Senate Bill No. 162
(By Senators Tomblin, Mr. President, and Sprouse,
By Request of the Executive)
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[Introduced January 16, 2006; referred to the Committee
on Health and Human Resources; then to the Committee on Banking
and Insurance; and then to the Committee on Finance.]
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A BILL to amend the Code of West Virginia, 1931, as amended, by
adding thereto a new article, designated §33-15D-1, §33-15D-2,
§33-15D-3, §33-15D-4, §33-15D-5, §33-15D-6, §33-15D-7,
§33-15D-8, §33-15D-9 and §33-15D-10, all relating to
individual limited health benefits insurance plans; including
preventive and primary care services; declaring legislative
intent; requiring approval of plans by Insurance Commissioner;
providing eligibility requirements for individuals; setting
forth statutory or regulatory provisions that do not apply to
such plans; providing underwriting standards; establishing
criteria for filing and approval of premium rates; requiring
certification of creditable coverage; authorizing Insurance
Commissioner to promulgate emergency rules; mandating
disclaimer on policies; exempting plans from premium taxes;
providing for severability; and providing rule of construction.
Be it enacted by the Legislature of West Virginia:
That the Code of West Virginia, 1931, as amended, be amended
by adding thereto a new article, designated §33-15D-1, §33-15D-2,
§33-15D-3, §33-15D-4, §33-15D-5, §33-15D-6, §33-15D-7, §33-15D-8,
§33-15D-9 and §33-15D-10, all to read as follows:
ARTICLE 15D. INDIVIDUAL LIMITED HEALTH BENEFITS PLANS.
§33-15D-1. Declaration of legislative intent.
The Legislature recognizes that health insurance is priced
beyond the reach of many citizens who could benefit from a basic
health plan. One of the ways affordable premiums can be obtained
is by some combination of limiting benefits and increasing copays
or deductibles. In order to provide greater access to such
affordable plans, the Legislature has determined that authorization
of the sale of insurance policies with limited benefits that would
include physician, inpatient and outpatient care, with an emphasis
on preventive and primary care, will serve to bring insurance
coverage to many of those West Virginians without any insurance
coverage. It is, therefore, the intent of the Legislature to
introduce flexibility in the design of health insurance plans to
allow insurers to offer basic benefits, including preventive and
primary care services, at affordable prices. This article may be
known as the Affordable Health Insurance Act.
§33-15D-2. Individual limited health benefits plans; approval by
commissioner; eligibility of individuals.
(a) As used in this article, "individual plan" means any plan
approved by the commissioner as an "individual limited health
benefits plan" in accordance with this article. Each such plan
constitutes a "particular type of accident and sickness insurance
coverage" for the purposes of subsection (a), section two-e,
article fifteen of this chapter.
(b) Notwithstanding any other provision of this code,
including provisions mandating the inclusion of certain benefits in
individual health insurance plans, upon filing with and approval by
the commissioner as an individual plan, any insurer, including a
health maintenance organization or health service corporation, may
offer the plan and rates associated with the plan to individuals
subject to the conditions of this article.
(c) Any plan approved as an individual plan may,
notwithstanding any other provisions of this chapter and subject to
any other limitations on eligibility in this article or that may be
contained in rules proposed by the commissioner for approval of the
Legislature in accordance with article three, chapter twenty-nine-a
of this code, only be offered to an adult between the ages of
eighteen and sixty-four, inclusive, who:
(1) Has not had a health benefit plan covering him or her for
at least the prior twelve consecutive months:
Provided, That such
a plan may not be offered to an employee of an employer that offers
a health benefits plan to its employees unless that employee does
not qualify for coverage under such employer plan; or
(2) Has lost coverage due to a qualifying event. A qualifying
event shall include loss of coverage due to: (I) Emancipation and
resultant loss of coverage under a parent's or guardian's plan;
(ii) divorce and loss of coverage under the former spouse's plan;
(iii) termination of employment and resultant loss of coverage
under an employer group plan except for loss of employment for
gross misconduct; or (iv) involuntary termination of coverage under
a group health benefit plan except for termination due to
nonpayment of premiums or fraud by the insured.
(d) Every individual plan offered pursuant to this article may
limit eligibility on the basis of health status and an individual
who has been treated for a health condition in the prior twelve
months may have that condition excluded from coverage for the first
twelve months of the policy term.
§33-15D-3. Applicability of certain provisions; commissioner's
authority to forbear from applying certain
provisions.
(a) Only the following provisions of article fifteen of this
chapter apply to insurers offering individual plans pursuant to
this article: Sections two-a, two-b, two-d, two-e, three, four,
four-e, four-g, five, six, seven, eight, nine, eighteen and
nineteen:
Provided, That the provisions of subsection (a), section
two-b, article fifteen of this chapter do not apply to such plans
if the Secretary of the United States Department of Health and
Human Services finds that the state is implementing an acceptable alternative mechanism in accordance with the provisions of 42 U. S.
C. §300gg-44.
(b) Notwithstanding any other provision of this code, the
provisions of article twenty-eight of this chapter and legislative
rules regulating individual accident and sickness policies,
including the rule contained in series 12, title 114 of the West
Virginia Code of State Rules, do not apply to individual plans
issued pursuant to this article unless and to the extent
specifically incorporated in rules promulgated pursuant to the
authority conferred by section seven of this article.
(c) The commissioner may forbear from applying any other
statutory or regulatory requirements to an insurer offering an
individual plan approved pursuant to this article, including any
requirements in articles twenty-four and twenty-five-a, provided
that the commissioner first determines that such forbearance serves
the principles set forth in section one of this article.
§33-15D-4. Underwriting standards for individual plans.
Insurers shall underwrite individual plans in a comparable
manner as they underwrite other individual health insurance plans
governed by this chapter.
§33-15D-5. Filing and approval of rates.
(a) Premium rate charges for any individual plans shall:
(1) Be reasonable in relation to the benefits available under
the policy; and
(2) Notwithstanding the provisions of section one, article sixteen-b of this chapter, be filed with the commissioner for a
waiting period of thirty days before the charges become effective.
At the expiration of thirty days the premium rate charges filed are
deemed approved unless prior thereto the charges have been
affirmatively approved or disapproved by the commissioner.
(b) The commissioner shall disapprove premium rates that are
not in compliance with the requirements of any rule promulgated
pursuant to section seven of this article. The commissioner shall
send written notice of the disapproval to the insurer. The
commissioner may approve the premium rates before the thirty-day
period expires by giving written notice of approval.
§33-15D-6. Certification of creditable coverage.
An insurer offering individual plans pursuant to the
provisions of this article shall provide certification of
creditable coverage in the same manner as provided in section
three-m, article sixteen of this chapter.
§33-15D-7. Emergency rules authorized.
The commissioner shall promulgate emergency and legislative
rules under the provisions of article three, chapter twenty-nine-a
of this code on or before the first day of September, two thousand
six, to prescribe requirements regarding ratemaking, which may
include rules establishing loss ratio standards for individual
plans; to place further limitations on the eligibility of
individuals; to determine what medical treatments, procedures and
related health services benefits must be included in such individual plans; and to provide for any other matters deemed
necessary to further the intent of this article. In determining
what medical treatments, procedures and related health services
benefits must be included in such plans, the commissioner shall
consider their effectiveness in improving the health status of
individuals, their impact on maintaining and improving health and
on reducing the unnecessary consumption of health care services and
their impact on the affordability of health care coverage.
§33-15D-8. Disclaimer.
Each individual plan issued pursuant to this article shall
include the following disclaimer printed in boldface type and
located in a prominent portion of each policy, subscriber contract
and certificate of coverage: "THIS LIMITED INDIVIDUAL HEALTH
BENEFITS PLAN DOES NOT PROVIDE COMPREHENSIVE MEDICAL COVERAGE. IT
IS A BASIC OR LIMITED BENEFITS POLICY AND CONTAINS SPECIFIC DOLLAR
LIMITS THAT WILL BE PAID FOR MEDICAL SERVICES WHICH MAY NOT BE
EXCEEDED. IF THE COST OF SERVICES EXCEEDS THOSE LIMITS, THE
BENEFICIARY AND NOT THE INSURER IS RESPONSIBLE FOR PAYMENT OF THE
EXCESS AMOUNTS".
§33-15D-9. Exemption from premium taxes.
Products authorized under this article are exempt from the
premium taxes and surcharges assessed under article three of this
chapter.
§33-15D-10. Severability; controlling provisions.
(a) If any provision of this act or the application thereof to any person or circumstance is for any reason held to be invalid,
the remainder of the act and application of such provision to other
persons or circumstances shall not be affected thereby.
(b) To the extent that provisions of this article differ from
those contained elsewhere in this chapter, the provisions of this
article control.
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(NOTE: The purpose of this bill is to introduce flexibility
in the design of health insurance plans to allow insurers to offer
basic benefits, including preventive and primary care services, at
affordable prices.
This is a new article; therefore, underscoring and strike-
throughs have been omitted.)
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HEALTH AND HUMAN RESOURCES COMMITTEE AMENDMENTS
On page five, after section four, by inserting a new section,
designated section five, to read as follows:
§33-15D-5. Reimbursement rates for individual plans.
Insurers shall reimburse providers pursuant to reimbursement
rates previously negotiated with the providers.;
And,
By renumbering the remaining sections.
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BANKING AND INSURANCE COMMITTEE AMENDMENTS
On page two, by striking out the enacting section and
inserting in lieu thereof a new enacting section, to read as
follows:
That the Code of West Virginia, 1931, as amended, be amended
by adding thereto a new article, designated §33-15D-1, §33-15D-2,
§33-15D-3, §33-15D-4, §33-15D-5, §33-15D-6, §33-15D-7, §33-15D-8,
§33-15D-9, §33-15D-10 and §33-15D-11, all to read as follows:;
And,
On pages one and two, by striking out the title and substituting therefor a new title, to read as follows:
Eng. Senate Bill No. 162--A Bill
to amend the Code of West
Virginia, 1931, as amended, by adding thereto a new article,
designated §33-15D-1, §33-15D-2, §33-15D-3, §33-15D-4, §33-15D-5,
§33-15D-6, §33-15D-7, §33-15D-8, §33-15D-9, §33-15D-10 and §33-15D-
11, all relating to individual limited health benefits insurance
plans; including preventive and primary care services; declaring
legislative intent; requiring approval of plans by Insurance
Commissioner; providing eligibility requirements; setting forth
statutory or regulatory provisions that do not apply to such plans;
providing underwriting standards; continuing use of existing
reimbursement rates;
establishing criteria for filing and approval
of premium rates; requiring certification of creditable coverage;
authorizing Insurance Commissioner to promulgate emergency rules;
mandating disclaimer on policies; exempting plans from premium
taxes; providing for severability; and providing rule of
construction.
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