H. B. 4294
(By Delegates Walters and Pulliam)
[Introduced February 6, 1998; referred to the
Committee on Government Organization 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- d, relating to creating the children's health insurance
program act; legislative purpose; providing definitions;
program administration and financing; eligibility; and scope
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-d, to
read as follows:
WEST VIRGINIA CHILDREN'S HEALTH INSURANCE PROGRAM.
§33-15D-1. Short title.
This article shall be known as and may be cited as the "West Virginia Children's Health Insurance Program."
The purpose of this article is to create a state health
insurance program eligible for payment under section two thousand
one hundred five of the Social Security Act (42 U.S.C.). The
program will expand the health insurance options of targeted
low-income children through the service of private health
insurers meeting the requirement of sections five and seven of
this article that contract with the department to provide
targeted low-income children with health insurance coverage.
As used in this article:
(a) "Child" means a natural person less than nineteen years
of age who is a resident of this state.
(b) "Commissioner" means the insurance commissioner of West
(c) "Creditable health coverage" has the meaning given the
term "creditable coverage" under section two thousand seven
hundred one (c) of the Public Health Service Act (42 U.S.C. 300gg
(c)) and includes coverage that meets the requirements of section
two thousand one hundred three of the Social Security Act (42
U.S.C.) provided to a targeted low-income child under this
article or under a waiver approved under section two thousand one
hundred five (c) (2) (B) of the Social Security Act (42 U.S.C.) (relating to a direct service waiver).
(d) "Group health plan" has the meaning given that term
under section 2791 of the Public Health Service Act (42
(e) "Health insurance coverage" has the meaning given that
term under section 2791 (b) (1) of the Public Health Service Act
(42 U.S.C. 300gg-91).
(f) "Low-income child" means a child whose family income is
at or below one hundred fifty percent of poverty.
(g) "Participating insurer" means any entity licensed to
provide health insurance in this state that has contracted with
the commissioner to offer health insurance coverage to targeted
low-income children pursuant to this article.
(h) "Poverty" has the meaning given that term in section 673
(2) of Community Service Block Grant Act (42 U.S.C. 9902 (2),
including any revision in that section.
(i) "Preexisting condition exclusion" has the meaning given
that term in section 2701 (b) (1) (A) of the Public Health
Service Act (42 U.S.C. 300gg (b) (1) (A).
(j) "Qualified child health plan" means health insurance
coverage provided by a participating insurer consistent with
section seven of this article.
(k) "State medicaid office" means the office responsible for
administering Title XIX of the United States Code.
(l) "Target low-income child" means a child, except as
provided by paragraph (4) of this subdivision, who:
(1) Has been determined eligible by this state under this
(2) (A) Is a low-income child; or
(B) Is a child whose family income exceeds the medicaid- applicable income level by not more than fifty percentage points;
(3) Is not found to be eligible for medicaid or covered
under a group health plan or under health insurance coverage.
(This does not include a health insurance coverage program
offered that receives no federal funds and that has been in
operation since before the first day of July, one thousand nine
(4) This term does not include:
(i) A child who is an inmate of a public institution or a
patient in an institution or a patient in an institution for
mental diseases; or
(ii) A child who is a member of a family that is eligible
for health benefits coverage under a state employee health
-4. Program administration and financing.
(a) The commissioner shall prepare a state children's
health insurance program or submission to the secretary of the United States department of health and human services within six
months of the date of enactment of this article.
(b) The commissioner shall enter into contracts with at
least two insurers and at least two health maintenance
organizations that offer a qualified child health plan.
(c) The state medicaid office is responsible for certifying
the eligibility of children for the state children's health
(d) Upon notice of enrollment of a targeted low-income child
in a qualified child health plan, the commissioner shall forward
the annual negotiated cost of insuring each targeted low-income
child to the appropriate participating insurer.
(e) In no event, may more than ten percent of the federal
and state funds be used for:
(1) Other children's health programs for targeted low-income
(2) Initiatives for improving the health of children
(including targeted low-income and other low-income children);
(3) Outreach activities that inform families of children who
are likely to be eligible for this program or other public or
private health coverage programs, or for coordination of the
administration of this program with other public and private
health insurance programs; and
(4) Other reasonable costs incurred by the state to administer the program.
-5. Insurer provisions.
(a) To be eligible for the state payment, a participating
insurer shall offer a qualified child health plan to eligible
children without regard to health status and without the
imposition of preexisting condition exclusion, except that a
preexisting condition exclusion may be applied if the qualified
child health plan is provided through a group health plan or
group health insurance coverage, consistent with the limitations
on the imposition of preexisting condition exclusions in
connection with coverage under state and federal law.
(b) Premium and cost-sharing amounts are limited to the
(1) No deductibles, coinsurance or other cost-sharing is
permitted with respect to benefits for well-baby and well-child
care including age-appropriate immunizations; and
(2) For children whose family income is at or below one
hundred fifty percent of poverty:
(A) Premiums, enrollment fees or similar charges may not
exceed the maximum monthly charge permitted consistent with
standards established to carry out section 1916 (b) (1) of the
Social Security Act, (42 U.S.C. 201 et seq.);
(B) Deductibles and other cost-sharing may not exceed an
amount that is nominally consistent with standards provided under section 1916 (a) (3) of the Social Security Act (42 U.S.C. 301 et
seq.), as adjusted; and
(C) For children whose family income is more than one
hundred fifty percent of poverty, premiums, deductibles and other
cost-sharing may be imposed on a sliding scale related to income,
provided that the total annual aggregate cost-sharing with
respect to all targeted low-income children in a family under
this article shall not exceed five percent of such family's
income for the year involved.
(c) Existing health insurance sales and marketing methods,
including the use of agents and payment of commissions, shall be
utilized to inform families of the availability of the state
children's health insurance program and assist them in obtaining
coverage for children under the program.
-6. Eligibility provisions.
(a) Targeted low-income children are eligible for coverage
with a participating insurer regardless of health status.
(b) Eligible children shall be allowed to change enrollment
between participating insurers upon the annual coverage renewal
date, provided that at least six months notice of an election to
change enrollment is provided to the participating insurer with
which the child is currently enrolled. The notice provision
shall be reduced to sixty days if the child has changed residence
to an area outside the geographic service area of the participating insurer with which the child is currently enrolled.
-7. Scope of benefits.
A qualified health plan shall contain benefits consistent
with either subdivision (a), (b) or (c) of this section.
However, nothing in this article may be construed to prevent a
qualified child health plan from offering a category of benefits
that are not specified in this article.
(a) Health insurance coverage equivalent to one of the
(1) The standard Blue Cross/Blue Shield preferred provider
option under the federal Employees Health Benefit Plan (5 U.S.C.
8903 (1); or
(2) A health benefits coverage plan that is offered and
generally available to state employees; or
(3) Health insurance coverage offered by health maintenance
organizations that has the largest insured commercial,
nonmedicaid enrollment of covered lives in the state.
(b) (1) Health insurance coverage that has an aggregate
actuarial value at least equivalent to the provisions of
paragraph (1), (2) or (3), subdivision (a) of this section and
that includes coverage for the following basic services:
(A) Inpatient and outpatient hospital services;
(B) Physicians' surgical and medical services;
(C) Laboratory and X ray services; and
(D) Well-baby and well-child care, including age-appropriate
(2) Health insurance coverage based on actuarial equivalence
for basic services (as described in paragraph (1) of this
subdivision) may provide the following additional services if the
coverage for such services has an actuarial value of at least
seventy-five percent of the actuarial value of the coverage
provided in that category of services in such package:
(A) Coverage of prescription drugs;
(B) Mental health services;
(C) Vision services; and
(D) Hearing services.
(c) Upon application by this state, any other health
insurance coverage that has been approved by the United States
secretary of health and human services.
NOTE: The purpose of this bill is to create the West
Virginia Children's Health Insurance Program Act and expand
health insurance options for targeted low-income children.
This article is new; therefore, strike-throughs and
underscoring have been omitted.