House Bill 3253 History
OTHER VERSIONS -
Enrolled Version - Final Version
BILL ORIGINATING FROM COMMITTEE
H. B. 3253
(By Delegates Leach, Frederick, Keener, R. M. Thompson, Fletcher,
Ashley and Hall)
(Originating in the Committee on Finance)
[April 5, 2001]
A BILL to amend and reenact section two, article twenty five-a,
chapter thirty-three of the code of West Virginia, one
thousand thirty-one, as amended, relating to redefining
Be it enacted by the Legislature of West Virginia:
That section two, article twenty five-a, chapter thirty-three
of the code of West Virginia, one thousand nine hundred thirty-
one, as amended, be amended and reenacted to read as follows:
(1) "Basic health care services" means physician, hospital,
out-of-area, podiatric, chiropractic, laboratory, X ray, emergency,
short-term mental health services not exceeding twenty outpatient
visits in any twelve-month period, and cost-effective preventive services including immunizations, well-child care, periodic health
evaluations for adults, voluntary family planning services,
infertility services, and children's eye and ear examinations
conducted to determine the need for vision and hearing corrections,
which services need not necessarily include all procedures or
services offered by a service provider.
(2) "Capitation" means the fixed amount paid by a health
maintenance organization to a health care provider under contract
with the health maintenance organization in exchange for the
rendering of health care services.
(3) "Commissioner" means the commissioner of insurance.
(4) "Consumer" means any person who is not a provider of care
or an employee, officer, director or stockholder of any provider of
(5) "Copayment" means a specific dollar amount or percentage
except as otherwise provided for by statute, that the subscriber
must pay upon receipt of covered health care services and which is
set at an amount or percentage
consistent with allowing subscriber
access to health care services.
(6) "Employee" means a person in some official employment or
position working for a salary or wage continuously for no less than
one calendar quarter and who is in such a relation to another
person that the latter may control the work of the former and direct the manner in which the work shall be done.
(7) "Employer" means any individual, corporation, partnership,
other private association, or state or local government that
employs the equivalent of at least two full-time employees during
any four consecutive calendar quarters.
(8) "Enrollee", "subscriber" or "member" means an individual
who has been voluntarily enrolled in a health maintenance
organization, including individuals on whose behalf a contractual
arrangement has been entered into with a health maintenance
organization to receive health care services.
(9) "Evidence of coverage" means any certificate, agreement or
contract issued to an enrollee setting out the coverage and other
rights to which the enrollee is entitled.
(10) "Health care services" means any services or goods
included in the furnishing to any individual of medical, mental or
dental care, or hospitalization or incident to the furnishing of
the care or hospitalization, osteopathic services, chiropractic
services, podiatric services, home health, health education or
rehabilitation, as well as the furnishing to any person of any and
all other services or goods for the purpose of preventing,
alleviating, curing or healing human illness or injury.
(11) "Health maintenance organization" or "HMO" means a public
or private organization which provides, or otherwise makes available to enrollees, health care services, including at a
minimum basic health care services, and
(a) Receives premiums for the provision of basic health care
services to enrollees on a prepaid per capita or prepaid aggregate
fixed sum basis, excluding copayments;
(b) Provides physicians' services primarily: (i) Directly
through physicians who are either employees or partners of the
organization; or (ii) through arrangements with individual
physicians or one or more groups of physicians organized on a group
practice or individual practice arrangement; or (iii) through some
combination of paragraphs (i) and (ii) of this subdivision;
(c) Assures the availability, accessibility and quality,
including effective utilization, of the health care services which
it provides or makes available through clearly identifiable focal
points of legal and administrative responsibility; and
(d) Offers services through an organized delivery system in
which a primary care physician is designated for each subscriber
upon enrollment. The primary care physician is responsible for
coordinating the health care of the subscriber and is responsible
for referring the subscriber to other providers when necessary:
That when dental care is provided by the health
maintenance organization the dentist selected by the subscriber
from the list provided by the health maintenance organization shall coordinate the covered dental care of the subscriber, as approved
by the primary care physician or the health maintenance
(12) "Impaired" means a financial situation in which, based
upon the financial information which would be required by this
chapter for the preparation of the health maintenance
organization's annual statement, the assets of the health
maintenance organization are less than the sum of all of its
liabilities and required reserves including any minimum capital and
surplus required of the health maintenance organization by this
chapter so as to maintain its authority to transact the kinds of
business or insurance it is authorized to transact.
(13) "Individual practice arrangement" means any agreement or
arrangement to provide medical services on behalf of a health
maintenance organization among or between physicians or between a
health maintenance organization and individual physicians or groups
of physicians, where the physicians are not employees or partners
of the health maintenance organization and are not members of or
affiliated with a medical group.
(14) "Insolvent" or "insolvency" means a financial situation
in which, based upon the financial information that would be
required by this chapter for the preparation of the health
maintenance organization's annual statement, the assets of the health maintenance organization are less than the sum of all of its
liabilities and required reserves.
(15) "Medical group" or "group practice" means a professional
corporation, partnership, association or other organization
composed solely of health professionals licensed to practice
medicine or osteopathy and of other licensed health professionals,
including podiatrists, dentists and optometrists, as are necessary
for the provision of health services for which the group is
responsible: (a) A majority of the members of which are licensed
to practice medicine or osteopathy; (b) who as their principal
professional activity engage in the coordinated practice of their
profession; (c) who pool their income for practice as members of
the group and distribute it among themselves according to a
prearranged salary, drawing account or other plan; and (d) who
share medical and other records and substantial portions of major
equipment and professional, technical and administrative staff.
(16) "Premium" means a prepaid per capita or prepaid aggregate
fixed sum unrelated to the actual or potential utilization of
services of any particular person which is charged by the health
maintenance organization for health services provided to an
(17) "Primary care physician" means the general practitioner,
family practitioner, obstetrician/gynecologist, pediatrician or specialist in general internal medicine who is chosen or designated
for each subscriber who will be responsible for coordinating the
health care of the subscriber, including necessary referrals to
other providers: Provided,
That a certified nurse-midwife may be
chosen or designated in lieu of as a subscriber's primary care
physician during the subscriber's pregnancy and for a period
extending through the end of the month in which the sixty-day
period following termination of pregnancy ends: Provided, however,
That nothing in this subsection shall expand the scope of practice
for certified nurse-midwives as defined in article fifteen, chapter
thirty of this code.
(18) "Provider" means any physician, hospital or other person
or organization which is licensed or otherwise authorized in this
state to furnish health care services.
(19) "Uncovered expenses" means the cost of health care
services that are covered by a health maintenance organization, for
which a subscriber would also be liable in the event of the
insolvency of the organization.
(20) "Service area" means the county or counties approved by
the commissioner within which the health maintenance organization
may provide or arrange for health care services to be available to
(21) "Statutory surplus" means the minimum amount of unencumbered surplus which a corporation must maintain pursuant to
the requirements of this article.
(22) "Surplus" means the amount by which a corporation's
assets exceeds its liabilities and required reserves based upon the
financial information which would be required by this chapter for
the preparation of the corporation's annual statement except that
assets pledged to secure debts not reflected on the books of the
health maintenance organization shall not be included in surplus.
(23) "Surplus notes" means debt which has been subordinated to
all claims of subscribers and general creditors of the
(24) "Qualified independent actuary" means an actuary who is
a member of the American academy of actuaries or the society of
actuaries and has experience in establishing rates for health
maintenance organizations and who has no financial or employment
interest in the health maintenance organization.
(25) "Quality assurance" means an ongoing program designed to
objectively and systematically monitor and evaluate the quality and
appropriateness of the enrollee's care, pursue opportunities to
improve the enrollee's care and to resolve identified problems at
the prevailing professional standard of care.
(26) "Utilization management" means a system for the
evaluation of the necessity, appropriateness and efficiency of the use of health care services, procedures and facilities."
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would