Senate Bill No.186
(By Senators Rowe, Mitchell and Burnette)
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[Introduced January 11, 2002; referred to the Committee
on Banking and Insurance; and then to the Committee on
Finance.]
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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; and to amend article
five, chapter nine of said code by adding thereto a new
section, designated section twenty, all relating to
requiring a copayment be made to medical providers by adult
recipients of medicaid and persons covered under the public
employees insurance act who have used tobacco products
within the previous six months prior to receiving the
subject medical attention.
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; and that article five,
chapter nine of said code be amended by adding thereto a new
section, designated section twenty, 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 provided
for in this article 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 includes 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 the employees
covered under this article;
(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 the plans with the benefits to which the
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 to increase utilization of, and to encourage the
use of, lower cost alternative health care facilities, health
care providers and generic drugs. The 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:
Provided, That on or before the first day of January, two
thousand three, as a condition of coverage, an adult insured
shall be required by a participating medical provider to sign a
statement, whether or not they have used tobacco products within
the previous six months before the date of treatment requested:
Provided, however, That if the insured does not provide the
statement or states that he or she has used a tobacco product
within the previous six months, the insured shall be charged a
copayment of ten dollars to be paid to the medical provider.
The director of the public employees insurance agency shall
prescribe and disseminate a form to all participating medical
providers upon which an insured may verify his or her nonuse of
tobacco products in accordance with this requirement. In
establishing "wellness" programs, the division of vocational
rehabilitation shall cooperate with the public employees
insurance agency in establishing statewide wellness programs.
The director of the public employees insurance agency shall
contract with county boards of education for the use of facilities, equipment or any service related to that purpose.
Boards of education may charge 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 may 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 the 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; and
(12)(a) 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, an ambulance providing related services under the
provisions of article four-c, chapter sixteen of this code or
the private office of a dentist to evaluate and treat a medical
condition manifesting itself by the sudden, and at the time,
unexpected onset of symptoms that require immediate medical
attention and for which 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.
(b) From the first day of July, one thousand nine hundred
ninety-eight, plans shall provide coverage for emergency
services, including any prehospital services, to the extent
necessary to screen and stabilize the covered person. The plans
shall reimburse, less any applicable copayments, deductibles, or
coinsurance, for emergency services rendered and related to the
condition for which the covered person presented. Prior
authorization of coverage
shall may not be required for the
screening services if a prudent layperson acting reasonably
would have believed that an emergency medical condition existed. Prior authorization of coverage
shall may not be required for
stabilization if an emergency medical condition exists. In the
event that prior authorization was obtained, the authorization
may not be retracted after the services have been provided
except when the authorization was based on a material
misrepresentation about the medical condition by the provider of
the services or the insured person. The provider of the
emergency services and the plan representative shall make a good
faith effort to communicate with each other in a timely fashion
to expedite postevaluation or poststabilization services.
Payment of claims for emergency services
shall be is based on
the retrospective review of the presenting history and symptoms
of the covered person.
(c) For purposes of this subdivision:
(A) "Emergency services" means those services required to
screen for or treat an emergency medical condition until the
condition is stabilized, including prehospital care;
(B) "Prudent layperson" means a person who is without
medical training and who draws on his or her practical
experience when making a decision regarding whether an emergency
medical condition exists for which emergency treatment should be
sought;
(C) "Emergency medical condition for the prudent layperson" means one that manifests itself by acute symptoms of sufficient
severity, including severe pain,
such that the person could
reasonably expect the absence of immediate medical attention to
result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction
of any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical
condition, to provide medical treatment of the condition
necessary to assure, with reasonable medical probability that no
medical deterioration of the condition is likely to result from
or occur during the transfer of the individual from a facility:
Provided, That this provision may not be construed to prohibit,
limit or otherwise delay the transportation required for a
higher level of care than that possible at the treating
facility;
(E) "Medical screening examination" means an appropriate
examination within the capability of the hospital's emergency
department, including ancillary services routinely available to
the emergency department, to determine whether or not an
emergency medical condition exists; and
(F) "Emergency medical condition" means a condition that
manifests itself by acute symptoms of sufficient severity including severe pain
such that the absence of immediate medical
attention could reasonably be expected to result in serious
jeopardy to the individual's health or with respect to a
pregnant woman the health of the unborn child, serious
impairment to bodily functions or serious dysfunction of any
bodily part or organ.
CHAPTER 9. HUMAN SERVICES.
ARTICLE 5. MISCELLANEOUS PROVISIONS.
§9-5-20. Copayment requirement for tobacco users.
The secretary of the department of health and human
resources shall require adult recipients of medical assistance
under the medicaid program to sign a written statement which
shall be provided to them by participating medical providers for
care to be billed as part of the medicaid program, whether or
not they have used tobacco products within the previous six
months before the date of the treatment requested. If a
recipient does not provide the statement or states that he or
she has used a tobacco product within the previous six months,
the recipient shall be charged a copayment to be paid to the
medical provider in an amount to be determined by the secretary
of the department of health and human resources, as allowed by
federal law but not to exceed ten dollars to any one provider
in any seven-day period for any recipient. The secretary of the department of health and human resources shall prescribe and
disseminate a form to all participating medical providers upon
which an insured may verify his or her nonuse of tobacco
products in accordance with the requirement of this section.
NOTE: The purpose of this bill is to require a copayment
to be made to medical providers by recipients of medicaid and
persons covered under the public employees insurance act who
have used tobacco products within the previous six months prior
to receiving the subject medical attention.
Strike-throughs indicate language that would be stricken
from the present law, and underscoring indicates new language
that would be added.
§9-5-20 is new; therefore, strike-throughs and underscoring
have been omitted.
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