Senate Bill No. 411
(By Senators Prezioso, Foster, Jenkins, Stollings, Unger and
Kessler)
____________
[Introduced March 2, 2009; referred to the Committee on Health
and Human Resources; and then to the Committee on Finance.]
____________
A BILL to amend and reenact §5-16-7 of the Code of West Virginia,
1931, as amended; and to amend said code by adding thereto a
new section, designated §33-3-14e, all relating to creating a
temporary health information technology reinvestment fee for
health insurers; providing definitions; establishing penalties
for noncompliance; providing rule-making authority; and
establishing an effective date.
Be it enacted by the Legislature of West Virginia:
That §5-16-7 of the Code of West Virginia, 1931, as amended,
be amended and reenacted; and that said code be amended by adding
thereto a new section, designated §33-3-14e, all to read as
follows:
CHAPTER 5. GENERAL POWERS 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.
§5-16-7. Authorization to establish group hospital and surgical
insurance plan, group major medical insurance plan,
group prescription drug plan and group life and
accidental death insurance plan; rules for
administration of plans; mandated benefits; what
plans may provide; optional plans; separate rating
for claims experience purposes.
(a) The agency shall establish a group hospital and surgical
insurance plan or plans, a group prescription drug insurance plan
or plans, a group major medical insurance plan or plans and a group
life and accidental death insurance plan or plans for those
employees herein made eligible and establish and promulgate rules
for the administration of these plans, subject to the limitations
contained in this article. Those plans shall include:
(1) Coverages and benefits for X-ray and laboratory services
in connection with mammograms when medically appropriate and
consistent with current guidelines from the United States
Preventive Services Task Force; pap smears, either conventional or
liquid-based cytology, whichever is medically appropriate and
consistent with the current guidelines from either the United
States Preventive Services Task Force or The American College of Obstetricians and Gynecologists; and a test for the human papilloma
virus (HPV) when medically appropriate and consistent with current
guidelines from either the United States Preventive Services Task
Force or The American College of Obstetricians and Gynecologists,
when performed for cancer screening or diagnostic services on a
woman age eighteen or over;
(2) Annual checkups for prostate cancer in men age fifty and
over;
(3) Annual screening for kidney disease as determined to be
medically necessary by a physician using any combination of blood
pressure testing, urine albumin or urine protein testing and serum
creatinine testing as recommended by the National Kidney
Foundation;
(4) For plans that include maternity benefits, coverage for
inpatient care in a duly licensed health care facility for a mother
and her newly born infant for the length of time which the
attending physician considers medically necessary for the mother or
her newly born child: Provided, That a plan may not deny payment
for a mother or her newborn child prior to forty-eight hours
following a vaginal delivery, or prior to ninety-six hours
following a caesarean section delivery, if the attending physician
considers discharge medically inappropriate;
(5) For plans which provide coverages for post-delivery care
to a mother and her newly born child in the home, coverage for inpatient care following childbirth as provided in subdivision (4)
of this subsection if inpatient care is determined to be medically
necessary by the attending physician. Those plans may also
include, among other things, medicines, medical equipment,
prosthetic appliances, and any other inpatient and outpatient
services and expenses considered appropriate and desirable by the
agency; and
(6) Coverage for treatment of serious mental illness.
(A) The coverage does not include custodial care, residential
care or schooling. For purposes of this section, "serious mental
illness" means an illness included in the American psychiatric
association's diagnostic and statistical manual of mental
disorders, as periodically revised, under the diagnostic categories
or subclassifications of: (i) Schizophrenia and other psychotic
disorders; (ii) bipolar disorders; (iii) depressive disorders; (iv)
substance-related disorders with the exception of caffeine-related
disorders and nicotine-related disorders; (v) anxiety disorders;
and (vi) anorexia and bulimia. With regard to any covered
individual who has not yet attained the age of nineteen years,
"serious mental illness" also includes attention deficit
hyperactivity disorder, separation anxiety disorder and conduct
disorder.
(B) Notwithstanding any other provision in this section to the
contrary, in the event that the agency can demonstrate actuarially that its total anticipated costs for the treatment of mental
illness for any plan will exceed or have exceeded two percent of
the total costs for such plan in any experience period, then the
agency may apply whatever cost-containment measures may be
necessary, including, but not limited to, limitations on inpatient
and outpatient benefits, to maintain costs below two percent of the
total costs for the plan.
(C) The agency shall not discriminate between medical-surgical
benefits and mental health benefits in the administration of its
plan. With regard to both medical-surgical and mental health
benefits, it may make determinations of medical necessity and
appropriateness, and it may use recognized health care quality and
cost management tools, including, but not limited to, limitations
on inpatient and outpatient benefits, utilization review,
implementation of cost-containment measures, preauthorization for
certain treatments, setting coverage levels, setting maximum number
of visits within certain time periods, using capitated benefit
arrangements, using fee-for-service arrangements, using third-party
administrators, using provider networks and using patient cost
sharing in the form of copayments, deductibles and coinsurance.
(b) The agency shall make available to each eligible employee,
at full cost to the employee, the opportunity to purchase optional
group life and accidental death insurance as established under the
rules of the agency. In addition, each employee is entitled to have his or her spouse and dependents, as defined by the rules of
the agency, included in the optional coverage, at full cost to the
employee, for each eligible dependent; and with full authorization
to the agency to make the optional coverage available and provide
an opportunity of purchase to each employee.
(c) The finance board may cause to be separately rated for
claims experience purposes:
(1) All employees of the State of West Virginia;
(2) All teaching and professional employees of state public
institutions of higher education and county boards of education;
(3) All nonteaching employees of the Higher Education Policy
Commission, West Virginia Council for Community and Technical
College Education and county boards of education; or
(4) Any other categorization which would ensure the stability
of the overall program.
(d) The agency shall maintain the medical and prescription
drug coverage for Medicare-eligible retirees by providing coverage
through one of the existing plans or by enrolling the
Medicare-eligible retired employees into a Medicare-specific plan,
including, but not limited to, the Medicare/Advantage Prescription
Drug Plan. In the event that a Medicare-specific plan would no
longer be available or advantageous for the agency and the
retirees, the retirees shall remain eligible for coverage through
the agency.
(e) The agency shall comply with the provisions of section
fourteen-e, article three, chapter thirty-three relating to the
Health Care Information Technology Reinvestment Fee.
CHAPTER 33. INSURANCE.
ARTICLE 3. LICENSING, FEES AND TAXATION.
§33-3-14e. Health Care Information Technology Reinvestment Fee.
(a) The Legislature finds the following:
(1) Improving the capability to access and exchange electronic
health information is a key component of the health care reform
efforts in West Virginia.
(2) The access and exchange of electronic health information
improves the quality of care and the efficiency of health
practitioners.
(3) The financing model of the existing health care system
results in most of the financial benefits of the use of health
information technology not being realized by the primary care
practitioners who have to invest in and use the electronic medical
record but by those who pay for health care services.
(b) As used in this section:
(1) "Commission" means the Insurance Commission.
(2) "Commissioner" means the commissioner of the Insurance
Commission.
(3) "Health insurance" means any group or individual health
care benefit policy, contract, or other health benefit plan offered, issued, renewed, or administered by any health insurer,
including any health care benefit plan offered, issued, or renewed
by any health insurance company, any nonprofit hospital and medical
service corporation, or any managed care organization as defined in
chapter 33 of this code. The term does include the Public Employees
Insurance Agency. The term does not include Medicaid, State
Children's Health Insurance Program, or any other state health care
assistance program financed, in whole or in part, through a federal
program, until authorized by the federal program. The term does
not include policies issued for specified disease, accident,
injury, hospital indemnity, dental care, long term care, disability
income, or other limited benefit health insurance policies.
(4)"Health insurer" means an entity licensed by the
commissioner to transact accident and sickness in this state,
service corporations licensed pursuant to article twenty-four of
this chapter or health maintenance organizations licensed pursuant
to article twenty-six-a of this chapter, and "health TPA" means a
TPA registered in accordance with the provisions of article
forty-six of this chapter that handles health claims for any entity
other than a health insurer.
(5) "WVHIN" is the West Virginia Health Information Network
created in article twenty-nine-g of this chapter.
(c) The fee shall be established in the following manner:
(1) Quarterly, beginning October 1, 2009, each health insurer shall pay a fee into the West Virginia Health Information Network
Account established in section four, article twenty-nine-g, chapter
sixteen. The health insurer may choose either of the following fee
options: (A) 0.199 of one percent of all health care claims paid
by the health insurer for its West Virginia members in the previous
fiscal quarter, or
(2) An annual fee payable quarterly, to be calculated on or
before August 1, 2009 and on or before August 1 of each succeeding
year by the Insurance Commission or by an agent retained by the
commission, in consultation with the Governor's Office of Health
System Improvement, based on the proportion which the health
insurer's total annual health care claims for the most recent four
quarters of data available to the commission bears to the total
health care claims for all health insurers for the most recent four
quarters of data available to the commission, multiplied by the
total fee revenue which would be raised if all health insurers
chose the fee option established in subdivision (1) of this
subsection. Such fee shall be subject to an annual recalculation by
the Insurance Commission, or an agent retained by the commission,
with any surplus or shortfall in the amount collected adjudicated
in the following fiscal quarter and bearing no interest or penalty
to any party.
(d) It is the intent of the Legislature that all health
insurers shall contribute equitably to the West Virginia Health Information Network Account established in section four, article
twenty-nine-g, chapter four.
(e) The West Virginia Health Information Network may adopt
such legislative rules and issue such orders as are necessary to
carry out the purposes of this section.
(f) If any health insurer fails to pay the fee established in
subsection (a) of this section within forty-five days after notice
from the WVHIN, the Director of WVHIN, or his or her designee,
shall notify the Insurance Commission, and the Director of the
Governor's Office of Health System Improvement of the failure to
pay. In addition to any other remedy or sanction provided for by
law, if the commissioner finds, after notice and an opportunity to
be heard, that the health insurer has violated this section or any
legislative rule or order adopted or issued pursuant to this
section, the commissioner may take any one or more of the following
actions:
(1) Assess an administrative penalty on the health insurer of
not more than $1,000 for each violation and not more than $10,000
for each willful violation;
(2) Order the health insurer to cease and desist in further
violations; or
(3) Order the health insurer to remediate the violation,
including the payment of fees in arrears and payment of interest on
fees in arrears at the rate of twelve percent per annum.
(g) No later than June 30, 2011, the Director of WVHIN and
the Director of the Governor's Office of Health System Improvement,
or his or her designee, shall assess the adequacy of funding and
make recommendations to the Legislature and the Governor concerning
the appropriateness of the duration of the health care information
technology reinvestment fee.
(h) This section shall be effective from July 1,2009 through
June 30, 2012.
NOTE: The purpose of this bill is to create a temporary
reinvestment fee for health insurers, third party administrators
and others to assist in funding health information technology in
the state.
§33-3-14e is new; therefore, strike-throughs and underscoring
have been omitted.
This bill is an interim bill from Select Committee D on
Health. Strike-throughs indicate language that would be stricken
from the present law, and underscoring indicates new language that
would be added.