WEST virginia legislature

2020 regular session

Introduced

House Bill 4875

By Delegate  S. Brown

[Introduced February 11, 2020; Referred to the Committee on Banking and Insurance then the Judiciary]

A BILL to amend the Code of West Virginia, 1931, as amended, by adding thereto a new section, designated §5-16-7g; and to amend said code by adding thereto a new section, designated, §33-25A-8u, all relating to requiring certain insurance providers to enter into provider service agreements with a health care provider that meets certain criteria.

Be it enacted by the Legislature of West Virginia:

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.

§5-16-7g. Participation by any qualified, willing provider.

(a) The Public Employees Insurance Agency shall be ready and willing at all times to enter into care provider service agreements with all qualified providers of the category or categories which are necessary to provide the health care services covered by the Public Employees Insurance Agency if the health care providers: are qualified under the laws of this state, desire to become participant providers of the Public Employees Insurance Agency, meet the requirements of the Public Employees Insurance Agency, and practice within the general area served by the Public Employees Insurance Agency.

(b) Nothing in this section precludes the Public Employees Insurance Agency from refusing to contract with a provider who is unqualified or who does not meet the terms and conditions of the Public Employees Insurance Agency’s participating provider contract or from terminating or refusing to renew the contract of a health care provider who is unqualified or who does not comply with, or who refuses to comply with, the terms and conditions of the participating provider contract including, but not limited to, practice standards and quality requirements. The contract shall provide for written notice to the participating health care provider setting forth any breach of contract for which the Public Employees Insurance Agency proposes that the contract be terminated or not renewed and shall provide for a reasonable period of time for the participating health care provider to cure such breach prior to termination or nonrenewal. If the breach has not been cured within such period of time the contract may be terminated or not renewed. However, if the breach of contract for which the Public Employees Insurance Agency proposes that the contract be terminated or not renewed is a willful breach, fraud or a breach which poses an immediate danger to the public health or safety, the contract may be terminated or not renewed immediately.

(c) The Public Employees Insurance Agency shall establish a grievance system for providers.

(d)  The provisions of the section apply to provider participation contracts entered into after July 1, 2020.

chapter33.  insurance.

ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.

§33-25A-8u. Participation by any qualified, willing provider.

(a) A managed care organization, providing coverage to Medicaid recipients, shall be ready and willing at all times to enter into care provider service agreements with all qualified providers of the category or categories which are necessary to provide the health care services covered by an organization if the health care providers are qualified under the laws of this state, desire to become participant providers of the organization, meet the requirements of the organization, and practice within the general area served by the organization.

(b) Nothing in this section precludes an organization from refusing to contract with a provider who is unqualified or who does not meet the terms and conditions of the organization’s participating provider contract or from terminating or refusing to renew the contract of a health care provider who is unqualified or who does not comply with, or who refuses to comply with, the terms and conditions of the participating provider contract including, but not limited to, practice standards and quality requirements. The contract shall provide for written notice to the participating health care provider setting forth any breach of contract for which the organization proposes that the contract be terminated or not renewed and shall provide for a reasonable period of time for the participating health care provider to cure such breach prior to termination or nonrenewal. If the breach has not been cured within such period of time the contract may be terminated or not renewed. However, if the breach of contract for which the organization proposes that the contract be terminated or not renewed is a willful breach, fraud or a breach which poses an immediate danger to the public health or safety, the contract may be terminated or not renewed immediately.

(c) A managed care organization issuing benefits pursuant to this article shall establish a grievance system for providers.

(d) The provisions of the section apply to provider participation contracts entered into after January 1, 2021.

NOTE: The purpose of this bill is to require certain insurance providers to enter into provider service agreements with a health care provider that meets certain criteria.

Strike-throughs indicate language that would be stricken from a heading or the present law and underscoring indicates new language that would be added.