Senate Bill No. 31
(By Senator Boley)
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[Introduced February 10, 1993;
referred to the Committee on Banking and Insurance.]
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A BILL to amend and reenact section fifteen, article fifteen,
chapter thirty-three of the code of West Virginia, one
thousand nine hundred thirty-one, as amended; to amend and
reenact section three, article sixteen of said chapter; and
to amend and reenact section three, article sixteen-c of
said chapter, all relating to accident and health insurance
policies; and requiring that certain sterilization
procedures for women and men be covered.
Be it enacted by the Legislature of West Virginia:
That section fifteen, article fifteen, chapter thirty-three
of the code of West Virginia, one thousand nine hundred
thirty-one, as amended, be amended and reenacted; that section
three, article sixteen of said chapter be amended and reenacted;
and that section three, article sixteen-c of said chapter be
amended and reenacted, all to read as follows:
ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.
§33-15-15. Insurance commissioner to establish minimum benefits
and coverages for an individual policy design; basic policy
benefits; exemptions; legislative rules; premiums;
applicability.
(a) The insurance commissioner shall establish minimum
benefits which may be included in any individual accident and
sickness insurance policy issued pursuant to this article. The
commissioner may accept bids on designs for such minimum plans
and shall compile a final basic benefit plan for use by insurers
within six months after the effective date of this article.
(b) The basic policy plan established by the insurance
commissioner may include coverage for the services of medical
physicians or surgeons, podiatrists, physician assistants,
osteopathic physicians or surgeons, chiropractors, midwives,
advanced nurse practitioners or any other professional health
care provider as deemed appropriate by the insurance
commissioner.
(c) The following shall serve as a guide to the commissioner
in the design of a basic policy issued pursuant to this article:
(1) Inpatient hospital care up to twenty days per year;
(2) Outpatient hospital care including, but not limited to,
surgery and anesthesia, preadmission testing, radiation therapy
and chemotherapy;
(3) Accident or emergency care through emergency room care
and emergency admissions to a hospital;
(4) Physician office visits for primary, preventive, well,
acute or sick care, up to four visits per year, and laboratoryfees, surgery and anesthesia, diagnostic X-rays, physician care
in a hospital inpatient or outpatient setting;
(5) Prenatal care, including a minimum of one prenatal
office visit per month during the first two trimesters of
pregnancy, two office visits per month during the seventh and
eighth months of pregnancy, and one office visit per week during
the ninth month and until term. Coverage for each such visit
shall include necessary appropriate screening, including history,
physical examination, and such laboratory and diagnostic
procedures as may be deemed appropriate by the physician based
upon recognized medical criteria for the risk group of which the
patient is a member. Coverage for each office visit shall also
include such prenatal counseling as the physician deems
appropriate;
(6) Obstetrical care, including physician's services,
delivery room and other medically necessary hospital services;
and
(7) X-ray and laboratory services in connection with
mammograms or pap smears when performed for cancer screening or
diagnostic purposes, at the direction of a physician, including,
but not limited to, the following:
(A) Baseline or other recommended mammograms for women age
thirty-five to thirty-nine, inclusive;
(B) Mammograms recommended or required for women age forty
to forty-nine, inclusive, every two years or as needed;
(C) A mammogram every year for women age fifty and over; or
(D) A pap smear annually or more frequently based on the
woman's physician's recommendation for women age eighteen or
over. A basic policy issued pursuant to this article may apply
to mammograms or pap smears the same deductibles or copayments as
apply to other covered services;
(8) Medical and laboratory services in connection with
annual checkups for prostate cancer in men age fifty and over;
and
(9) Sterilization procedures, specifically "bilateral tubal
ligation" and "laparoscopic electric transverse transection" and
"laparoscopic tubal with Fallope Rings" procedures for women and
vasectomies for men.
(d) Notwithstanding any other provision of this code to the
contrary, any basic policy issued pursuant to this section shall
be exempt from all statutorily and regulatorily mandated benefits
and coverages except for the minimum benefits and coverages as
established by the commissioner pursuant to subsection (a) of
this section.
(e) Nothing in this section shall preclude an insurer from
offering any other benefit or coverage under a basic policy
issued pursuant to this article, for an appropriate additional
premium: Provided, That any additional benefit or coverage must
first be approved by the insurance commissioner.
(f) A basic policy issued pursuant to this section may
include deductibles, copayments and maximum benefits: Provided,
That any additional benefit must first be approved by theinsurance commissioner.
(g) The insurance commissioner shall promulgate legislative
rules pursuant to chapter twenty-nine-a of this code to implement
the provisions of this section, including, but not limited to,
rules regarding bids, forms and rates.
(h) The premiums paid for insurance provided pursuant to
this article shall be exempt from the premium tax required to be
paid pursuant to sections fourteen and fourteen-a, article three
of this chapter.
(i) A basic policy provided by this section shall be issued
only to individuals who have been without health insurance
coverage for at least one year prior to application for the same.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-3. Required policy provisions.
Each such policy hereafter delivered or issued for delivery
in this state shall contain in substance the following
provisions:
(a) A provision that the policy, the application of the
policyholder, a copy of which shall be attached to such policy,
and the individual applications, if any, submitted in connection
with such policy by the employees or members, shall constitute
the entire contract between the parties, and that all statements
made by any applicant or applicants shall be deemed
representations and not warranties, and that no such statement
shall void the insurance or reduce benefits thereunder unless
contained in a written application.
(b) A provision that the insurer will furnish to the
policyholder, for delivery to each employee or member of the
insured group, an individual certificate setting forth in
substance the essential features of the insurance coverage of
such employee or member and to whom benefits thereunder are
payable. If dependents are included in the coverage, only one
certificate need be issued for each family unit.
(c) A provision that all new employees or members, as the
case may be, in the groups or classes eligible for insurance,
shall from time to time be added to such groups or classes
eligible to obtain such insurance in accordance with the terms of
the policy.
(d) No provision relative to notice or proof of loss or the
time for paying benefits or the time within which suit may be
brought upon the policy shall be less favorable to the insured
than would be permitted in the case of an individual policy by
the provision set forth in article fifteen of this chapter.
(e) A provision that all members in groups or classes
eligible for insurance provided through an employee's group plan
shall be permitted to pay the premiums at the same group rate and
receive the same coverages for a period not to exceed eighteen
months when they are involuntarily laid off from work.
(f) A provision that sterilization procedures, specifically
"bilateral tubal ligation," "laparoscopic electric transverse
transection" and "laparoscopic tubal with Fallope Rings"
procedures for women and vasectomies for men shall be included.
ARTICLE 16C. EMPLOYER GROUP ACCIDENT AND SICKNESS INSURANCE
POLICIES.
§33-16C-3. Exemption from mandatory benefits and coverages;
optional benefits and coverages; deductibles and copayments.
(a) Notwithstanding any other provision of this code to the
contrary, any basic policy issued pursuant to this article shall
be exempt from all statutorily and regulatorily mandated benefits
and coverages except for the minimum benefits and coverages
provided for in section four of this article.
(b) Nothing in this article shall preclude an insurer from
offering any other benefit or coverage under a basic policy
issued pursuant to this article, for an appropriate additional
premium: Provided, That any additional benefit or coverage must
first be approved by the insurance commissioner.
(c) A basic policy issued pursuant to this article may
include deductibles, copayments and maximum benefits: Provided,
That any additional benefit must first be approved by the
insurance commissioner.
(d) Notwithstanding the provisions of subsection (a) of this
section, a basic policy issued pursuant to this article shall
include coverage for sterilization procedures, specifically
"bilateral tubal ligation," "laparoscopic electric transverse
transection" and "laparoscopic tubal with Fallope Rings" for
women and vasectomies for men.
NOTE: The purpose of this bill is to include specificsterilization procedures for women and men as covered procedures
in accident and health insurance policies.
Strike-throughs indicate language that would be stricken
from the present law, and underscoring indicates new language
that would be added.