H. B. 2772
(By Delegates Rodighiero, Ellis, Hrutkay,
Shook, Reynolds, Craig, Staggers, Eldridge, Stephens,
Fleischauer and Beach)
[Introduced January 31, 2007; referred to the
Committee on Health and Human Resources then Finance.]
A BILL to amend and reenact §5-16-7 of the Code of West Virginia,
1931, as amended, relating to ensuring the Public Employees
Insurance Agency will continue and maintain medical and
prescription drug coverage for Medicare eligible retired
employees; and, providing that if a Medicare/Advantage
Prescription Drug Plan should fail, the Public Employees
Insurance Agency will take all Medicare eligible retired
employees back into the existing Public Employees Insurance
Agency plan or provide another plan of equal or better
coverage.
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 to read as follows:
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 to establish and promulgate
rules for the administration of these plans, subject to the
limitations contained in this article.
Provided, That the Public
Employees Insurance Agency will continue and maintain the quality
Public Employees Insurance Agency medical and prescription drug
coverage for Medicare eligible retired employees and, if the
Medicare/Advantage Prescription Drug Plan should fail, the Public
Employees Insurance Agency will take all Medicare eligible retired
employees back into the existing Public Employees Insurance Agency
Plan. 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) 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) 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) 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 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.
NOTE: The purpose of this bill is to ensure the Public
Employees Insurance Agency will continue and maintain medical and
prescription drug coverage for Medicare eligible retired employees.
The bill further provides that if a Medicare/Advantage Prescription
Drug Plan should fail, the Public Employees Insurance Agency will
take all Medicare eligible retired employees back into the existing
Public Employees Insurance Agency plan or provide another plan of
equal or better coverage.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.