COMMITTEE SUBSTITUTE
FOR
Senate Bill No. 552
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[Originating in the Committee on Banking and Insurance;
reported March 30, 2009.]
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A BILL to repeal §33-15D-1, §33-15D-2, §33-15D-3, §33-15D-4, §33-
15D-5, §33-15D-6, §33-15D-7, §33-15D-8, §33-15D-9, §33-15D-10
and §33-15D-11 of the Code of West Virginia, 1931, as amended;
to amend and reenact §33-16F-1, §33-16F-2, §33-16F-3, §33-16F-
4, §33-16F-5, §33-16F-6, §33-16F-7 and §33-16F-8 of said code;
and to amend said code by adding thereto two new sections,
designated §33-16F-9 and §33-16F-10, all relating to health
insurance; requiring the Insurance Commissioner to invite
carriers and other entities to submit proposals for affordable
health insurance plans; defining terms; specifying that plans
do not create an entitlement; establishing eligibility and
standards for such plans; providing for evaluation of the
plans and reports to the Legislature; providing for
continuation of existing limited benefit plans; and
authorizing emergency legislative rules.
Be it enacted by the Legislature of West Virginia:
That §33-15D-1, §33-15D-2, §33-15D-3, §33-15D-4, §33-15D-5, §33-15D-6, §33-15D-7, §33-15D-8, §33-15D-9, §33-15D-10 and §33-15D-
11 of the Code of West Virginia, 1931, as amended, be repealed;
that §33-16F-1, §33-16F-2, §33-16F-3, §33-16F-4, §33-16F-5, §33-
16F-6, §33-16F-7 and §33-16F-8 of said code be amended and
reenacted; and that said code be amended by adding thereto two new
sections, designated §33-16F-9 and §33-16F-10, all to read as
follows:
ARTICLE 16F. WEST VIRGINIA AFFORDABLE HEALTH CARE PLAN.
§33-16F-1. Legislative intent.
The Legislature finds that the inability of a significant
number of state residents to obtain affordable health insurance
coverage adversely affects everyone in our state. Therefore, it is
the intent of the Legislature to expand the availability of health
care options for uninsured residents by developing affordable
health care products that emphasize coverage for basic and
preventive health care services, provide inpatient hospital and
emergency care services and offer optional catastrophic coverage.
§33-16F-2. Definitions.
As used in this article:
"West Virginia affordable health care plan" means a health
insurance plan approved under this article.
"West Virginia affordable health care plan entity" or "plan
entity" means an entity licensed under this chapter that develops
and proposes a West Virginia affordable health care plan and, if
the plan is approved, is responsible for administering the plan and paying claims of plan enrollees.
"Enrollee" means an individual who has been determined to be
eligible for and is receiving health insurance coverage under a
West Virginia affordable health care plan.
§33-16F-3. Plan proposals; approval of plans.
(a) The commissioner shall announce, no later than July 1,
2009, an invitation to prospective West Virginia affordable health
care plan entities to submit West Virginia affordable health care
plan proposals. The invitation shall include guidelines for the
review of West Virginia affordable health care plan applications,
policies and associated rates.
(b) In reviewing proposals under this article, the
commissioner shall consider the proposed plans' effectiveness in
improving the health status of individuals, their impact on
maintaining and improving health and their potential to reduce the
unnecessary consumption of health care services.
§33-16F-4. Required plan provisions; grounds for disapproval;
alternative plans
.
(a) To be approved, plan entities must assure that each
proposed plan will provide cost containment through the use of plan
design features such as limits on the number of services, caps on
benefit payments or copayments for services.
(b) To provide consumer choice, plan entities must develop and
submit two alternative benefit option plans having different cost
and benefit levels, including at least one plan that provides catastrophic coverage.
(1) Plans without catastrophic coverage must provide coverage
for preventive health services that include, but are not limited
to, one or more of the following: Immunizations; annual health
assessments; preventive screenings such as mammograms, cervical
cancer screenings and noninvasive colorectal or prostate
screenings; incentives for routine preventive care; and office
visits for the diagnosis and treatment of illness or injury and
office surgery.
(2) Plans providing catastrophic coverage must, at a minimum,
provide coverage for preventive health services and inpatient
hospital stays and may also include coverage of one or more of the
following: Hospital emergency care services and outpatient
facility services; outpatient surgery; or outpatient diagnostic
services.
(c) All plans must offer prescription drug benefit coverage.
(d) Plan enrollment materials must provide information in
plain language on policy benefit coverage, benefit limits, cost-
sharing requirements, exclusions and a clear representation of what
is not covered in the plan. The enrollment materials must include
a standard disclosure form developed by the commissioner that must
be reviewed and executed by all consumers purchasing West Virginia
affordable health care plan coverage.
(e) The commissioner shall disapprove any plan that:
(1) Contains any ambiguous, inconsistent or misleading
provisions or any exceptions or conditions that deceptively affect or limit the benefits purported to be assumed in the general
coverage provided by the plan;
(2) Provides benefits that are unreasonable in relation to the
premium charged; or
(3) Contains provisions that are unfair or inequitable,
contrary to the public policy of this state, encourage
misrepresentation or result in unfair discrimination in sales
practices.
§33-16F-5. Eligibility of individuals and groups.
(a)
Individuals. -- Eligibility to enroll in an individual
West Virginia affordable health care plan is limited to any
resident of this state who:
(1) Is not covered by a private insurance policy and is not
eligible for coverage under an employer-sponsored group plan or
through a public health insurance program, such as Medicare,
Medicaid or the state Children's Health Insurance Program; and
(2) Has not been covered by any health insurance program at
any time during the past six months, unless coverage under a health
insurance program was terminated within the previous six months due
to loss of a job that provided an employer-sponsored health benefit
plan or death of, or divorce from, a spouse who was provided an
employer-sponsored health benefit plan or, with respect to a public
health insurance program, eligibility for such program was lost due
to an inability to meet income or categorical requirements:
Provided, That an individual may not be excluded from enrollment in
a West Virginia affordable health care plan on the ground that he or she is eligible for or is enrolled in a COBRA plan.
(b)
Group. -- An otherwise eligible group may not obtain
coverage under a West Virginia affordable health care plan unless
the group has not had coverage under any health insurance plan at
any time during the previous six months.
§33-16F-6. Regulation and marketing of plans.
(a) The commissioner shall issue guidelines to ensure that
West Virginia affordable health care plans meet minimum standards
for quality of and access to care.
(b) Initial filings and changes in West Virginia affordable
health care plan benefits, premiums and policy forms are subject to
regulatory oversight by the commissioner.
(c) The commissioner shall develop a public awareness program
to be implemented throughout the state for the promotion of the
plans approved under this article, which may include assistance
from state health insurance benefits advisors.
(d) Each West Virginia affordable health care plan must
maintain enrollment data and provide network data and reasonable
records to enable the commissioner to assess the plans.
§33-16F-7. Applicability of certain provisions; commissioner's
authority to forbear from applying certain
provisions.
(a)
Individual plans. -- Only the following provisions of
article fifteen of this chapter apply to West Virginia entities
offering individual plans pursuant to this article: Sections two-a, two-d, two-e, three, four, four-c, four-e, four-f, four-g, five,
six, seven, eight, nine, seventeen, eighteen and nineteen.
Notwithstanding any other provision of this code, the provisions of
article twenty-eight of this chapter and legislative rules
regulating individual accident and sickness policies, including the
rule contained in series 12, title 114 of the West Virginia Code of
State Rules, do not apply to individual plans issued pursuant to
this article unless and to the extent specifically incorporated in
rules promulgated pursuant to the authority conferred by section
eleven of this article.
(b)
Group plans. -- Only the following provisions of article
sixteen of this chapter apply to insurers offering group plans
pursuant to this article: Sections one-a, three, three-g, three-j,
three-k, three-l, three-m, three-n, three-o, three-p, four, five,
six, seven, nine, ten, eleven, twelve, thirteen, fourteen and
fifteen; all other provisions of article sixteen do not apply to
group plans approved pursuant to this article unless and to the
extent the provisions are specifically incorporated in rules
promulgated by the commissioner. Notwithstanding any other
provision of this code or of the code of state rules, the
provisions of article sixteen-e of this chapter and of legislative
rules regulating group accident and sickness policies, including
the rule set forth in series 39, title 114 of the West Virginia
Code of State Rules, do not apply to group plans approved pursuant
to this article unless and to the extent specifically incorporated
in rules promulgated by the commissioner pursuant to the authority conferred by section eleven of this article.
(c)
Small group plans. -- With respect to any group plan
approved under this article and offered to any "small employer", as
that term is defined in section two, article sixteen-d of this
chapter, the following provisions of article sixteen-d apply:
Sections two, four, seven, eight, twelve, thirteen and fourteen:
Provided, That only the sentence preceding the proviso in section
thirteen, article sixteen-d of this chapter applies to small
employer plans approved pursuant to this article. Notwithstanding
any other provision of this code, all other provisions of article
sixteen-d of this chapter do not apply to small employer plans
approved pursuant to this article unless and to the extent such
provisions are specifically incorporated in rules promulgated by
the commissioner.
(d)
Forbearance by the commissioner. -- The commissioner may
forbear from applying any other statutory or regulatory
requirements to an insurer offering an individual or group plan
approved pursuant to this article, including any requirements in
articles twenty-four and twenty-five-a of this chapter, if he or
she determines that such forbearance serves the principles set
forth in section one of this article.
(e)
Existing limited benefit plans. -- Plans approved pursuant
to the provisions of article fifteen-d of this chapter, as that
article existed prior to its repeal during the 2009 regular
legislative session, and this article, as that it existed prior to
its amendment and reenactment during the 2009 regular legislative session, remain in effect and are subject to those provisions.
§33-16F-8. Assessment of the West Virginia program.
The commissioner shall:
(1) Provide an assessment of the West Virginia affordable
health care plans and their potential applicability in other
settings;
(2) Use West Virginia affordable health care plans to gather
more information to evaluate low-income, consumer-driven benefit
packages; and
(3) Submit by March 1, 2011, and annually thereafter, a report
to the Governor, the President of the Senate and the Speaker of the
House of Delegates that provides the information specified in this
section and recommendations relating to the successful
implementation and administration of the program.
§33-16F-9. Nonentitlement.
Coverage under a West Virginia affordable health care plan is
not an entitlement and a cause of action does not arise against the
state, a local government entity, any other political subdivision
of the state or any agency for failure to make coverage available
to eligible persons under this article.
§33-16F-10. Emergency and legislative rules authorized.
The commissioner may promulgate emergency and legislative
rules under the provisions of article three, chapter twenty-nine-a
of this code, to prescribe requirements regarding rate making,
which may include rules establishing loss ratio standards for the plans; to place limitations on eligibility for coverage under the
approved plans; to establish standards to determine whether a plan
qualifies as creditable coverage; to determine what medical
treatments, procedures and related health services benefits must be
included in the plans; and to provide for any other matters deemed
necessary to further the intent of this article.
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(NOTE: This bill repeals the existing provisions on limited
benefit plans and creates a new program under which insurance
companies would submit limited benefit plans, individual and group,
for approval by the commissioner and provides for the marketing of
such plans by the commissioner.
Article 16F has been completely rewritten; therefore, strike-
throughs and underscoring have been omitted.)
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