WEST virginia legislature

2019 regular session

Introduced

House Bill 2770

By Delegate Rohrbach, Ellington, Barrett, Queen, Waxman, Byrd, Westfall and Nelson

[Introduced January 30, 2019; 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 article, designated §33-52-1, §33-52-2, §33-52-3, and §33-52-4, all relating to establishing the Fairness in Cost-Sharing Calculation Act; providing for definitions; establishing health plan cost sharing calculations; establishing pharmacy benefits cost sharing calculations; and providing for rule-making authority.

Be it enacted by the Legislature of West Virginia:

atricle 52. fairness in cost-sharing calculation act.

§33-52-1. Definitions.

As used in this article:

“Commissioner” meant the West Virginia Insurance Commissioner.

“Cost sharing” means any copayment, coinsurance, or deductible required by or on behalf of an insured in order to receive a specific health care item or service covered by a health plan.

“Health care services” means items or services furnished to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical or mental disability.

“Health plan” means any individual or group health care plan, subscription contract, evidence of coverage, certificate, health services plan, medical or hospital services plan as defined in §33-24-1 et seq, accident and sickness insurance policy or certificate, managed care health insurance plan, or health maintenance organization subject to state regulation pursuant to §33-25-1 et seq of this code, which is offered, arranged, issued, or administered in the state by an insurer authorized under this chapter, a third-party administrator or an intermediary. Health plan does not mean:

(A) Coverages issued pursuant to Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq, Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq, or Title XX of the Social Security Act, 42 U.S.C. §1397 et seq, 5 U.S.C. §8901 et seq, or 10 U.S.C. §1071 et seq; or §5-16-1 et seq of this code;

(B) Accident only, credit or disability insurance, long-term care insurance, TRICARE supplement, Medicare supplement, workers’ compensation coverages, or limited benefits policy as defined in §33-16E-1 et seq of this code; or

(C) Any third-party administrator or an intermediary acting on behalf of providers as denoted in subparagraphs (A) and (B).

“Insured” means a person who is provided health insurance coverage or other health care services coverage from an insurer under a health plan.

“Insurer” means any person required to be licensed under chapter 33 or this code, which offers or administers as a third-party administrator, health insurance; operates a health plan subject to this chapter; or provides or arranges for the provisions of health care services through networks or provider panels which are subject to regulation as the business of insurance under this chapter. “Insurer” also included intermediaries. “Insurer” does not include:

(A) Credit accident and sickness insurance;

(B) Accidence and sickness policies which provide benefits for loss of income due to disability;

(C) Any policy of liability of workers’ compensation insurance;

(D) Hospital indemnity or other fixed indemnity insurance;

(E) Life insurance, including endowment or annuity contracts, or contracts supplemental thereto, which contain on provisions relating to accident and sickens insurance that:

(i) Provide additional benefits in cases of death by accidental means; or

(ii) Operate to safeguard the contracts against lapse, in the event that the insured shall become totally and permanently disabled as defined by the contract or supplemental contract;

(F) Property and casualty insurance; and

(G) Any coverage issued pursuant to §5-16-1 et seq of this code.

“Person” means a natural person, corporation, mutual company, unincorporated association, partnership, joint venture, limited liability company, trust, estate, foundation, nonprofit corporation, unincorporated organization, or government or governmental subdivision or agency.

“Pharmacy benefits manager” means the performance of any of the following:

(A) The procurement of prescription drugs at a negotiated contracted rate for dispensation within this state insureds;

(B) The administration or management of prescription drug benefits provided by an insurer or health plan for the benefit of insureds;

(C) The administration of pharmacy benefits, including, but not limited to:

(i) Operating a mail-service pharmacy;

(ii) Claims processing;

(iii) Managing a retail pharmacy network;

(iv) Paying claims to a pharmacy for prescription drugs dispensed to insureds via retail or mail-order pharmacy;

(v) Developing and managing a clinical formulary including utilization management and quality assurance programs;

(vi) Rebate contracting administration; and

(vii) Managing a patient compliance, therapeutic intervention and generic substitution program.

“Pharmacy benefits manager” means a person business, or other entity that performs pharmacy benefits management for an insurer or health plan.

§33-52-2. Health plan cost sharing calculation.

When calculating an insured’s contribution to any applicable cost sharing requirement, including, but not limited to, the annual limitation on cost sharing subject to 42 U.S.C. §18022(c) and 42 U.S.C. § 300gg-6(b), an insurer shall include any cost sharing amounts paid by the insured or on behalf of the insured by another person.

§33-52-3. Pharmacy benefits manager cost sharing calculation.

When calculating an insured’s contribution to any applicable cost sharing requirement, including, but not limited to, the annual limitation on cost sharing subject to 42 U.S.C. §18022(c) and 42 U.S.C. § 300gg-6(b), a pharmacy benefits manger shall include any cost sharing amounts paid by the insured or on behalf of the insured by another person.

§33-52-4. Commissioner is authorized to propose rules.

The commissioner is authorized to propose rules for legislative approval in accordance with §29A-3-1 et seq of this code, to implement the provisions of this article.

NOTE: The purpose of this bill is to create the Fairness in Cost-Sharing Calculation Act by establishing cost sharing calculations for health plans and pharmacy benefits.

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