H. B. 4021
(By Mr. Speaker, Mr. Kiss, and Delegate Trump)
[By Request of the Executive]
[Introduced January 16, 2006; referred to the
Committee on Finance.]
A BILL to amend the Code of West Virginia, 1931, as amended, by
adding thereto a new article, designated §16-2J-1, §16-2J-2,
§16-2J-3, §16-2J-4, §16-2J-5, §16-2J-6, §16-2J-7, §16-2J-8 and
§16-2J-9, all relating to a pilot program authorizing
participating health care clinics and private medical
practitioners to provide primary and preventive health
services for a prepaid fee; declaring legislative intent;
authorizing approval of participants based on guidelines
developed by the Health Care Authority and the Insurance
Commissioner; requiring licensure by the Health Care
Authority; authorizing the Insurance Commissioner to approve
fees, marketing materials and forms and to certify financial
soundness; exempting participating providers from insurance
regulation; authorizing study of the program by the Health
Care Authority; mandating a Health Care Authority report to the Legislative Oversight Commission; setting grounds for
revocation, suspension and failure to renew licenses; and
creating penalties.
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 §16-2J-1, §16-2J-2,
§16-2J-3, §16-2J-4, §16-2J-5, §16-2J-6, §16-2J-7, §16-2J-8 and
§16-2J-9, all to read as follows:
ARTICLE 2J. PREVENTIVE CARE CLINIC-BASED PILOT PROGRAM.
§16-2J-1. Legislative findings and statement of purpose.
(a) The Legislature finds and declares that a pilot program
that would allow health clinics and private medical practitioners
to provide primary and preventive health services for a prepaid fee
would enable state health and insurance officials to study this
method of delivering health services and to determine the
feasibility of expanding such a program and allowing similar
programs to operate on a statewide basis.
(b) In carrying out this pilot program, it is the intent of
the Legislature
to eliminate legal barriers to the establishment of
pilot programs providing preventive and primary care services for
a prepaid fee; to encourage residents of this state to establish
and use a "medical home"; to expand preventive and primary care
services for the uninsured; and to exempt health providers
participating in the pilot program from regulation as an insurer, the operation of insurance laws of the state and all other laws
inconsistent with the purposes of this article.
§16-2J-2. Definitions.
(a) For the purposes of this article, the following
definitions apply:
(1) "Provider" has the same meaning as "ambulatory health care
facility" set forth in subsection (b), section two, article two-d
of this chapter or "private office practice" as set forth in
subsection (a)(1), section four of said article.
(2) "Participating provider" means a provider under this
article that has been granted a license under this article to
operate as part of the pilot program.
(3) "Primary care" means basic or general health care which
emphasizes the point when the patient first seeks assistance from
the medical care system and the care of the simpler and more common
illnesses.
(4) "Subscriber" means any individual who subscribes to a
prepaid program approved and operated in accordance with the
provisions of this article, including an employee of any employer
that has purchased a group enrollment on behalf of its employees.
(5) "Family" means a subscriber and his or her dependents.
(6) "Dependent" has the same meaning set forth in subsection
(d), section one-a, article sixteen, chapter thirty-three of this
code.
(7) "Qualifying event" means loss of coverage due to: (i)
Emancipation and resultant loss of coverage under a parent or
guardian's plan; (ii) divorce and loss of coverage under the former
spouse's plan; (iii) termination of employment and resultant loss
of coverage under an employer group plan except for loss of
employment for gross misconduct; or (iv) involuntary termination of
coverage under a group health benefit plan except for termination
due to nonpayment of premiums or fraud by the insured.
§16-2J-3. Authorization of preventive care clinic-based pilot
program; number of participants and sites; Health
Care Authority considerations in selection of
participating providers; funding.
(a) The Health Care Authority shall, in consultation with the
Insurance Commissioner, develop and implement during the fiscal
year beginning the first day of July, two thousand six, a pilot
program that permits no more than eight providers to market and
sell prepaid memberships entitling subscribers to obtain preventive
and primary health care from the participating providers.
Participating providers shall not be allowed to offer their
qualifying services at more than three separate sites. The pilot
program will be three years in length.
(b) Subject to the provisions of this article, the Health Care
Authority is vested with discretion to select providers using
diversity in practice organization, geographical diversity and other criteria it deems appropriate. The Health Care Authority
also shall give consideration to providers located in rural areas
or serving a high percentage or large numbers of uninsured.
(c) The Health Care Authority may apply for and receive
funding from any source to implement funding of the pilot program.
§16-2J-4. License for preventive care clinic-based pilot program.
(a) No provider may participate in the pilot program without
first obtaining a preventive care clinic-based pilot program
license from the Health Care Authority.
(b) The Health Care Authority shall determine the eligibility
of providers to obtain licenses on the basis of applications filed
by providers on forms developed by the Health Care Authority.
(c) Upon approval of the application, the participating
provider shall be granted a license to market and sell prepaid
health services under such terms as may be established in
guidelines developed by the Health Care Authority and Insurance
Commissioner.
§16-2J-5. Insurance Commissioner approval of fees, marketing
materials and forms and certification of financial
condition; statement of services; exemption from
treatment as insurance.
(a) The Insurance Commissioner shall develop guidelines for
all forms, marketing materials and fees proposed by program
applicants and participating providers under the same criteria generally applicable to accident and sickness insurance policies.
(b) All fees, marketing materials and forms proposed to be
used by any program applicant or participating provider are subject
to prior approval of the Insurance Commissioner, which the
Insurance Commissioner shall communicate to the Health Care
Authority. Fees may not be excessive, inadequate, or unfairly
discriminatory.
(c) The Insurance Commissioner must certify whether a program
applicant or, upon the request of the Health Care Authority, an
already participating provider is in a sound financial condition
and capable of operating in a manner that is not hazardous to its
prospective subscribers or the people of West Virginia.
(d) Every subscriber is entitled to evidence of program
membership that shall contain a clear, concise and complete
statement of the services provided by the participating provider
and the benefits, if any, to which the subscriber is entitled; any
exclusions or limitations on the service, kind of service,
benefits, or kind of benefits, to be provided, including any
copayments; and where and in what manner information is available
as to how a service may be obtained.
(e) Fees paid to participating providers are not subject to
premium taxes and surcharges imposed on insurance companies.
(f) Notwithstanding the provisions of chapter thirty-three of
this code to the contrary, participation by providers in the preventive care clinic-based pilot program created and authorized
pursuant to this article is not to be considered as providing
insurance or as offering insurance services. Such providers and
services are specifically excluded from the definitions of
"insurer" and "insurance" as defined in article one, chapter
thirty-three of this code, and are not subject to regulation by the
Insurance Commissioner except to the extent set forth in this
article, nor are participating providers unauthorized insurers
pursuant to section four, article forty-four of chapter
thirty-three of this code.
§16-2J-6. Rulemaking authority.
The Health Care Authority and the Insurance Commissioner each
may propose rules for legislative approval in accordance with the
provisions of article three, chapter twenty-nine-a of this code as
necessary to implement the provisions of this article, including
emergency rules promulgated pursuant to section fifteen, article
three, chapter twenty-nine-a of this code.
§16-2J-7. Participating provider plan requirements: Primary care
services; prior coverage restrictions; notice of
discontinuance or reduction of benefits.
(a) In addition to the provisions of this article and any
guidelines established by the Health Care Authority and Insurance
Commissioner, the plans offered pursuant to this article shall be
subject to the following:
(1) Each participating provider and site must offer a minimum
set of preventive and primary care services as established by the
Health Care Authority;
(2) No participating provider may offer: (i) An individual
plan to any individual who was covered by a health benefit plan
within the preceding twelve months unless said coverage was lost
due to a qualifying event; (ii) a family plan to any family that
includes an adult to be covered who was covered by a health benefit
plan within the preceding twelve months; or (iii) an employee group
plan to any employer that had a group health benefit plan covering
its employees within the preceding twelve months.
(3) A participating provider must provide subscribers and,
where applicable, subscribers' employers with a minimum of thirty
days' notice of discontinuance or reduction of subscriber benefits.
§16-2J-8. Guidelines for evaluation of pilot program; Health Care
Authority report to Legislative Oversight Commission.
(a) The Health Care Authority shall establish guidelines to
evaluate the pilot program and may require participating providers
to submit such data and other information related to the pilot
program as may be required by the Health Care Authority.
(b) No later than the first day of December, two thousand
seven and annually thereafter during the operation of the pilot
program, the Health Care Authority must submit a report to the
Legislative Oversight Commission of Health and Human Resources Accountability as established in article twenty-nine-e of this
chapter.
§16-2J-9. Grounds for refusal to renew; revocation and suspension
of pilot program license; penalties; termination of
suspension, reissuance and renewal of license.
(a) The Health Care Authority may after notice and hearing
refuse to renew, or may revoke or suspend the license of a
participating provider, in addition to other grounds therefor in
this article, if the participating provider:
(1) Violates any provision of this article;
(2) Fails to comply with any lawful rule, regulation or order
of the Health Care Authority;
(3) Is operating in an illegal, improper or unjust manner;
(4) Is found by the Insurance Commissioner to be in an unsound
condition or in such condition as to render its further operation
in West Virginia hazardous to its subscribers or to the people of
West Virginia;
(5) Compels subscribers under its contract to accept less
service than due them or to bring suit against it to secure full
service when it has no substantial defense;
(6) Refuses to be examined or to produce its accounts, records
and files for examination by the Insurance Commissioner when
requested to do so pursuant to section five of this article;
(7) Fails to pay any final judgment rendered against it in West Virginia within thirty days after the judgment became final or
time for appeal expired, whichever is later;
(8) Fails to pay when due to the State of West Virginia any
taxes, fees, charges or penalties.
(b) In addition to or in lieu of refusing to renew, revoking
or suspending the license of a participating provider in any case,
the Health Care Authority may, by order, require the participating
provider to pay to the State of West Virginia a penalty in a sum
not exceeding five thousand dollars for each violation. Upon the
failure of the provider to pay such penalty within thirty days
after notice thereof, the Health Care Authority shall revoke or
suspend the license of such participating provider.
(c) When any license has been revoked or suspended or renewal
thereof refused, the Health Care Authority may reissue, terminate
the suspension of or renew such license when it is determined that
the conditions causing such revocation, suspension or refusal to
renew have ceased to exist and are unlikely to recur.
NOTE: The purpose of this bill is to establish a pilot program
overseen by the Health Care Authority authorizing participating
health care providers and private medical practitioners to provide
primary and preventive health services to subscribers for a prepaid
fee.
This article is new; therefore, strike-throughs and
underscoring have been omitted.
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