COMMITTEE SUBSTITUTE
FOR
COMMITTEE SUBSTITUTE
FOR
Senate Bill No. 164
(By Senators Tomblin, Mr. President, and Sprouse,
By Request of the Executive)
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[Originating in the Committee on Banking and Insurance;
reported January 25, 2006.]
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A BILL to amend the Code of West Virginia, 1931, as amended, by
adding thereto a new article, designated §16-2J-1, §16-2J-2,
§16-2J-3, §16-2J-4, §16-2J-5, §16-2J-6, §16-2J-7, §16-2J-8 and
§16-2J-9, all relating to a pilot program authorizing
participating health care clinics and private medical
practitioners to provide primary and preventive health
services for a prepaid fee; declaring legislative intent;
authorizing approval of participants based on guidelines by
the Health Care Authority and the Insurance Commissioner;
requiring licensure by the Health Care Authority; authorizing
the Insurance Commissioner to approve fees, marketing
materials and forms and to certify financial soundness;
authorizing study of the program by the Health Care Authority;
providing for legislative rules; mandating a Health Care Authority report to the Legislative Oversight Commission on
Health and Human Resources Accountability; setting grounds for
revocation, suspension and failure to renew licenses; and
creating penalties.
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 §16-2J-1, §16-2J-2,
§16-2J-3, §16-2J-4, §16-2J-5, §16-2J-6, §16-2J-7, §16-2J-8 and §16-
2J-9, all to read as follows:
ARTICLE 2J. PREVENTIVE CARE PILOT PROGRAM.
§16-2J-1. Legislative findings and statement of purpose.
(a) The Legislature finds that a program that would allow
health clinics and private medical practitioners
to provide primary
and preventive health services for a prepaid fee would enable more
West Virginians to gain access to affordable health care and to
establish a medical home for purposes of receiving primary and
preventive health care services. By establishing a pilot project
for clinic based health care, the Legislature intends to enable
state health and insurance officials to study this method of
delivering health services, to encourage all West Virginians to
establish a medical home and to determine the success, continued
need and feasibility of expanding such a program and allowing
similar programs to operate on a statewide basis.
(b) In carrying out this pilot program, it is the intent of
the Legislature
to eliminate legal, statutory and regulatory
barriers to the establishment of pilot programs providing preventive and primary care services for a prepaid fee; to
encourage residents of this state to establish and use a medical
home; to expand preventive and primary care services for the
uninsured; and to exempt health providers participating in the
pilot program from regulation as an insurer, the operation of
insurance laws of the state and all other laws inconsistent with
the purposes of this article.
§16-2J-2. Definitions.
For the purposes of this article, the following definitions
apply:
(1) "Dependent" has the same meaning set forth in subsection
(d), section one-a, article sixteen, chapter thirty-three of this
code;
(2) "Family" means an subscriber and his or her dependents;
(3) "Medical home" means a clinic, hospital or other health
care facility where a patient has an established relationship, has
his or her routine medical care or treatment and where his or her
medical records are maintained.
(4) "Participating provider" means a provider under this
article that has been granted a license under this article to
operate as part of the pilot program;
(5) "Primary care" means basic or general health care which
emphasizes the point when the patient first seeks assistance from
the medical care system and the care of the simpler and more common
illnesses;
(6)"Provider" has the same meaning as "ambulatory health care facility" set forth in subsection (b), section two, article two-d
of this chapter or "private office practice" as set forth in
subdivision (1), subsection (a), section four of said article;
(7)"Qualifying event" means loss of coverage due to: (i)
Emancipation and resultant loss of coverage under a parent 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:
Provided, That any rights
of coverage under a COBRA continuation plan as that term is defined
in section three-m, article sixteen, chapter thirty-three of this
code shall not be considered coverage under an employer group
health plan; (iv) involuntary termination of coverage under a group
health benefit plan except for termination due to nonpayment of
premiums or fraud by the insured; or (v) exhaustion of COBRA
benefits; and
(8) "Subscriber" means any individual who subscribes to a
prepaid program approved and operated in accordance with the
provisions of this article, including an employee of any employer
that has purchased a group enrollment on behalf of its employees.
§16-2J-3. Authorization of preventive care pilot program; number
of participants and sites; Health Care Authority
considerations in selection of participating providers;
funding.
(a) The Health Care Authority shall, in consultation with the
Insurance Commissioner, develop and implement during the fiscal
year beginning the first day of July, two thousand six, a pilot
program that permits no more than eight providers to market and sell prepaid memberships entitling subscribers to obtain preventive
and primary health care from the participating providers.
Participating providers shall not be allowed to offer their
qualifying services at more than three separate sites. The pilot
program will be three years in length.
(b) Subject to the provisions of this article, the Health Care
Authority is vested with discretion to select providers using
diversity in practice organization, geographical diversity and
other criteria it deems appropriate. The Health Care Authority also
shall give consideration to providers located in rural
areas or
serving a high percentage or large
numbers of uninsured.
© In furtherance of the objectives of this article, the Health
Care Authority is authorized to accept any and all gifts, grants
and matching funds whether in the form of money or services:
Provided, That no gifts, grants and matching funds shall be
provided to the Health Care Authority by the State of West Virginia
to further the objectives of this article.
§16-2J-4. License for preventive care pilot program.
(a) No provider may participate in the pilot program without
first obtaining a preventive care pilot program license from the
Health Care Authority.
(b) The Health Care Authority shall determine the eligibility
of providers to obtain licenses on the basis of applications filed
by providers on forms developed by the Health Care Authority.
© Upon approval of the application, the participating provider
shall be granted a license to market and sell prepaid health
services under such terms as may be established in guidelines developed by the Health Care Authority or the Insurance
Commissioner.
§16-2J-5.
Insurance Commissioner approval of fees, marketing
materials and forms and certification of financial condition;
statement of services.
(a) The Insurance Commissioner shall develop guidelines for
all forms, marketing materials and fees proposed by program
applicants and participating providers under the same criteria
generally applicable to accident and sickness insurance policies.
(b) All fees, marketing materials and forms proposed to be
used by any program applicant or participating provider are subject
to prior approval of the Insurance Commissioner, which the
Insurance Commissioner shall communicate to the Health Care
Authority. Fees may not be excessive, inadequate or unfairly
discriminatory.
© The Insurance Commissioner must certify whether a program
applicant or, upon the request of the Health Care Authority, an
already participating provider is in a sound financial condition
and capable of operating in a manner that is not hazardous to its
prospective subscribers or the people of West Virginia.
(d) Every subscriber is entitled to evidence of program
membership that shall contain a clear, concise and complete
statement of the services provided by the participating provider
and the benefits, if any, to which the subscriber is entitled; any
exclusions or limitations on the service, kind of service,
benefits, or kind of benefits, to be provided, including any
copayments; and where and in what manner information is available as to how a service may be obtained.
(e) Fees paid to participating providers are not subject to
premium taxes and surcharges imposed on insurance companies.
(f) Notwithstanding the provisions of chapter thirty-three of
this code to the contrary, participation by providers in the
preventive care clinic-based pilot program created and authorized
pursuant to this article is not to be considered as providing
insurance or as offering insurance services. Such providers and
services are specifically excluded from the definitions of
"insurer" and "insurance" as defined in article one, chapter
thirty-three of this code and are not subject to regulation by the
Insurance Commissioner except to the extent set forth in this
article, nor are participating providers unauthorized insurers
pursuant to section four, article forty-four, chapter thirty-three
of this code.
§16-2J-6. Rule-making authority.
The Health Care Authority and the Insurance Commissioner shall
promulgate rules as necessary to implement the provisions of this
article, including emergency rules promulgated pursuant to chapter
twenty-nine-a of this code.
§16-2J-7. Participating provider plan requirements: primary care
services; prior coverage restrictions; notice of
discontinuance or reduction of benefits.
In addition to the provisions of this article and any
guidelines established by the Health Care Authority and Insurance
Commissioner, the plans offered pursuant to this article shall be
subject to the following:
(1) Each participating provider and site must offer a minimum
set of preventive and primary care services as established by the
Health Care Authority.
(2) No participating provider may offer: (i) An individual
plan to any individual who currently has a health benefit plan or
who was covered by a health benefit plan within the preceding
twelve months unless said coverage was lost due to a qualifying
event; (ii) a family plan to any family that includes an adult to
be covered who currently has a health benefit plan or who was
covered by a health benefit plan within the preceding twelve months
unless said coverage was lost due to a qualifying event;
or (iii)
an employee group plan to any employer that currently has a group
health benefit plan or had a group health benefit plan covering its
employees within the preceding twelve months.
(3) The Health Care Authority and the Insurance Commissioner
may, by legislative rule, permit participation by an employer with
a comprehensive high deductible plan if such employer is able to
demonstrate that such participation will not negatively impact the
coverage currently offered by such employer.
(4) A participating provider must provide subscribers and,
where applicable, subscribers' employers with a minimum of thirty
days' notice of discontinuance or reduction of subscriber benefits.
§16-2J-8.
Guidelines for evaluation of the pilot program; report
to Legislative Oversight Commission on Health and Human
Resources Accountability.
(a) The Health Care Authority shall establish by guidelines
criteria to evaluate the pilot program and may require participating providers to submit such data and other information
related to the pilot program as may be required by the
Health Care
Authority.
(b) No later than the first day of December, two thousand
seven, and annually thereafter during the operation of the pilot
program, the Health Care Authority must submit a report to the
Legislative Oversight Commission of Health and Human Resources
Accountability as established in article twenty-nine-e of this
chapter on progress made by the pilot project including suggested
legislation, necessary changes to the pilot program and suggested
expansion of the pilot program.
§16-2J-9. Grounds for refusal to renew; revocation and suspension
of pilot program license; penalties; termination of
suspension, reissuance and renewal of license.
(a) The Health Care Authority may, after notice and hearing,
refuse to renew, or may revoke or suspend, the license of a
participating provider, in addition to other grounds therefor in
this
article, if the participating provider:
(1) Violates any provision of this article;
(2) Fails to comply with any lawful rule or order of the
Health Care Authority;
(3) Is operating in an illegal, improper or unjust manner;
(4) Is found by the Insurance Commissioner to be in an unsound
condition or in such condition as to render its further operation
in West Virginia hazardous to its subscribers or to the people of
West Virginia;
(5) Compels subscribers under its contract to accept less service than due them or to bring suit against it to secure full
service when it has no substantial defense;
(6) Refuses to be examined or to produce its accounts, records
and files for examination by the Insurance Commissioner when
requested to do so pursuant to section five of this article;
(7) Fails to pay any final judgment rendered against it in
West Virginia within thirty days after the judgment became final or
time for appeal expired, whichever is later;
(8) Fails to pay when due to the State of West Virginia any
taxes, fees, charges or penalties.
(b) In addition to or in lieu of refusing to renew, revoking
or suspending the license of a participating provider in any case,
the Health Care Authority may, by order, require the participating
provider to pay to the State of West Virginia a penalty in a sum
not exceeding five thousand dollars for each violation. Upon the
failure of the provider to pay such penalty within thirty days
after notice thereof, the Health Care Authority shall revoke or
suspend the license of such participating provider.
© When any license has been revoked or suspended or renewal
thereof refused, the Health Care Authority may reissue, terminate
the suspension of or renew such license when it is determined that
the conditions causing such revocation, suspension or refusal to
renew have ceased to exist and are unlikely to recur.
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(NOTE: The purpose of this bill is to establish a pilot
program overseen by the health care authority authorizing
participating health care providers and private medical
practitioners to provide primary and preventive health services to
subscribers for a prepaid fee.
This is a new article; therefore, underscoring and strike-
throughs have been omitted.
)