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Senate Bill 22 History
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Key: Green = existing Code. Red = new code to be enacted
Senate Bill No. 22
(By Senators Stollings, Jenkins, Kessler (Mr. President), Miller
and Beach)
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[Introduced February 13, 2013; 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 §5-16-7 of the Code of West Virginia,
1931, as amended; to amend said code by adding thereto a new
section, designated §33-15-4k; to amend said code by adding
thereto a new section, designated §33-16-3w; to amend and
reenact §33-16E-2 of said code; to amend said code by adding
thereto a new section, designated §33-24-7l; to amend said
code by adding thereto a new section, designated §33-25-8i;
and to amend said code by adding thereto a new section,
designated §33-25A-8k, all relating generally to requiring
health insurance coverage of maternity and contraceptive
services in certain circumstances; providing maternity and
contraceptive services
for all individuals participating in or
receiving insurance coverage under a health insurance policy if those services are covered under the policy; excluding
certain drugs and devices from the definition of
"contraceptives"; modifying required benefits for public
employees insurance, accident and sickness insurance, group
accident and sickness insurance, hospital medical and dental
corporations, health care corporations and health maintenance
organizations; and providing exceptions to the extent that
required benefits exceed the essential health benefits
specified under the Patient Protection and Affordable Care
Act.
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; that said code be amended by adding
thereto a new section, designated §33-15-4k; that said code be
amended by adding thereto a new section, designated §33-16-3w; that
§33-16E-2
of said code be amended and reenacted;
that said code be
amended by adding thereto a new section, designated §33-24-7l; that
said code be amended by adding thereto a new section, designated
§33-25-8i; and that said code be amended by adding thereto a new
section, designated §33-25A-8k,
all to read as follows:
CHAPTER 5. GENERAL POWERS AND AUTHORITY OF 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 and to establish and promulgate
rules for the administration of these plans subject to the
limitations contained in this article. Those These 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) Annual screening for kidney disease as determined to be
medically necessary by a physician using any combination of blood
pressure testing, urine albumin or urine protein testing and serum
creatinine testing as recommended by the National Kidney
Foundation;
(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;
(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 (4)
of this subsection if inpatient care is determined to be medically
necessary by the attending physician. Those These 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
(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 a 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 if the
agency demonstrates that its total costs for the treatment of
mental illness for any plan exceeded exceeds two percent of the
total costs for such plan in any experience period, then the agency
may apply whatever additional 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 for the next experience period. in order
to maintain costs below two percent of the total costs for the plan
for the next experience period. These measures may include, but
are not limited to, limitations on inpatient and outpatient
benefits.
(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.
(7) Coverage for general anesthesia for dental procedures and
associated outpatient hospital or ambulatory facility charges
provided by appropriately licensed health care individuals in
conjunction with dental care if the covered person is:
(A) Seven years of age or younger or is developmentally
disabled and is an individual for whom a successful result cannot
be expected from dental care provided under local anesthesia
because of a physical, intellectual or other medically compromising
condition of the individual and for whom a superior result can be
expected from dental care provided under general anesthesia;
(B) A child who is twelve years of age or younger with
documented phobias or with documented mental illness and with
dental needs of such magnitude that treatment should not be delayed
or deferred and for whom lack of treatment can be expected to
result in infection, loss of teeth or other increased oral or
dental morbidity and for whom a successful result cannot be
expected from dental care provided under local anesthesia because
of such condition and for whom a superior result can be expected from dental care provided under general anesthesia.
(8) (A) Any plan issued or renewed on or after January 1, 2012
shall include coverage for diagnosis, evaluation and treatment of
autism spectrum disorder in individuals ages eighteen months to
eighteen years. To be eligible for coverage and benefits under
this subdivision, the individual must be diagnosed with autism
spectrum disorder at age eight or younger. Such policy shall
provide coverage for treatments that are medically necessary and
ordered or prescribed by a licensed physician or licensed
psychologist and in accordance with a treatment plan developed from
a comprehensive evaluation by a certified behavior analyst for an
individual diagnosed with autism spectrum disorder.
(B) The coverage shall include, but not be limited to, applied
behavior analysis Applied behavior analysis which shall be
provided or supervised by a certified behavior analyst. The annual
maximum benefit for applied behavior analysis required by this
subdivision shall be in an amount not to exceed $30,000 per
individual for three consecutive years from the date treatment
commences. At the conclusion of the third year, coverage for
applied behavior analysis required by this subdivision shall be in
an amount not to exceed $2,000 per month, until the individual
reaches eighteen years of age, as long as the treatment is
medically necessary and in accordance with a treatment plan developed by a certified behavior analyst pursuant to a
comprehensive evaluation or reevaluation of the individual. This
subdivision shall not be construed as limiting, replacing or
affecting does not limit, replace or affect any obligation to
provide services to an individual under the Individuals with
Disabilities Education Act, 20 U.S.C. 1400 et seq., as amended from
time to time or other publicly funded programs. Nothing in this
subdivision shall be construed as requiring requires reimbursement
for services provided by public school personnel.
(C) The certified behavior analyst shall file progress reports
with the agency semiannually. In order for treatment to continue,
the agency must receive objective evidence or a clinically
supportable statement of expectation that:
(i) The individual's condition is improving in response to
treatment; and
(ii) A maximum improvement is yet to be attained; and
(iii) There is an expectation that the anticipated improvement
is attainable in a reasonable and generally predictable period of
time.
(D) On or before January 1 each year, the agency shall file an
annual report with the Joint Committee on Government and Finance
describing its implementation of the coverage provided pursuant to
this subdivision. The report shall include, but shall not be limited to, the number of individuals in the plan utilizing the
coverage required by this subdivision, the fiscal and
administrative impact of the implementation and any recommendations
the agency may have as to changes in law or policy related to the
coverage provided under this subdivision. In addition, the agency
shall provide such other information as may be required by the
Joint Committee on Government and Finance as it may from time to
time request.
(E) For purposes of this subdivision, the term:
(i) "Applied Behavior Analysis" means the design,
implementation and evaluation of environmental modifications using
behavioral stimuli and consequences in order to produce socially
significant improvement in human behavior including and includes
the use of direct observation, measurement and functional analysis
of the relationship between environment and behavior.
(ii) "Autism spectrum disorder" means any pervasive
developmental disorder including autistic disorder, Asperger's
Syndrome, Rett Syndrome, childhood disintegrative disorder or
Pervasive Development Disorder as defined in the most recent
edition of the Diagnostic and Statistical Manual of Mental
Disorders of the American Psychiatric Association.
(iii) "Certified behavior analyst" means an individual who is
certified by the Behavior Analyst Certification Board or certified by a similar nationally recognized organization.
(iv) "Objective evidence" means standardized patient
assessment instruments, outcome measurements tools or measurable
assessments of functional outcome. Use of objective measures at
the beginning of treatment, during and after treatment is
recommended to quantify progress and support justifications for
continued treatment. The tools are not required but their use will
enhance the justification for continued treatment.
(F) To the extent that the application of this subdivision for
autism spectrum disorder causes an increase of at least one percent
of actual total costs of coverage for the plan year, the agency may
apply additional cost containment measures.
(G) To the extent that the provisions of this subdivision
require benefits that exceed the essential health benefits
specified under section 1302(b) of the Patient Protection and
Affordable Care Act, Pub. L. No. 111-148, as amended, the specific
benefits that exceed the specified essential health benefits shall
not be required of insurance plans offered by the Public Employees
Insurance Agency.
(9) For plans that include maternity benefits, coverage for
the same maternity benefits for all individuals participating in or
receiving coverage under plans that are issued or renewed on or
after July 1, 2013: Provided, That to the extent that the provisions of this subdivision require benefits that exceed the
essential health benefits specified under section 1302(b) of the
Patient Protection and Affordable Care Act, Pub. L. No. 111-148, as
amended, the specific benefits that exceed the specified essential
health benefits shall not be required of a health benefit plan when
the plan is offered in this state.
(b) The agency shall, with full authorization, 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 Higher Education Policy
Commission, West Virginia Council for Community and Technical College Education and county boards of education; or
(4) Any other categorization which would ensure the stability
of the overall program.
(d) The agency shall maintain the medical and prescription
drug coverage for Medicare eligible retirees by providing coverage
through one of the existing plans or by enrolling the Medicare
eligible retired employees into a Medicare specific plan,
including, but not limited to, the Medicare/Advantage Prescription
Drug Plan. In the event that If a Medicare specific plan would no
longer be is no longer available or advantageous for the agency and
the retirees, the retirees shall remain eligible for coverage
through the agency.
CHAPTER 33. INSURANCE.
ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE
§33-15-4k. Maternity coverage.
Notwithstanding any provision of any policy, provision,
contract, plan or agreement applicable to this article, any health
insurance policy subject to this article that provides health
insurance coverage for maternity services shall, on or after July
1, 2013, provide coverage for maternity services for all persons
participating in or receiving coverage under the policy. To the
extent that the provisions of this section require benefits that
exceed the essential health benefits specified under section 1302(b) of the Patient Protection and Affordable Care Act, Pub. L.
No. 111-148, as amended, the specific benefits that exceed the
specified essential health benefits are not required of a health
benefit plan when the plan is offered by a health care insurer in
this state. Coverage required under this section may not be
subject to exclusions or limitations which are not applied to other
maternity coverage under the policy.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-3w. Maternity coverage.
Notwithstanding any provision of any policy, provision,
contract, plan or agreement applicable to this article, any health
insurance policy subject to this article that provides health
insurance coverage for maternity services shall, on or after July
1, 2013, provide coverage for maternity services for all persons
participating in, or receiving coverage under the policy. To the
extent that the provisions of this section require benefits that
exceed the essential health benefits specified under section
1302(b) of the Patient Protection and Affordable Care Act, Pub. L.
No. 111-148, as amended, the specific benefits that exceed the
specified essential health benefits are not required of a health
benefit plan when the plan is offered by a health care insurer in
this state. Coverage required under this section may not be
subject to exclusions or limitations which are not applied to other maternity coverage under the policy.
ARTICLE 16E. CONTRACEPTIVE COVERAGE.
§33-16E-2. Definitions.
For the purposes of this article, these the following
definitions are applicable unless a different meaning clearly
appears from the context:
(1) "Contraceptives" means drugs or devices approved by the
food and drug administration to prevent pregnancy but does not
include drugs or devices that may cause the demise of a zygote or
embryo at any time after its fertilization by the combination of
sperm and egg.
(2) "Covered person" means the policyholder, subscriber,
certificate holder, enrollee or other individual who is
participating in or receiving coverage under a health insurance
plan. For the purposes of this article, covered person does not
include a dependent child.
(3) "Health insurance plan" means benefits consisting of
medical care provided directly, through insurance or reimbursement,
or indirectly, including items and services paid for as medical
care, under any hospital or medical expense incurred policy or
certificate; hospital, medical or health service corporation
contract; health maintenance organization contract; fraternal
benefit society contract; plan provided by a multiple-employer trust or a multiple-employer welfare arrangement; or plan provided
by the West Virginia Public Employees Insurance Agency pursuant to
article sixteen, chapter five of this code.
(4) "Outpatient contraceptive services" means consultations,
examinations, procedures and medical services, provided on an
outpatient basis and related to the use of prescription
contraceptive drugs and devices to prevent pregnancy issued under
a health insurance plan that provides benefits for prescription
drugs or prescription devices in a prescription drug plan.
(5) "Religious employer" is an entity whose sincerely held
religious beliefs or sincerely held moral convictions are central
to the employer's operating principles and the entity is an
organization listed under 26 U.S.C. 501 (c)(3), 26 U.S.C. 3121, or
listed in the Official Catholic Directory published by P.J. Kennedy
and Sons.
ARTICLE 24. HOSPITAL MEDICAL AND DENTAL CORPORATIONS.
§33-24-7l. Maternity coverage.
Notwithstanding any provision of any policy, provision,
contract, plan or agreement applicable to this article, a health
insurance policy subject to this article that provides health
insurance coverage for maternity services shall, on or after July
1, 2013, provide coverage for maternity services for all persons
participating in, or receiving coverage under the policy. To the extent that the provisions of this section require benefits that
exceed the essential health benefits specified under section
1302(b) of the Patient Protection and Affordable Care Act, Pub. L.
No. 111-148, as amended, the specific benefits that exceed the
specified essential health benefits are not required of a health
benefit plan when the plan is offered by a health care insurer in
this state. Coverage required under this section may not be
subject to exclusions or limitations which are not applied to other
maternity coverage under the policy.
ARTICLE 25. HEALTH CARE CORPORATION.
§33-25-8i. Maternity coverage.
Notwithstanding any provision of any policy, provision,
contract, plan or agreement applicable to this article, a health
insurance policy subject to this article that provides health
insurance coverage for maternity services shall, on or after July
1, 2013, provide coverage for maternity services for all persons
participating in, or receiving coverage under the policy. To the
extent that the provisions of this section require benefits that
exceed the essential health benefits specified under section
1302(b) of the Patient Protection and Affordable Care Act, Pub. L.
No. 111-148, as amended, the specific benefits that exceed the
specified essential health benefits are not required of a health
benefit plan when the plan is offered by a health care insurer in this state. Coverage required under this section may not be
subject to exclusions or limitations which are not applied to other
maternity coverage under the policy.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-8k. Maternity coverage.
Notwithstanding any provision of any policy, provision,
contract, plan or agreement applicable to this article, a health
insurance policy subject to this article that provides health
insurance coverage for maternity services shall, on or after July
1, 2013, provide coverage for maternity services for all persons
participating in, or receiving coverage under the policy. To the
extent that the provisions of this section require benefits that
exceed the essential health benefits specified under section
1302(b) of the Patient Protection and Affordable Care Act, Pub. L.
No. 111-148, as amended, the specific benefits that exceed the
specified essential health benefits are not required of a health
benefit plan when the plan is offered by a health care insurer in
this state. Coverage required under this section may not be
subject to exclusions or limitations which are not applied to other
maternity coverage under the policy.
NOTE: The purpose of this bill is to require health insurers
to cover maternity and contraceptive services for all individuals
who are participating in or receiving coverage under a policyholder's health insurance plan if those services are covered
under the policy. Under current law, health insurers are not
required to cover maternity or contraceptive services for
dependents.
The bill passed out of the Legislative oversight Commission on
Health and Human Resource Accountability, recommended for passage.
§33-15-4k, §33-16-3w, §33-24-7l, §33-25-8i and §33-25A-8k are
new; therefore, strike-throughs and underscoring have been omitted.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.