H. B. 4672
(By Delegate McGraw)
[Introduced February 27, 1998; referred to the
Committee on Banking and Insurance then Government Organization.]
A BILL to amend article twenty-five-a, chapter thirty-three of
the code of West Virginia, one thousand nine hundred
thirty-one, as amended, by adding thereto a new section,
designated section thirty-six, relating to enacting a
patient protection act.
Be it enacted by the Legislature of West Virginia:
That article twenty-five-a, chapter thirty-three of the code
of West Virginia, one thousand nine hundred thirty-one, as
amended, be amended by adding thereto a new section, designated
section thirty-six, to read as follows:
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-36. Patient protection act.
(a)(1) "Appropriate medical practice" means medical practice
that is commonly accepted among health care practitioners as the
standard of care.
(2) "Beneficiary" means any individual enrolled by any third
party payer, policy, contract, plan or agreement.
(3) "Provider" means any licensed individual, facility or
entity that delivers health care services to any beneficiary that
is covered under any third party payer's policy, contract, plan
or agreement.
(4) "Third party payer" means any sickness and accident
insurer, health maintenance organization, preferred provider
organization, health care corporation or medical care corporation
that is authorized to operate or do business in this state.
"Third party payer" also includes any employer acting as a
self-insurer by providing, or by providing payment for, health
care benefits for employees resident in this state, any person or
entity performing utilization review, managed care or claims
payment processing under contract with, or on behalf of, an
employer or a third party that provides or administers health
care benefits, or any health service paid for or purchased by a
state agency or its program or designee.
(b) No third party payer may prohibit, contractually or
otherwise, a provider from making any statement to a patient or
a patient's representative regarding the patient's health care
policy, contract, plan or agreement, including statements
regarding the patient's rights or the third party payer's duties
and obligations under the health care policy, contract, plan or agreement.
(c) No third party payer may discriminate against, take any
adverse action against or otherwise penalize a provider for
making statements that are protected under subsection (b) of this
section.
(d) No third party payer may, without just cause, do either
of the following:
(1) Cancel or refuse to renew the contract of any provider;
or
(2) Suspend, revoke or limit the participating status of any
provider; or
(3) As used in subsection (d) of this section, "just cause"
does not include the use of information regarding a provider's
economic profile to cancel or refuse to renew the contract of the
provider or to otherwise suspend, revoke or limit the
participating status of the provider.
(e) No third party payer may refuse to contract with a
provider for the treatment of conditions or for the provision of
services under any policy, contract, plan or agreement for the
provision of health care services that is delivered, issued for
delivery, renewed, established, modified or entered into in this
state on or after the effective date of this section, if the
refusal is based on race, gender, national origin, age or
religion.
(f) No third party payer may refuse to contract with a
provider for the treatment of conditions or for the provision of
services under any policy, contract, plan or agreement for the
provision of health care services that is delivered, issued for
delivery, renewed, established, modified or entered into in this
state on or after the first day of January, one thousand nine
hundred ninety-nine, if the refusal is based on the fact that the
provider is licensed or registered for a particular practice.
(g) Nothing in this section may be construed as mandating
coverage for any specific condition or service.
(h) No third party payer may deny a beneficiary the right to
choose a provider of health care or dental services if the
following conditions are met:
(1) The provider accepts the standard terms and conditions
offered by the third party payer to other providers and any
hospital or other health care facility to which a beneficiary may
be referred by the provider accepts the standard terms and
conditions offered by the third party payer to other health care
facilities;
(2) "Standard terms and conditions" includes utilization
review guidelines, practice protocols, quality assurance
guidelines, data reporting requirements and levels of payment
with respect to credentialing. "Standard terms and conditions"
is not more restrictive than the licensing standards imposed by this state;
(3) The beneficiary notifies the third party payer of the
beneficiary's choice of provider on a form prescribed by the
third party payer;
(4) The health care services sought by the beneficiary are
to be rendered by a provider licensed in this state to perform
such services; and
(5) The provider has not been the subject of any
disciplinary action imposed by a licensure or regulatory agency
of another state.
(i) No third party payer may impose upon a beneficiary any
copayment fee or other charge or condition that is not similarly
imposed upon all other beneficiaries under the health care
policy, contract, plan or agreement.
NOTE: The purpose of this bill is to enact a patient
protection act.
This section is new; therefore, strike-throughs and
underscoring have been omitted.