Senate Bill No. 507
(By Senator Blatnik)
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[Introduced February 21, 1994; referred to the Committee
on Banking and Insurance.]
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A BILL to amend and reenact chapter thirty-three of the code of
West Virginia, one thousand nine hundred thirty-one, as
amended, by adding thereto a new article, designated article
sixteen-f, relating to insurance coverage for serious mental
illness.
Be it enacted by the Legislature of West Virginia:
That chapter thirty-three of the code of West Virginia, one
thousand nine hundred thirty-one, as amended, be amended and
reenacted by adding thereto a new article, designated article
sixteen-f, to read as follows:
CHAPTER 33. INSURANCE.
ARTICLE 16F. INSURANCE COVERAGE FOR SERIOUS MENTAL ILLNESS
§33-16F-1. Mental illness coverage.
Every health care insurer shall provide coverage for the
medical treatment of serious mental illness under the same terms
and conditions as such coverage is provided for other illnesses
and diseases. Insurance coverage offered pursuant to this articleshall include the same durational limits, amount limits,
deductibles and coinsurance factors for serious mental illness as
for other illnesses and diseases.
§33-16F-2. Definitions.
For the purposes of this chapter, the following words and
terms shall have the following meanings:
(a) "Health insurers" means all persons, firms, corporations
or other organizations offering and assuring health services on
a prepaid or primarily expense-incurred basis, including but not
limited to policies of accident or sickness insurance, as defined
in section ten, article one of this chapter, nonprofit hospital
or medical service plans, whether organized under the provisions
of this chapter or under any other law, health maintenance
organizations, or any other entity which insures or reimburses
for diagnostic, therapeutic, or preventive services to a
determined population on the basis of a periodic premium, except
for supplemental policies which only provide coverage for
specified diseases.
(b) "Serious mental illness" means any mental disorder that
current medical science attributes to a biological disorder of
the brain and that substantially limits the life activities of
the person with the illness. The term includes, but is not
limited to:
(1) Schizophrenia;
(2) Schizoaffective disorder;
(3) Delusional disorder;
(4) Bipolar affective disorders;
(5) Major depression; or
(6) Obsessive compulsive behavior;
(c) "Medical coverage" means inpatient hospitalization and
outpatient medication visits.
§33-16F-3. Medical necessity and appropriateness of treatment.
Upon request of the reimbursing health insurers, all
providers of treatment of serious mental illness shall furnish
medical records or other necessary data which substantiates that
initial or continued treatment is at all times medically
necessary and appropriate. When the provider cannot establish the
medical necessity or appropriateness of the treatment modality
being provided, neither the health insurer nor the patient shall
be obligated to reimburse or pay for any type of care that was
dispensed in the period in which medical necessity or
appropriateness of treatment was not established: Provided, That
this exception to reimbursement or payment may only be applicable
if the patient has been informed of such exception and has agreed
in writing to continue to receive treatment at his or her own
expense.
Any health insurer regulated by the provisions of this
chapter shall, when making a determination of medical necessity
or appropriateness in treatment, make such determination in a
manner consistent with other determinations for the treatment of
other illnesses or diseases or injuries covered under the same
health insurance policy or agreement.
§33-16F-4. Limitations of coverage.
The health care benefits outlined in this article apply only
to services delivered within this state.
Inpatient coverage in cases where continuous hospitalization
is medically necessary shall be limited to ninety consecutive
days.
NOTE: The purpose of this bill is to require insurance
coverage for medical treatment of serious mental illness.
This article is new; therefore, strike-throughs and
underscoring have been omitted.