect until amended by rule or
regulation of the director promulgated pursuant to this subsection.
§5-16-5. Purpose, powers and duties of the finance board; initial
financial plan; financial plan for following year; and annual financial plans.
(a) The purpose of the finance board created by this article
is to bring fiscal stability to the public employees insurance
agency through development of an annual financial plan plans and
long-range plans designed to meet the agency's estimated total
financial requirements, taking into account all revenues projected
to be made available to the agency, and apportioning necessary
costs equitably among participating employers, employees and
retired employees and providers of health care services.
(b) The finance board shall retain the services of an
impartial, professional actuary, with demonstrated experience in
analysis of large group health insurance plans, to estimate the
total financial requirements of the public employees insurance
agency for each fiscal year and to review and render written
professional opinions as to financial plans proposed by the finance
board. The finance board actuary shall also employ the actuary to develop also assist in the development of alternative financing
options and to perform such any other services as may be requested
by the finance board or the director. All reasonable fees and
expenses for actuarial services shall be paid by the public
employees insurance agency. Any financial plan or modifications to
a financial plan approved or proposed by the finance board pursuant
to this section shall be submitted to and reviewed by the actuary,
and may not be finally approved and submitted to the governor and
to the Legislature without the actuary's written professional
opinion that the plan may be reasonably expected to generate
sufficient revenues to meet all estimated program and
administrative costs of the agency, excluding including incurred
but unreported claims, for the fiscal year for which the plan is
proposed. The actuary's opinion on the initial plan required by
subsection (d) of this section shall allow for a target of
forty-five days of accounts payable to be carried over into the
next fiscal year. The actuary's opinion on the financial plan for
fiscal year one thousand nine hundred ninety-two shall allow for
between thirty and forty-five days of accounts payable to be
carried over into the next fiscal year. The actuary's opinion on
the financial plan for any succeeding each fiscal year shall allow
for no more than thirty days of accounts payable to be carried over into the next fiscal year. The actuary's opinion for any fiscal
year shall not include a requirement for establishment of a reserve
fund.
(c) All financial plans required by this section shall include
the design of a benefit plan or plans. All financial plans
required by this section shall establish:
(1) Maximum levels of reimbursement which the public employees
insurance agency makes to categories of health care providers;
(2) Any necessary cost containment measures for implementation
by the director;
(3) The levels of premium costs to participating employers;
and
(4) The types and levels of cost to participating employees
and retired employees.
The financial plans may provide for different levels of costs
based on the insureds' ability to pay. The finance board may
establish different levels of costs to retired employees based upon
length of employment with a participating employer, ability to pay,
or other relevant factors. The financial plans may also include
optional alternative benefit plans with alternative types and
levels of cost. The finance board may develop policies which
encourage the use of West Virginia health care providers.
In addition, the finance board may allocate a portion of the
premium costs charged to participating employers to subsidize the
cost of coverage for participating retired employees, on such terms
as the finance board determines are equitable and financially
responsible.
(d) Initial plan. -- The director shall convene the first
meeting of the finance board no later than the fifteenth day of
September, one thousand nine hundred ninety. For presentation by
the director at the first meeting, the governor shall prepare an
estimate of the total amount of general and special revenues which
the state has or will have available to fund the public employees
insurance agency and its programs for the fiscal year ending on the
thirtieth day of June, one thousand nine hundred ninety-one.
Notwithstanding any provision of this article to the contrary,
during any meeting authorized by subsection (h) of this section to
review implementation of the initial financial plan in light of
actual experience, the finance board, in its discretion, may elect
to redesign the initial financial plan so that revenues generated
will meet all incurred and projected program and administrative
costs of the public employees insurance agency by the end of the
fiscal year ending on the thirtieth day of June, one thousand nine
hundred ninety-two, rather than by the thirtieth day of June, one thousand nine hundred ninety-one. Before implementing any such
modifications, the finance board shall obtain a written
professional opinion from its actuary stating that the modified
plan may be reasonably expected to generate sufficient revenues to
meet all estimated program and administrative costs of the public
employees insurance agency for the remainder of fiscal year one
thousand nine hundred ninety-one and for fiscal year one thousand
nine hundred ninety-two, allowing for between thirty and forty-five
days of accounts payable to be carried over into fiscal year one
thousand nine hundred ninety-three. The finance board shall also
afford interested and affected persons an opportunity to offer
comment on the modified plan at a public meeting of the finance
board. Regardless of whether or not the finance board modifies the
initial financial plan as authorized by this subsection, the
finance board shall prepare a financial plan for fiscal year one
thousand nine hundred ninety-two in accordance with subsection (e)
of this section.
The finance board shall prepare, no later than the tenth day
of November, one thousand nine hundred ninety, a proposed financial
plan designed to generate revenues sufficient to meet all program
and administrative costs of the public employees insurance agency
which have already been incurred but are unpaid, or which the actuary estimates will be incurred and paid during the remainder of
fiscal year one thousand nine hundred ninety-one, excluding
incurred but unreported claims. The finance board shall establish
in the proposed financial plan a target of forty-five days of
accounts payable which may be carried over into the next fiscal
year.
The finance board shall request its actuary to review the
proposed financial plan and to render a written professional
opinion stating whether the plan may be reasonably expected to
generate sufficient revenues to meet all estimated program and
administrative costs of the public employees insurance agency for
the fiscal year. The actuary's report shall explain the basis of
his or her opinion. If the actuary concludes that the proposed
financial plan will not generate sufficient revenues to meet all
anticipated costs, then the finance board shall make necessary
modifications to the proposed plan to ensure that all actuarially- determined financial requirements of the agency will be met.
Upon obtaining the actuary's opinion and making all necessary
modifications to the proposed plan, the finance board shall conduct
two or more public hearings to receive public comment on the
proposed financial plan, shall review such comments, and shall
finalize and approve the financial plan no later than the twentieth day of November, one thousand nine hundred ninety. Employees shall
be notified of any changes in the types and levels of employee
costs or benefits contained in the financial plan at least thirty
days prior to the date of implementation of the financial plan.
The finance board shall submit to the governor and to the
Legislature the final, approved financial plan no later than the
first day of December, one thousand nine hundred ninety. The
financial plan shall become effective and shall be implemented by
the director on the first day of January, one thousand nine hundred
ninety-one.
(e) Plan for fiscal year one thousand nine hundred ninety-two.
-- No later than the first day of December, one thousand nine
hundred ninety, the governor shall prepare and provide to the
finance board an estimate of the total amount of general and
special revenues which the state will have available to fund the
public employees insurance agency and its programs for the fiscal
year beginning the first day of July, one thousand nine hundred
ninety-one. The finance board shall request its actuary to
estimate the total financial requirements of the public employees
insurance agency for the fiscal year.
The finance board shall prepare a proposed financial plan
designed to generate revenues sufficient to meet all estimated program and administrative costs of the public employees insurance
agency for the fiscal year. The proposed financial plan shall
allow for between thirty and forty-five days of accounts payable to
be carried over into the next fiscal year. Before final adoption
of the proposed financial plan, the finance board shall request its
actuary to review the plan and to render a written professional
opinion stating whether the plan will generate sufficient revenues
to meet all estimated program and administrative costs of the
public employees insurance agency for the fiscal year. The
actuary's report shall explain the basis of its opinion. If the
actuary concludes that the proposed financial plan will not
generate sufficient revenues to meet all anticipated costs, then
the finance board shall make necessary modifications to the
proposed plan to ensure that all actuarially-determined financial
requirements of the agency will be met.
Upon obtaining the actuary's opinion, the finance board shall
conduct one or more public hearings in each congressional district
to receive public comment on the proposed financial plan, shall
review such comments, and shall finalize and approve the financial
plan.
The finance board shall submit to the governor and to the
Legislature its final, approved financial plan for fiscal year one thousand nine hundred ninety-two, together with the actuary's final
written opinion, no later than the first day of May, one thousand
nine hundred ninety-one. The financial plan shall become effective
and shall be implemented by the director on the first day of July,
one thousand nine hundred ninety-one.
(f) Annual plans. (d) (1) The finance board shall prepare in
the manner provided in subsection (e) of this section, an annual
financial plan for fiscal year one thousand nine hundred ninety-
three and each fiscal year thereafter during which the finance
board remains in existence. The finance board chairman shall
request the actuary to estimate the total financial requirements of
the public employees insurance agency for the fiscal year.
(2) The finance board shall prepare a proposed financial plan
designed to generate revenues sufficient to meet all estimated
program and administrative costs of the public employees insurance
agency for the fiscal year. The proposed financial plan shall
allow for no more than thirty days of accounts payable to be
carried over into the next fiscal year. Before final adoption of
the proposed financial plan, the finance board shall request the
actuary to review the plan and to render a written professional
opinion stating whether the plan will generate sufficient revenues
to meet all estimated program and administrative costs of the public employees insurance agency for the fiscal year. The
actuary's report shall explain the basis of its opinion. If the
actuary concludes that the proposed financial plan will not
generate sufficient revenues to meet all anticipated costs, then
the finance board shall make necessary modifications to the
proposed plan to ensure that all actuarially-determined financial
requirements of the agency will be met.
(3) Upon obtaining the actuary's opinion, the finance board
shall conduct one or more public hearings in each congressional
district to receive public comment on the proposed financial plan,
shall review such comments, and shall finalize and approve the
financial plan.
(4) Any such financial plan shall be designed to allow thirty
days or less of accounts payable to be carried over into the next
fiscal year. For each such fiscal year, the governor shall provide
his or her estimate of total revenues to the finance board no later
than the first fifteenth day of July October of the preceding
fiscal year. The finance board shall submit its final, approved
financial plan, after obtaining the necessary actuary's opinion and
conducting one or more public hearings in each congressional
district, to the governor and to the Legislature no later than the
first day of January preceding the fiscal year. The financial plan for a fiscal year shall become becomes effective and shall be
implemented by the director on the first day of July of such the
fiscal year. In addition to each final, approved financial plan
required under this section, the finance board shall also
simultaneously submit financial statements based on generally
accepted accounting practices (GAAP) and the final, approved plan
restated on an accrual basis of accounting, which shall include
allowances for incurred but not reported claims: Provided, That
the financial statements and the accrual-based financial plan
restatement shall not affect the approved financial plan.
(g) (e) The provisions of chapter twenty-nine-a of this code
shall not apply to the preparation, approval and implementation of
the financial plans required by this section.
(f) Beginning on the first day of January, two thousand, and
every year thereafter, the finance board shall submit to the
governor and the Legislature, a prospective financial plan, for a
period not to exceed five years, for the programs provided for in
this article. Factors that the board shall consider include, but
shall not be limited to, the trends for the program and the
industry; the medical rate of inflation; utilization patterns; cost
of services; and, state specific information such as average age of
employee population, active to retiree ratios, the service delivery system and health status as these relate to the employees and
retirees insured by the public employees insurance agency, their
spouses and their dependents of the population.
(h) (g) The finance board shall meet on at least a quarterly
basis to review implementation of its current financial plan in
light of the actual experience of the public employees insurance
agency. The board shall review actual costs incurred, any revised
cost estimates provided by the actuary, expenditures, and any other
factors affecting the fiscal stability of the plan, and may make
any additional modifications to the plan necessary to ensure that
the total financial requirements of the agency for the current
fiscal year are met. The financial board may not increase the
types and levels of cost to employees during its quarterly review
except in the event of a true emergency.
(i) (h) For any fiscal year in which legislative
appropriations differ from the governor's estimate of general and
special revenues available to the agency, the finance board shall,
within thirty days after passage of the budget bill, make any
modifications to the plan necessary to ensure that the total
financial requirements of the agency for the current fiscal year
are met.
(j) The types and levels of costs to employers, employees and retired employees participating in public employees insurance
agency group insurance plans which are currently in effect on the
effective date of this article are hereby authorized. The types
and levels of costs to employees participating in public employees
insurance agency group insurance plans which are currently in
effect on the effective date of this article shall remain in effect
unless and until changed or authorized to be changed by the finance
board in a financial plan prepared and approved in accordance with
this section.
§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 covered employees; 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) Baseline or other recommended mammograms for women age
thirty-five to thirty-nine, inclusive;
(2) Mammograms recommended or required for women age forty to
forty-nine, inclusive, every two years or as needed;
(3) A mammogram every year for women age fifty and over;
(4) A pap smear annually or more frequently based on the
woman's physician's recommendation for women age eighteen and over;
and
(5) A checkup for prostate cancer annually for men age fifty or over.
(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 purchases 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 herein authorized
in this article, said 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 such 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 such 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 such 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 such contract or
contracts shall receive a statement of benefits to which such the
employee, his or her spouse and his or her dependents are entitled
thereunder under the contract, setting forth such the information
as to whom such the benefits shall be are payable, to whom claims
shall be submitted, and a summary of the provisions of any such 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 influenzae-b and whooping cough.
Additional immunizations may be required by the commissioner of the
bureau of 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.
§5-16-12. Misrepresentation by employer, employee or provider;
penalty.
(a) Any person who knowingly secures or attempts to secure benefits payable under this article or anything of value to which
the person is not entitled, or who knowingly secures or attempts to
secure greater benefits than those to which the person is entitled,
by willfully misrepresenting the presence or extent of benefits to
which the person is entitled under a collateral insurance source,
or by willfully misrepresenting any material fact relating to any
other information requested by the director or by willfully
overcharging for services provided, or by willfully misrepresenting
the diagnosis or nature of the service provided, may be found to be
overpaid and shall be civilly liable for any overpayment. In
addition to the civil remedy provided herein, the director shall
withhold payment of any benefits or other payment due to that
person until any overpayment has been recovered or may directly set
off, after holding internal administrative proceedings to assure
due process, any such overcharges or improperly derived payment
against benefits or other payment due such person hereunder.
Nothing in this section shall be construed to limit any other
remedy or civil or criminal penalty provided by law.
(b) Any employer, employee or provider who knowingly secures
or attempts to secure benefits payable under this article or any
other thing of value to which the person is not entitled, or
knowingly attempts to secure greater benefits than those to which the person is entitled, by willfully misrepresenting, or aiding in
the misrepresentation of, any material fact relating to employment,
diagnosis or services rendered is guilty of a felony and, upon
conviction thereof, shall be fined not more than five thousand
dollars, imprisoned for not longer than two years, or both.
§5-16-12a. Inspections; violations and penalties.
(a) The director or his or her designated representative is
authorized to refer instances of suspected or potential fraud,
abuse and other illegal activities involving transactions with the
agency to the insurance commissioner for investigation and, if
appropriate, prosecution, pursuant to article forty-one, chapter
thirty-three of this code. For purposes of this section,
"transactions with the agency" includes, but is not limited to,
application by any insured or dependent, any employer, or any type
of health care provider for payment to be made to that person or
any third party by the agency.
(b) Any person who violates any provision of this article for
which no other penalty is specifically provided is guilty of a
misdemeanor and, upon conviction thereof, is subject to a fine of
not less than one hundred dollars but not more than five hundred
dollars, or imprisonment for a period of not less than twenty-four
hours but not more than fifteen days, or both.
§5-16-12b. Privileges and immunity.
(a) Any person who makes a report or furnishes information,
written or oral, concerning suspected, anticipated or fraudulent
activity to secure benefits payable under this article, or to
secure greater benefits than those to which the person or provider
is entitled, is entitled to those privileges and immunities
existing under common or statutory law, as well as the immunity
established in this section.
(b) In the absence of fraud, malice or bad faith, no person or
agent, employee or designee of that person shall be subject to
civil liability of any nature arising out of that person's
provision of information related to suspected, anticipated or
fraudulent activity in the securing of benefits payable or securing
greater benefits than those to which the person or provider is
entitled.
(c) Nothing in this section shall be construed to limit,
abrogate or modify existing statutes or case law applicable to the
duties or liabilities of persons acting in a manner that is itself
fraudulent, with malice or in bad faith.
§5-16-24. Rules for administration of article; eligibility of
certain retired employees and dependents of deceased members
for coverage; employees on medical leave of absence entitled to coverage; life insurance.
The director shall promulgate such any necessary rules and
regulations as may be required for the effective administration of
the provisions of this article. Except as specifically provided in
subsection (e), section four of this article, all rules and
regulations of the public employees insurance agency and all
hearings held by the public employees insurance agency shall be are
exempt from the provisions of chapter twenty-nine-a of this code.
Any rules and regulations now in existence promulgated by the
public employees insurance board or director shall remain in full
force and effect until they are amended or replaced by the
director.
Such regulations The rules shall provide that any employee of
the state who has been compelled or required by law to retire
before reaching the age of sixty-five years shall be is eligible to
participate in the public employees' health insurance program at
the premium contribution established by the finance board after any
extended coverage to which he or she, his or her spouse and
dependents may be entitled by virtue of his or her accrued annual
leave or sick leave, pursuant to the provisions of section thirteen
of this article, has expired. Any employee who voluntarily
retires, as provided by law, shall be is eligible to participate in the public employees' health insurance program at the premium
contribution established by the finance board after any extended
coverage to which he or she, his or her spouse and dependents may
be entitled by virtue of his or her accrued annual leave or sick
leave, pursuant to the provisions of section thirteen of this
article, has expired: Provided, That the employee's last employer
is a participating employer. The dependents of any deceased
retired employee shall be are entitled to continue their
participation and coverage upon payment of the premium contribution
established by the finance board. In establishing the cost of
health insurance coverage for retired employees and their spouses
and dependents, the finance board, in its discretion, may cause the
claims experience of such the retired employees and their spouses
and dependents to be rated separately from that of active employees
and their spouses and dependents, or may cause the claims
experience of retired and active employees, and their spouses and
dependents, to be rated together.
Any employee who is on a medical leave of absence, approved by
his or her employer, shall, is subject to the following provisions
of this paragraph, be is entitled to continue his or her coverage
until he or she returns to his or her employment, and such the
employee and employer shall continue to pay their proportionate share of premium costs as provided by this article: Provided, That
the employer shall be is obligated to pay its proportionate share
of the premium cost only for a period of one year: Provided,
however, That during the period of such the leave of absence, the
employee shall, at least once each month, submit to the employer
the statement of a qualified physician certifying that the employee
is unable to return to work.
Any retiree retiring heretofore or hereafter, shall be is
eligible to participate in the public employees' life insurance
program, including the optional life insurance coverage as already
available to active employees under this article, at his or her own
expense for the cost of coverage, based upon actuarial experience;
and the director shall prepare, by rule and regulation, for such
that participation and coverages under declining term insurance and
optional additional coverage for such the retirees.