Senate Bill No. 143
(By Senators Tomblin (Mr. President) and Sprouse
By Request of the Executive)
[Introduced January 14, 2004; referred to the Committee on
Banking and Insurance; and then to the Committee on Finance.]
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of West Virginia, 1931, as amended, be repealed; and that said code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
(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
(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
(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
(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
(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
(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
NOTE: The purpose of this bill is to provide health benefit
plans to small employers that do not have such plans covering their
This section is new; therefore, strike-throughs and
underscoring have been omitted.