ENROLLED
COMMITTEE SUBSTITUTE
FOR
H. B. 4021
(By Delegates Mr. Speaker, Mr. Kiss, and Delegate Trump)
[By Request of the Executive]
[Passed March 11, 2006; in effect from passage.]
AN ACT to
amend the Code of West Virginia, 1931, as amended, by
adding thereto a new section, designated §5-16B-6d; to amend
and reenact §9-2-9 of said code; to amend said code 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; to amend said code by adding thereto a new article,
designated §16-29G-1, §16-29G-2, §16-29G-3, §16-29G-4, and
§16-29G-5; and to amend said code 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 health care programs,
authorizing an expansion of the children's health insurance
program; providing criteria for the expansion; providing
limitations based on funding availability; providing for a
Medicaid management reporting system
; providing for quarterly
financial reports from the Medicaid claims management system
to the Legislative Oversight Commission on Health and Human Resources Accountability; requiring specific utilization data
from the Medicaid claims management system; creating 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;
setting forth goals for health care reform; providing for an
Interagency Health Council; providing for membership on the
council; requiring council develop appropriate incentives,
initiatives and assessments; providing for council to evaluate
and recommend alternative reimbursement mechanisms; providing
for council to establish an advisory committee; providing for
council to measure and report on specific benchmarks;
providing for council to make recommendations to the
Legislative Oversight Commission on Health and Human Resources
Accountability regarding the strategies to be used to meet the
state's goals; requiring council to hold public hearings for the purpose of receiving relevant input; authorizing
individual limited health benefits insurance plans; including
preventive and primary care services; 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; providing rule of
construction; 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 section, designated §5-16B-6d; that §9-2-9
of said code be amended and reenacted; that said code 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; that said code be amended by adding thereto a new
article, designated §16-29G-1, §16-29G-2, §16-29G-3, §16-29G-4 and
§16-29G-5; and that said code 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:
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 16B. WEST VIRGINIA CHILDREN'S HEALTH INSURANCE PROGRAM.
§5-16B-6d. Modified benefit plan implementation.
(a) Upon approval by the Centers for Medicare and Medicaid
Services, the board shall implement a program for uninsured
children of families with income between two hundred and three
hundred percent of the federal poverty level.
(b) The benefit plans offered pursuant to this section shall
include services determined to be appropriate for children, but may
vary from those currently offered by the board.
(c) The board shall structure the benefit plans for this
expansion to include premiums, co-insurance or co-pays and
deductibles. The board shall develop the cost sharing features in
such a manner as to keep the program fiscally stable without
creating a barrier to enrollment. Such features may include
different cost-sharing features within this group based upon the
percentage of the federal poverty level.
(d) Children covered by an employer sponsored health insurance
plan during the previous twelve month period are not eligible for
coverage under this expansion, unless that coverage is lost due to
the parent's loss of employment.
(e) Provider reimbursement schedules shall be no lower than
the reimbursement provided for the same services under the plans
offered in article sixteen of this chapter.
(f) All provisions of this article are applicable to this
expansion unless expressly addressed in this section.
(g) Nothing in this section may be construed to require any
appropriation of state general revenue funds for the payment of any
benefit provided pursuant to this section, except for the state
appropriation used to match the federal financial participation
funds. In the event that federal funds are no longer authorized for
participation by individuals eligible at income levels above two
hundred percent, the board shall take immediate steps to terminate
the expansion provided for in this section and notify all enrollees
of such termination. In the event federal appropriations decrease
for the programs created pursuant to Title XXI of the Social
Security Act of 1997, the board is directed to make those decreases
in this expansion program before making changes to the programs
created for those children whose family income is less than two
hundred percent of the federal poverty level.
(h) The board is directed to report no less than quarterly to
the Legislative Oversight Commission on Health and Human Resources
Accountability on the development, implementation and progress of
the expansion authorized in this section.
CHAPTER 9. HUMAN SERVICES.
ARTICLE 2. COMMISSIONER OF HUMAN SERVICES; POWERS, DUTIES AND
RESPONSIBILITIES GENERALLY.
§9-2-9. Secretary to develop medicaid monitoring and case
management.
(a) The secretary of the department of health and human
resources shall:
(1) Develop a managed care system to monitor the services
provided by the medicaid program to individual clients;
(2) Develop an independent referral service, including the
review of individual cases for abuses of the program; and
(3) Develop a schedule for implementation of the managed care
and independent referral system. The managed care system shall
focus on, but not be limited to, the behavioral health and mental
health services.
(b) In addition thereto, and in accordance with applicable
federal medicaid laws, the secretary shall prepare recommendations,
to be submitted to the joint committee on government and finance.
In developing recommendations the secretary shall consider as
options the following:
(1) Review of medicaid services which are optional under
federal medicaid law and identification of services to be retained,
reduced or eliminated;
(2) The elimination, reduction or phase-out of: (i) Services
which are not generally available to West Virginia citizens not
covered under the state's medicaid program; or (ii) services which
are not generally covered under group policies of insurance made
available to employees of employers within the state;
(3) The elimination or reduction of services, or reduction of
provider reimbursement rates, for identified services of marginal
utility;
(4) Higher reimbursement rates for primary and preventive
care;
(5) Changes in fee structure, which may include a system of
prospective payments, and may include establishment of global fees
for identified services or diagnoses including maternity care;
(6) Utilization caps for certain health care procedures;
(7) Restriction of coverage for cosmetic procedures;
(8) Identification of excessive use of certain health care
procedures by individuals and a policy to restrict excessive use;
(9) Identification of services which reduce the need for more
costly options for necessary care and retention or expansion of
those programs;
(10) Identification of services for which preauthorization is
a requirement for medicaid reimbursement;
(11) Recommendations relating to the development of a
demonstration project on long-term care, which demonstration
project may be limited to patients with alzheimer's disease;
(12) A policy concerning the department's procedures for
compliance, monitoring and inspection; and
(13) Such other options as may be developed.
(c) The secretary shall utilize in-state health care
facilities for inpatient treatment when such facilities are
available. Prior authorization, consistent with applicable federal
law, shall be required for out-of-state inpatient treatment.
(d) The secretary shall report to the joint committee on
government and finance on the development and implementation of medicaid programs that provide incentives to working persons. The
secretary shall consider: Subsidies for low income working
persons; individual or small employer buy-ins to the state medicaid
fund; prospective payment systems for primary care physicians in
underserved areas; and a system to improve monitoring of
collections, expenditures, service delivery and utilization.
(e) The secretary shall report quarterly to the joint
committee on government and finance regarding provider and facility
compliance with federal and state medicaid laws, including, but not
limited to, the following: The number of inspections conducted
during the previous quarter; description of programs, services and
facilities reviewed; findings; and recommendations for corrections.
(f) The secretary shall, upon federal certification of the
claims management system, ensure that the claims management system
processing medicaid claims provides:
(1) Detailed quarterly financial reports to the Legislative
Oversight Commission on Health and Human Resources Accountability;
(2) A management reporting system no later than the first day
of July, two thousand six; and
(3) Specific utilization data by provider, member eligibility
groups and service no later than the first day of October, two
thousand six.
CHAPTER 16. PUBLIC HEALTH.
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
preventative healthcare 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 a subscriber and his or her dependents;
(3) "Medical home" means a team approach to providing health
care and care management. Whether involving a primary care
provider, specialist or sub-specialist, care management includes
the development of a plan of care, the determination of the
outcomes desired, facilitation and navigation of the health care
system, provision of follow-up and support for achieving the
identified outcomes. The medical home maintains a centralized,
comprehensive record of all health related services to provide
continuity of care.
(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
subsection (a)(1), 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.
(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.
(c) 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.
(c) 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 and 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.
(c) 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 of chapter thirty-
three of this code.
§16-2J-6. Rule-making authority.
The Health Care Authority and the Insurance Commissioner shall
promulgate joint 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:
Provided, That all personal income tax returns filed
pursuant to this article shall be treated as confidential pursuant
to the provisions of section five-d, article ten, chapter 11 of this code. For purposes of this article, this information shall be
exempt from disclosure under the freedom of information act in
article one, chapter twenty-nine-b of this code.
(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.
(c) 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
.
ARTICLE 29G. Interagency Health Council.
§16-29G-1. Purpose and scope.
The purpose of this article is to establish the standards and
criteria for evaluating the unmet health care needs within this state, to evaluate methods to meet those needs and to set forth
recommendations related to services provided and services needed,
access issues, and related financing proposals.
§16-29G-2. Legislative findings and goals.
(a) The Legislature finds that the general welfare and well-
being of the citizens of the state is greatly affected by their
health status. The Legislature further finds that many of the
citizens have unmet health care needs, which impairs their ability
to lead full and productive lives. The Legislature further finds
that the current health care system is sufficiently funded to meet
those needs, but is not currently structured to adequately and
uniformly meet the state-wide needs of the population. The
Legislature further finds that reforms to the health care delivery
system, including the reimbursement structure, may address the
inequities in access, the inequities in funding and result in a
modified system that meets the needs of the state and its citizens.
(b) In consideration of the need for health care reform, the
Legislature adopts the following goals:
(1) Access. West Virginia policy will reflect that access to
health care is a public good. West Virginia shall develop
strategies for having an integrated health care system that will
attempt to provide all West Virginians, regardless of their age,
employment, economic status, or their town of residency, access to
affordable, high quality health care that is financed in a fair and
equitable manner.
(A) In order to develop an integrated health care delivery
system, the state shall consider promoting local or regional collaborative efforts among provider groups that are designed to
use available resources in a more equitable and efficient fashion.
(B) To improve access to health care, the state shall consider
methods to expand benefits over time after meeting appropriate
benchmarks set forth in section four of this article. A process
will be developed to define the benefits, taking into consideration
scientific evidence, available funds and the values and priorities
of West Virginia citizens.
(2) It is of critical importance that health care costs are
brought under control. Likewise, it is essential that cost
containment initiatives address both the financing of health care
and the delivery and quality of health services offered in West
Virginia. To ensure financial sustainability of any proposed plan,
the state is committed to the extent possible to slow the rate of
growth of health care costs by the year two thousand ten.
Strategies for containing costs may include consideration of:
(A) A budgeting process for hospitals and other health care
providers as determined by the council established pursuant to this
article;
(B) Increased consumer access to health care price and quality
information;
(C) Promotion of self-care and healthy lifestyles;
(D) Enhanced prescription drug initiatives;
(E) Funding of chronic care initiatives;
(F) Investments in health information technology;
(G) Alignment of health care professional reimbursement with
best practices and outcomes rather than utilization; and
(H) Development of a long-term strategy for integrating the
health care delivery system as well as a strategy for integrating
health care policy, planning, and regulation within government.
(3) Quality. West Virginia's health delivery system should
model continuous improvement of health care quality and safety.
The tools and resources necessary to make informed use of all
health care services should be available to all West Virginians.
The state should look to incentives to health care professionals
and facilities to provide the best and most appropriate care to
West Virginians. The state's role in improving quality and safety
should be through coordination of health care policy, planning and
regulation.
(4) Equitable Financing. The health care system in West
Virginia should be funded fairly and equitably. All residents
should have access to health care and all participating residents
should contribute to its cost.
(c) No private cause of action, either express or implied, is
created by or otherwise arises from the enactment, provisions or
implementation of this article.
§16-29G-3. Interagency council created; duties
.
(a) There is hereby created the "Interagency Health Council"
consisting of the chairperson of the Health Care Authority, the
Insurance Commissioner, the secretary of the Department for Health
and Human Resources, the director of the Public Employees Insurance
Agency, and the director of the Children's Health Insurance
Program, and such other government agency persons as may be deemed
necessary by the council. Each ex-officio member of the council may appoint a designee. The council shall be chaired jointly by
the chairperson of the Health Care Authority and the Insurance
Commissioner until the Governor appoints another chairperson or co-
chairpersons. The council shall:
(1) Identify and report emerging trends and behaviors among
various participants in the health care system;
(2) Develop incentives to contain costs and methods to assess
the effectiveness of cost-containment efforts;
(3) Develop quality of care initiatives;
(4) Direct the studies required to accomplish the goals of
this section;
(5) Assess the feasibility of a publicly financed reinsurance
program for all health plans doing business in West Virginia;
(6) Recommend alternative reimbursement mechanisms for health
services that encourage cost effectiveness, improve the quality of
care, increase efficiency, reward primary care practices that
prevent chronic illnesses, avoid preventable hospitalizations, and
reduce long-term costs to the system;
(7) Assess whether any federal programs including, but not
limited to, Medicaid and the Children's Health Insurance Program
could be used to expand services if it is determined to be the most
cost effective means available;
(8) Receive reports and analysis from the West Virginia Health
Information Network established in article twenty nine-g, chapter
sixteen of this code and ensure that this information is integrated
into health planning;
(9) Collaborate with any entity charged with responsibility for the development of a behavioral health plan to ensure a fully
integrated system including both physical and mental health;
(10) Receive input and make recommendations, generally, to the
Senate and House committees on Health and Finance, and the Joint
Committee on Government and Finance regarding the long-term
development of policies and programs designed to ensure that West
Virginia is moving towards an integrated system of care that
provides all citizens of West Virginia access to affordable, high
quality health care that is financed in a fair and equitable
manner.
(b) The council shall establish committees and subcommittees
to assist in their work.
(c) The council shall propose demonstration or pilot projects
designed to contain health care costs and improve the delivery and
quality of health care including, but not limited to, a
demonstration project to establish a regional system with providers
and hospitals working cooperatively to provide and coordinate
health care for all residents of the region.
(d) The council shall establish an advisory committee to
study a payment and regulatory system that provides incentives to
improve patient safety and quality while controlling the rate of
growth of health care expenditures below current projected growth
rates. The study shall include consideration of such items as
hospital services, budgeting processes, efficient and economic
operations, performance standards, utilization and inflation
benchmarks, estimated cost shifts, uncompensated care, government
payors, and the impact of the state health plan. The council shall review the work of the advisory committee and report its findings
and recommendations to the Legislature prior to the first day of
January, two thousand eight.
(e) The council shall report to the Joint Committee on
Government and Finance on an annual basis the estimated cost shift
to the private sector created by the federal and state government
payors. Government payors include, but are not limited to, the
Bureau for Medical Services, the Children's Health Insurance
Program, Workers' Compensation and the Public Employees Insurance
Agency.
(f) The council may request analysis from appropriate state
agencies as needed. The agencies shall report this information at
such times as determined necessary to fulfill the council's
oversight responsibilities.
§16-29G-4. Benchmarks and schedule.
(a) On or before the first day of January, two-thousand seven
and each year thereafter, the council shall recommend to the
Legislative Commission on Health and Human Resources Accountability
those strategies that could move the state toward the goals
established in this article.
(b) Prior to making recommendations the council shall find
that the appropriate benchmarks for the strategy being recommended
have been met:
(1) Financing necessary to support the recommendations is
cost-neutral or less expensive with respect to the health care
system and will not require more money than is projected to be
spent in the existing system by West Virginia employers and individuals through taxes, premiums, and out-of-pocket expenses;
(2) Administrative bureaucracy and costs will decrease as a
percentage of total health care spending;
(3) Quality of care will be improved; and
(4) The future costs of health care will be less than the
current growth rate, or the resources will be allocated in a manner
that is more efficient and cost-effective, based on progress in
implementing the following cost containment measures:
(A) Payment system to hospitals;
(B) Increased consumer access to health care price and quality
information;
(C) Promotion of self-care and healthy lifestyles;
(D) Enhanced prescription drug initiatives developed in
cooperation with the pharmaceutical advocate;
(E) Funding of chronic care initiatives;
(F) Investments in health information technology;
(G) Alignment of health care professional reimbursement with
best practices and outcomes rather than utilization; and
(H) The creation of additional federally qualified health
centers (FQHC) or FQHC look-alikes if data supports this effort and
the federal government so approves.
(c) Recommendations to the Legislature shall include an
assessment of the cost savings or the reallocation of resources,
increased access, improvements in quality and delivery,
administrative simplification, fairness and equity in financing,
continuity of coverage, and financial sustainability.
§16-29G-5. Public notice and hearings.
(a) In recognition of the importance of public engagement, the
council shall have four public hearings prior to the first day of
January, two thousand seven to solicit input from citizens,
employers, hospitals, health care professionals, insurers, other
stakeholders, and interested parties about health care.
(b) The council shall report no less than quarterly to the
Legislative Commission on Health and Human Resource Accountability
and the Joint Committee on Government and Finance on the their
activities and recommendations in health care reform to date.
CHAPTER 33. INSURANCE.
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. Reimbursement rates for individual plans.
Insurers shall reimburse providers pursuant to reimbursement
rates previously negotiated with the providers.
§33-15D-6. 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-7. 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-8. 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-9. 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-10. 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-11. 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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