Senate Bill No. 465
(By Senator Walker)
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[Introduced February 19, 1996; referred to the Committee on Banking and Insurance.]
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A BILL to amend and reenact section eight, article sixteen, chapter five of the code of West Virginia, one thousand nine hundred thirty-one, as amended; to amend article one, chapter thirty- three of said code by adding thereto a new section, designated section twenty-one; to amend article sixteen of said chapter by adding thereto a new section, designated section three-i; to amend article twenty-four of said chapter by adding thereto a new section, designated section seven-e; to amend article twenty-five of said chapter by adding thereto a new section, designated section eight-d; and to amend article twenty-five-a of said chapter by adding thereto a new section, designated section eight-d, all relating to the West Virginia public employees insurance agency and other cooperative or private third-party payors of health services; defining emergency services for purposes of coverage within policies issued for accidents and sickness; requiring emergency services coverage to be included in policies issued for groups under the West Virginia public employees insurance agency; hospital, medical and dental corporations; health care corporations; and health maintenance organizations.

Be it enacted by the Legislature of West Virginia:
That section eight, article sixteen, chapter five of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended and reenacted; that article one, chapter thirty-three of said code be amended by adding thereto a new section, designated section twenty-one; that article sixteen of said chapter be amended by adding thereto a new section, designated section three-i; that article twenty-four of said chapter be amended by adding thereto a new section, designated section seven-e; that article twenty-five of said chapter be amended by adding thereto a new section, designated section eight-d; and that article twenty-five-a of said chapter be amended by adding thereto a new section, designated section eight-d, 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.

§5-16-8. Conditions of insurance program.

The insurance plans herein provided for shall be designed by the public employees insurance agency:
(1) To provide a reasonable relationship between the hospital, surgical, medical and prescription drug benefits to be included and the expected reasonable and customary hospital, surgical, medical and prescription drug expenses as established by the director to be incurred by the affected employee, his or her spouse and his or her dependents. The establishment of reasonable and customary expenses by the public employees insurance agency pursuant to the preceding sentence is not subject to the state administrative procedures act in chapter twenty-nine-a of this code.
(2) To include reasonable controls which may include deductible and coinsurance provisions applicable to some or all of the benefits, and shall include other provisions, including, but not limited to, copayments, preadmission certification, case management programs and preferred provider arrangements.
(3) To prevent unnecessary utilization of the various hospital, surgical, medical and prescription drug services available.
(4) To provide reasonable assurance of stability in future years for the plans.
(5) To provide major medical insurance for said employees.
(6) To provide certain group life and accidental death insurance for the employees covered under this article.
(7) To include provisions for the coordination of benefits payable by the terms of such plans with the benefits to which such employee, or his or her spouse or his or her dependents may be entitled by the provisions of any other group hospital, surgical, medical, major medical, or prescription drug insurance or any combination thereof.
(8) To provide a cash incentive plan for employees, spouses and dependents by the thirty-first day of December, one thousand nine hundred eighty-eight, to increase utilization of, and to encourage the use of, lower cost alternative health care facilities, health care providers and generic drugs. Such plan shall be reviewed annually by the director and the advisory board.
(9) To provide "wellness" programs and activities which will include, but not be limited to, benefit plan incentives to discourage tobacco, alcohol and chemical abuse and an educational program to encourage proper diet and exercise. In establishing "wellness" programs, the division of vocational rehabilitation shall cooperate with the public employees insurance agency in establishing statewide wellness programs and with such division of vocational rehabilitation to contact county boards of education for the use of facilities, equipment or any service related to such purpose, at the request of the director, under the authority hereby granted to contract therefor. Boards of education shall be limited to charging only the cost of janitorial service and increased utilities for the use of the gymnasium and related equipment. The cost of the exercise program shall be paid by county boards of education, the public employees insurance agency, or participating employees, their spouses or dependents. All exercise programs shall be made available to all employees, their spouses or dependents and shall not be limited to employees of county boards of education.
(10) To provide a program, to be administered by the director, for a patient audit plan with reimbursement up to a maximum of one thousand dollars annually, to employees for discovery of health care provider or hospital overcharges when the affected employee brings such overcharge to the attention of the plan. The hospital or health care provider shall certify to the director that it has provided, prior to or simultaneously with the submission of the statement of charges for payments, an itemized statement of the charges to the employee participant for which payment is requested of the plan.
(11) To require that all employers give written notice to each covered employee prior to institution of any changes in benefits to employees, and to include appropriate penalty for any employer not providing the required information to any employee.
(12) To provide coverage for emergency services under offered plans. For the purposes of this subsection, "emergency services" means services provided in or by a hospital emergency facility to evaluate and treat a medical condition manifesting itself by symptoms of sufficient severity that the absence of prompt medical attention could reasonably be expected by a prudent lay person, who possesses an average knowledge of health and medicine, to result in placing the health of the recipient of those services in serious jeopardy, serious impairment to body function, serious dysfunction of any body organ or part or the continuance of severe pain.
CHAPTER 33. INSURANCE.

ARTICLE 1. DEFINITIONS.

§33-1-21. Emergency services.

Emergency services are those services provided in or by a hospital emergency facility to evaluate and treat a medical condition manifesting itself by symptoms of sufficient severity that the absence of prompt medical attention could reasonably be expected by a prudent lay person, who possesses an average knowledge of health and medicine, to result in placing the health of the recipient of the services in serious jeopardy, serious impairment to body function, serious dysfunction of any body organ or part or the continuance of severe pain.

ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.

§33-16-3i. Coverage of emergency services.

ARTICLE 24. HOSPITAL, MEDICAL AND DENTAL CORPORATIONS.

§33-24-7e. Coverage of emergency services.

ARTICLE 25. HEALTH CARE CORPORATIONS.

§33-25-8d. Coverage of emergency services.

ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.

§33-25A-8d. Coverage of emergency 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 and after the first day of July, one thousand nine hundred ninety-six, provide as benefits to all subscribers and members coverage for emergency services. A policy, provision, contract, plan or agreement may apply to emergency services the same deductibles, coinsurance and other limitations as apply to other covered services: Provided, That preauthorization or precertification shall not be required.

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(NOTE: The purpose of this bill is to require the Public Employees Insurance Agency, cooperative and private third-party payors to provide coverage for emergency services, defined as those services provided in or by a hospital emergency facility to evaluate and treat a medical condition manifesting itself by symptoms of sufficient severity that the absence of prompt medical attention could reasonably be expected by a prudent lay person, who possesses an average knowledge of health and medicine, to result in placing the health of the recipient of such services in serious jeopardy, serious impairment to body function, serious dysfunction of any body organ or part or the continuance of severe pain.

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

§§31-1-21, 33-16-3i, 33-24-7e, 33-25-8d and 33-25A-8d are new; therefore, strike-throughs and underscoring have been omitted.)

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BANKING AND INSURANCE COMMITTEE AMENDMENTS

On page five, section eight, line twenty-two, after the word "by" by striking out the remainder of the paragraph and inserting in lieu thereof the words "the sudden, and at the time, unexpected onset of a health condition tht requires immediate medical attention and that failure to provide medical attention would result in serious impairment to bodily function, serious dysfunction to any bodily organ or part, or would place the person's health in jeopardy.";

And,

On page six, section twenty-one, line eight, after he word "by" by striking out the remainder of the paragraph and inserting in lieu thereof the words "the sudden, and at the time, unexpected onset of a health condition tht requires immediate medical attention and that failure to provide medical attention would result in serious impairment to bodily function, serious dysfunction to any bodily organ or part, or would place the person's health in jeopardy."