ENGROSSED
COMMITTEE SUBSTITUTE
FOR
H. B. 4043
(By Delegates Beane, Cann, Thompson, Compton, Faircloth, Amores
and Hutchins)
(Originating in the Committee on
Finance)
[March 4, 1998]
A BILL to amend and reenact section eight, article sixteen,
chapter five of the code of West Virginia, one thousand nine
hundred thirty-one, as amended; to amend and reenact section
twenty-one, article one, chapter thirty-three of said code;
to amend article fifteen of said chapter by adding thereto
a new section, designated section twenty-one; to amend and
reenact section three-i, article sixteen of said chapter; to
amend and reenact section seven-e, article twenty-four of
said chapter; to amend and reenact section eight-d, article
twenty-five of said chapter; and to amend and reenact
section eight-d, article twenty-five-a of said chapter, all
relating to defining emergency medical services and
emergency medical condition; requiring coverage for medical
screenings and stabilization of emergency medical
conditions; and directing that services be covered for
prudent layperson; and requiring reporting to the
legislative oversight commission on health and human
resources accountability.
Be it enacted by the Legislature of West Virginia:
That section eight, article sixteen, chapter five of the
code of West Virginia, one thousand nine hundred thirty-one, as
amended, be amended and reenacted; that section twenty-one,
article one, chapter thirty-three of said code be amended and
reenacted; that article fifteen of said chapter be amended by
adding thereto a new section, designated section twenty-one; that
section three-i, article sixteen of said chapter be amended and
reenacted; that section seven-e, article twenty-four of said
chapter be amended and reenacted; that section eight-d, article
twenty-five of said chapter be amended and reenacted; and that
section eight-d, article twenty-five-a of said chapter be amended
and reenacted, 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 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.
§5-16-8. Conditions of insurance program.
The insurance plans herein provided for shall be designed by
the public employees insurance agency:
(1) To provide a reasonable relationship between the
hospital, surgical, medical and prescription drug benefits to be
included and the expected reasonable and customary hospital,
surgical, medical and prescription drug expenses as established
by the director to be incurred by the affected employee, his or
her spouse and his or her dependents. The establishment of reasonable and customary expenses by the public employees
insurance agency pursuant to the preceding sentence is not
subject to the state administrative procedures act in chapter
twenty-nine-a of this code.
(2) To include reasonable controls which may include
deductible and coinsurance provisions applicable to some or all
of the benefits, and shall include other provisions, including,
but not limited to, copayments, preadmission certification, case
management programs and preferred provider arrangements.
(3) To prevent unnecessary utilization of the various
hospital, surgical, medical and prescription drug services
available.
(4) To provide reasonable assurance of stability in future
years for the plans.
(5) To provide major medical insurance for said employees.
(6) To provide certain group life and accidental death
insurance for the employees covered under this article.
(7) To include provisions for the coordination of benefits
payable by the terms of such plans with the benefits to which
such employee, or his or her spouse or his or her dependents may
be entitled by the provisions of any other group hospital,
surgical, medical, major medical, or prescription drug insurance
or any combination thereof.
(8) To provide a cash incentive plan for employees, spouses
and dependents by the thirty-first day of December, one thousand
nine hundred eighty-eight, to increase utilization of, and to encourage the use of, lower cost alternative health care
facilities, health care providers and generic drugs. Such plan
shall be reviewed annually by the director and the advisory
board.
(9) To provide "wellness" programs and activities which will
include, but not be limited to, benefit plan incentives to
discourage tobacco, alcohol and chemical abuse and an educational
program to encourage proper diet and exercise. In establishing
"wellness" programs, the division of vocational rehabilitation
shall cooperate with the public employees insurance agency in
establishing statewide wellness programs and with such division
of vocational rehabilitation to contact county boards of
education for the use of facilities, equipment or any service
related to such purpose, at the request of the director, under
the authority hereby granted to contract therefor. Boards of
education shall be limited to charging only the cost of
janitorial service and increased utilities for the use of the
gymnasium and related equipment. The cost of the exercise
program shall be paid by county boards of education, the public
employees insurance agency, or participating employees, their
spouses or dependents. All exercise programs shall be made
available to all employees, their spouses or dependents and shall
not be limited to employees of county boards of education.
(10) To provide a program, to be administered by the
director, for a patient audit plan with reimbursement up to a
maximum of one thousand dollars annually, to employees for discovery of health care provider or hospital overcharges when
the affected employee brings such overcharge to the attention of
the plan. The hospital or health care provider shall certify to
the director that it has provided, prior to or simultaneously
with the submission of the statement of charges for payments, an
itemized statement of the charges to the employee participant for
which payment is requested of the plan.
(11) To require that all employers give written notice to
each covered employee prior to institution of any changes in
benefits to employees, and to include appropriate penalty for any
employer not providing the required information to any employee.
(12) To provide coverage for emergency services under
offered plans. For the purposes of this subsection, "emergency
services" means services provided in or by a hospital emergency
facility or the private office of a dentist to evaluate and treat
a medical condition manifesting itself by the sudden, and at the
time, unexpected onset of symptoms that require immediate medical
attention and that failure to provide medical attention would
result in serious impairment to bodily function, serious
dysfunction to any bodily organ or part, or would place the
person's health in jeopardy. From the first day of July, one
thousand nine hundred ninety-eight, through the thirtieth day of
June, two thousand, the following provisions shall apply: Plans
shall provide coverage for emergency services, including any pre- hospital services, to the extent necessary to screen and
stabilize the covered person. The plans shall reimburse, less any applicable copayments, deductibles, or coinsurnace, for
emergency services rendered and related to the condition for
which the covered person presented. Prior authorization of
coverage shall not be required for the screening services if a
prudent layperson acting reasonably would have believed that an
emergency medical condition existed. Prior authorization of
coverage shall not be required for stabilization if an emergency
medical condition exists. In the event that prior authorization
was obtained, such authorization may not be retracted after the
services have been provided except when the authorization was
based on a material misrepresentation about the medical condition
by the provider of the services or the insured person. The
provider of the emergency services and the plan representative
shall make a good faith effort to communicate with each other in
a timely fashion to expedite postevaluation or poststabilization
services. Payment of claims for emergency services shall be
based on the retrospective review of the presenting history and
symptoms of the covered person. For purposes of this
subdivision: (A) "Emergency services" means those services
required to screen for or treat an emergency medical condition
until the condition is stabilized, including prehospital care;
(B) "prudent layperson" means a person who is without medical
training and who draws on his or her practical experience when
making a decision regarding whether an emergency medical
condition exists for which emergency treatment should be sought;
(C) "emergency medical condition for the prudent layperson" means one that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the person could
reasonably expect the absence of immediate medical attention to
result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction of
any bodily organ or part; (D) "stabilize" means with respect to
an emergency medical condition, to provide such medical treatment
of the condition as may be necessary to assure, with reasonable
medical probability that no medical deterioration of the
condition is likely to result from or occur during the transfer
of the individual from a facility; and (E) "medical screening
examination" means an appropriate examination within the
capability of the hospital's emergency department, including
ancillary services routinely available to the emergency
department, to determine whether or not an emergency medical
condition exists. The director is to report quarterly to the
legislative oversight commission on health and human resources
accountability on the utilization of emergency services, the cost
of those services, a comparison of utilization and costs between
enrollees of the various plans, and possible plan amendments
designed to decrease any inappropriate utilization of emergency
services.
CHAPTER 33. INSURANCE.
ARTICLE 1. DEFINITIONS.
§33-1-21. Emergency services.
(a) Emergency services are: those services provided in or
by a hospital emergency facility or the private office of a
dentist to evaluate and treat a medical condition manifesting
itself by the sudden, and at the time, unexpected onset of
symptoms that require immediate medical attention and that
failure to provide medical attention would result in serious
impairment to bodily function, serious dysfunction to any bodily
organ or part, or would place the person's health in jeopardy.
(b) From the first day of July, one thousand nine hundred
ninety-eight, through the thirtieth day of June, two thousand,
the following provisions shall apply:
(1) "Emergency medical services" means those services
required to screen for or treat an emergency medical condition
until the condition is stabilized, including prehospital care. (2) "Prudent layperson" means a person who is without
medical training and who draws on his or her practical experience
when making a decision regarding whether an emergency medical
condition exists for which emergency treatment should be sought.
(3) "Emergency medical condition for the prudent layperson"
means one that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the person could
reasonably expect the absence of immediate medical attention to
result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction of
any bodily organ or part.
(4) "Stabilize" means with respect to an emergency medical
condition, to provide such medical treatment of the condition as
may be necessary to assure, with reasonable medical probability
that no medical deterioration of the condition is likely to
result from or occur during the transfer of the individual from
a facility.
(5) "Medical screening examination" means an appropriate
examination within the capability of the hospital's emergency
department, including ancillary services routinely available to
the emergency department, to determine whether or not an
emergency medical condition exists.
ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.
§33-15-21. Coverage of emergency services.
From the first day of July, one thousand nine hundred
ninety-eight, through the thirtieth day of June, two thousand,
the following provisions shall apply:
(a) Every insurer shall provide coverage for emergency
medical services, including pre-hospital services, to the extent
necessary to screen and to stabilize an emergency medical
condition. The insurer shall not require prior authorization of
the services if a prudent layperson acting reasonably would have
believed that an emergency medical condition existed. Payment of
claims for emergency services shall be based on the retrospective
review of the presenting history and symptoms of the covered
person.
(b) An insurer that has given prior authorization for emergency services shall cover the services and shall not retract
the authorization after the services have been provided unless
the authorization was based on a material misrepresentation about
the covered person's health condition made by the referring
provider, the provider of the emergency services or the covered
person.
(c) Coverage of emergency services shall be subject to
coinsurance, co-payments and deductibles applicable under the
health benefit plan.
(d) The emergency department and the insurer shall make a
good faith effort to communicate with each other in a timely
fashion to expedite postevaluation or poststabilization services
in order to avoid material deterioration of the covered person's
condition.
(e) As used in this section:
(1) "Emergency medical services" means those services
required to screen for or treat an emergency medical condition
until the condition is stabilized, including prehospital care; (2) "Prudent layperson" means a person who is without
medical training and who draws on his or her practical experience
when making a decision regarding whether an emergency medical
condition exists for which emergency treatment should be sought;
(3) "Emergency medical condition for the prudent layperson"
means one that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the person could
reasonably expect the absence of immediate medical attention to result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction of
any bodily organ or part;
(4) "Stabilize" means with respect to an emergency medical
condition, to provide such medical treatment of the condition as
may be necessary to assure, with reasonable medical probability
that no medical deterioration of the condition is likely to
result from or occur during the transfer of the individual from
a facility; and
(5) "Medical screening examination" means an appropriate
examination within the capability of the hospital's emergency
department, including ancillary services routinely available to
the emergency department, to determine whether or not an
emergency medical condition exists.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-3i. Coverage of emergency services.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
entity regulated by this article shall
on and after the first day
of July, one thousand nine hundred ninety-six, provide as
benefits to all subscribers and members coverage for emergency
services. A policy, provision, contract, plan or agreement may
apply to emergency services the same deductibles, coinsurance and
other limitations as apply to other covered services:
Provided,
That preauthorization or precertification shall not be required.
(b) From the first day of July, one thousand nine hundred
ninety-eight, through the thirtieth day of June, two thousand,
the following provisions shall apply:
(1) Every insurer shall provide coverage for emergency
medical services, including pre-hospital services, to the extent
necessary to screen and to stabilize an emergency medical
condition. The insurer shall not require prior authorization of
the services if a prudent layperson acting reasonably would have
believed that an emergency medical condition existed. Payment of
claims for emergency services shall be based on the retrospective
review of the presenting history and symptoms of the covered
person.
(2) An insurer that has given prior authorization for
emergency services shall cover the services and shall not retract
the authorization after the services have been provided unless
the authorization was based on a material misrepresentation about
the covered person's health condition made by the referring
provider, the provider of the emergency services or the covered
person.
(3) Coverage of emergency services shall be subject to
coinsurance, co-payments and deductibles applicable under the
health benefit plan.
(4) The emergency department and the insurer shall make a
good faith effort to communicate with each other in a timely
fashion to expedite postevaluation or poststabilization services
in order to avoid material deterioration of the covered person's condition.
(5) As used in this section:
(A) "Emergency medical services" means those services
required to screen for or treat an emergency medical condition
until the condition is stabilized, including prehospital care; (B) "Prudent layperson" means a person who is without
medical training and who draws on his or her practical experience
when making a decision regarding whether an emergency medical
condition exists for which emergency treatment should be sought;
(C) "Emergency medical condition for the prudent layperson"
means one that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the person could
reasonably expect the absence of immediate medical attention to
result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction of
any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical
condition, to provide such medical treatment of the condition as
may be necessary to assure, with reasonable medical probability
that no medical deterioration of the condition is likely to
result from or occur during the transfer of the individual from
a facility; and
(E) "Medical screening examination" means an appropriate
examination within the capability of the hospital's emergency
department, including ancillary services routinely available to the emergency department, to determine whether or not an
emergency medical condition exists.
(c) The commissioner shall require periodic reports
regarding emergency services utilization and costs provided
pursuant to the provisions of this article. Those reports will
be provided quarterly to the legislative oversight commission on
health and human resources accountability.
ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE
CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH SERVICE CORPORATIONS.
§33-24-7e. Coverage of emergency services.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
entity regulated by this article shall
on and after the first day
of July, one thousand nine hundred ninety-six, provide as
benefits to all subscribers and members coverage for emergency
services. A policy, provision, contract, plan or agreement may
apply to emergency services the same deductibles, coinsurance and
other limitations as apply to other covered services:
Provided,
That preauthorization or recertification shall not be required.
(b) From the first day of July, one thousand nine hundred
ninety-eight, through the thirtieth day of June, two thousand,
the following provisions shall apply:
(1) Every insurer shall provide coverage for emergency
medical services, including pre-hospital services, to the extent
necessary to screen and to stabilize an emergency medical condition. The insurer shall not require prior authorization of
the services if a prudent layperson acting reasonably would have
believed that an emergency medical condition existed. Payment of
claims for emergency services shall be based on the retrospective
review of the presenting history and symptoms of the covered
person.
(2) An insurer that has given prior authorization for
emergency services shall cover the services and shall not retract
the authorization after the services have been provided unless
the authorization was based on a material misrepresentation about
the covered person's health condition made by the referring
provider, the provider of the emergency services or the covered
person.
(3) Coverage of emergency services shall be subject to
coinsurance, co-payments and deductibles applicable under the
health benefit plan.
(4) The emergency department and the insurer shall make a
good faith effort to communicate with each other in a timely
fashion to expedite postevaluation or poststabilization services
in order to avoid material deterioration of the covered person's
condition.
(5) As used in this section:
(A) "Emergency medical services" means those services
required to screen for or treat an emergency medical condition
until the condition is stabilized, including prehospital care; (B) "Prudent layperson" means a person who is without medical training and who draws on his or her practical experience
when making a decision regarding whether an emergency medical
condition exists for which emergency treatment should be sought;
(C) "Emergency medical condition for the prudent layperson"
means one that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the person could
reasonably expect the absence of immediate medical attention to
result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction of
any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical
condition, to provide such medical treatment of the condition as
may be necessary to assure, with reasonable medical probability
that no medical deterioration of the condition is likely to
result from or occur during the transfer of the individual from
a facility; and
(E) "Medical screening examination" means an appropriate
examination within the capability of the hospital's emergency
department, including ancillary services routinely available to
the emergency department, to determine whether or not an
emergency medical condition exists.
ARTICLE 25. HEALTH CARE CORPORATIONS.
§33-25-8d. Coverage of emergency services.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any entity regulated by this article shall
on and after the first day
of July, one thousand nine hundred ninety-six, provide as
benefits to all subscribers and members coverage for emergency
services. A policy, provision, contract, plan or agreement may
apply to emergency services the same deductibles, coinsurance and
other limitations as apply to other covered services:
Provided,
That preauthorization or precertification shall not be required.
(b) From the first day of July, one thousand nine hundred
ninety-eight, through the thirtieth day of June, two thousand,
the following provisions shall apply:
(1) Every insurer shall provide coverage for emergency
medical services, including pre-hospital services, to the extent
necessary to screen and to stabilize an emergency medical
condition. The insurer shall not require prior authorization of
the services if a prudent layperson acting reasonably would have
believed that an emergency medical condition existed. Payment of
claims for emergency services shall be based on the retrospective
review of the presenting history and symptoms of the covered
person.
(2) An insurer that has given prior authorization for
emergency services shall cover the services and shall not retract
the authorization after the services have been provided unless
the authorization was based on a material misrepresentation about
the covered person's health condition made by the referring
provider, the provider of the emergency services or the covered
person.
(3) Coverage of emergency services shall be subject to
coinsurance, co-payments and deductibles applicable under the
health benefit plan.
(4) The emergency department and the insurer shall make a
good faith effort to communicate with each other in a timely
fashion to expedite postevaluation or poststabilization services
in order to avoid material deterioration of the covered person's
condition.
(5) As used in this section:
(A) "Emergency medical services" means those services
required to screen for or treat an emergency medical condition
until the condition is stabilized, including prehospital care; (B) "Prudent layperson" means a person who is without
medical training and who draws on his or her practical experience
when making a decision regarding whether an emergency medical
condition exists for which emergency treatment should be sought;
(C) "Emergency medical condition for the prudent layperson"
means one that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the person could
reasonably expect the absence of immediate medical attention to
result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction of
any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical
condition, to provide such medical treatment of the condition as may be necessary to assure, with reasonable medical probability
that no medical deterioration of the condition is likely to
result from or occur during the transfer of the individual from
a facility; and
(E) "Medical screening examination" means an appropriate
examination within the capability of the hospital's emergency
department, including ancillary services routinely available to
the emergency department, to determine whether or not an
emergency medical condition exists.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-8d. Coverage of emergency services.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
entity regulated by this article shall
on and after the first day
of July, one thousand nine hundred ninety-six, provide as
benefits to all subscribers and members coverage for emergency
services. A policy, provision, contract, plan or agreement may
apply to emergency services the same deductibles, coinsurance and
other limitations as apply to other covered services:
Provided,
That preauthorization or precertification shall not be required.
(b) From the first day of July, one thousand nine hundred
ninety-eight, through the thirtieth day of June, two thousand,
the following provisions shall apply:
(1) Every insurer shall provide coverage for emergency
medical services, including pre-hospital services, to the extent
necessary to screen and to stabilize an emergency medical condition. The insurer shall not require prior authorization of
the services if a prudent layperson acting reasonably would have
believed that an emergency medical condition existed. Payment of
claims for emergency services shall be based on the retrospective
review of the presenting history and symptoms of the covered
person.
(2) An insurer that has given prior authorization for
emergency services shall cover the services and shall not retract
the authorization after the services have been provided unless
the authorization was based on a material misrepresentation about
the covered person's health condition made by the referring
provider, the provider of the emergency services or the covered
person.
(3) Coverage of emergency services shall be subject to
coinsurance, co-payments and deductibles applicable under the
health benefit plan.
(4) The emergency department and the insurer shall make a
good faith effort to communicate with each other in a timely
fashion to expedite postevaluation or poststabilization services
in order to avoid material deterioration of the covered person's
condition.
(5) As used in this section:
(A) "Emergency medical services" means those services
required to screen for or treat an emergency medical condition
until the condition is stabilized, including prehospital care; (B) "Prudent layperson" means a person who is without medical training and who draws on his or her practical experience
when making a decision regarding whether an emergency medical
condition exists for which emergency treatment should be sought;
(C) "Emergency medical condition for the prudent layperson"
means one that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the person could
reasonably expect the absence of immediate medical attention to
result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction of
any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical
condition, to provide such medical treatment of the condition as
may be necessary to assure, with reasonable medical probability
that no medical deterioration of the condition is likely to
result from or occur during the transfer of the individual from
a facility; and
(E) "Medical screening examination" means an appropriate
examination within the capability of the hospital's emergency
department, including ancillary services routinely available to
the emergency department, to determine whether or not an
emergency medical condition exists.
(6) Each insurer shall provide the enrolled member with a
description of procedures to be followed by the member for
emergency services, including the following:
(A) The appropriate use of emergency facilities;
(B) The appropriate use of any prehospital services provided
by the health maintenance organization;
(C) Any potential responsibility of the member for payment
for nonemergency services rendered in an emergency facility; (D) Any cost-sharing provisions for emergency services; and
(E) An explanation of the prudent layperson standard for
emergency medical condition.
(c) The commissioner shall require periodic reports
regarding emergency services utilization and costs provided
pursuant to the provisions of this article. Those reports will
be provided quarterly to the legislative oversight commission on
health and human resources accountability.