H. B. 4016


(By Delegate Walters)
[Introduced January 10, 1996; referred to the
Committee on Banking and Insurance then Finance.]




A BILL to amend 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 fifteen-c, relating to requiring that all mandated health insurance benefits be reviewed.

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 by adding thereto a new article, designated article fifteen-c, to read as follows:
ARTICLE 15C. MANDATED BENEFITS REVIEW ACT.
§33-15C-1. Short title.
This act may be cited as the "Mandated Benefits Review Act."
§33-15C-2. Statement of purpose.
The purpose of this article is to provide for independent review of mandated benefits. This article requires that all existing mandated health benefits, proposals or an amendment to a proposal for mandated benefits, mandated health insurance coverage, and mandated offerings of health benefits be accompanied by independently certified documentation with regard to the proposals' social impact, medical efficacy and financial impact.
§33-15C-3. Mandated health benefits review panel.
(a) Documentation. -- Proposals or an amendment to a proposal for mandated health benefits or mandated health insurance coverage shall be accompanied by adequate independently certified documentation defining the proposals' social impact, medical efficacy and financial impact.
Mandated benefits shall include:
(1) Any mandated coverage for specific services, treatments or practices;
(2) Any mandated direct reimbursement to specific health care practitioners;
(3) Any mandated offering for specific services, treatments or practices; and
(4) Any mandated reimbursement amount to specific health care practitioners.
(b) Report. -- Every person or organization which promotes or seeks sponsorship of a legislative proposal or an amendment to a proposal which does or would mandate a health coverage or offering of a health coverage by an insurance carrier, health care service contractor or health maintenance organization as a component of individual or group policies shall submit a report to the legislative committee having jurisdiction. The committee shall refer the proposal or any amendment to a proposal for review to the mandated benefits review panel created by this article.
(c) Panel. -- The panel shall consist of three senior researchers, two being experts in health research or biostatistics chosen from universities within the state and the third a senior research associate, each appointed by the secretary of health and human resources.
(d) Panel's report. -- The panel will review the documentation submitted with the proposed legislation and will issue a report within thirty days as to:
(1) Whether the information is complete;
(2) Whether the research cited meets professional standards;
(3) Whether all relevant research has been brought to light; or
(4) Whether the conclusions and interpretations drawn from the evidence are consistent with the data presented. If the panel reaches a favorable conclusion on all points, the documentation will be certified accordingly. If the panel finds the documentation deficient, the panel will identify the deficiencies. The panel shall judge the completeness of the information provided and the validity of the conclusions drawn, based on the facts presented, but shall not comment upon the merits or desirability of the proposal.
(e) Guidelines. -- The panel shall apply the following guidelines in determining the adequacy of the information presented:
(1) Evidence of social impact, to what extent is the treatment or service:
(A) Needed by the people of this state;
(B) Available to the people of this state; and
(C) Utilized by the population of this state.
(2) If insurance coverage is not generally in place, the panel should determine to what extent does the lack of coverage result in inadequate health care and/or major financial hardship.
(3) The panel should determine what indications are there of demand for the proposed health care coverage from the public at large and in collective bargaining negotiations.
(4) The panel should determine if all relevant findings bearing on social impact have been presented.
(5) Evidence of medical efficacy:
(A) If the legislation seeks to mandate coverage of a particular therapy:
(i) The results of at least one professionally acceptable, controlled trial demonstrating the medical consequences of that therapy compared to no therapy and to alternatives therapies; and
(ii) The results of any other relevant research.
(B) If the legislation seeks to mandate coverage of additional class of practitioners:
(i) The results of at least one professionally acceptable, controlled trial demonstrating the medical results achieved by the additional class of practitioners relative to those already covered; and
(ii) The results of any relevant research.
(6) Review evidence of financial impact:
(A) To what extent will the coverage increase or decrease the cost of treatment or service;
(B) To what extent have similar mandates affected charges, costs and payments experienced in other states with such mandates;
(C) To what extent will the coverage increase the appropriate use of treatment or service;
(D) To what extent will the mandated treatment or service be a substitute for more expensive or less expensive treatment or service;
(E) To what extent will the coverage increase or decrease the administrative expenses of insurance companies in the premium and administrative expenses of policyholders;
(F) To what extent do existing mandates meet the requirements of this article;
(G) What will be the financial impact of this coverage on small employers, medium-sized employers and large employers; and
(H) What will be the impact of this coverage on the total cost of health care.
§33-15C-4. Review of existing mandated benefits.
(a) In addition to the duties prescribed by this article, the panel shall undertake a separate and complete review of all existing state mandated benefits, mandated health insurance coverage, and mandated offerings of health benefits in the same manner as prescribed in sections two and three of this article. The panel shall report its findings of existing state mandated benefits, mandated health insurance coverage, and mandated offerings of health benefits to the legislative committee having jurisdiction no later than the first day of January, one thousand nine hundred ninety-eight.
(b) All existing mandated benefits, mandated health insurance coverage, and mandated offerings of health benefits shall expire within one year after the effective date of this article unless specifically reauthorized by the Legislature on the basis of the review required under subsection (a) of this section.




NOTE: The purpose of this bill is to require that all mandated health insurance benefits be reviewed with regard to social impact, medical efficacy and financial impact.

This article is new; therefore, strike-throughs and underscoring have been omitted.