ENROLLED
COMMITTEE SUBSTITUTE
FOR
Senate Bill No. 361
(Senators Hunter, White, Kessler and Ball, original sponsors)
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[Passed March 14, 1998; in effect ninety days from passage.]
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AN ACT to amend and reenact section twenty-four, article twenty- five-a, chapter thirty-three of the code of West Virginia, one
thousand nine hundred thirty-one, as amended; and to further
amend said chapter by adding thereto two new articles,
designated articles twenty-five-c and forty-two, all relating
to managed care plans and their patients' rights; and
providing for direct access to women's health care providers.
Be it enacted by the Legislature of West Virginia:
That section twenty-four, article twenty-five-a, chapter
thirty-three of the code of West Virginia, one thousand nine
hundred thirty-one, as amended, be amended and reenacted; and that
said chapter be further amended by adding thereto two new articles,
designated articles twenty-five-c and forty-two, all to read as
follows:
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-24. Statutory construction and relationship to other laws.
(a) Except as otherwise provided in this article, provisions
of the insurance laws and provisions of hospital or medical service
corporation laws are not applicable to any health maintenance
organization granted a certificate of authority under this article.
The provisions of this article shall not apply to an insurer or
hospital or medical service corporation licensed and regulated
pursuant to the insurance laws or the hospital or medical service
corporation laws of this state except with respect to its health
maintenance corporation activities authorized and regulated
pursuant to this article. The provisions of this article shall not
apply to an entity properly licensed by a reciprocal state to
provide health care services to employer groups, where residents of
West Virginia are members of an employer group, and the employer
group contract is entered into in the reciprocal state. For
purposes of this subsection, a "reciprocal state" means a state
which physically borders West Virginia and which has subscriber or
enrollee hold harmless requirements substantially similar to those
set out in section seven-a of this article.
(b) Factually accurate advertising or solicitation regarding
the range of services provided, the premiums and copayments
charged, the sites of services and hours of operation, and any
other quantifiable, nonprofessional aspects of its operation by a
health maintenance organization granted a certificate of authority,
or its representative shall not be construed to violate any
provision of law relating to solicitation or advertising by health
professions: Provided, That nothing contained in this subsection shall be construed as authorizing any solicitation or advertising
which identifies or refers to any individual provider or makes any
qualitative judgment concerning any provider.
(c) Any health maintenance organization authorized under this
article shall not be considered to be practicing medicine and is
exempt from the provisions of chapter thirty of this code, relating
to the practice of medicine.
(d) The provisions of sections fifteen and twenty, article
four (general provisions); section seventeen, article six
(noncomplying forms); article six-c (guaranteed loss ratio);
article seven (assets and liabilities); article eight
(investments); article nine (administration of deposits); article
twelve (agents, brokers, solicitors and excess line); section
fourteen, article fifteen (individual accident and sickness
insurance); section sixteen, article fifteen (coverage of
children); section eighteen, article fifteen (equal treatment of
state agency); section nineteen, article fifteen (coordination of
benefits with medicaid); article fifteen-b (uniform health care
administration act); section three, article sixteen (required
policy provisions); section three-f, article sixteen (treatment of
temporomandibular disorder and craniomandibular disorder); section
eleven, article sixteen (coverage of children); section thirteen,
article sixteen (equal treatment of state agency); section
fourteen, article sixteen (coordination of benefits with medicaid);
article sixteen-a (group health insurance conversion); article
sixteen-d (marketing and rate practices for small employers); article twenty-five-c (health maintenance organization patient bill
of rights); article twenty-seven (insurance holding company
systems); article thirty-four-a (standards and commissioner's
authority for companies deemed to be in hazardous financial
condition); article thirty-five (criminal sanctions for failure to
report impairment); article thirty-seven (managing general agents);
article thirty-nine (disclosure of material transactions); article
forty-one (privileges and immunity); and article forty-two (women's
access to health care) shall be applicable to any health
maintenance organization granted a certificate of authority under
this article. In circumstances where the code provisions made
applicable to health maintenance organizations by this section
refer to the "insurer", the "corporation" or words of similar
import, the language shall be construed to include health
maintenance organizations.
(e) Any long-term care insurance policy delivered or issued
for delivery in this state by a health maintenance organization
shall comply with the provisions of article fifteen-a of this
chapter.
(f) A health maintenance organization granted a certificate of
authority under this article shall be exempt from paying municipal
business and occupation taxes on gross income it receives from its
enrollees, or from their employers or others on their behalf, for
health care items or services provided directly or indirectly by
the health maintenance organization. This exemption applies to all
taxable years through the thirty-first day of December, one thousand nine hundred ninety-six. The commissioner and the tax
department shall conduct a study of the appropriations of
imposition of the municipal business and occupation tax or other
tax on health maintenance organizations, and shall report to the
regular session of the Legislature, one thousand nine hundred
ninety-seven, on their findings, conclusions and recommendations,
together with drafts of any legislation necessary to effectuate
their recommendations.
ARTICLE 25C. HEALTH MAINTENANCE ORGANIZATION PATIENT BILL OF
RIGHTS.
§33-25C-1. Short title.
This article may be referred to as the "Patients' Bill of
Rights".
§33-25C-2. Definitions.
(a) "Commissioner" means the commissioner of insurance.
(b) "Managed care plan" or "plan" means any health maintenance
organization or prepaid limited health care organization.
(c) "Provider" means any physician, hospital or other person
or organization which is licensed or otherwise authorized in this
state to provide health care services or supplies.
§33-25C-3. Notice of certain subscriber rights.
All managed care plans must provide to subscribers on a form
prescribed by the commissioner a notice of certain subscriber
rights. The notice shall address the following areas:
(1) The ability of the subscriber to pursue grievance and
hearing procedures without reprisal from the managed care plan;
(2) How the subscriber may choose providers within the plan;
(3) The subscriber's right to privacy and confidentiality;
(4) The subscriber's ability to examine and offer corrections
to their own medical records;
(5) The subscriber's right to be informed of plan policies and
any charges for which the subscriber will be responsible;
(6) The subscriber's ability to obtain evidence of the medical
credentials of a plan provider such as diploma and board
certifications;
(7) The right of subscriber's to have coverage denials reviewed
by appropriate medical professionals consistent with plan review
procedures;
(8) Any other areas the commissioner may by rule require.
ARTICLE 42. WOMEN'S ACCESS TO HEALTH CARE ACT.
§33-42-1. Short title.
This article shall be known and may be cited as the "Women's
Access To Health Care Act".
§33-42-2. Legislative findings and purpose.
The Legislature finds and declares that adequate delivery of
health care services to women requires direct access to primary and
preventative obstetrical and gynecological services, which services
may be provided as "well woman examinations", and direct access
without prior authorization to prenatal and obstetrical services
for pregnant women.
§33-42-3. Definitions.
For purposes of this article:
(1) "Advanced nurse practitioner" means a certified nurse-
midwife, or an advanced nurse practitioner certified to practice in
family practice, women's health (ob/gyn), or primary care adult,
geriatric or pediatric practice, practicing within the lawful scope
of that provider's practice.
(2) "Health benefits policy" means any individual or group
plan, policy or contract for health care services issued,
delivered, issued for delivery, or renewed in this state by a
health care corporation, health maintenance organization, accident
and sickness insurer, fraternal benefit society, nonprofit hospital
service corporation, nonprofit medical service corporation or
similar entity, when the policy or plan covers hospital, medical or
surgical expenses.
(3) "Women's health care provider" means an
obstetrician/gynecologist, advanced nurse practitioner certified to
practice in women's health (ob/gyn), certified nurse-midwife or
physician assistant-midwife practicing within the lawful scope of
that provider's practice.
§33-42-4. Limitations on conditions of coverage.
No health benefits policy may require as a condition to the
coverage of basic primary and preventative obstetrical and
gynecological services that a woman first obtain a referral from a
primary care physician: Provided, That for a health maintenance
organization authorized under article twenty-five-a of this
chapter, direct access, at least annually, to a women's health care
provider for purposes of a well woman examination shall satisfy the foregoing requirement. No health benefits policy may require as a
condition to the coverage of prenatal or obstetrical care that a
woman first obtain a referral for those services by a primary care
physician.
§33-42-5. Required disclosure.
Every health benefits policy that is issued, delivered, issued
for delivery or renewed in this state on or after the first day of
July, one thousand nine hundred ninety-eight, shall disclose in
writing to enrollees, subscribers and insureds, in clear and
accurate language, the female enrollee's right of direct access to
a women's health care provider of her choice. The information
required to be disclosed shall include, at a minimum, any specific
women's health care services that are excluded from coverage and
the health benefits policy's right to limit coverage to medically
necessary and appropriate women's health care services.
§33-42-6. Certain cost-sharing prohibited.
No health benefits policy may impose additional copayments or
deductibles for female enrollees' direct access to in-network,
participating women's health care providers unless the same
additional cost-sharing is imposed for other types of health care
services not delineated in this article.
§33-42-7. Limitation on number of women's health care providers.
A health benefits policy may limit the number of women's
health care providers in a network: Provided, That a sufficient
number of providers are available to serve a defined population or
geographic service area so that female enrollees will have direct and timely access to women's health care providers.