H.
B.
4516
(By Mr. Speaker, Mr. Chambers, and Delegates P. White,
Gallagher, Kiss, Rowe, Ashcraft and Rutledge)
[Introduced February 18, 1994; referred to the
Select Committee on Health Care Policies.]
A BILL to amend and reenact section nine, article sixteen, chapter five of the code of West Virginia, one thousand nine hundred thirty-one, as amended; to amend and reenact section five, article three, chapter sixteen of said code; to amend and reenact section fifteen, article fifteen, chapter thirty of said code; to further amend said article fifteen by adding thereto a new section, designated section seventeen; to amend article sixteen of said chapter by adding thereto a new section, designated section fifteen; to amend and reenact sections three and four, article sixteen-c of said chapter; to amend article sixteen-d of said chapter by adding thereto a new section, designated section fourteen; to amend article twenty-four of said chapter by adding thereto a new section, designated section seven-d; to amend article twenty-five of said chapter by adding thereto a new section, designated section eight-a; and to amend article twenty-five-a of said chapter by adding thereto a new section, designated section eight-a, all relating to child immunization services and the payment by third party payors of the cost of childhood immunization administration.
Be it enacted by the Legislature of West Virginia:
That section nine, article sixteen, chapter five of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended and reenacted; that section five, article three, chapter sixteen of said code be amended and reenacted; that section fifteen, article fifteen of chapter thirty-three of said code be amended and reenacted; that said article be further amended by adding thereto a new section, designated section seventeen; that article sixteen of said chapter be amended by adding thereto a new section, designated section fifteen; that sections three and four, article sixteen-c of said chapter be amended and reenacted; that article sixteen-d of said chapter be amended by adding thereto a new section, designated section fourteen; that article twenty-four of said chapter be amended by adding thereto a new section, designated section seven-d; that article twenty-five of said chapter be amended by adding thereto a new section, designated section eight-a; and that article twenty-five-a of said chapter be amended by adding thereto a new section, designated section eight-a, 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, COMMISSIONS,
OFFICES, PROGRAMS, ETC.
ARTICLE 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.
§
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 for shall include coverages and benefits for X-ray and laboratory services in connection with mammograms 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) Baseline or other recommended mammograms for women ages thirty-five to thirty-nine, inclusive;
(2) Mammograms recommended or required for women age forty to forty-nine, inclusive, every two years or as needed;
(3) A mammogram every year for women age fifty and over;
(4) A pap smear annually or more frequently based on the woman's physician's recommendation for women age eighteen and over; and
(5) A checkup for prostate cancer annually for men age fifty or over.
(c) The group life and accidental death insurance herein provided for shall be in the amount of ten thousand dollars 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 five thousand dollars 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 purchases 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 herein authorized, said 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. The director shall deal directly with insurers 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 such agent or agents may be paid by the underwriting company or companies:
Provided,
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 such 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 such 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 such contract or contracts shall receive a statement of benefits to which such employee, his or her spouse and his or her dependents are entitled thereunder, setting forth such information as to whom such benefits shall be payable, to whom claims shall be submitted, and a summary of the provisions of any such 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 immunizations services from birth through age sixteen years to provide immunization against the following illnesses: Diphtheria, polio, mumps, measles, rubeola, rubella, tetanus, hepatitis B, haemophilus influenzae b and whooping cough. Additional immunizations may be required by the state director of 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 co-payment 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 co-payment provisions.
CHAPTER 16. PUBLIC HEALTH.
ARTICLE 3. PREVENTION AND CONTROL OF COMMUNICABLE AND OTHER
INFECTIOUS DISEASES.
§
16
-
3
-
5. Distribution of free vaccine preventives of
disease.
(a) Declaration of legislative findings and purpose. The Legislature finds and declares that early immunization for preventable diseases represents one of the most cost-effective means of disease prevention. The savings which can be realized from immunization, compared to the cost of health care necessary to treat the illness and lost productivity, are substantial. Immunization of children at an early age serves as a preventative measure both in time and money and is essential to maintain our children's health and well-being. The costs of childhood immunizations should not be allowed to preclude the benefits available from a comprehensive, medically supervised, child immunization service. Furthermore, the federal government has established goals that require ninety percent of all children to be immunized by age two and provided funding to allow uninsured children to meet this goal.
(b) The state director of health shall acquire vaccine for the prevention of polio, measles, mumps, rubella, diphtheria, pertussis, tetanus, smallpox hepatitis B, Haemophilus influenzae b and other vaccine preventives of disease as may be deemed necessary or required by law, and shall distribute the same, free of charge, in such quantities as he may deem necessary, to county and municipal health officers, to be used by them for the benefit of, and without expense to the citizens within their respective jurisdictions, to check contagions and control epidemics.
(c) The county and municipal health officers shall have the responsibility to properly store and distribute, free of charge, vaccines to private medical or osteopathic physicians within their jurisdictions to be utilized to check contagions and control epidemics:
Provided,
That the private medical or osteopathic physicians shall not make a charge for the vaccine itself when administering it to a patient. The county and municipal health officers shall provide a receipt to the state director of health for any vaccine delivered as herein provided.
(d) The department of health and human resources, commissioner of the bureau of public health is charged with establishing a Childhood Immunization Advisory Committee to plan for universal access, make recommendations on the distribution of vaccines acquired pursuant to this section and tracking of immunization compliance in accordance with federal and state laws. The Childhood Immunization Advisory Committee shall be appointed by the secretary of the department of health and human resources no later than the first day of July, one thousand nine hundred ninety-four, and will be comprised of representatives from the following groups: Public health nursing, public health officers, primary health care providers, pediatricians, family practice physicians, health care administrators, state medicaid program, the health insurance industry, Public Employee Insurance Agency, the self-insured industry and consumers. The state epidemiologist shall serve as an advisor to the committee. Members of the advisory committee will serve two year terms.
(e) All health insurance policies and prepaid care policies issued in this State which provide coverage for the children of the insured shall provide coverage for child immunization services to include the cost of the vaccine, if incurred by the health care provider, and all costs of administration from through age sixteen years. These services shall be exempt from any deductible, per visit charge and/or co-payment provisions which may be in force in these policies or contracts. This section does not exempt other health care services provided at the time of immunization from any deductible and/or co-payment provisions.
(f) Attending physicians, midwives, nurse practitioners, hospitals, birthing centers, clinics and other appropriate health care providers shall provide parents of newborns and preschool age children with information on the following immunizations: Diphtheria, polio, mumps, measles, rubeola, rubella, tetanus, hepatitis B, haemophilus influenzae b and whooping cough. This information should include the availability of free immunization services for children.
CHAPTER 33. INSURANCE.
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.
(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 laboratory fees, 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.
(9) Child immunization services as described in section five, article three, chapter sixteen of this code. This coverage will cover all costs associated with immunization, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration. These services shall be exempt from any deductible, per visit charge and/or co-payment 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 co-payment provisions.
§
33-15-17. Child Immunization services coverage.
All policies issued pursuant to this article shall cover the cost of child immunization services as described in section five, article three, chapter sixteen of this code, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration. These services shall be exempt from any deductible, per visit charge and/or co-payment 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 co-payment provisions.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§
33-16-12. Child Immunization services coverage.
All policies issued pursuant to this article shall cover the cost of child immunization services as described in section five, article three, chapter sixteen of this code, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration. These services shall be exempt from any deductible, per visit charge and/or co-payment 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 co-payment provisions.
ARTICLE 16A. GROUP HEALTH INSURANCE CONVERSION.
§
33-16A-15. Child Immunization services coverage.
All policies issued pursuant to this article shall cover the cost of child immunization services as described in section five, article three, chapter sixteen of this code, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration. These services shall be exempt from any deductible, per visit charge and/or co-payment 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 co-payment provisions.
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:
Provided
further
, That child immunization services shall be exempt from any deductible, per visit charge and/or co-payment provisions which may be in force in these policies or contracts. This section does not exempt other health care services provided at the time of immunization from any deductible and/or co-payment provisions.
§
33-16C-4. Insurance commissioner to establish minimum benefits
and coverages; basic policy benefits.
(a) The insurance commissioner shall establish minimum benefits which shall be included in every 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 laboratory fees, 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.
(9) Child immunization services as described in section five, article three, chapter sixteen of this code. This coverage will cover all costs associated with immunization, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration, These services shall be exempt from any deductible, per visit charge and/or co-payment 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 co-payment provisions.
ARTICLE 16D. MARKETING AND RATE PRACTICES FOR SMALL EMPLOYER
ACCIDENT AND SICKNESS INSURANCE POLICIES.
§
33-16D-14. Child Immunization services coverage.
All policies issued pursuant to this article shall cover the cost of child immunization services as described in section five, article three, chapter sixteen of this code, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration. These services shall be exempt from any deductible, per visit charge and/or co-payment 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 co-payment provisions.
ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE
CORPORATIONS, DENTAL SERVICE CORPORATIONS AND
HEALTH SERVICE CORPORATIONS.
§
33
-
24
-
7d. Required provisions in contracts which include child
immunization services in the terms of the contract.
Each contract made by the corporation with participating hospitals, physicians, and other health agencies which provide immunizations to children shall require that bills submitted to the corporation for child immunization services rendered under the terms of their contracts will set forth separately those charges for said services. Charges for other health care services provided during the same visit shall not be included in the charge for immunization services.
ARTICLE 25. HEALTH CARE CORPORATIONS.
§
33-25-8a.
Third party payment for child immunization services.
Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall, on or after the first day of July, one thousand nine hundred ninety-four, provide as benefits to all subscribers and members coverage for child immunization services as described in section five, article three, chapter sixteen of this code. This coverage will cover all costs associated with immunization, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration, These services shall be exempt from any deductible, per visit charge and/or co-payment provisions which may be in force in these policies, provisions, plans, agreements 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 co-payment provisions.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§
33-25A-8a.
Third party payment for child immunization services.
Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall, on or after the first day of July, one thousand nine hundred ninety-four, provide as benefits to all subscribers and members coverage for child immunization services as described in section five, article three, chapter sixteen of this code. This coverage will cover all costs associated with immunization, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration, These services shall be exempt from any deductible, per visit charge and/or co-payment provisions which may be in force in these policies, provisions, plans, agreements 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 co-payment provisions.
NOTE: The purpose of this bill is to require third party payors to provide coverage for childhood immunizations which does not require co-payment or payment by the subscriber under the deductible provisions of the plan.
Section seventeen of article fifteen, section fifteen of article 16, section fourteen of article sixteen-d, section seven-d of article twenty-four, section eight-a of section twenty-five and section eight-a of section twenty-five-a 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.