H. B. 2385
(By Delegate Pino)
[Introduced
January 17, 2003
; referred to the
Committee on Banking and Insurance then Finance.]
A BILL to amend and reenact section seven, article sixteen, chapter
five of the code of West Virginia, one thousand nine hundred
thirty-one, as amended; to amend article six, chapter
thirty-three of said code by adding thereto a new section,
designated section thirty-seven; to amend article fifteen of
said chapter by adding thereto a new section, designated
section four-h; to amend article sixteen of said chapter by
adding thereto a new section, designated section three-q; to
amend article twenty-four of said chapter by adding thereto a
new section, designated section seven-h; to amend article
twenty-five of said chapter by adding thereto a new section,
designated section eight-f; and to amend article twenty-five-a
of said chapter by adding thereto a new section, designated
section eight-g, all relating to health insurance; foods and
food products for inherited metabolic diseases; and requiring insurance coverage of medically necessary low protein foods
and medical foods (formulas) for treatment of inherited
metabolic diseases as prescribed by a physician.
Be it enacted by the Legislature of West Virginia:
That section seven, article sixteen, chapter five of the code
of West Virginia, one thousand nine hundred thirty-one, as amended,
be amended and reenacted; that article six, chapter thirty-three of
said code be amended by adding thereto a new section, designated
section thirty-seven; that article fifteen of said chapter be
amended by adding thereto a new section, designated section four-h;
that article sixteen of said chapter be amended by adding thereto
a new section, designated section three-q; that article twenty-four
of said chapter be amended by adding thereto a new section,
designated section seven-h; that article twenty-five of said
chapter be amended by adding thereto a new section, designated
section eight-f; and that article twenty-five-a of said chapter be
amended by adding thereto a new section, designated section
eight-g, 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.
§5-16-7. 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
by this section, and to 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 and pap smears when performed for
cancer screening or diagnostic services;
(2) Annual checkups for prostate cancer in men age fifty and
over;
(3) Medically necessary food products as a part of a dietary
treatment of an inherited metabolic disease;
(3) (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 no plan may 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;
(4) (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 (3)
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
(5) (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 the 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 may 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 university of West
Virginia board of trustees or the board of directors of the state
college system and county boards of education; or (4) any other
categorization which would ensure the stability of the overall program.
CHAPTER 33. INSURANCE.
ARTICLE 6. THE INSURANCE POLICY.
§33-6-37. Foods and food products for inherited metabolic
diseases; and requiring insurance coverage of low
protein foods and medical foods (formulas) for
treatment of inherited metabolic diseases to be
covered by all health insurance policies.
(a) All individual and group health insurance policies,
including hospital or major medical insurance policies, group or
blanket health insurance policies, health maintenance
organizations, nonprofit health service plans, hospital or major
medical insurance policies, nonprofit health service plans
providing coverage on an expense incurred basis and individual and
group service or indemnity type contracts, including, but not
limited to those polices, plans or contracts written and issued
pursuant to the provisions of section seven, article sixteen,
chapter five and articles fifteen, sixteen, twenty-four,
twenty-five and twenty-five-a of this chapter, shall also provide
as to the family members' coverage that the health insurance
benefits include coverage for certain foods and food products for
the treatment of certain inherited metabolic diseases.
(b) For the purpose of requiring certain health insurance policies as set forth is subsection (a) of this section to include
coverage for certain foods and food products for the treatment of
certain inherited metabolic diseases under certain circumstances in
this section the following words have the meanings indicated:
(1) "Inherited metabolic disease" means a disease caused by an
inherited abnormality of body chemistry and includes a disease for
which the state screens newborn babies;
(2) "Low protein modified food product" means a food product
that is: (i) Specially formulated to have less than one gram of
protein per serving; and (ii) intended to be used under the
direction of a physician for dietary treatment of an inherited
metabolic disease; it does not include a natural food that is
naturally low in protein;
(3) "Medical food" means that a food is: (i) Intended for the
dietary treatment of a disease or condition for which nutritional
requirements are established by medical evaluation; and (ii)
formulated to be consumed or administered internally under the
direction of a physician.
(c) The requirements of this section apply to all insurance
polices and subscriber contracts now existing or hereafter
delivered or issued for delivery in this state.
ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.
§33-15-4h. Third party reimbursement for medically necessary food
products as a part of a dietary treatment of an inherited metabolic disease.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement applicable to this article,
reimbursement or indemnification for medically necessary food
products as a part of a dietary treatment of an inherited metabolic
disease may not be denied.
(b) The same deductibles, coinsurance, network restrictions
and other limitations for covered services found in the policy,
provision, contract, plan or agreement of the covered person may
apply to medically necessary food products as a part of a dietary
treatment of an inherited metabolic disease.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-3q. Third party reimbursement for medically necessary food
products as a part of a dietary treatment of an
inherited metabolic disease.
Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, whenever
reimbursement or indemnity for medically necessary food products as
a part of a dietary treatment of an inherited metabolic disease
covered, reimbursement or indemnification may not be denied for
medically necessary food products as a part of a dietary treatment
of an inherited metabolic disease. A policy, provision, contract,
plan or agreement may apply to medically necessary food products as a part of a dietary treatment of an inherited metabolic disease
the same deductibles, coinsurance and other limitations as apply to
other covered services.
ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE
CORPORATIONS, DENTAL SERVICE CORPORATIONS AND
HEALTH SERVICE CORPORATIONS.
§33-24-7h. Third party reimbursement for medically necessary food
products as a part of a dietary treatment of an
inherited metabolic disease.
Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, whenever
reimbursement or indemnity for medically necessary food products as
a part of a dietary treatment of an inherited metabolic disease are
covered, reimbursement or indemnification may not be denied for
medically necessary food products as a part of a dietary treatment
of an inherited metabolic disease for any nonsymptomatic person
covered under the policy or contract. A policy, provision,
contract, plan or agreement may apply to medically necessary food
products as a part of a dietary treatment of an inherited metabolic
disease the same deductibles, coinsurance and other limitations as
apply to other covered services.
ARTICLE 25. HEALTH CARE CORPORATIONS.
§33-25-8f. Third party reimbursement for medically necessary food products as a part of a dietary treatment of an
inherited metabolic disease.
Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, whenever
reimbursement or indemnity for medically necessary food products as
a part of a dietary treatment of an inherited metabolic disease are
covered, reimbursement or indemnification may not be denied for
medically necessary food products as a part of a dietary treatment
of an inherited metabolic disease. A policy, provision, contract,
plan or agreement may apply to medically necessary food products as
a part of a dietary treatment of an inherited metabolic disease the
same deductibles, coinsurance and other limitations as apply to
other covered services.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-8g. Third party reimbursement for medically necessary
food products as a part of a dietary treatment of
an inherited metabolic disease.
Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, whenever
reimbursement or indemnity for medically necessary food products as
a part of a dietary treatment of an inherited metabolic disease are
covered, reimbursement or indemnification may not be denied for
medically necessary food products as a part of a dietary treatment of an inherited metabolic disease. A policy, provision, contract,
plan or agreement may apply to medically necessary food products as
a part of a dietary treatment of an inherited metabolic disease the
same deductibles, coinsurance and other limitations as apply to
other covered services.
NOTE: The purpose of this bill is to require insurance
companies that provide health care coverage to provide for dietary
treatment of medically necessary low protein foods and medical
foods (formulas) for treatment of inherited metabolic diseases when
prescribed by a physician.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.
§§33-6-37, 33-15-4h, 33-16-3q, 33-24-7h, 33-25-8f and
33-25A-8g are new; therefore, strike-throughs and underscoring have
been omitted.
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