ENGROSSED
COMMITTEE SUBSTITUTE
FOR
H. B. 4021
(By Delegates Mr. Speaker, Mr. Kiss, and Delegate Trump)
[By Request of the Executive]
(Originating in the Committee on Finance)
[January 20, 2006]
A BILL to amend the code of West Virginia, 1931, as amended, by
adding thereto a new section, designated §5-16-6a; to amend by
adding thereto a new article, designated §16-5U-1, §16-5U-2,
§16-5U-3, §16-5U-4, §16-5U-5, §16-5U-6, §16-5U-7, and
§16-5U-8; to amend said code by adding thereto a new article,
designated §16-5V-1, §16-5V-2, §16-5V-3, §16-5V-4, §16-5V-5,
§16-5V-6, §16-5V-7, §16-5V-8, §16-5V-9 and §16-5V-10; to amend
said code by adding thereto a new article, designated §16-29G-
1, §16-29G-2, §16-29G-3, §16-29G-4, §16-29G-5, §16-29G-6, §16-
29G-7 and §16-29G-8; 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 and §33-15D-10, all relating to health care availability
and access by requiring the finance board of the Public
Employee Insurance Agency to analyze the value of transferring
retirees to a Medicare Advantage Plan from both the benefits and cost saving perspective; identifying findings by the
Legislature, establishing guidelines for health care reform,
establishing goals for health care reform, establishing a
process for attaining health care goals, establishing a
schedule and benchmarks for attaining health care goals
including establishing a pilot program for participating
health care clinics and private medical practitioners to
provide primary and preventive health services for a prepaid
fee; establishing dates for providing primary and preventive
care to all citizens of the state; establishing a basic health
care package for all citizens of the state after certain
benchmarks are reached; establishing goals and creating a
commission on health care reform, defining its membership,
establishing responsibilities, creating the authority to hire
necessary staff, creating the Appalachian State Health Plan to
provide health care coverage to the citizens of the state,
establishing an advisory committee to work with the Health
Care Authority and establishing specific requirements;
establishing the West Virginia Health Information Network by
establishing its purpose, establishing the members of the
network, its powers and duties, an account to receive funds
and disperse funds, protection from liability, property
rights, rules, resolution of disputes, privacy and protection
of information; establishing individual limited health
benefits insurance plans focusing on preventive and primary
care services; declaring legislative intent; requiring approval of plans by Insurance Commissioner; providing
eligibility requirements for individuals; setting forth
statutory or regulatory provisions that do not apply to such
plans; providing underwriting standards; 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; and providing rule of
construction.
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 §5-16-6a; to amend by
adding thereto a new article, designated §16-5U-1, §16-5U-2,
§16-5U-3, §16-5U-4, §16-5U-5, §16-5U-6, §16-5U-7, §16-5U-8; that
said code be amended by adding thereto a new article, designated
§16-5V-1, §16-5V-2, §16-5V-3, §16-5V-4, §16-5V-5, §16-5V-6,
§16-5V-7, §16-5V-8, §16-5V-9 and §16-5V-10;
that said code be
amended by adding thereto a new article, designated §16-29G-1, §16-
29G-2, §16-29G-3, §16-29G-4, §16-29G-5, §16-29G-6, §16-29G-7 and
§16-29G-8; and that said code by 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 and §33-15D-
10,
all to read as follows:
ARTICLE 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.
§5-16-6a. Medicare Advantage Program.
On or before the first day of July, two thousand six, the
finance board shall conduct an actuarial analysis in order to
evaluate the benefit of replacing health care coverage currently
offered by the Public Employee Insurance agency for retirees
eligible for a Medicare Advantage plan with equal to or greater
benefits. The analysis shall include coverage design and cost
savings or losses both to the retiree and to the state. The
results of the analysis shall be reported to the Joint Committee on
Government and Finance by the board on or before the first day of
September, two thousand six.
ARTICLE 5U. WEST VIRGINIA HEALTH CARE ACT OF 2006.
§16-5U-1. Findings.
(a)The Legislature finds that:
(1) Health care costs are rising at an unsustainable rate,
causing hardships to individuals, families, businesses, taxpayers,
and public institutions and making the need for comprehensive
health care reform essential.
(2) Health care costs have risen an average of nine to ten
percent per year over the past thirty to forty years, with the rate
rising to ten to eleven percent in more recent years. These
figures are well above the Consumer Price Index and, moreover,
exceed by far the state's capacity to pay for health care costs as
measured against our gross state product and personal income.
(3) In two thousand six, it is projected that West Virginia
will spend at least thirteen billion dollars on health care. That
amount has doubled since 1998. If the trend continues, health care spending will double again in eight years. In other words, for
every year West Virginia fails to address the health care crisis,
health care costs will rise by at least another one hundred million
dollars.
(4) Over one-half of bankruptcies nationally are associated
with high medical expenses. In approximately three-quarters of
health-related bankruptcies, the patient had insurance.
(5) In two thousand five, the state of West Virginia spent an
estimated seven thousand five hundred dollars per capita on health
care, more than any nation -- except the United States itself --
when measured as a proportion of gross domestic product.
(6) Between two thousand and two thousand three, there was an
eight and nine-tenths percent increase in the number of uninsured
children in West Virginia going from twenty-eight thousand three
hundred seventy one in two thousand to thirty thousand eight
hundred eighty-four in two thousand three. There was also an eight
and three-tenths percent increase in the number of uninsured adults
going from two hundred nineteen thousand, nine hundred seventy-one
to two hundred thirty-eight thousand two hundred twelve.
(7) The cost of health care has a strong and negative impact
on the ability of West Virginia businesses and employers to compete
in national and international markets.
(8) There is a large and increasing number of people who have
no health insurance or who are underinsured. For this growing
population, health care is unaffordable and, as a result, often not
received in the most timely and effective manner. The existing disparities in coverage result in an irrational rationing of
available health care services.
(9) Over three hundred and ninety thousand West Virginians
have no health insurance at some time during each year. Lack of
insurance is associated with an increased rate of illness and a
shorter life expectancy.
(10) Premium cost increases have contributed to the growing
rate of under-insurance, with more and more residents purchasing
high-deductible and less comprehensive plans.
(11) The costs of health services provided to individuals who
are unable to pay are shifted to others. Over four hundred forty-
five million dollars worth of uncompensated care was provided by
the hospitals in West Virginia in two thousand four alone. Those
who bear the burden of this cost shift have an increasingly
difficult time affording their own health care costs, including
premiums.
(12) The current financing of health care is complex,
fragmented, and inequitable, resulting in inefficiencies and
placing administrative burdens on health care professionals, in
particular. The financing is accomplished through a patchwork of
public programs, private sector employer-sponsored self-insurance,
commercial insurance, and individual payers.
(13) In general, costs fall disproportionately on those with
serious health conditions and those with moderate and lower
incomes.
(14) At any particular point in time, approximately ten percent of the West Virginia population generates approximately
seventy percent of all health care spending.
(15) Although the quality of health care services in West
Virginia is generally good, there is a need to improve quality,
efficiency, and safety. Improvements in health care quality will
result in improved health and reduced costs. The existing payment
system, because it is based on the amount of care provided, does
not tie reimbursement to improved health.
(16) There are an unacceptable number of adverse events
attributable to medical errors. According to the Institute of
Medicine report entitled "To Err is Human: Building a Safer Health
System," nationwide, the right care is given to the right person at
the right time only about half the time.
(17) In addition, our health care infrastructure and services
tend to be "disease-focused" rather than "health-focused,"
resulting in missed opportunities for less costly and more
effective forms of care.
(18) West Virginia currently does not have a clearly defined,
integrated health care "system." Fragmentation and disorganization
at both the regional and statewide levels lead in some instances to
excessive care or inadequate care and create barriers to
coordination and accountability among health care professionals,
payers, and patients. In addition, the ability of the system to
respond to rapid changes in technology and medical advances and to
provide the highest quality of care to the greatest number of
people is compromised.
(19) Federal laws and programs, such as Medicaid, Medicare,
and the Employee Retirement Income Security Act of 1974 (ERISA)
constrain West Virginia's ability to establish immediately an
integrated health care system. Presently, there are over three
hundred thousand West Virginians enrolled in some aspect of
Medicaid, over three hundred thousand West Virginians enrolled in
Medicare, and over two hundred thousand in private sector
employer-sponsored self-insured plans. Combined, it is projected
that these individuals will account for nearly six billion of the
over thirteen billion dollars West Virginia will spend on health
care in two thousand and six.
(b)In an effort to improve the health care available to the
residents of West Virginia, the Legislature finds that it is its
responsibility to make every effort to improve the health care
system for all residents of the state of West Virginia.
§16-5U-2. Guidelines for Health Care Reform.
The Legislature adopts the following guidelines as a framework
for reforming health care in West Virginia:
(1) It is the policy of the state of West Virginia to ensure
access to and coverage for essential health care services for all
West Virginians.
(2) Health care coverage needs to be comprehensive and
continuous.
(3) West Virginia's health delivery system must model
continuous improvement of health care quality and safety.
(4) The financing of health care in West Virginia must be sufficient, equitable, fair, and sustainable.
(5) Built-in accountability for quality, for cost, for access
and for participation must be the hallmark of West Virginia's
health care system.
(6) West Virginians must be engaged to pursue healthy
lifestyles, to focus on preventive care and wellness efforts, and
to make informed use of all health care services throughout their
lives.
§16-5U-3. Goals of Health Care Reform.
Consistent with the adopted guidelines for reforming health
care in West Virginia, the Legislature adopts the following goals:
(1) Access. West Virginia policy will reflect that access to
health care is a public good. By two thousand ten, West Virginia
shall have an integrated health care system that provides all West
Virginians, regardless of their age, employment, economic status,
or their town of residency, with access to affordable, high quality
health care that is financed in a fair and equitable manner.
(A) In order to reach this goal, the state shall begin by
offering limited benefits and shall expand benefits over time after
meeting specified benchmarks. 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.
(B) The benchmarks shall measure the appropriateness and
feasibility of a proposed expansion based on its ability to promote
the following: long-term cost savings, increased access, improved quality and delivery, administrative simplification, fair and
equitable financing, financial sustainability, and continuity of
coverage.
(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 also the delivery and quality of health services offered in
West Virginia. To ensure financial sustainability of Appalachian
State Health Plan established in article five-u of this chapter,
the state is committed to slowing the rate of growth of health care
costs by the year two thousand ten. Strategies for containing costs
shall include:
(A) A budgeting process for hospitals and other entities if
appropriate as determined by the Commission on Health Care Reform;
(B) Increased consumer access to health care price and quality
information;
© 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 must model continuous improvement of health care quality and safety.
West Virginians must have the tools and resources necessary to make
informed use of all health care services. Health care professionals
and facilities should have incentives to provide the best and most
appropriate care to West Virginians. The state should also do its
part to improve quality and safety by coordinating 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; all participating residents
should contribute to its cost.
§16-5U-4. Process for Attaining Health Care Goals.
(a) There is hereby created the Commission on Health Care
Reform. The commission shall include representatives from the
following: The Department of Health and Human Resources, the
Insurance Commission, the Health Care Authority, the Public
Employees Insurance Agency, the West Virginia Hospital Association,
the West Virginia Medical Association, the West Virginia University
School of Medicine, the Marshall University School of Medicine,
the West Virginia School of Osteopathic Medicine, the West Virginia
Chamber of Commerce, an organized labor organization, providers of
worker's compensation services, and the West Virginia Primary Care
Association. Those members who do not represent a specified agency
or organization shall be appointed by the Governor. A member of
the Senate appointed by the President of the Senate shall serve as
an ex-officio member. A member of the House of Delegates appointed by the Speaker shall serve as an ex-officio member. Further, three
public members shall be appointed by the Governor with the advise
and consent of the Senate. One public member shall benefit from the
establishment of this program, one public member shall represent
current providers of health insurance in the state, and one member
shall represent health care practitioners in the state. Each
public member shall serve for a term of four years. Of the public
members of the commission first appointed, one member shall be
appointed for a term ending the thirtieth day of June, two thousand
eight. and one shall be appointed for terms of three and four
years respectively. Each public member shall serve until his or
her successor is appointed and has qualified. The members of the
commission may be removed by the Governor for cause. A chairperson
shall be chosen by the members of the commission. To initiate the
commission's work, the Department of Health and Human Resources
shall call the first meeting. The commission shall monitor health
care reform and recommend to the Legislature actions needed to
attain the health care goals established by this act.
(b) Beginning in the interim of the two thousand six
legislative session through the first day of July, two thousand
ten, the commission shall:
(1) Oversee and monitor Appalachian State Health Plan
established in article five-u of this article, propose to the
Legislature a package of benefits to be covered under that program
and, based on an assessment of whether specified benchmarks have
been met, make recommendations to the Legislature on whether the programs should continue and whether expansions to the program
should occur;
(2) Develop administrative and operational recommendations for
expansions to Appalachian State Health Plan, including residency
requirements; treatment of preexisting conditions; the
interrelationship between Appalachian State Health Plan, Medicare,
Medicaid and any Medicaid waiver programs; the establishment of a
special committee study of hospital services covered by Appalachian
State Health Plan; and payment mechanisms for out-of-state hospital
coverage by Appalachian State Health Plan;
(3) Identify and report emerging trends and behaviors among
various participants in the health care system;
(4) Assess the effectiveness of cost-containment and quality
of care initiatives;
(5) Establish 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;
(6) Direct the studies established in this act;
(7) Assess the feasibility of:
(A) A publicly financed reinsurance program for all health
plans doing business in West Virginia;
(B) Organizational structures that integrate the delivery of
care and improve the quality of care at both the regional and state level, including developing a plan for creating an integrated,
regional delivery system and developing integrated systems of care;
(8) 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;
(9) Receive reports and evaluate the clinic-based pilot
program being operated by the Health Care Authority and the
Insurance Commission as the program is implemented pursuant to
section five of this article;
(10) 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 the health planning of the commission;
(11)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;
(12) 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, by
two thousand ten, West Virginia has 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.
© The commission shall select the services of one full-time
director and such other staff as is needed and as determined by
legislative appropriation. The director shall have expertise in
finance, planning, systems analysis, and processes involving
weighing competing interests among parties. In addition, the
commission may retain the services of one or more consultants or
experts knowledgeable in health care systems, financing, or
delivery to assist in its work and may request funding through
Legislative appropriation. The commission may establish committees
and subcommittees to assist in the work of the commission.
(d) The commission shall establish an advisory committee to
work in conjunction with the Health Care Authority 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, cost
shifts, uncompensated care, government payors, and the impact of
the state health plan. The commission shall review the work of the
advisory committee and report its findings and recommendations to
the legislature prior to the two thousand eight session.
(e) The commission may request analysis from appropriate
state agencies as needed. The agencies shall report to the
commission at such times and with such information as the
commission determines is necessary to fulfill its oversight responsibilities.
(f) The commission may meet as needed and each member, in
addition to such reimbursement for necessary expenses, shall
receive an amount not to exceed the same compensation as is paid to
members of the Legislature for their interim duties as recommended
by the citizens legislative compensation commission and authorized
by law for each day or substantial portion thereof that the members
are engaged in the work of the commission.
(g) Office space near the state capitol building for those
individuals employed by the commission shall be made available by
the department of administration.
§16-5U-5. Schedule and Benchmarks for Attaining Health Care Goals.
(a) For the purposes of this section, the following
definitions apply:
(1) "Appalachian State Health Plan" is the plan established in
article five-V of this chapter.
(2) "Dependent" has the same meaning set forth in subsection
(d), section one-a, article sixteen, chapter thirty-three of this
code.
(3) "Family" means an subscriber and his or her dependents.
(4)
"Primary care" means health services provided by health
care professionals specifically trained for and skilled in
first-contact and continuing care for individuals with signs,
symptoms, or health concerns, not limited by problem origin
(biological, behavioral, or social), organ system, or diagnosis and
shall include prenatal care. Primary care services include health promotion, preventive care, health maintenance, counseling, patient
education, case management, and the diagnosis and treatment of
acute and chronic illnesses in a variety of health care settings.
(5) "Provider" has the same meaning as "ambulatory health care
facility" set forth in section (b), section two of this article.
(6) "Participating provider" means a provider that has been
granted a license under this section to operate as part of the
pilot program.
(7) "Subscriber" means any individual who subscribes to a
participating clinic prepaid program approved and operated in
accordance with the provisions of this section, including an
employee of any employer that has purchased a group enrollment on
behalf of its employees.
(b) On or before the first day of July two-thousand six, The
Health Care Authority and the Insurance Commission in cooperation
with the Commission on Health Care Reform shall initiate a pilot
program to provide primary and preventive health care in the manner
described in this section. In carrying out this pilot program, it
is the intent of the Legislature to eliminate legal 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 section.
(1) 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 unless otherwise determined
by legislative action.
(2) Subject to the provisions of this section, 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.
(3) The Health Care Authority may apply for and receive
funding from any source to implement funding of the pilot program.
(4) No provider may participate in the pilot program without
first obtaining a preventive care clinic-based pilot program
license from the Health Care Authority.
(5) 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.
(6) 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 Insurance
Commissioner.
(7) 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.
(8) 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.
(9) 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.
(10) 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 co-
payments; and where and in what manner information is available as
to how a service may be obtained.(11) Fees paid to participating providers are not subject to
premium taxes and surcharges imposed on insurance companies.
(12) 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.
(13) 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:
(A) Each participating provider and site must offer a minimum
set of preventive and primary care services as established by the
Health Care Authority;
(B) No participating provider may offer an employee group plan
to any employer that had a group health benefit plan covering its
employees within the preceding twelve months.
© 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.
(14) The Health Care Authority shall establish guidelines 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.
(15) 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 in cooperation with the
Commission on health Care Reform 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.
(16) 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:
(A) Violates any provision of this article;
(B) Fails to comply with any lawful rule, regulation or order
of the Health Care Authority;
© Is operating in an illegal, improper or unjust manner;
(D) 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;
(E) 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;
(F) 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;
(G) 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;
(H) Fails to pay when due to the State of West Virginia any
taxes, fees, charges or penalties.
(17) 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.
(18) 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.
© On or before the first day of January, two-thousand seven,
the Commission on Health Care Reform shall recommend to the
Legislature a package of primary and preventive care health
services to be covered under Appalachian Health Plan beginning the first day of July, two-thousand seven.
(d) Prior to making recommendations for expansions to
Appalachian State Health Plan as described in subsections (c)-(j)
of this section, the commission, based on projections, shall find
that:
(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;
(4) All federal programs including, but not limited to,
Medicaid and the Children's Health Insurance Program will be used
to expand services when it is determined to be the most cost
affective means available; and
(5) The future costs of health care will be less than the
current growth rate 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;
© 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) Additional federally qualified health center's (FQHC) or
FQHC look-alikes if data supports this effort and the federal
government so approves.
(e) On or before the first day of January, two-thousand seven,
provided the commission determines that the conditions and
benchmarks established under this section are met, the commission
shall recommend to the Legislature a plan to make primary and
preventive care, or select primary or preventive care health
services available to all West Virginians under Appalachian State
Health Plan beginning the first day of July, two thousand seven.
Coverage shall be offered through health insurers and other
practitioners as determined by the commission;
(f) On or before the first day of January, two thousand
eight, provided the commission determines that the conditions and
benchmarks established under this section are met, the commission
shall recommend to the Legislature a plan to make hospital and
specialty care care available to all West Virginians under
Appalachian State Health Plan beginning on or before the first day
of July, two-thousand nine.
(g) On or before the first day of January, two-thousand nine,
provided the commission determines that the conditions and
benchmarks established under this section are met, the commission shall recommend to the Legislature a plan to make a minimum common
benefit available to all West Virginians under Appalachian State
Health Plan beginning on or before the first day of July, two-
thousand ten.
(h) Recommendations by the commission shall be based on data
received or proposals made by any state agencies as well as on any
other relevant public input received by the commission, including
all studies established under this act.
(i) Recommendations by the commission to the Legislature shall
be assessed in terms of cost savings; increased access,
improvements in quality and delivery, administrative
simplification, fairness and equity in financing, continuity of
coverage, and financial sustainability.
(j) The Department of Health and Human Resources shall
request a waiver of any necessary federal requirements from the
Centers for Medicaid and Medicare Services to allow the state to
negotiate a global, unified payment to each West Virginia hospital
for all health care services received in a hospital by individuals
covered by Medicaid and Medicare. This waiver request shall be
jointly developed by the Bureau of Medical Services and the Health
Care Authority.
§16-5U-6. Public Engagement Process.
(a) In recognition of the importance of public engagement,
the Commission on Health care Reform shall have six public hearings
during the interim of the 2006 legislative session to solicit input
from citizens, employers, hospitals, health care professionals, insurers, other stakeholders, and interested parties about health
care.
(b) Throughout the interim, the Commission on Health Care
Reform at the request of the Legislative Commission on Health and
Human Resource Accountability and the chairs of the Senate and
House Health committees shall brief the committees on the
commission's activities and recommendations to date.
§16-5U-7. Rule-Making authority.
The Health Care Authority, the Insurance Commissioner and the
Commission on Health Care Reform may propose rules for legislative
approval in accordance with the provisions of article three,
chapter twenty-nine-a of this code as necessary to implement the
provisions of this article, including emergency rules promulgated
pursuant to section fifteen, article three, chapter twenty-nine-a
of this code.
§16-5U-8. Sunset Provisions.
The commission shall continue to exist, pursuant to the
provisions of article ten, chapter four of this code, until the
first day of July, two-thousand ten, unless sooner terminated,
continued or reestablished pursuant to the provisions of that
article.
ARTICLE 5V. APPALACHIAN STATE HEALTH PLAN.
§16-5V-1. Policy and Purpose.
In order to ensure all West Virginia residents have access to
key health services and all contribute to the financial sustainability of West Virginia's health care system, Appalachian
State Health Plan is established to provide uninsured West Virginia
residents a defined benefit package of primary and preventive care.
Expansions to the program shall be consistent with recommendations
by the Commission on Health Care Reform approved by the
Legislature.
§16-5V-2. Definitions.
For purposes of this article:
(1) "Appalachian State Health Plan" means the plan established
under this article.
(2) "Benefits" means primary and preventive care health
services.
(3) "Commission" means the Commission on Health Care Reform
established in article five-U of this chapter,
(4) "Health care professional" means an individual licensed,
registered, or certified in the state of West Virginia to provide
health services.
(5) "Health service" means any medically necessary treatment
or procedure to maintain, diagnose, or treat an individual's
physical or mental condition, including services provided pursuant
to a physician's order and services to assist in activities of
daily living.
(6) "Preventive care" means health services that include
screening, counseling, treatment, or medication determined by
scientific evidence to be effective in preventing or detecting
disease and shall include immunizations.
(7) "Primary care" means health services provided by health
care professionals specifically trained for and skilled in
first-contact and continuing care for individuals with signs,
symptoms, or health concerns, not limited by problem origin
(biological, behavioral, or social), organ system, or diagnosis and
shall include prenatal care. Primary care services include health
promotion, preventive care, health maintenance, counseling, patient
education, case management, and the diagnosis and treatment of
acute and chronic illnesses in a variety of health care settings.
(7) "Uninsured" means not having health insurance coverage
under either a private or public plan, including Medicaid and the
Children's Health Insurance Program.
(8) "West Virginia resident" means an individual domiciled in
West Virginia as evidenced by an intent to maintain a principal
dwelling place in West Virginia indefinitely and to return to West
Virginia if temporarily absent, coupled with an act or acts
consistent with that intent. The commissioner shall establish
specific criteria to demonstrate residency.
§16-5V-3. Benefits.
(a) Not later than the first day of December, two-thousand
six, the Commission on Health Care Reform shall propose a package
of benefits to be provided uninsured West Virginia residents under
Appalachian State Health Plan, beginning the first day of July, two
-thousand seven. The commission shall recommend for approval
benefits to the Legislature by the first day of January, two
thousand seven.
(b) The office shall ensure that a package of primary and
preventive care will provide a choice of services and health care
professionals, contain costs over time, and improve quality of care
and health outcomes. In developing the package of health services
under this section, the office shall:
(1) Engage in a public process designed to respond to West
Virginians' health care values and priorities;
(2) Consider the current range of health services received by
West Virginia residents through public and private benefit
packages;
(3) Consider a credible evidence-based, scientific research
and comment by health care professionals both nationally and
internationally concerning clinical efficacy and risk;
(4) Consider health care ethics;
(5) Consider the cost-effectiveness of health services and
technology;
(6) Consider revenues anticipated to be available to finance
Appalachian State Health Plan;
(7) Consider the state health plan established in chapter
sixteen of this code; and
(8) Consider any West Virginia-specific initiatives that would
inform the commission.
§16-5V-4. Budget.
(a) Beginning on the fifteenth day of January, two-thousand
seven, and annually thereafter, the office shall propose to the
Legislature a budget for the benefits covered under Appalachian State Health Plan. The budget shall include recommended
expenditures during the next succeeding state fiscal year and
anticipated revenues available to support such expenditures.
(b) In developing the proposed budget, the office shall
consider the payment methods described in this article, the
negotiated payment amounts described in this article, and cost
sharing developed in this article.
§16-5V-5. Payment Methodologies for Appalachian State Health Plan.
(a) By the first day of February, two thousand seven, the
Commission on Healthcare Reform shall determine by rule in
accordance with article three, chapter twenty-nine-a of this code,
the payment method to be used for each health care sector which
provides health services under Appalachian State Health Plan. The
payment methods shall be in alignment with the goals of this
article and shall encourage cost-containment, provision of high
quality, evidence-based health services in an integrated setting,
patient self-management, and healthy lifestyles. In developing the
payment methods, the office shall consult with health care
professionals prior to filing the draft rules for comment.
(b) The commission shall consider, but not be limited to, the
following payment methods:
(1) Capitated payments;
(2) Incentive payments to the health care professionals based
on performance standards, which may include evidence-based standard
physiological measures, or another means as determined by the
commission;
(3) Fee supplements if necessary to encourage specialized
health care professionals to offer a specific, necessary health
service which is not available in a specific geographic region;
(4) Fixed annual payments to health care facilities; and
(5) Fees for service.
§16-5V-6. Payment Amounts.
(a) The intent of this section is to ensure reasonable
payments to health care professionals and not contribute to the
shift of costs between the payers of health services by ensuring
that the amount paid to health care professionals under the
Appalachian State Health Plan is not equivalent to the Medicaid
rate if that rate is insufficient payment for the health service
provided. The payment amounts should reflect fair reimbursement
for the health services provided under Appalachian State Health
Plan. This is a basic requirement of all insurance carriers
participating in providing coverage under this plan.
(b) The commission shall negotiate with hospitals, health care
professionals, and groups of health care professionals to establish
a payment amount for the health services provided by Appalachian
State Health Plan over time. The amount shall be sufficient to
provide reasonable access to health services, provide sufficient
payment to health care professionals, and encourage the financial
stability of health care professionals. In determining the payment
amount, the commission shall consider:
(1) The actual cost of the health service;
(2) Expected revenues;
(3) Cost containment targets;
(4) Shared costs between affiliated health care professionals;
and
(5) Co-payments developed on a sliding scale basis.
§16-5V-7. Administration.
(a) Appalachian State Health Plan shall be administered by the
licensed health insurance carriers in the state who agree to the
terms established by the commission ON Health Care Reform. It will
be the responsibility of the health insurance carriers who agree to
participate in this program to market the program to all eligible
residents in the state. The commission may consider applications
from in-state entities to administer Appalachian State Health Plan.
In addition, the commission may consider contracts with primary
care centers, clinics, physician practices and other entities
determined by the commission to be capable of providing the primary
and preventive care programs in the manner established by the
commission.
(b) Nothing in this article shall require an individual
already covered by health insurance to terminate that insurance,
enroll in Appalachian State Health Plan, or contribute to the
financing of Appalachian State Health Plan.
(c) West Virginia residents shall not be billed any additional
amount for health services covered by Appalachian State Health
Plan, except as provided for in this article.
(d) The health insurance carriers shall make available the
necessary information, forms, and billing procedures to health care professionals to ensure payment for health services covered under
Appalachian State Health Plan. The office or plan administrator
shall use a single, uniform, simplified form to determine
eligibility for Medicaid, any Medicaid waiver program, the
Children's Health Insurance Program, any state-funded pharmacy
program, and Appalachian State Health Plan to ensure that any
individual eligible for these programs has the opportunity to
enroll. The office shall provide coverage for health services up
to three months prior to the date of application for Medicaid, any
Medicaid waiver program, the Children's Health Insurance Program or
any state pharmacy programs.
(e) An individual aggrieved by an adverse decision of the plan
administrator may appeal to the insurance commissioner's office.
§16-5V-8. Cost Sharing; Wellness Discount.
(a) As part of the commission's budget, the commission shall
propose to the Legislature reasonable sliding-scale deductibles,
co-payments, or other cost-sharing amounts applicable to
Appalachian State Health Plan. The cost-sharing amounts shall not
apply to preventive health services covered by Appalachian State
Health Plan.
(b) The commission may include financial or other incentives
applicable to Appalachian State Health Plan to encourage healthy
lifestyles and patient self-management. In particular, the
commission may establish discounts, rebates, or modifications of
applicable cost-sharing amounts in return for an individual's
adherence to programs of health promotion and disease prevention consistent with federal regulations relating to wellness. If such
incentives are included, the commission shall adopt by rule
standards to be applied to this program.
§16-5V-9. Rulemaking.
The commission may promulgate rules pursuant to the provisions
of section fifteen, article three, chapter twenty-nine-a of this
code if necessary to implement the provisions of this act.
§16-5V-10. Appalachian State Health Trust Fund.
(a) The Appalachian State Health Trust Fund is hereby
established in the state treasury for the purpose of establishing
a special fund to be the single source to finance health care
coverage for beneficiaries of Appalachian State Health Plan as
established under this article.
(b) Into the fund shall be deposited:
(1) Transfers or appropriations from the general fund,
authorized by the Legislature;
(2) The proceeds from grants, donations, contributions, taxes
and any other sources of revenue as may be provided by
appropriation by the Legislature;
(c) Expenditures from the fund shall be for the purposes set
forth in this article and are not authorized from collections, but
are to be made only in accordance with appropriation by the
Legislature and in accordance with the provisions of article three,
chapter twelve of this code and upon the fulfillment of the
provisions of article two, chapter five-a eleven-b of this code.
(d) All monies received by or generated to the fund shall be used only for the administration and delivery of health care
covered through the Appalachian State Health Plan administered by
the commission on health care reform under this article.
(e) To the extent permitted under federal law and any Medicaid
waiver, the monies received by or generated to the fund shall be
matched by federal funds.
ARTICLE 29G. WEST VIRGINIA HEALTH INFORMATION NETWORK.
§16-29G-1. Purpose.
(a) The purpose of this article is to create a governmental
instrumentality of this state known as the West Virginia Health
Information Network under the oversight of the Health Care
Authority to promote the design, implementation, operation and
maintenance of a network to facilitate public and private use of
health care information in the state.
(b) It is intended that the network be a public-private
partnership for the benefit of all of the citizens of this state.
(c) In its fully implemented form, the network is envisioned
to support and facilitate, among other things, the following types
of electronic transactions or activities over time:
(1) Automatic drug-drug interaction and allergy alerts;
(2) Automatic preventive medicine alerts;
(3) Electronic access to the results of laboratory, X ray, or
other diagnostic examinations;
(4) Disease management;
(5) Disease surveillance and reporting;
(6) Educational offerings for health care providers;
(7) Health alert system and other applications related to
homeland security;
(8) Links to evidence-based medical practice;
(9) Links to patient educational materials;
(10) Medical record information transfer to other providers
with the patient's consent;
(11) Physician order entry;
(12) Prescription drug tracking;
(13) Registries for vital statistics, cancer, case management,
immunizations, and other public health registries;
(14) Secured electronic consultations between providers and
patients;
(15) A single-source insurance credentialing system for health
care providers; and
(16) Electronic health care claims submission and processing.
(d) The network shall ensure the privacy of patient health
care information.
§16-29G-2. Creation of West Virginia Health Information Network.
(a) The network is hereby created and under the Health Care
Authority for administrative, personnel, and technical support
purposes. The network will be managed and operated by a board of
directors consisting of seventeen members.
(b) The board shall consist of the following members:
(1) The Dean of the West Virginia University School of
Medicine or his or her designee;
(2) The Dean of the Marshall University John C. Edwards School of Medicine or his or her designee;
(3) The President of the West Virginia School of Osteopathic
Medicine or his or her designee;
(4) The Secretary of the Department of Health and Human
Resources or his or her designee;
(5) The President of the West Virginia Board of Pharmacy or
his or her designee;
(6) The Director of the Public Employees Insurance Agency or
his or her designee;
(7) The Chief Technology Officer of the Office of Technology
or his or her designee;
(8) The Chair of the Health Care Authority or his or her
designee;
(9) The President of the West Virginia Hospital Association or
his or her designee;
(10) The President of the West Virginia State Medical
Association or his or her designee;
(11) The Chief Executive Officer of the West Virginia Health
Care Association or his or her designee;
(12) The Executive Director of the West Virginia Primary Care
Association or his or her designee; and
(13) Five public members that serve at the will and pleasure
of the Governor and are appointed by the Governor as follows:
(I) One member with legal expertise in matters concerning the
privacy and security of health care information;
(ii) Two physicians actively engaged in the practice of medicine in the state;
(iii) One member engaged in the business of health insurance
who is employed by a company that has its headquarters in West
Virginia; and
(iv) The chief executive officer of a West Virginia
corporation working with West Virginia health care providers,
insurers, businesses and government to facilitate the use of
information technology to improve the quality, efficiency and
safety of health care for West Virginians.
(c) The Governor shall appoint one of the board members to
serve as chair of the board at the Governor's will and pleasure.
The board shall annually select one of its members to serve as vice
chair. The Chair of the Health Care Authority shall serve as the
secretary-treasurer of the board.
(d) The public members of the board shall serve a term of four
years and may serve two consecutive terms. At the end of a term,
a member of the board shall continue to serve until a successor is
appointed. Those members designated in subdivisions (1) through
(12) of subsection (b) of this section shall serve on the board
only while holding their respective titles.
(e) The board may propose the adoption or amendment of rules
or regulations to the Health Care Authority to carry out the
objectives of this article.
(f) The board may appoint committees or subcommittees to
investigate and make recommendations to the full board. Members of
such committees or subcommittees need not be members of the board.
(g) Each member of the board and the board's committees and
subcommittees is entitled to be reimbursed for actual and necessary
expenses incurred for each day or portion thereof engaged in the
discharge of official duties in a manner consistent with guidelines
of the travel management office of the Department of
Administration.
§16-29G-3. Powers and duties.
In furtherance of the purposes of this article, the network
shall have the following duties:
(1) To develop a community-based health information network to
facilitate communication of patient clinical and financial
information, designed to:
(A) Promote more efficient and effective communication among
multiple health care providers, including, but not limited to,
hospitals, physicians, payers, employers, pharmacies, laboratories
and other health care entities;
(B) Create efficiencies in health care costs by eliminating
redundancy in data capture and storage and reducing administrative,
billing and data collection costs;
(C) Create the ability to monitor community health status; and
(D) Provide reliable information to health care consumers and
purchasers regarding the quality and cost-effectiveness of health
care, health plans and health care providers;
(2) Develop or design other initiatives in furtherance of the
network's purpose;
(3) Report and make recommendations to the Health Care Authority:
(4) Report to the Commission on Health Care Reform established
in article five-u, chapter sixteen of this code, the
recommendations of the board and cooperate in the work of the
Commission on Health Care Reform.
To carry out the above duties, the network is granted all
other incidental powers, including, but not limited to, the
following:
(A) Make and enter into all contracts and agreements and
execute all instruments necessary or incidental to the performance
of its duties and the execution of its powers, subject to the
availability of funds: Provided, That the provisions of article
three, chapter five-a of this code do not apply to the agreements
and contracts executed under the provisions of this article;
(B) Acquire by gift or purchase, hold or dispose of real and
personal property in the exercise of its powers and performance of
its duties as set forth in this article;
(C) Receive and dispense funds appropriated for its use by the
Legislature or other funding sources or solicit, apply for, and
receive any funds, property, or services from any person,
governmental agency, or organization to carry out its statutory
duties;
(D) Represent the state with respect to national health
information network initiatives;
(E) Perform any and all other activities in furtherance of its
purpose or as directed by the Health Care Authority;
(F) Report to and work cooperatively with the Commission on
Health Care Reform established in article five-u, chapter sixteen
of this code.
§16-29G-4. Creation of the West Virginia Health Information
Network account; authorization of Health Care
Authority to expend funds to support the network.
(a) There is hereby created in the State Treasury a special
revenue account to be known as the "West Virginia Health
Information Network" account. The West Virginia Health Information
Network account may receive state appropriations, gifts, grants,
revolving funds, transaction, service or other fees set by the
board and any other public and private funds. Moneys in the
account shall be expended solely for purposes related to the
network and its fulfillment of its statutory duties, as approved by
the board.
(b) Consistent with section eight, article twenty-nine-b of
this chapter, the Health Care Authority's provision of
administrative, personnel, technical and other forms of support to
the network is necessary to support the activities of the Health
Care Authority Board and constitutes a legitimate, lawful purpose
of the Health Care Authority Board. Therefore, the Health Care
Authority is hereby authorized to expend funds from its health care
cost review fund, established under section eight, article
twenty-nine-b of this chapter, to support the network's
administrative, personnel, and technical needs and any other network activities the Health Care Authority deems necessary.
§16-29G-5. Immunity from suit; limitation of liability.
The network is not a health care provider and is not subject
to claims under article seven-b, chapter fifty-five of this code.
No person who participates or subscribes to the services or
information provided by the network is liable in any action for
damages or costs of any nature, in law or equity, which result
solely from that person's use or failure to use network information
or data that was imputed or retrieved in accordance with the Health
Insurance Portability and Accountability Act of 1996 and any
amendments and regulations under the Act, state confidentiality
laws and the rules or regulations of the network as approved by the
Health Care Authority. In addition, no person is subject to
antitrust or unfair competition liability based on membership or
participation in the network, which provides an essential
governmental function for the public health and safety and enjoys
state action immunity.
§16-29G-6. Property rights.
(a) All persons providing information and data to the network
shall retain a property right in that information or data, but
grant to the other participants or subscribers a nonexclusive
license to retrieve and use that information or data in accordance
with the Health Insurance Portability and Accountability Act of
1996 and any amendments and regulations under the Act, state
confidentiality laws and the rules proposed by the Health Care
Authority.
(b) All processes or software developed, designed or purchased
by the network shall remain its property subject to use by
participants or subscribers in accordance with the rules or
regulations proposed by the Health Care Authority.
§16-29G-7. Regulations; resolution of disputes.
(a) The Health Care Authority is hereby authorized to propose
rules under and pursuant to article twenty-nine-b of this chapter
to carry out the objectives of this article.
(b) To resolve disputes under this article or the rules
proposed herein among participants, subscribers or the public, the
Health Care Authority is hereby authorized to conduct hearings and
render decisions under and pursuant to section twelve, article
twenty-nine-b of this chapter.
§16-29G-8. Privacy; protection of information.
(a) The Health Care Authority shall ensure that patient
specific protected health information be disclosed only in
accordance with the patient's authorization or best interest to
those having a need to know, in compliance with state
confidentiality laws and the Health Insurance Portability and
Accountability Act of 1996 and any amendments and regulations under
the Act.
(b) The health information, data and records of the network
shall be exempt from disclosure under the provisions of chapter
twenty-nine-b of this code.
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 an
HMO 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 article 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. 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-6. 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-7. 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 rate making, 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-8. 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-9. 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-10. 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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