HB4543 Shott AM #1 3-7
Reese 3133
Delegate Shott moves to amend the bill by striking out everything after the enacting clause and inserting in lieu thereof the following:
CHAPTER 5. GENERAL POWERS AND AUTHORITY OF THE GOVERNOR, SECRETARY OF STATE, AND ATTORNEY GENERAL; BOARD OF PUBLIC WORKS; MISCELLANEOUS AGENCIES, COMMISSIONS, OFFICES, PROGRAMS, ETC.
ARTICLE 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.
§5-16-7.
Authorization to establish group hospital and surgical insurance plan, group
major medical insurance plan, group prescription drug plan, and group life and
accidental death insurance plan; rules for administration of plans; mandated
benefits; what plans may provide; optional plans; separate rating for claims
experience purposes.
(a) The agency shall establish a group hospital and surgical
insurance plan or plans, a group prescription drug insurance plan or plans, a
group major medical insurance plan or plans, and a group life and accidental
death insurance plan or plans for those employees herein made eligible, and
establish and promulgate rules for the administration of these plans subject to
the limitations contained in this article. These plans shall include:
(1) Coverages and benefits for x-ray and laboratory services in
connection with mammograms when medically appropriate and consistent with
current guidelines from the United States Preventive Services Task Force; pap
smears, either conventional or liquid-based cytology, whichever is medically
appropriate and consistent with the current guidelines from either the United
States Preventive Services Task Force or The American College of Obstetricians
and Gynecologists; and a test for the human papilloma virus (HPV) when
medically appropriate and consistent with current guidelines from either the
United States Preventive Services Task Force or the American College of
Obstetricians and Gynecologists, when performed for cancer screening or
diagnostic services on a woman age 18 or over;
(2) Annual checkups for prostate cancer in men age 50 and over;
(3) Annual screening for kidney disease as determined to be
medically necessary by a physician using any combination of blood pressure
testing, urine albumin or urine protein testing, and serum creatinine testing
as recommended by the National Kidney Foundation;
(4) For plans that include maternity benefits, coverage for
inpatient care in a duly licensed healthcare facility for a mother and her
newly born infant for the length of time which the attending physician
considers medically necessary for the mother or her newly born child. No plan
may deny payment for a mother or her newborn child prior to 48 hours following
a vaginal delivery or prior to 96 hours following a caesarean section delivery
if the attending physician considers discharge medically inappropriate;
(5) For plans which provide coverages for post-delivery care to a
mother and her newly born child in the home, coverage for inpatient care
following childbirth as provided in §5-16-7(a)(4) of this code if inpatient
care is determined to be medically necessary by the attending physician. These
plans may include, among other things, medicines, medical equipment, prosthetic
appliances, and any other inpatient and outpatient services and expenses
considered appropriate and desirable by the agency; and
(6) Coverage for treatment of serious mental illness:
(A) The coverage does not include custodial care, residential
care, or schooling. For purposes of this section, “serious mental illness”
means an illness included in the American Psychiatric Association’s diagnostic
and statistical manual of mental disorders, as periodically revised, under the
diagnostic categories or subclassifications of: (i) Schizophrenia and other
psychotic disorders; (ii) bipolar disorders; (iii) depressive disorders; (iv)
substance-related disorders with the exception of caffeine-related disorders
and nicotine-related disorders; (v) anxiety disorders; and (vi) anorexia and
bulimia. With regard to a covered individual who has not yet attained the age
of 19 years, “serious mental illness” also includes attention deficit
hyperactivity disorder, separation anxiety disorder, and conduct disorder.
(B) Notwithstanding any other provision in this section to the
contrary, if the agency demonstrates that its total costs for the treatment of
mental illness for any plan exceeds two percent of the total costs for such
plan in any experience period, then the agency may apply whatever additional
cost-containment measures may be necessary in order to maintain costs below two
percent of the total costs for the plan for the next experience period. These
measures may include, but are not limited to, limitations on inpatient and
outpatient benefits.
(C) The agency shall not discriminate between medical-surgical
benefits and mental health benefits in the administration of its plan. With
regard to both medical-surgical and mental health benefits, it may make
determinations of medical necessity and appropriateness and it may use
recognized healthcare quality and cost management tools, including, but not
limited to, limitations on inpatient and outpatient benefits, utilization
review, implementation of cost-containment measures, preauthorization for
certain treatments, setting coverage levels, setting maximum number of visits
within certain time periods, using capitated benefit arrangements, using
fee-for-service arrangements, using third-party administrators, using provider
networks, and using patient cost-sharing in the form of copayments,
deductibles, and coinsurance.
(7) Coverage for general anesthesia for dental procedures and
associated outpatient hospital or ambulatory facility charges provided by
appropriately licensed health care individuals in conjunction with dental care
if the covered person is:
(A) Seven years of age or younger or is developmentally disabled
and is an individual for whom a successful result cannot be expected from
dental care provided under local anesthesia because of a physical, intellectual,
or other medically compromising condition of the individual and for whom a
superior result can be expected from dental care provided under general
anesthesia.
(B) A child who is 12 years of age or younger with documented
phobias or with documented mental illness and with dental needs of such
magnitude that treatment should not be delayed or deferred and for whom lack of
treatment can be expected to result in infection, loss of teeth, or other
increased oral or dental morbidity and for whom a successful result cannot be
expected from dental care provided under local anesthesia because of such
condition and for whom a superior result can be expected from dental care
provided under general anesthesia.
(8) (A) Any plan issued or renewed on or after January 1, 2012,
shall include coverage for diagnosis, evaluation, and treatment of autism
spectrum disorder in individuals ages 18 months to 18 years. To be eligible for
coverage and benefits under this subdivision, the individual must be diagnosed
with autism spectrum disorder at age eight or younger. Such plan shall provide
coverage for treatments that are medically necessary and ordered or prescribed
by a licensed physician or licensed psychologist and in accordance with a
treatment plan developed from a comprehensive evaluation by a certified
behavior analyst for an individual diagnosed with autism spectrum disorder.
(B) The coverage shall include, but not be limited to, applied
behavior analysis which shall be provided or supervised by a certified behavior
analyst. The annual maximum benefit for applied behavior analysis required by
this subdivision shall be in an amount not to exceed $30,000 per individual for
three consecutive years from the date treatment commences. At the conclusion of
the third year, coverage for applied behavior analysis required by this
subdivision shall be in an amount not to exceed $2,000 per month, until the
individual reaches 18 years of age, as long as the treatment is medically
necessary and in accordance with a treatment plan developed by a certified
behavior analyst pursuant to a comprehensive evaluation or reevaluation of the
individual. This subdivision does not limit, replace, or affect any obligation
to provide services to an individual under the Individuals with Disabilities
Education Act, 20 U. S. C. §1400 et seq. as amended from time to time or
other publicly funded programs. Nothing in this subdivision requires
reimbursement for services provided by public school personnel.
(C) The certified behavior analyst shall file progress reports
with the agency semiannually. In order for treatment to continue, the agency
must receive objective evidence or a clinically supportable statement of
expectation that:
(i) The individual’s condition is improving in response to
treatment;
(ii) A maximum improvement is yet to be attained; and
(iii) There is an expectation that the anticipated improvement is
attainable in a reasonable and generally predictable period of time.
(D) On or before January 1 each year, the agency shall file an
annual report with the Joint Committee on Government and Finance describing its
implementation of the coverage provided pursuant to this subdivision. The
report shall include, but not be limited to, the number of individuals in the
plan utilizing the coverage required by this subdivision, the fiscal and
administrative impact of the implementation, and any recommendations the agency
may have as to changes in law or policy related to the coverage provided under
this subdivision. In addition, the agency shall provide such other information
as required by the Joint Committee on Government and Finance as it may request.
(E) For purposes of this subdivision, the term:
(i) “Applied behavior analysis” means the design, implementation,
and evaluation of environmental modifications using behavioral stimuli and
consequences in order to produce socially significant improvement in human
behavior and includes the use of direct observation, measurement, and
functional analysis of the relationship between environment and behavior.
(ii) “Autism spectrum disorder” means any pervasive developmental
disorder, including autistic disorder, Asperger’s Syndrome, Rett Syndrome,
childhood disintegrative disorder, or Pervasive Development Disorder as defined
in the most recent edition of the Diagnostic and Statistical Manual of Mental
Disorders of the American Psychiatric Association.
(iii) “Certified behavior analyst” means an individual who is
certified by the Behavior Analyst Certification Board or certified by a similar
nationally recognized organization.
(iv) “Objective evidence” means standardized patient assessment
instruments, outcome measurements tools, or measurable assessments of
functional outcome. Use of objective measures at the beginning of treatment,
during, and after treatment is recommended to quantify progress and support
justifications for continued treatment. The tools are not required but their
use will enhance the justification for continued treatment.
(F) To the extent that the application of this subdivision for
autism spectrum disorder causes an increase of at least one percent of actual
total costs of coverage for the plan year, the agency may apply additional cost
containment measures.
(G) To the extent that the provisions of this subdivision require
benefits that exceed the essential health benefits specified under section
1302(b) of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148,
as amended, the specific benefits that exceed the specified essential health
benefits shall not be required of insurance plans offered by the Public
Employees Insurance Agency.
(9) For plans that include maternity benefits, coverage for the
same maternity benefits for all individuals participating in or receiving
coverage under plans that are issued or renewed on or after January 1, 2014: Provided,
That to the extent that the provisions of this subdivision require benefits
that exceed the essential health benefits specified under section 1302(b) of
the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, as
amended, the specific benefits that exceed the specified essential health
benefits shall not be required of a health benefit plan when the plan is
offered in this state.
(10) (A) A policy, plan, or contract that is issued or renewed on
or after January 1, 2019, and that is subject to this section, shall provide
coverage, through the age of 20, for amino acid-based formula for the treatment
of severe protein-allergic conditions or impaired absorption of nutrients caused
by disorders affecting the absorptive surface, function, length, and motility
of the gastrointestinal tract. This includes the following conditions, if
diagnosed as related to the disorder by a physician licensed to practice in
this state pursuant to either §30-3-1 et seq. or §30-14-1 et seq.
of this code:
(i) Immunoglobulin E and Non-immunoglobulin E-medicated allergies
to multiple food proteins;
(ii) Severe food protein-induced enterocolitis syndrome;
(iii) Eosinophilic disorders as evidenced by the results of a
biopsy; and
(iv) Impaired absorption of nutrients caused by disorders
affecting the absorptive surface, function, length, and motility of the
gastrointestinal tract (short bowel).
(B) The coverage required by §5-16-7(a)(10)(A) of this code shall
include medical foods for home use for which a physician has issued a
prescription and has declared them to be medically necessary, regardless of
methodology of delivery.
(C) For purposes of this subdivision, “medically necessary foods”
or “medical foods” shall mean prescription amino acid-based elemental formulas
obtained through a pharmacy: Provided, That these foods are specifically
designated and manufactured for the treatment of severe allergic conditions or
short bowel.
(D) The provisions of this subdivision shall not apply to persons
with an intolerance for lactose or soy.
(A) For the purposes of this subdivision, “prescription insulin
drug” means a prescription drug that contains insulin and is used to treat
diabetes, and includes at least one type of insulin in all of the following categories:
(1) Rapid-acting;
(2) Short-acting;
(3) Intermediate-acting;
(4) Long-acting;
(5) Pre-mixed insulin products;
(6) Pre-mixed insulin/GLP-1 RA products; and
(7) Concentrated human regular insulin.
(B) Cost sharing for a 30-day supply of a covered prescription
insulin drug shall not exceed $100 for a 30-day supply of a covered
prescription insulin, regardless of the quantity or type of prescription
insulin used to fill the covered person’s prescription needs.
(C) Nothing in this section prevents the agency from reducing a
covered person’s cost sharing by an amount greater than the amount specified in
this subsection.
(D) No contract between the agency or its pharmacy benefits
manager and a pharmacy or its contracting agent shall contain a provision (i)
authorizing the agency’s pharmacy benefits manager or the pharmacy to charge,
(ii) requiring the pharmacy to collect, or (iii) requiring a covered person to
make a cost-sharing payment for a covered prescription insulin drug in an
amount that exceeds the amount of the cost-sharing payment for the covered
prescription insulin drug established by the agency as provided in
§5-16-7(a)(11)(B) of this code.
(E) The agency shall provide coverage for the following equipment
and supplies for the treatment or management of diabetes for both insulin-dependent
and noninsulin-dependent persons with diabetes and those with gestational
diabetes: Blood glucose monitors, monitor supplies, insulin, injection aids,
syringes, insulin infusion devices, pharmacological agents for controlling
blood sugar, and orthotics.
(F) The agency shall provide coverage for diabetes self-management
education to ensure that persons with diabetes are educated as to the proper
self-management and treatment of their diabetes, including information on
proper diets. Coverage for self-management education and education relating to
diet shall be provided by a health care practitioner who has been
appropriately trained as provided in §33-53-1(k) of this code.
(G) The education may be provided by a health care practitioner as
part of an office visit for diabetes diagnosis or treatment, or by a licensed
pharmacist for instructing and monitoring a patient regarding the proper use of
covered equipment, supplies, and medications, or by a certified diabetes
educator or registered dietitian.
(H) A pharmacy benefits manager, a health plan, or any other third
party that reimburses a pharmacy for drugs or services shall not reimburse a
pharmacy at a lower rate and shall not assess any fee, charge-back, or
adjustment upon a pharmacy on the basis that a covered person’s costs sharing
is being impacted.
(b) The agency shall, with full authorization, make available to
each eligible employee, at full cost to the employee, the opportunity to
purchase optional group life and accidental death insurance as established
under the rules of the agency. In addition, each employee is entitled to have
his or her spouse and dependents, as defined by the rules of the agency,
included in the optional coverage, at full cost to the employee, for each eligible
dependent.
(c) The finance board may cause to be separately rated for claims
experience purposes:
(1) All employees of the State of West Virginia;
(2) All teaching and professional employees of state public
institutions of higher education and county boards of education;
(3) All nonteaching employees of the Higher Education Policy
Commission, West Virginia Council for Community and Technical College Education,
and county boards of education; or
(4) Any other categorization which would ensure the stability of
the overall program.
(d) The agency shall maintain the medical and prescription drug
coverage for Medicare- eligible retirees by providing coverage through one of
the existing plans or by enrolling the Medicare-eligible retired employees into
a Medicare-specific plan, including, but not limited to, the Medicare/Advantage
Prescription Drug Plan. If a Medicare-specific plan is no longer available or
advantageous for the agency and the retirees, the retirees remain eligible for
coverage through the agency.
5-16-7F Coverage for prescription insulin drugs
(a) A policy, plan, or contract that is issued or renewed on or after July 1, 2020, shall provide coverage for prescription insulin drugs pursuant to this section.
(I) For the purposes of this subdivision, “prescription insulin drug” means a prescription drug that contains insulin and is used to treat diabetes, and includes at least one type of insulin in all of the following categories:
(A) Rapid-acting;
(B) Short-acting;
(C) Intermediate-acting;
(D) Long-acting;
(E) Pre-mixed insulin products;
(F) Pre-mixed insulin/GLP-1 RA products; and
(G) Concentrated human regular insulin.
(b) Cost sharing for a 30-day supply of a covered prescription insulin drug shall not exceed $100 for a 30-day supply of a covered prescription insulin, regardless of the quantity or type of prescription insulin used to fill the covered person’s prescription needs.
(c) Nothing in this section prevents the agency from reducing a covered person’s cost sharing by an amount greater than the amount specified in this subsection.
(d) No contract between the agency or its pharmacy benefits manager and a pharmacy or its contracting agent shall contain a provision (i) authorizing the agency’s pharmacy benefits manager or the pharmacy to charge, (ii) requiring the pharmacy to collect, or (iii) requiring a covered person to make a cost-sharing payment for a covered prescription insulin drug in an amount that exceeds the amount of the cost-sharing payment for the covered prescription insulin drug established by the agency as provided in §5-16-7(a)(11)(B) of this code.
(e) The agency shall provide coverage for the following equipment and supplies for the treatment or management of diabetes for both insulin-dependent and noninsulin-dependent persons with diabetes and those with gestational diabetes: Blood glucose monitors, monitor supplies, insulin, injection aids, syringes, insulin infusion devices, pharmacological agents for controlling blood sugar, and orthotics.
(f) The agency shall provide coverage for diabetes self-management education to ensure that persons with diabetes are educated as to the proper self-management and treatment of their diabetes, including information on proper diets. Coverage for self-management education and education relating to diet shall be provided by a health care practitioner who has been appropriately trained as provided in §33-53-1(k) of this code.
(g) The education may be provided by a health care practitioner as part of an office visit for diabetes diagnosis or treatment, or by a licensed pharmacist for instructing and monitoring a patient regarding the proper use of covered equipment, supplies, and medications, or by a certified diabetes educator or registered dietitian.
(h) A pharmacy benefits manager, a health plan, or any other third party that reimburses a pharmacy for drugs or services shall not reimburse a pharmacy at a lower rate and shall not assess any fee, charge-back, or adjustment upon a pharmacy on the basis that a covered person’s costs sharing is being impacted.
CHAPTER 33. INSURANCE.
ARTICLE 15C. DIABETES INSURANCE.
§33-15C-1. Insurance for diabetics.
[Repealed.]
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-16. Insurance for diabetics.
[Repealed.]
ARTICLE 53. Required coverage for Health INSURANCE.
§33-53-1. Cost sharing in prescription insulin drugs.
(a) Findings. –
(1) It is estimated that over 240,000 West Virginians are diagnosed and living with type 1 or type 2 diabetes and another 65,000 are undiagnosed;
(2) Every West Virginian with type 1 diabetes and many with type 2 diabetes rely on daily doses of insulin to survive;
(3) The annual medical cost related to diabetes in West Virginia is estimated at $2.5 billion annually;
(4) Persons diagnosed with diabetes will incur medical costs approximately 2.3 times higher than persons without diabetes;
(5) The cost of insulin has increased astronomically, especially the cost of insurance copayments, which can exceed $600 per month. Similar increases in the cost of diabetic equipment and supplies, and insurance premiums have resulted in out-of-pocket costs for many West Virginia diabetics in excess of $1,000 per month;
(6) National reports indicate as many as one in four type 1 diabetics underuse, or ration, insulin due to these increased costs. Rationing insulin has resulted in nerve damage, diabetic comas, amputation, kidney damage, and even death; and
(7) It is important to enact policies to reduce the costs for West Virginians with diabetes to obtain life-saving and life-sustaining insulin.
(b) As used in this section:
(1) “Cost-sharing payment” means the total amount a covered person is required to pay at the point of sale in order to receive a prescription drug that is covered under the covered person’s health plan.
(2) “Covered person” means a policyholder, subscriber, participant, or other individual covered by a health plan.
(3) “Health plan” means any health benefit plan, as defined in §33-16-1a(h) of this code, that provides coverage for a prescription insulin drug.
(4) “Pharmacy benefits manager” means an entity that engages in the administration or management of prescription drug benefits provided by an insurer for the benefit of its covered persons.
(5) “Prescription insulin drug” means a prescription drug that contains insulin and is used to treat diabetes.
(c) Each health plan shall cover at least one type of insulin in all the following categories:
(1) Rapid-acting;
(2) Short-acting;
(3) Intermediate-acting;
(4) Long-acting;
(5) Pre-mixed insulin products;
(6) Pre-mixed insulin/GLP-1 RA products; and
(7) Concentrated human regular insulin.
(d) Notwithstanding the provisions of §33-1-1 et seq. of this code, an insurer subject to §33-15-1 et seq., §33-16-1 et seq., §33-24-1 et seq., §33-25-1 et seq., and §33-25A-1 et seq. of this code which issues or renews a health insurance policy on or after July 1, 2020, shall provide coverage for prescription insulin drugs pursuant to this section.
(e) Cost sharing for a 30-day supply of a covered prescription insulin drug shall not exceed $100 for a 30-day supply of a covered prescription insulin, regardless of the quantity or type of prescription insulin used to fill the covered person’s prescription needs.
(f) Nothing in this section prevents an insurer from reducing a covered person’s cost sharing to an amount less than the amount specified in subsection (e) of this section.
(g) No contract between an insurer subject to §33-15-1 et seq., §33-16-1 et seq., §33-24-1 et seq., §33-25-1 et seq., and §33-25A-1 of this code or its pharmacy benefits manager and a pharmacy or its contracting agent shall contain a provision: (i) Authorizing the insurer’s pharmacy benefits manager or the pharmacy to charge; (ii) requiring the pharmacy to collect; or (iii) requiring a covered person to make a cost-sharing payment for a covered prescription insulin drug in an amount that exceeds the amount of the cost-sharing payment for the covered prescription insulin drug established by the insurer pursuant to subsection (e) of this code.
(h) An insurer subject to §33-15-1 et seq., §33-16-1 et seq., §33-24-1 et seq., §33-25-1 et seq., and §33-25A-1 of this code shall provide coverage for the following equipment and supplies for the treatment and/or management of diabetes for both insulin-dependent and noninsulin-dependent persons with diabetes and those with gestational diabetes: Blood glucose monitors, monitor supplies, insulin, injection aids, syringes, insulin infusion devices, pharmacological agents for controlling blood sugar, and orthotics.
(i) An insurer subject to §33-15-1 et seq., §33-16-1 et seq., §33-24-1 et seq., §33-25-1 et seq., and §33-25A-1 of this code shall include coverage for diabetes self-management education to ensure that persons with diabetes are educated as to the proper self-management and treatment of their diabetes, including information on proper diets.
(j) All health care plans must offer an appeals process for persons who are not able to take one or more of the offered prescription insulin drugs noted in subsection (c) of this code. The appeals process shall be provided to covered persons in writing and afford covered persons and their health care providers a meaningful opportunity to participate with covered persons health care providers.
(k) Diabetes self-management education shall be provided by a health care practitioner who has been appropriately trained. The Secretary of the Department of Health and Human Resources shall promulgate legislative rules to implement training requirements and procedures necessary to fulfill provisions of this subsection: Provided, That any rules promulgated by the secretary shall be done after consultation with the Coalition for Diabetes Management, as established in §16-5Z-1 et seq. of this code.
(l) A pharmacy benefits manager, a health plan, or any other third party that reimburses a pharmacy for drugs or services shall not reimburse a pharmacy at a lower rate and shall not assess any fee, charge-back, or adjustment upon a pharmacy on the basis that a covered person’s costs sharing is being impacted.
Adopted
Rejected