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, five, nine, twelve,
thirteen 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 three new sections, designated sections twelve-a,
twelve-b and fifteen-a, all relating to the West Virginia
public employee's insurance act; removing the design of the
benefit plan from the purview of the finance board; phasing in
a maximum premium cost for employers; providing criminal
penalties for knowingly obtaining benefits or payments greater
than those to which the individual is entitled; authorizing
inspection of the premises, documents and records to determine
compliance with billing practices; authorizing the director to
negotiate and contract directly with health care providers;
providing immunity for reporting fraudulent activities;
prohibiting employees from using annual or sick leave which
accrues after a specified date toward insurance coverage upon
retirement; allowing the employee to use leave accrued prior
to that date for extended insurance coverage; and permitting the employee to apply leave accrued after the specified date
towards additional credited service under the retirement
system, requiring approval of the director before any
participating employer may offer to or contract for optional
insurances; and limiting those retirees who are eligible for
subsidized insurance.
Be it enacted by the Legislature of West Virginia:
That sections two, five, nine, twelve, thirteen 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 three new sections, designated sections twelve-a, twelve-b
and fifteen-a, 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 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.
§5-16-5. 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 chairman 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:
Provided, That for the fiscal year beginning on the first day of
July, two thousand one, the premium cost for participating
employers may not exceed ninety-one percent of the total premium
cost: Provided, however, That for the fiscal year beginning on the
first day of July, two thousand two, the premium cost for
participating employers may not exceed ninety percent of the total
premium cost: Provided further, That for the fiscal year beginning
on the first day of July, two thousand three, the premium cost for
participating employers may not exceed eighty-seven percent of the
total premium cost: And provided further, That for the fiscal year
beginning on the first day of July, two thousand four, the premium
cost for participating employers may not exceed eighty-three
percent of the total premium cost: And provided further, That for
the fiscal year beginning on the first day of July, two thousand
five, the premium cost for participating employers may not exceed
eighty percent of the total premium cost: And provided further,
That for each fiscal year beginning on or after the first day of July, two thousand six, the premium cost for participating
employers shall be the lesser of: (A) Eighty percent of the total
premium cost; or (B) the industry standard, as established by the
finance board, for employer contributions in similar programs, 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 no
less than five years, for the programs provided for in this
article. The board shall consider 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 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.
(i) Upon a majority vote, the finance board may change the
benefit plan design presented by the director.
§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 mammograms 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,
said 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 may in his or her discretion negotiate and contract with
health care providers directly in order to secure competitive
premiums. The director shall deal directly with insurers or health
care providers 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
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 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 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
employee, his or her spouse and his or her dependents are entitled
thereunder, setting forth such information as to whom such benefits
shall be payable, to whom claims shall be submitted, and a summary
of the provisions of any such 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, designated representatives of the director,
and law-enforcement officers of the state, acting at the request of
the director, are authorized to inspect the place of business and
pertinent records, documents and papers of any person or provider
submitting a request for payment of claims under the provisions of this article to the extent deemed reasonably necessary to determine
compliance with proper and lawful billing practices. For the
purpose of making an inspection, the director, designated
representative and law-enforcement officers are authorized at
reasonable times, to enter the place of business for the sole
purpose of reviewing and auditing pertinent records, documents and
papers related to the payment of claims.
(b) Any person who violates any provision of this article is
guilty of a misdemeanor and 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 herein.
(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.
§5-16-13. Payment of costs by employer and employee; coverage for
employee's spouse and dependents generally; short term
continuance of coverage for involuntary employee termination; extended insurance coverage for retired employees with accrued annual leave and sick leave; increased retirement benefits for retired employees with accrued annual and sick leave; additional eligible retired employees; option for health insurance coverage without life insurance coverage made available to retirees; health insurance for surviving dependents of deceased employees.
(a) The director is hereby authorized to may provide under any
contract or contracts entered into under the provisions of this article that the costs of any such group hospital and surgical
insurance, group major medical insurance, group prescription drug
insurance, group life and accidental death insurance benefit plan
or plans may be paid by the employer and employee. In addition,
each employee shall be is entitled to have his or her spouse and
dependents, as defined by the rules of the public employees
insurance agency, included in any group hospital and surgical
insurance, group major medical insurance or group prescription drug
insurance coverage: Provided, That such the spouse and dependent
coverage shall be limited to excess or secondary coverage for each
spouse and dependent who has primary coverage from any other
source. For purposes of this section, the term "primary coverage"
means individual or group hospital and surgical insurance coverage
or individual or group major medical insurance coverage or group
prescription drug coverage in which the spouse or dependent is the
named insured or certificate holder. The director may require
proof regarding spouse and dependent primary coverage and shall
adopt rules governing the nature, discontinuance and resumption of
any employee's coverage for his or her spouse and dependents.
(b) Should If a participating employee be is terminated from
employment involuntarily or in through a reduction of work force,
the employee's insurance coverage provided under this article shall continue for a period of three months at no additional cost to the
employee. An employee discharged for misconduct shall is not be
eligible for extended benefits under this section. Coverage may be
extended up to the maximum period of three months, while
administrative remedies contesting the charge of misconduct are
pursued. If the discharge for misconduct be is upheld, the full
cost of the extended coverage shall be reimbursed by the employee.
If the employee is again employed or recalled to active employment
within twelve months of his or her prior termination, he or she
shall not be considered a new enrollee and shall not be required to
again contribute his or her share of the premium cost, if he or she
had already fully contributed such that share during the prior
period of employment.
(c) Except as otherwise provided in subsection (f) of this
section for higher education full-time faculty employed on an
annual contract basis other than for twelve months, when a
participating employee, who has elected to participate in the plan
before the first day of July, one thousand nine hundred
eighty-eight, is compelled or required by law to retire before
reaching the age of sixty-five, or when a participating employee
voluntarily retires as provided by law, that employee's accrued
annual leave and sick leave, if any, shall be credited toward an extension of the insurance coverage provided by this article,
according to the following formulae: Such The insurance coverage
for a retired employee shall continue one additional month for
every two days of annual leave or sick leave, or both, which the
employee had accrued as of the effective date of his or her
retirement. For a retired employee, his or her spouse and
dependents, such the insurance coverage shall continue one
additional month for every three days of annual leave or sick
leave, or both, which the employee had accrued as of the effective
date of his or her retirement: Provided, That the director may not
credit any annual or sick leave for any employee hired on or after
the first day of July, one thousand nine hundred ninety-nine,
toward an extension of the participating employee's insurance
coverage provided by this article: Provided, however, That the
employee hired on or after the first day of July, one thousand nine
hundred ninety-nine may elect to apply any leave accrued to acquire
additional credited service in the public employees retirement
system under the provisions of subsection (e) of this section.
(d) (1) Notwithstanding the preceding provisions of subsection
(c) of this section, except as otherwise provided in subsection (f)
of this section for higher education full-time faculty employed on an annual contract basis other than for twelve months, when a
participating employee who elects to participate in the plan on and
after the first day of July, one thousand nine hundred
eighty-eight, is compelled or required by law to retire before
reaching the age of sixty-five, or when such a participating
employee voluntarily retires as provided by law, that employee's
annual leave or sick leave, if any, shall be credited toward one
half of the premium cost of the insurance provided by this article,
for periods and scope of coverage determined according to the
following formulae: (1) One additional month of single retiree
coverage for every two days of annual leave or sick leave, or both,
which the employee had accrued as of the effective date of his or
her retirement; or (2) one additional month of coverage for a
retiree, his or her spouse and dependents for every three days of
annual leave or sick leave, or both, which the employee had accrued
as of the effective date of his or her retirement. The remaining
premium cost shall be borne by such the retired employee if he or
she elects such coverage: Provided, That the director may not
credit any annual or sick leave for any employee hired on or after
the first day of July, one thousand nine hundred ninety-nine,
toward an extension of the participating employee's insurance coverage provided by this article: Provided, however, That the
employee hired on or after the first day of July, one thousand nine
hundred ninety-nine may elect to apply any leave accrued to acquire
additional credited service in the public employees retirement
system under the provisions of subsection (e) of this section.
(2) For purposes of this subsection, an employee who has been
a participant under spouse or dependent coverage and who reenters
the plan within twelve months after termination of his or her prior
coverage shall be considered to have elected to participate in the
plan as of the date of commencement of the prior coverage. For
purposes of this subsection, an employee shall not be considered a
new employee after returning from extended authorized leave on or
after the first day of July, one thousand nine hundred
eighty-eight.
(e) In the alternative to the extension of insurance coverage
through premium payment provided in the two preceding subsections
(c) and (d) of this section, the participating employee's accrued
annual leave and sick leave may be applied, on the basis of two
days retirement service credit for each one day of accrued annual
and sick leave, toward an increase in the employee's retirement
benefits with such the days constituting additional credited
service in computation of such the benefits under any state retirement system. However, such the credited service shall not be
used in meeting initial eligibility for retirement criteria, but
only as additional service credited in excess thereof of the
required service.
(f) When a participating employee, who is a higher education
full-time faculty member employed on an annual contract basis other
than for twelve months, is compelled or required by law to retire
before reaching the age of sixty-five, or when such a the
participating employee voluntarily retires as provided by law, that
employee's insurance coverage, as provided by this article, shall
be extended according to the following formulae: Such The
insurance coverage for a retired higher education full-time faculty
member, formerly employed on an annual contract basis other than
for twelve months, shall continue beyond the effective date of his
or her retirement one additional year for each three and one-third
years of teaching service, as determined by uniform guidelines
established by the university of West Virginia board of trustees
and the board of directors of the state college system, for
individual coverage, or one additional year for each five years of
teaching service for "family" coverage: Provided, That the director
may not credit any annual or sick leave for employees hired after
the first day of July, one thousand nine hundred ninety-nine, toward an extension of the employee's insurance coverage provided
by this article: Provided, however, That the employee hired on or
after the first day of July, one thousand nine hundred ninety-nine
may elect to apply any leave accrued to acquire additional credited
service in the public employees retirement system under the
provisions of subsection (e) of this section.
(g) Any employee who retired prior to the twenty-first day of
April, one thousand nine hundred seventy-two, and who also
otherwise meets the conditions of the "retired employee" definition
in section two of this article, shall be is eligible for insurance
coverage under the same terms and provisions of this article. The
retired employee's premium contribution for any such the coverage
shall be established by the finance board.
(h) All retirees under the provisions of this article,
including those defined in section two of this article; those
retiring prior to the twenty-first day of April, one thousand nine
hundred seventy-two; and those hereafter retiring shall be from a
participating employer are eligible for and permitted to obtain
health insurance coverage. The retired employee's premium
contribution for any such the coverage shall be established by the
finance board.
(i) A surviving spouse and dependents of a deceased employee, who was either an active or retired employee just immediately prior
to such decease, shall be his or her death are entitled to be
included in any group insurance coverage provided under this
article, and such the spouse and dependents shall bear the premium
cost of such the insurance coverage. The finance board shall
establish the premium cost of any such the coverage.
(j) In construing the provisions of this section or any other
provisions of this code, the Legislature declares that it is not
now nor has it ever been the Legislature's intent that elected
public officials be provided any sick leave, annual leave or
personal leave, and the enactment of this section is based upon the
fact and assumption that no statutory or inherent authority exists
extending sick leave, annual leave or personal leave to elected
public officials and the very nature of such those positions
preclude the arising or accumulation of such sick leave, annual
leave or personal leave, so as to be thereafter usable as premium
paying credits for which such the officials may claim extended
insurance benefits.
(k) An employee, eligible for coverage under the provisions of
this article who has twenty years of service with any agency or
entity participating in the public employees insurance program or
who has been covered by the public employees insurance program for twenty years may, upon leaving employment with a participating
agency or entity, continue to be covered by the program if the
employee pays one hundred and five percent of the cost of retiree
coverage: Provided, That the employee shall elect to continue
coverage under this subsection within two years of the date the
employment with a participating agency or entity is terminated.
§5-16-15a. Prior notification and opportunity to comment for
optional insurance.
Any participating employer shall, prior to offering to its
employees any of the optional insurance described in section
fifteen of this article which is not made available by the
director, notify the director and allow him or her to comment on
the optional insurance to be offered. The employer may contract
for such optional insurance only with a solvent insurance company
that is licensed by the insurance commissioner to transact
insurance in this state and may place the insurance only through
agents duly licensed by the insurance commissioner.
§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.
____________
(NOTE: The purpose of this bill is to clarify the duties of
the Finance Board and the Director. It also phases in a maximum
premium percentage of 80% for employers over a five-year period,
which may be lowered in 2006, based on industry standards for
similar programs. It also provides that employees hired on or
after July 1, 1999 may not use sick or annual leave to extend
insurance coverage upon retirement, but allows use of accrued leave
to be used to increase credited service under the Public Employees
Retirement System. Additionally, this bill provides that to be
eligible for subsidized insurance upon retirement, the employee's
last employer had to be a participating employer. The bill
provides penalties for individuals receiving benefits or payments to which they are not entitled, penalties for fraudulent activity
and immunity from civil liability concerning reporting of those
activities. It also authorizes the PEIA director to negotiate and
contract directly with health care providers and insurers.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.
§5-16-12a, 12b and 15a are new; therefore, underlining and
strike-throughs have been omitted.)