HB 4043 Text

H. B. 4043

(By Delegates Beane, Cann, Thompson,

Compton Faircloth, Amores and Hutchins)

[Introduced January 21, 1998; referred to the
Committee on Banking and Insurance then Finance.]

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 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; to amend and reenact section eight-d, article twenty-five-a of said chapter; to amend article one of said chapter by adding thereto a new section, designated section twenty-two; and to amend article fifteen of said chapter by adding thereto a new section, designated section twenty-one, all relating to deleting the past deadline date for the public employees insurance agency to provide cash incentive plans; and providing definitions relative to services provided during emergencies.

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 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; that section eight-d, article twenty-five-a of said chapter thirty-three be amended and reenacted; that article one, chapter thirty-three of said code be amended by adding thereto a new section, designated section twenty-two; and that article fifteen of chapter thirty-three be amended by adding thereto a new section, designated section twenty-one, 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. the following definitions shall apply:
(A) "Emergency services" are:
(i) Those services which are needed to evaluate and stabilize an emergency medical condition;
(ii) An initial medical screening examination and any immediately necessary stabilizing treatment as required by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §1395dd; or
(iii) Any emergency service which any insurer, health maintenance organization, health care corporation, hospital, medical or dental corporation or any other third-party payor, or any representative thereof, has authorized, directed, referred or otherwise required or permitted the insured to use or obtain;
(B) "Emergency Medical Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual, or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.
CHAPTER 33. INSURANCE.
ARTICLE 1. DEFINITIONS.

§33-1-21. Emergency services.
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.
(a) Those services which are needed to evaluate and stabilize an emergency medical condition;
(b) An initial medical screening examination and any immediately necessary stabilizing treatment as required by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §1395dd; or
(c) Any emergency service which any insurer, health maintenance organization, health care corporation, hospital, medical or dental corporation or any other third-party payor, or any representative thereof, has authorized, directed, referred or otherwise required or permitted the insured to use or obtain.
§33-1-22. Emergency medical condition.
"Emergency Medical Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual, or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.

ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.

§33-15-21. 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 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) For purposes of this article, the following definitions shall apply:
(1) "Emergency services" are:
(A) Those services which are needed to evaluate and stabilize an emergency medical condition;
(B An initial medical screening examination and any immediately necessary stabilizing treatment as required by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §1395dd; or
(C) Any emergency service which any insurer, health maintenance organization, health care corporation, hospital, medical or dental corporation or any other third-party payor, or any representative thereof, has authorized, directed, referred or otherwise required or permitted the insured to use or obtain.
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) For purposes of this article, the following definitions shall apply:
(1) "Emergency services" are:
(a) Those services which are needed to evaluate and stabilize an emergency medical condition;
(b) An initial medical screening examination and any immediately necessary stabilizing treatment as required by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §1395dd; or
(c) Any emergency service which any insurer, health maintenance organization, health care corporation, hospital, medical or dental corporation or any other third-party payor, or any representative thereof, has authorized, directed, referred or otherwise required or permitted the insured to use or obtain.
(2) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual, or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.
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) For purposes of this article, the following definitions shall apply:
(1) "Emergency services" are:
(a) Those services which are needed to evaluate and stabilize an emergency medical condition;
(b) An initial medical screening examination and any immediately necessary stabilizing treatment as required by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §1395dd; or
(c) Any emergency service which any insurer, health maintenance organization, health care corporation, hospital, medical or dental corporation or any other third-party payor, or any representative thereof, has authorized, directed, referred or otherwise required or permitted the insured to use or obtain.
(2) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual, or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.
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) For purposes of this article, the following definitions shall apply:
(1) "Emergency services" are:
(a) Those services which are needed to evaluate and stabilize an emergency medical condition;
(b) An initial medical screening examination and any immediately necessary stabilizing treatment as required by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §1395dd; or
(c) Any emergency service which any insurer, health maintenance organization, health care corporation, hospital, medical or dental corporation or any other third-party payor, or any representative thereof, has authorized, directed, referred or otherwise required or permitted the insured to use or obtain.
(2) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual, or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.
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) For purposes of this article, the following definitions shall apply:
(1) "Emergency services" are:
(a) Those services which are needed to evaluate and stabilize an emergency medical condition;
(b) An initial medical screening examination and any immediately necessary stabilizing treatment as required by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §1395dd; or
(c) Any emergency service which any insurer, health maintenance organization, health care corporation, hospital, medical or dental corporation or any other third-party payor, or any representative thereof, has authorized, directed, referred or otherwise required or permitted the insured to use or obtain.
(2) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual, or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.

NOTE: The purpose of this bill is to change the definition of emergency services so as to be consistent with federal practice requirements for emergency room physicians and to also define "emergency medical condition." The definitions apply to the public employees insurance agency, individual and group accident and sickness insurance policies, hospital, medical and dental corporations, health care corporations and health maintenance organizations.

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

§§33-1-22 and 33-15-21 are new; therefore, strike-throughs and underscoring have been omitted.

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