HB 4043 Text

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.

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. Provided, That coverage shall only be provided for an appropriate medical screening to determine whether an emergency medical condition exists when the individual seeking medical treatment has a medical condition manifesting itself by acute symptoms of such 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 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. A prudent layperson is, among other things, a person who uses all resources available to him or her to determine the need for emergency services, including services provided by the health plan or insurer with whom he is insured. It is recognized that the emergency room is not the proper place to treat non-emergency conditions and, if used as such, costs of health care are unnecessarily increased for the consumer. For purposes of this subdivision:
(A) "Emergency services" means:
(1) Those services, including pre-hospital services, necessary to conduct an appropriate medical screening examination to determine whether an emergency medical condition exists; and
(2) If an emergency medical condition exists, those services which are necessary to stabilize the individual;
(B) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
(i) 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;
(ii) serious impairment to bodily functions; or
(iii) serious dysfunction of any bodily organ or part.
(C) "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.
(D) "Medical screening examination" means an initial examination or process by qualified licensed or certified medical personnel which distinguishes on a medical necessity basis the existence of emergency medical conditions from those medical conditions which can be addressed later and which can be safely managed in a physician's office, clinic or other appropriate setting; and is not a determination of a final diagnosis but only a determination as to the presence or the absence of an emergency medical condition.
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) "Emergency services" means:
(1) Those services, including pre-hospital services, necessary to conduct an appropriate medical screening examination to determine whether an emergency medical condition exists; and
(2) If an emergency medical condition exists, those services which are necessary to stabilize the individual;
(b) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
(1) 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;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
(c) "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.
(d) "Medical screening examination" means an initial examination or process by qualified licensed or certified medical personnel which distinguishes on a medical necessity basis the existence of emergency medical conditions from those medical conditions which can be addressed later and which can be safely managed in a physician's office, clinic or other appropriate setting; and is not a determination of a final diagnosis but only a determination as to the presence or the absence of an emergency medical condition.

ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.

§33-15-21. Coverage of emergency services.

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. Provided, however, That coverage shall only be provided for an appropriate medical screening to determine whether an emergency medical condition exists when the individual seeking medical treatment has a medical condition manifesting itself by acute symptoms of such 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 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. A prudent layperson is, among other things, a person who uses all resources available to him or her to determine the need for emergency services, including services provided by the health plan or insurer with whom he is insured. It is recognized that the emergency room is not the proper place to treat non-emergency conditions and, if used as such, costs of health care are unnecessarily increased for the consumer. For purposes of this section:
(1) "Emergency services" means:
(A) Those services, including pre-hospital services, necessary to conduct an appropriate medical screening examination to determine whether an emergency medical condition exists; and
(B) If an emergency medical condition exists, those services which are necessary to stabilize the individual;
(2) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
(A) 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;
(B) serious impairment to bodily functions; or
(C) serious dysfunction of any bodily organ or part.
(3) "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.
(4) "Medical screening examination" means an initial examination or process by qualified licensed or certified medical personnel which distinguishes on a medical necessity basis the existence of emergency medical conditions from those medical conditions which can be addressed later and which can be safely managed in a physician's office, clinic or other appropriate setting; and is not a determination of a final diagnosis but only a determination as to the presence or the absence of an emergency medical condition.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.

§33-16-3i. Coverage of emergency services.
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. Provided, however, That coverage shall only be provided for an appropriate medical screening to determine whether an emergency medical condition exists when the individual seeking medical treatment has a medical condition manifesting itself by acute symptoms of such 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 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. A prudent layperson is, among other things, a person who uses all resources available to him or her to determine the need for emergency services, including services provided by the health plan or insurer with whom he is insured. It is recognized that the emergency room is not the proper place to treat non-emergency conditions and, if used as such, costs of health care are unnecessarily increased for the consumer. For purposes of this section:
(1) "Emergency services" means:
(A) Those services, including pre-hospital services, necessary to conduct an appropriate medical screening examination to determine whether an emergency medical condition exists; and
(B) If an emergency medical condition exists, those services which are necessary to stabilize the individual;
(2) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
(A) 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;
(B) serious impairment to bodily functions; or
(C) serious dysfunction of any bodily organ or part.
(3) "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.
(4) "Medical screening examination" means an initial examination or process by qualified licensed or certified medical personnel which distinguishes on a medical necessity basis the existence of emergency medical conditions from those medical conditions which can be addressed later and which can be safely managed in a physician's office, clinic or other appropriate setting; and is not a determination of a final diagnosis but only a determination as to the presence or the absence of an emergency medical condition.
ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH SERVICE CORPORATIONS.
§33-24-7e. Coverage of emergency services.
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.
Provided, however, That coverage shall only be provided for an appropriate medical screening to determine whether an emergency medical condition exists when the individual seeking medical treatment has a medical condition manifesting itself by acute symptoms of such 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 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. A prudent layperson is, among other things, a person who uses all resources available to him or her to determine the need for emergency services, including services provided by the health plan or insurer with whom he is insured. It is recognized that the emergency room is not the proper place to treat non-emergency conditions and, if used as such, costs of health care are unnecessarily increased for the consumer. For purposes of this section:
(1) "Emergency services" means:
(A) Those services, including pre-hospital services, necessary to conduct an appropriate medical screening examination to determine whether an emergency medical condition exists; and
(B) If an emergency medical condition exists, those services which are necessary to stabilize the individual;
(2) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
(A) 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;
(B) serious impairment to bodily functions; or
(C) serious dysfunction of any bodily organ or part.
(3) "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.
(4) "Medical screening examination" means an initial examination or process by qualified licensed or certified medical personnel which distinguishes on a medical necessity basis the existence of emergency medical conditions from those medical conditions which can be addressed later and which can be safely managed in a physician's office, clinic or other appropriate setting; and is not a determination of a final diagnosis but only a determination as to the presence or the absence of an emergency medical condition.
ARTICLE 25. HEALTH CARE CORPORATIONS.

§33-25-8d. Coverage of emergency services.
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.
Provided, however, That coverage shall only be provided for an appropriate medical screening to determine whether an emergency medical condition exists when the individual seeking medical treatment has a medical condition manifesting itself by acute symptoms of such 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 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. A prudent layperson is, among other things, a person who uses all resources available to him or her to determine the need for emergency services, including services provided by the health plan or insurer with whom he is insured. It is recognized that the emergency room is not the proper place to treat non-emergency conditions and, if used as such, costs of health care are unnecessarily increased for the consumer. For purposes of this subsection:
(1) "Emergency services" means:
(A) Those services, including pre-hospital services, necessary to conduct an appropriate medical screening examination to determine whether an emergency medical condition exists; and
(B) If an emergency medical condition exists, those services which are necessary to stabilize the individual;
(2) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
(A) 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;
(B) serious impairment to bodily functions; or
(C) serious dysfunction of any bodily organ or part.
(3) "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.
(4) "Medical screening examination" means an initial examination or process by qualified licensed or certified medical personnel which distinguishes on a medical necessity basis the existence of emergency medical conditions from those medical conditions which can be addressed later and which can be safely managed in a physician's office, clinic or other appropriate setting; and is not a determination of a final diagnosis but only a determination as to the presence or the absence of an emergency medical condition.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.

§33-25A-8d. Coverage of emergency services.
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.
Provided, however, That coverage shall only be provided for an appropriate medical screening to determine whether an emergency medical condition exists when the individual seeking medical treatment has a medical condition manifesting itself by acute symptoms of such 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 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. A prudent layperson is, among other things, a person who uses all resources available to him or her to determine the need for emergency services, including services provided by the health plan or insurer with whom he is insured. It is recognized that the emergency room is not the proper place to treat non-emergency conditions and, if used as such, costs of health care are unnecessarily increased for the consumer. For purposes of this section:
(1) "Emergency services" means:
(A)Those services, including pre-hospital services, necessary to conduct an appropriate medical screening examination to determine whether an emergency medical condition exists; and
(B) If an emergency medical condition exists, those services which are necessary to stabilize the individual;
(2) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
(A) 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;
(B) Serious impairment to bodily functions; or
(C) Serious dysfunction of any bodily organ or part.
(3) "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.
(4) "Medical screening examination" means an initial examination or process by qualified licensed or certified medical personnel which distinguishes on a medical necessity basis the existence of emergency medical conditions from those medical conditions which can be addressed later and which can be safely managed in a physician's office, clinic or other appropriate setting; and is not a determination of a final diagnosis but only a determination as to the presence or the absence of an emergency medical condition.

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