H. B. 4847
(By Delegates Michael, Frederick, Proudfoot, H. K. White,
Browning, Susman, Palumbo, Hall, Border, Ashley and G. White)
[Passed March 11, 2006; in effect ninety days from passage.]
AN ACT to amend the code of West Virginia, 1931, as amended, by
adding thereto a new article designated §33-16F-1, §33-16F-2,
§33-16F-3, §33-16F-4, §33-16F-5, §33-16F-6, §33-16F-7 and §33-
16F-8, all relating to group limited health benefits insurance
plans; declaring legislative intent; requiring approval of
plans by insurance commissioner; providing eligibility
requirements for temporary, part time and seasonal employees
under such plans; setting forth statutory or regulatory
provisions that specifically do or do not apply to such plans;
authorizing insurance commissioner to forbear from enforcing
certain statutory and regulatory provisions; establishing
criteria for filing and approval of premium rates; authorizing
insurance commissioner to promulgate emergency rules;
mandating disclaimer on policies; exempting plans from premium
taxes; providing for severability; and providing rule of
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 article designated §33-16F-1, §33-16F-2,
§33-16F-3, §33-16F-4, §33-16F-5, §33-16F-6, §33-16F-7 and §33-16F-
8, all to read as follows:
ARTICLE 16F. Group limited health benefits plans.
§33-16F-1. Declaration of legislative intent.
The Legislature recognizes that a significant number of West
Virginia workers do not have health insurance coverage and that the
lack of coverage is an issue of affordability. 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 to employees, the
Legislature has determined that authorization of the sale of group
policies with limited benefits that would include physician,
inpatient and outpatient care, including preventive and primary
care, will serve to bring insurance coverage to many of those
working West Virginians and their families without any insurance
coverage. It is, therefore, the intent of the Legislature to
introduce flexibility in the design of group health insurance plans
to allow insurers to offer basic benefits at affordable prices.
This article may be known as the "Affordable Group Health Insurance
§33-16F-2. Eligibility for coverage.
(a) As used in this article, "group plan" means any plan
approved by the commissioner as a "group limited health benefits plan" in accordance with this article. Each such plan constitutes
a health benefit plan "of a particular type" for the purposes of
subsection (a), section three-l, article sixteen and subsection
(d), section seven, article sixteen-d of this chapter.
(b) Notwithstanding any other provision of this code,
including provisions mandating the inclusion of certain benefits in
group health insurance plans, upon filing with and approval by the
Commissioner as a "group limited health benefits plan," any
insurer, including a health maintenance organization or health
service corporation, may offer the plan and rates associated with
the plan to employers, subject to the conditions of this article.
(c) The Commissioner shall only approve a proposed "group
limited health benefits plan" that is limited to coverage of one or
more of the following classes of employees: any class of employees
that comprises part-time, temporary or seasonal employees that: (i)
Are ineligible for coverage under any of the employer's group
health benefits plans, or (ii) are employed by an employer that
does not offer a group health benefits plan to any of its
§33-16F-3. Applicability of other provisions.
(a) The following provisions of article sixteen of this
chapter apply to group limited health benefits plans: Sections
one-a, three, three-j, three-k, three-l, three-m, three-n, three-p,
four, five, six, seven, nine, ten, eleven, thirteen, fourteen and
fifteen; all other provisions of article sixteen do not apply to
plans approved pursuant to this article unless and to the extent such provisions are specifically incorporated in rules promulgated
by the Commissioner.
(b) With respect to any "group limited health benefits plan"
offered to any "small employer," as that term is defined in section
two, article sixteen-d of this chapter, the following provisions of
article sixteen-d apply: Sections two, four, seven, eight, twelve
and thirteen: Provided
, That only the clause preceding the proviso
in section thirteen, article sixteen-d of this chapter applies to
group plans approved pursuant to this article. Notwithstanding any
other provision of this code, all other provisions of article
sixteen-d of this chapter do not apply to group plans approved
pursuant to this article unless and to the extent such provisions
are specifically incorporated in rules promulgated by the
(c) Notwithstanding any other provision of this code or of the
code of state rules, the provisions of article sixteen-e of this
chapter and of legislative rules regulating group accident and
sickness policies, including the rule set forth in series 39, title
114 of the West Virginia Code of State Rules, do not apply to group
plans approved pursuant to this article unless and to the extent
specifically incorporated in rules promulgated by the Commissioner.
(d) The Commissioner may forbear from applying any other
statutory or regulatory requirements to insurers offering a group
plan approved pursuant to this article, including any requirements
in article twenty-four and twenty-five-a, if the Commissioner
determines that such forbearance furthers the legislative intent set forth in section one of this article.
(e) Nothing in this article may be construed to relieve an
insurer or employer from complying with all applicable federal
laws, including federal laws mandating the inclusion of benefits in
an insurance plan.
§33-16F-4. Filing and approval of rates.
(a) Premium rate charges for any group 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 by
the Commissioner. 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.
(c) This section does not apply to group plans issued pursuant
to this article upon which premiums are negotiated with the group
policyholder and are experience rated.
§33-16F-5. Emergency rules authorized; factors to be considered
in determining required benefits.
(a) The Commissioner shall promulgate emergency rules pursuant
to the provisions of section fifteen, article three, chapter
twenty-nine-a of this code on or before the first day of September,
two thousand six, to prescribe requirements regarding ratemaking,
which may include rules establishing loss ratio standards for group
plans; to place further limitations on the eligibility of classes
of employees or employees within a group; to determine benefits
that must be included in such group plans, except that the
Commissioner may not exclude from coverage any benefits mandated by
federal law; and to provide for any other matters deemed necessary
to further the intent of this article.
(b) 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.
Each group 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 GROUP 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."
§33-16F-7. Exemption from premium taxes.
Products authorized under this article are exempt from the
premium taxes and surcharges assessed under article three of this
§33-16F-8. 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