Senate Bill No. 465
(By Senator Walker)
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[Introduced February 19, 1996; referred to the Committee
on Banking and Insurance.]
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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 article one, chapter thirty-
three of said code by adding thereto a new section, designated
section twenty-one; to amend article sixteen of said chapter
by adding thereto a new section, designated section three-i;
to amend article twenty-four of said chapter by adding thereto
a new section, designated section seven-e; to amend article
twenty-five of said chapter by adding thereto a new section,
designated section eight-d; and to amend article twenty-five-a
of said chapter by adding thereto a new section, designated
section eight-d, all relating to the West Virginia public employees insurance agency and other cooperative or private
third-party payors of health services; defining emergency
services for purposes of coverage within policies issued for
accidents and sickness; requiring emergency services coverage
to be included in policies issued for groups under the West
Virginia public employees insurance agency; hospital, medical
and dental corporations; health care corporations; and health
maintenance organizations.
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 article one, chapter thirty-three of
said code be amended by adding thereto a new section, designated
section twenty-one; that article sixteen of said chapter be amended
by adding thereto a new section, designated section three-i; that
article twenty-four of said chapter be amended by adding thereto a
new section, designated section seven-e; that article twenty-five
of said chapter be amended by adding thereto a new section,
designated section eight-d; and that article twenty-five-a of said
chapter be amended by adding thereto a new section, designated
section eight-d, 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 to
evaluate and treat a medical condition manifesting itself by
symptoms of sufficient severity that the absence of prompt medical
attention could reasonably be expected by a prudent lay person, who
possesses an average knowledge of health and medicine, to result in
placing the health of the recipient of those services in serious
jeopardy, serious impairment to body function, serious dysfunction
of any body organ or part or the continuance of severe pain.
CHAPTER 33. INSURANCE.
ARTICLE 1. DEFINITIONS.
§33-1-21. Emergency services.
Emergency services are those services provided in or by a
hospital emergency facility to evaluate and treat a medical
condition manifesting itself by symptoms of sufficient severity
that the absence of prompt medical attention could reasonably be
expected by a prudent lay person, who possesses an average
knowledge of health and medicine, to result in placing the health
of the recipient of the services in serious jeopardy, serious
impairment to body function, serious dysfunction of any body organ
or part or the continuance of severe pain.
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.
ARTICLE 24. HOSPITAL, MEDICAL AND DENTAL 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.
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.
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.
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(NOTE: The purpose of this bill is to require the Public
Employees Insurance Agency, cooperative and private third-party
payors to provide coverage for emergency services, defined as those
services provided in or by a hospital emergency facility to
evaluate and treat a medical condition manifesting itself by
symptoms of sufficient severity that the absence of prompt medical
attention could reasonably be expected by a prudent lay person, who
possesses an average knowledge of health and medicine, to result in
placing the health of the recipient of such services in serious
jeopardy, serious impairment to body function, serious dysfunction of any body organ or part or the continuance of severe pain.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.
§§31-1-21, 33-16-3i, 33-24-7e, 33-25-8d and 33-25A-8d are new;
therefore, strike-throughs and underscoring have been omitted.)
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BANKING AND INSURANCE COMMITTEE AMENDMENTS
On page five, section eight, line twenty-two, after the word
"by" by striking out the remainder of the paragraph and inserting
in lieu thereof the words "the sudden, and at the time, unexpected
onset of a health condition tht requires 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.";
And,
On page six, section twenty-one, line eight, after he word
"by" by striking out the remainder of the paragraph and inserting
in lieu thereof the words "the sudden, and at the time, unexpected
onset of a health condition tht requires 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."