WEST virginia legislature

2017 regular session

Introduced

Senate Bill 526

By Senator Takubo

[Introduced March 7, 2017; Referred
to the Committee on Banking and Insurance; and then to the Committee on Finance]

A BILL to amend the Code of West Virginia, 1931, as amended, by adding thereto a new section, designated §5-16-7b; to amend and reenact §5-16-9 of said code; to amend said code by adding thereto a new section, designated §5-16B-6f; to amend said code by adding thereto a new section, designated §9-5-25; to amend said code by adding thereto a new section, designated §33-15-4p; to amend said code by adding thereto a new section, designated §33-16-3bb; to amend said code by adding thereto a new section, designated §33-24-7p; to amend said code by adding thereto a new section, designated §33-25-8n; and to amend said code by adding thereto a new section, designated §33-25A-8p, all relating to mandatory insurance coverage for inherited enzymatic disorders; providing a list of diagnosed conditions for which insurance coverage should extend; providing that coverage extends to medically necessary foods for home use when prescribed by a physician; defining terms; and providing for exclusions. 

Be it enacted by the Legislature of West Virginia:

That the Code of West Virginia, 1931, as amended, be amended by adding thereto a new section, designated §5-16-7b; that §5-16-9 of said code be amended and reenacted; that said code be amended by adding thereto a new section, designated §5-16B-6f; that said code be amended by adding thereto a new section, designated §9-5-25; that said code be amended by adding thereto a new section, designated §33-15-4p; that said code be amended by adding thereto a new section, designated §33-16-3bb; that said code be amended by adding thereto a new section, designated §33-24-7p; that said code be amended by adding thereto a new section, designated §33-25-8n; and that said code be amended by adding thereto a new section, designated §33-25A-8p, 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, COMMISSION, OFFICES PROGRAMS, ETC.

ARTICLE 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.

§5-16-7b. Coverage for inherited enzymatic disorders.

(a) A policy, plan or contract subject to this section shall provide coverage for inherited enzymatic disorders caused by a single gene defects involved in the metabolism of amino, organic and fatty acids as well as severe protein allergic conditions. This includes the following conditions if diagnosed as related to the disorder by a physician licensed to practice in this state pursuant to either article three or fourteen of chapter thirty of this code:  

(1) Phenylketonuria;

(2) Maternal phenylketonuria;

(3) Maple syrup urine disease;

(4) Tyrosinemia;

(5) Homocystinuria;

(6) Histidinemia;

(7) Urea cycle disorders;

(8) Hyperlysinemia;

(9) Glutaric acidemias;

(10) Methylmalonic acidemia;

(11) Propionic academia;

(12) Immunoglobulin E and Nonimmunoglobulin E-medicated allergies to multiple food proteins;

(13) Severe food protein induced enterocolitis syndrome;

(14) Eosinophilic disorders as evidenced by the results of a biopsy; and

(15) Impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length and motility of the gastrointestinal tract.

(b) The coverage required by subsection (a) of this section shall include medical foods for home use for which a physician has issued a prescription and has declared them to be medically necessary.

(c) For purposes of this section, medically necessary foods or medical foods shall mean prescription metabolic formulas and their modular counterparts and amino acid-based elemental formulas obtained through a pharmacy. These foods are specifically designated and manufactured for the treatment on inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic and fatty acids and for severe allergic conditions. 

(d) The provisions of this section shall not apply to persons diagnosed with cystic fibrosis or persons with an intolerance for lactose or soy.

§5-16-9. Authorization to execute contracts for group hospital and surgical insurance, group major medical insurance, group prescription drug insurance, group life and accidental death insurance and other accidental death insurance; mandated benefits; limitations; awarding of contracts; reinsurance; certificates for covered employees; discontinuance of contracts.

(a) The director is hereby given exclusive authorization to execute such contract or contracts as are necessary to carry out the provisions of this article and to provide the plan or plans of group hospital and surgical insurance coverage, group major medical insurance coverage, group prescription drug insurance coverage and group life and accidental death insurance coverage selected in accordance with the provisions of this article, such contract or contracts to be executed with one or more agencies, corporations, insurance companies or service organizations licensed to sell group hospital and surgical insurance, group major medical insurance, group prescription drug insurance and group life and accidental death insurance in this state.

(b) The group hospital or surgical insurance coverage and group major medical insurance coverage herein provided shall include coverages and benefits for X ray and laboratory services in connection with mammogram and pap smears when performed for cancer screening or diagnostic services and annual checkups for prostate cancer in men age fifty and over. Such benefits shall include, but not be limited to, the following:

(1) Mammograms when medically appropriate and consistent with the current guidelines from the United States Preventive Services Task Force;

(2) A pap smear, either conventional or liquid-based cytology, whichever is medically appropriate and consistent with the current guidelines from the United States Preventive Services Task Force or The American College of Obstetricians and Gynecologists, for women age eighteen and over;

(3) A test for the human papilloma virus (HPV) for women age eighteen or over, when 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 for women age eighteen and over;

(4) A checkup for prostate cancer annually for men age fifty or over; and

(5) 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.

(6) Coverage for general anesthesia for dental procedures and associated outpatient hospital or ambulatory facility charges provided by appropriately licensed healthcare individuals in conjunction with dental care if the covered person is:

(A) Seven years of age or younger or is developmentally disabled and is either 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; or

(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.

(7) (A) A policy, plan or contract subject to this section shall provide coverage for inherited enzymatic disorders caused by a single gene defects involved in the metabolism of amino, organic and fatty acids as well as severe protein allergic conditions. This includes the following conditions if diagnosed as related to the disorder by a physician licensed to practice in this state pursuant to either article three or fourteen of chapter thirty of this code:  

(i) Phenylketonuria;

(ii) Maternal phenylketonuria;

(iii) Maple syrup urine disease;

(iv) Tyrosinemia;

(v) Homocystinuria;

(vi) Histidinemia;

(vii) Urea cycle disorders;

(viii) Hyperlysinemia;

(ix) Glutaric acidemias;

(x) Methylmalonic acidemia;

(xi) Propionic academia;

(xii) Immunoglobulin E and Nonimmunoglobulin E-medicated allergies to multiple food proteins;

(xiii) Severe food protein induced enterocolitis syndrome;

(xiv) Eosinophilic disorders as evidenced by the results of a biopsy; and

(xv) Impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length and motility of the gastrointestinal tract.

(B) The coverage required by subsection (7)(A) of this section shall include medical foods for home use for which a physician has issued a prescription and has declared them to be medically necessary.

(C) For purposes of this section, medically necessary foods or medical foods shall mean prescription metabolic formulas and their modular counterparts and amino acid-based elemental formulas obtained through a pharmacy. These foods are specifically designated and manufactured for the treatment on inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic and fatty acids and for severe allergic conditions. 

(D) The provisions of this section shall not apply to persons diagnosed with cystic fibrosis or persons with an intolerance for lactose or soy.  

(c) The group life and accidental death insurance herein provided shall be in the amount of $10,000 for every employee. The amount of the group life and accidental death insurance to which an employee would otherwise be entitled shall be reduced to $5,000 upon such employee attaining age sixty-five.

(d) All of the insurance coverage to be provided for under this article may be included in one or more similar contracts issued by the same or different carriers.

(e) The provisions of article three, chapter five-a of this code, relating to the Division of Purchasing of the Department of Finance and Administration, shall not apply to any contracts for any insurance coverage or professional services authorized to be executed under the provisions of this article. Before entering into any contract for any insurance coverage, as authorized in this article, the director shall invite competent bids from all qualified and licensed insurance companies or carriers, who may wish to offer plans for the insurance coverage desired: Provided, That the director shall negotiate and contract directly with health care providers and other entities, organizations and vendors in order to secure competitive premiums, prices and other financial advantages. The director shall deal directly with insurers or health care providers and other entities, organizations and vendors in presenting specifications and receiving quotations for bid purposes. No commission or finder's fee, or any combination thereof, shall be paid to any individual or agent; but this shall not preclude an underwriting insurance company or companies, at their own expense, from appointing a licensed resident agent, within this state, to service the companies' contracts awarded under the provisions of this article. Commissions reasonably related to actual service rendered for the agent or agents may be paid by the underwriting company or companies: Provided, however, That in no event shall payment be made to any agent or agents when no actual services are rendered or performed. The director shall award the contract or contracts on a competitive basis. In awarding the contract or contracts the director shall take into account the experience of the offering agency, corporation, insurance company or service organization in the group hospital and surgical insurance field, group major medical insurance field, group prescription drug field and group life and accidental death insurance field, and its facilities for the handling of claims. In evaluating these factors, the director may employ the services of impartial, professional insurance analysts or actuaries or both. Any contract executed by the director with a selected carrier shall be a contract to govern all eligible employees subject to the provisions of this article. Nothing contained in this article shall prohibit any insurance carrier from soliciting employees covered hereunder to purchase additional hospital and surgical, major medical or life and accidental death insurance coverage.

(f) The director may authorize the carrier with whom a primary contract is executed to reinsure portions of the contract with other carriers which elect to be a reinsurer and who are legally qualified to enter into a reinsurance agreement under the laws of this state.

(g) Each employee who is covered under any contract or contracts shall receive a statement of benefits to which the employee, his or her spouse and his or her dependents are entitled under the contract, setting forth the information as to whom the benefits are payable, to whom claims shall be submitted and a summary of the provisions of the contract or contracts as they affect the employee, his or her spouse and his or her dependents.

(h) The director may at the end of any contract period discontinue any contract or contracts it has executed with any carrier and replace the same with a contract or contracts with any other carrier or carriers meeting the requirements of this article.

(i) The director shall provide by contract or contracts entered into under the provisions of this article the cost for coverage of children's immunization services from birth through age sixteen years to provide immunization against the following illnesses: Diphtheria, polio, mumps, measles, rubella, tetanus, hepatitis-b, haemophilus influenzae-b and whooping cough. Additional immunizations may be required by the Commissioner of the Bureau for Public Health for public health purposes. Any contract entered into to cover these services shall require that all costs associated with immunization, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration be exempt from any deductible, per visit charge and/or copayment provisions which may be in force in these policies or contracts. This section does not require that other health care services provided at the time of immunization be exempt from any deductible and/or copayment provisions.

ARTICLE 16B. WEST VIRGINIA CHILDRENS HEALTH INSURANCE PROGRAM.

§5-16B-6f. Coverage for inherited enzymatic disorders. 

(a) A policy, plan or contract subject to this section shall provide coverage for inherited enzymatic disorders caused by a single gene defects involved in the metabolism of amino, organic and fatty acids as well as severe protein allergic conditions. This includes the following conditions if diagnosed as related to the disorder by a physician licensed to practice in this state pursuant to either article three or fourteen of chapter thirty of this code:  

(1) Phenylketonuria;

(2) Maternal phenylketonuria;

(3) Maple syrup urine disease;

(4) Tyrosinemia;

(5) Homocystinuria;

(6) Histidinemia;

(7) Urea cycle disorders;

(8) Hyperlysinemia;

(9) Glutaric acidemias;

(10) Methylmalonic acidemia;

(11) Propionic academia;

(12) Immunoglobulin E and Nonimmunoglobulin E-medicated allergies to multiple food proteins;

(13) Severe food protein induced enterocolitis syndrome;

(14) Eosinophilic disorders as evidenced by the results of a biopsy; and

(15) Impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length and motility of the gastrointestinal tract.

(b) The coverage required by subsection (a) of this section shall include medical foods for home use for which a physician has issued a prescription and has declared them to be medically necessary.

(c) For purposes of this section, medically necessary foods or medical foods shall mean prescription metabolic formulas and their modular counterparts and amino acid-based elemental formulas obtained through a pharmacy. These foods are specifically designated and manufactured for the treatment on inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic and fatty acids and for severe allergic conditions. 

(d) The provisions of this section shall not apply to persons diagnosed with cystic fibrosis or persons with an intolerance for lactose or soy.

CHAPTER 9. HUMAN SERVICES.

ARTICLE 5. MISCELLANEOUS PROVISIONS.

§9-5-25. Coverage for inherited enzymatic disorders. 

(a) A policy, plan or contract subject to this section shall provide coverage for inherited enzymatic disorders caused by a single gene defects involved in the metabolism of amino, organic and fatty acids as well as severe protein allergic conditions. This includes the following conditions if diagnosed as related to the disorder by a physician licensed to practice in this state pursuant to either article three or fourteen of chapter thirty of this code:

(1) Phenylketonuria;

(2) Maternal phenylketonuria;

(3) Maple syrup urine disease;

(4) Tyrosinemia;

(5) Homocystinuria;

(6) Histidinemia;

(7) Urea cycle disorders;

(8) Hyperlysinemia;

(9) Glutaric acidemias;

(10) Methylmalonic acidemia;

(11) Propionic academia;

(12) Immunoglobulin E and Nonimmunoglobulin E-medicated allergies to multiple food proteins;

(13) Severe food protein induced enterocolitis syndrome;

(14) Eosinophilic disorders as evidenced by the results of a biopsy; and

(15) Impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length and motility of the gastrointestinal tract.

              (b) The coverage required by subsection (a) of this section shall include medical foods for home use for which a physician has issued a prescription and has declared them to be medically necessary.

(c) For purposes of this section, medically necessary foods or medical foods shall mean prescription metabolic formulas and their modular counterparts and amino acid-based elemental formulas obtained through a pharmacy. These foods are specifically designated and manufactured for the treatment on inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic and fatty acids and for severe allergic conditions. 

(d) The provisions of this section shall not apply to persons diagnosed with cystic fibrosis or persons with an intolerance for lactose or soy.  

CHAPTER 33. INSURANCE.

ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.

§33-15-4p. Coverage for inherited enzymatic disorders. 

(a) A policy, plan or contract subject to this section shall provide coverage for inherited enzymatic disorders caused by a single gene defects involved in the metabolism of amino, organic and fatty acids as well as severe protein allergic conditions. This includes the following conditions if diagnosed as related to the disorder by a physician licensed to practice in this state pursuant to either article three or fourteen of chapter thirty of this code:  

(1) Phenylketonuria;

(2) Maternal phenylketonuria;

(3) Maple syrup urine disease;

(4) Tyrosinemia;

(5) Homocystinuria;

(6) Histidinemia;

(7) Urea cycle disorders;

(8) Hyperlysinemia;

(9) Glutaric acidemias;

(10) Methylmalonic acidemia;

(11) Propionic academia;

(12) Immunoglobulin E and Nonimmunoglobulin E-medicated allergies to multiple food proteins;

(13) Severe food protein induced enterocolitis syndrome;

(14) Eosinophilic disorders as evidenced by the results of a biopsy; and

(15) Impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length and motility of the gastrointestinal tract.

(b) The coverage required by subsection (a) of this section shall include medical foods for home use for which a physician has issued a prescription and has declared them to be medically necessary.

(c) For purposes of this section, medically necessary foods or medical foods shall mean prescription metabolic formulas and their modular counterparts and amino acid-based elemental formulas obtained through a pharmacy. These foods are specifically designated and manufactured for the treatment on inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic and fatty acids and for severe allergic conditions. 

(d) The provisions of this section shall not apply to persons diagnosed with cystic fibrosis or persons with an intolerance for lactose or soy.

ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.

§33-16-3bb. Coverage for inherited enzymatic disorders.

(a) A policy, plan or contract subject to this section shall provide coverage for inherited enzymatic disorders caused by a single gene defects involved in the metabolism of amino, organic and fatty acids as well as severe protein allergic conditions. This includes the following conditions if diagnosed as related to the disorder by a physician licensed to practice in this state pursuant to either article three or fourteen of chapter thirty of this code:

(1) Phenylketonuria;

(2) Maternal phenylketonuria;

(3) Maple syrup urine disease;

(4) Tyrosinemia;

(5) Homocystinuria;

(6) Histidinemia;

(7) Urea cycle disorders;

(8) Hyperlysinemia;

(9) Glutaric acidemias;

(10) Methylmalonic acidemia;

(11) Propionic academia;

(12) Immunoglobulin E and Nonimmunoglobulin E-medicated allergies to multiple food proteins;

(13) Severe food protein induced enterocolitis syndrome;

(14) Eosinophilic disorders as evidenced by the results of a biopsy; and

(15) Impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length and motility of the gastrointestinal tract.

(b) The coverage required by subsection (a) of this section shall include medical foods for home use for which a physician has issued a prescription and has declared them to be medically necessary.

(c) For purposes of this section, medically necessary foods or medical foods shall mean prescription metabolic formulas and their modular counterparts and amino acid-based elemental formulas obtained through a pharmacy. These foods are specifically designated and manufactured for the treatment on inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic and fatty acids and for severe allergic conditions.

(d) The provisions of this section shall not apply to persons diagnosed with cystic fibrosis or persons with an intolerance for lactose or soy.

ARTICLE 24. HOSPITAL MEDICAL AND DENTAL CORPORATIONS.

§33-24-7p. Coverage for inherited enzymatic disorders. 

(a) A policy, plan or contract subject to this section shall provide coverage for inherited enzymatic disorders caused by a single gene defects involved in the metabolism of amino, organic and fatty acids as well as severe protein allergic conditions. This includes the following conditions if diagnosed as related to the disorder by a physician licensed to practice in this state pursuant to either article three or fourteen of chapter thirty of this code:  

(1) Phenylketonuria;

(2) Maternal phenylketonuria;

(3) Maple syrup urine disease;

(4) Tyrosinemia;

(5) Homocystinuria;

(6) Histidinemia;

(7) Urea cycle disorders;

(8) Hyperlysinemia;

(9) Glutaric acidemias;

(10) Methylmalonic acidemia;

(11) Propionic academia;

(12) Immunoglobulin E and Nonimmunoglobulin E-medicated allergies to multiple food proteins;

(13) Severe food protein induced enterocolitis syndrome;

(14) Eosinophilic disorders as evidenced by the results of a biopsy; and

(15) Impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length and motility of the gastrointestinal tract.

(b) The coverage required by subsection (a) of this section shall include medical foods for home use for which a physician has issued a prescription and has declared them to be medically necessary.

(c) For purposes of this section, medically necessary foods or medical foods shall mean prescription metabolic formulas and their modular counterparts and amino acid-based elemental formulas obtained through a pharmacy. These foods are specifically designated and manufactured for the treatment on inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic and fatty acids and for severe allergic conditions. 

(d) The provisions of this section shall not apply to persons diagnosed with cystic fibrosis or persons with an intolerance for lactose or soy.

ARTICLE 25. HEALTHCARE CORPORATION.

§33-25-8n. Coverage for inherited enzymatic disorders. 

(a) A policy, plan or contract subject to this section shall provide coverage for inherited enzymatic disorders caused by a single gene defects involved in the metabolism of amino, organic and fatty acids as well as severe protein allergic conditions. This includes the following conditions if diagnosed as related to the disorder by a physician licensed to practice in this state pursuant to either article three or fourteen of chapter thirty of this code:  

(1) Phenylketonuria;

(2) Maternal phenylketonuria;

(3) Maple syrup urine disease;

(4) Tyrosinemia;

(5) Homocystinuria;

(6) Histidinemia;

(7) Urea cycle disorders;

(8) Hyperlysinemia;

(9) Glutaric acidemias;

(10) Methylmalonic acidemia;

(11) Propionic academia;

(12) Immunoglobulin E and Nonimmunoglobulin E-medicated allergies to multiple food proteins;

(13) Severe food protein induced enterocolitis syndrome;

(14) Eosinophilic disorders as evidenced by the results of a biopsy; and

(15) Impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length and motility of the gastrointestinal tract.

(b) The coverage required by subsection (a) of this section shall include medical foods for home use for which a physician has issued a prescription and has declared them to be medically necessary.

(c) For purposes of this section, medically necessary foods or medical foods shall mean prescription metabolic formulas and their modular counterparts and amino acid-based elemental formulas obtained through a pharmacy. These foods are specifically designated and manufactured for the treatment on inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic and fatty acids and for severe allergic conditions.

(d) The provisions of this section shall not apply to persons diagnosed with cystic fibrosis or persons with an intolerance for lactose or soy.

ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.

§33-25A-8p. Coverage for inherited enzymatic disorders.

(a) A policy, plan or contract subject to this section shall provide coverage for inherited enzymatic disorders caused by a single gene defects involved in the metabolism of amino, organic and fatty acids as well as severe protein allergic conditions. This includes the following conditions if diagnosed as related to the disorder by a physician licensed to practice in this state pursuant to either article three or fourteen of chapter thirty of this code:  

(1) Phenylketonuria;

(2) Maternal phenylketonuria;

(3) Maple syrup urine disease;

(4) Tyrosinemia;

(5) Homocystinuria;

(6) Histidinemia;

(7) Urea cycle disorders;

(8) Hyperlysinemia;

(9) Glutaric acidemias;

(10) Methylmalonic acidemia;

(11) Propionic academia;

(12) Immunoglobulin E and Nonimmunoglobulin E-medicated allergies to multiple food proteins;

(13) Severe food protein induced enterocolitis syndrome;

(14) Eosinophilic disorders as evidenced by the results of a biopsy; and

(15) Impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length and motility of the gastrointestinal tract.

(b) The coverage required by subsection (a) of this section shall include medical foods for home use for which a physician has issued a prescription and has declared them to be medically necessary.

(c) For purposes of this section, medically necessary foods or medical foods shall mean prescription metabolic formulas and their modular counterparts and amino acid-based elemental formulas obtained through a pharmacy. These foods are specifically designated and manufactured for the treatment on inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic and fatty acids and for severe allergic conditions. 

(d) The provisions of this section shall not apply to persons diagnosed with cystic fibrosis or persons with an intolerance for lactose or soy.

NOTE:  The purpose of this bill is to provide for mandatory insurance coverage for inherited enzymatic disorders.

Strike-throughs indicate language that would be stricken from a heading or the present law and underscoring indicates new language that would be added.