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Introduced Version Senate Bill 143 History

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Key: Green = existing Code. Red = new code to be enacted
sb143 intr
Senate Bill No. 143

(By Senators Tomblin (Mr. President) and Sprouse

By Request of the Executive)

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[Introduced January 14, 2004; referred to the Committee on Banking and Insurance; and then to the Committee on Finance.]

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A BILL to repeal §5-16A-1, §5-16A-2, §5-16A-3, §5-16A-4, §5-16A-5, §5-16A-6, §5-16A-7, §5-16A-8, §5-16A-9, §5-16A-10 and §5-16A-11 of the code of West Virginia, 1931, as amended; and to amend said code by adding thereto a new section, designated §33-16D-16, relating to small employer group health benefit plans for uninsured groups.

Be it enacted by the Legislature of West Virginia:
That §5-16A-1, §5-16A-2, §5-16A-3,§5-16A-4,§5-16A-5, §5-16A-6, §5-16A-7, §5-16A-8, §5-16A-9, §5-16A-10 and §5-16A-11 of the code of West Virginia, 1931, as amended, be repealed; and that said code be amended by adding thereto a new section, designated §33-16D-16, to read as follows:
ARTICLE 16D. MARKETING AND RATE PRACTICES FOR SMALL EMPLOYER ACCIDENT AND SICKNESS INSURANCE POLICIES.

§33-16D-16. Authorization of uninsured small group health benefit plans.

(a) Upon filing with and approval by the commissioner any carrier licensed pursuant to this chapter, and which carrier accesses a provider network to deliver services, may offer a health benefit plan and rates associated therewith to a small employer subject to the conditions of this section and subject to the provisions of this article. Such health benefit plan shall be subject to the following conditions:
(1) The health benefit plan may be offered by the carrier only to small employers which have not had a health benefit plan covering their employees for at least six consecutive months before the effective date of this section. After the passage of six months from the effective date of this section, the health benefit plan hereunder may be offered by carriers only to small employers which have not had a health benefit plan covering their employees for twelve consecutive months.
(2) If a small employer covered by a health benefit plan offered pursuant to this section no longer meets the definition of a small employer as a result of an increase in eligible employees, that employer shall remain covered by the health benefit plan until the next annual renewal date.
(3) The small employer must pay at least fifty percent of its employees premium amount for individual employee coverage.
(4) The commissioner shall promulgate emergency rules on or before the first day of September, 2004, to place additional restrictions upon the eligibility requirements for health benefit plans authorized by this section in order to prevent manipulation of eligibility criteria by small employers to obtain coverage under health benefit plans issued pursuant to this section, and to otherwise implement the provisions of this section.
(5) Carriers must offer the health benefit plans issued pursuant to this section through one of their existing networks of health care providers.
(A)The director of the public employees insurance agency shall, on or before the first day of May, two thousand four, and each year thereafter, by regular mail, provide a written notice to all known in-state health care providers that:
(i)Informs the provider regarding the provisions of this section; and
(ii)Notifies the provider that if the provider does not give written refusal to the director of the public employees insurance agency within thirty days from receipt of the notice or the provider has not previously filed a written refusal of the provider's refusal to participate, the provider must participate with and accept the products and provider reimbursements authorized pursuant to this section.
(B) The carrier's network health care providers, as well as any health care provider which provides health care goods or services to beneficiaries of any departments or divisions of the state, as identified in article twenty-nine-d, chapter sixteen of this code, must accept the health care provider reimbursement rates set by the carrier pursuant to this section unless the health care provider gives written refusal to the director of the public employees insurance agency between the first day of May and the first day of June, that the provider will not participate in this program for the next calendar year. Such health care providers shall annually have the ability to file with the director of the public employees insurance agency written notice that the provider will not participate with products issued pursuant to this section. Once a health care provider has filed a notice with the director, the notice shall remain effective until rescinded by the provider and the provider shall not be required to renew the notice each year.
(C)The public employees insurance agency shall be responsible for receiving the response, if any, from the providers that have elected not to participate, and providing a list of those providers that have elected not to participate to the commissioner. (D)Those providers that do not opt out shall be deemed to have accepted participation in this program and to accept public employees insurance agency rates for their services.
(E) Health care provider reimbursement rates used by the carrier for a health benefit plan offered pursuant to this section shall have no effect on provider rates for other products offered by the carrier and "most favored nation" clauses do not apply to such rates.
(6) With respect to the health benefit plans authorized by this section, the carrier shall reimburse network health care providers at the same health care reimbursement rates then in effect for the managed care and/or health maintenance organization plans offered by the West Virginia public employees insurance agency. If there is a dispute regarding appropriate rates, the director of the public employees insurance agency shall, in their sole discretion, specify the appropriate rate to be applied.
(A) The health care provider reimbursement rates as authorized by this section shall be accepted by the health care provider as payment in full for services or products provided to a person covered by a product authorized by this section.
(B) Except for the health care provider rates as authorized herein, the carriers payment methodology, including copayments and deductibles and other conditions of coverage shall remain unaffected by this section.
(C) The provisions of this section shall not give access by carriers to the purchasing networks of the public employees insurance agency, provided however the public employees insurance agency is authorized to enter into agreements with carriers offering health benefit plans under this section to permit the carrier, at its election, to participate in drug purchasing arrangements pursuant to article sixteen-c, chapter five of this code, including the multi-state drug purchasing program. This paragraph provides authorization of such agreements pursuant to section four, article sixteen-c, chapter five of this code.
(7) Carriers may not underwrite products under this section more strictly than other small group policies governed by this article.
(8) With respect to health benefit plans authorized by this section, a carrier shall have a minimum anticipated loss ratio of eighty percent to be eligible to make a rate increase request after the first year of providing a health benefit plan under this section.
(9) Products authorized under this section shall be exempt from the premium taxes assessed under sections fourteen and fourteen-a, article three of this chapter.
(10)A carrier may elect to nonrenew any health benefit plan to an eligible employer if at any time the carrier determines, by applying the same network criteria which it applies to other small employer health benefit plans, that it no longer has an adequate network of health care providers accessible for that eligible small employer. If the carrier makes a determination that an adequate network does not exist, the carrier shall have no obligation to obtain additional providers to establish an adequate network.
(11)Upon thirty days advance notice to the commissioner, a carrier may elect to nonrenew all health benefit plans issued pursuant to this section at any time. If a carrier nonrenews all its business issued pursuant to this section for any reason other than the adequacy of the provider network, the carrier may not offer this health benefit plan to any eligible employer for a period of at least two years after the last eligible employer is nonrenewed.
(12)The insurance commissioner shall not approve any health benefit plan issued pursuant to this section until it has obtained any necessary federal governmental authorizations or waivers. The insurance commissioner shall apply for and obtain all such necessary federal authorizations or waivers.
(b) Health benefit plans authorized by this section shall not be held to violate the prohibition set out in subsection (a), section four, article sixteen-d of this chapter.
(c) If no carrier has offered a health benefit plan under this section by the first day of July, two thousand five, except for failure to obtain a federal authorization or waiver pursuant to subdivision twelve, subsection (a) of this section, the director of the public employees insurance agency and the insurance commissioner may, if they so agree, jointly present a proposal to the public employees insurance agency finance board that a small employer health coverage program for uninsured small employer groups be offered by the public employees insurance agency. Before the public employees insurance agency begins such program, written notice shall be given to the Legislature's joint committee on government and finance, the public employees insurance agency finance board must have reviewed and approved of the proposal by a sixty percent majority vote, and the proposal must be reviewed and approved by the health care authority.
(d)If neither a carrier nor the public employees insurance agency has offered a health benefit plan pursuant to this section within three years from the effective date of this section, the provisions of this section shall expire and become null and void.
(e)The commissioner shall appoint a policy advisory committee to provide advice to the commissioner regarding providing health insurance to uninsureds and to monitor the effectiveness of this legislation. The committee shall contain such members as the commissioner deems appropriate, but shall have members representing at least the following interest groups; labor, hospital providers, physician providers, private business, local government, insurance carriers and the uninsured.
(f) Carriers offering health benefit plans pursuant to this section shall annually or before the first day of December of each year report in a form acceptable to the commissioner the number of health benefit plans written by the carrier and the number of individuals covered under such health benefit plans. The commissioner shall report on or before the first day of each year to the Legislature's joint committee on government and finance regarding any health benefit plans offered under this section.
(g) To the extent that provisions of this section differ from those contained in this chapter, the provisions of this section shall control.



NOTE: The purpose of this bill is to provide health benefit plans to small employers that do not have such plans covering their employees.

This section is new; therefore, strike-throughs and underscoring have been omitted.
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