Senate Bill No. 549
(By Senators Prezioso, Oliverio, Snyder, Ross,
Macnaughtan, Fanning and Plymale)
[Introduced February 16, 1998; referred to the
Committee on Banking and Insurance.]
A BILL to amend and reenact section two, article twenty-five-a,
chapter thirty-three of the code of West Virginia, one
thousand nine hundred thirty-one, as amended, relating to
health maintenance organizations (HMOs); definitions; and
providing that certain advanced nurse practitioners may
serve in lieu of an HMO subscriber's primary care physician.
Be it enacted by the Legislature of West Virginia:
That section two 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 to read as follows:
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
(1) "Basic health care services" means physician, hospital,
out-of-area, podiatric, chiropractic, laboratory, X ray,
emergency, short-term mental health services not exceeding twenty outpatient visits in any twelve-month period, and cost-effective
preventive services including immunizations, well-child care,
periodic health evaluations for adults, voluntary family planning
services, infertility services and children's eye and ear
examinations conducted to determine the need for vision and
hearing corrections, which services need not necessarily include
all procedures or services offered by a service provider.
(2) "Capitation" means the fixed amount paid by a health
maintenance organization to a health care provider under contract
with the health maintenance organization in exchange for the
rendering of health care services.
(3) "Commissioner" means the commissioner of insurance.
(4) "Consumer" means any person who is not a provider of
care or an employee, officer, director or stockholder of any
provider of care.
(5) "Copayment" means a specific dollar amount, except as
otherwise provided for by statute, that the subscriber must pay
upon receipt of covered health care services and which is set at
an amount consistent with allowing subscriber access to health
(6) "Employee" means a person in some official employment or
position working for a salary or wage continuously for no less
than one calendar quarter and who is in such a relation to
another person that the latter may control the work of the former and direct the manner in which the work shall be done.
(7) "Employer" means any individual, corporation,
partnership, other private association, or state or local
government that employs the equivalent of at least two full-time
employees during any four consecutive calendar quarters.
(8) "Enrollee", "subscriber" or "member" means an individual
who has been voluntarily enrolled in a health maintenance
organization, including individuals on whose behalf a contractual
arrangement has been entered into with a health maintenance
organization to receive health care services.
(9) "Evidence of coverage" means any certificate, agreement
or contract issued to an enrollee setting out the coverage and
other rights to which the enrollee is entitled.
(10) "Health care services" means any services or goods
included in the furnishing to any individual of medical, mental
or dental care, or hospitalization or incident to the furnishing
of the care or hospitalization, osteopathic services,
chiropractic services, podiatric services, home health, health
education, or rehabilitation, as well as the furnishing to any
person of any and all other services or goods for the purpose of
preventing, alleviating, curing or healing human illness or
(11) "Health maintenance organization" or "HMO" means a
public or private organization which provides, or otherwise makes available to enrollees, health care services, including at a
minimum basic health care services which:
(a) Receives premiums for the provision of basic health care
services to enrollees on a prepaid per capita or prepaid
aggregate fixed sum basis, excluding copayments;
(b) Provides physicians' services primarily: (i) Directly
through physicians who are either employees or partners of the
organization; or (ii) through arrangements with individual
physicians or one or more groups of physicians organized on a
group practice or individual practice arrangement; or (iii)
through some combination of paragraphs (i) and (ii) of this
(c) Assures the availability, accessibility and quality,
including effective utilization, of the health care services
which it provides or makes available through clearly identifiable
focal points of legal and administrative responsibility; and
(d) Offers services through an organized delivery system in
which a primary care physician is designated for each subscriber
upon enrollment. The primary care physician is responsible for
coordinating the health care of the subscriber and is responsible
for referring the subscriber to other providers when necessary:
Provided, That when dental care is provided by the health
maintenance organization the dentist selected by the subscriber
from the list provided by the health maintenance organization shall coordinate the covered dental care of the subscriber, as
approved by the primary care physician or the health maintenance
(12) "Impaired" means a financial situation in which, based
upon the financial information which would be required by this
chapter for the preparation of the health maintenance
organization's annual statement, the assets of the health
maintenance organization are less than the sum of all of its
liabilities and required reserves including any minimum capital
and surplus required of the health maintenance organization by
this chapter so as to maintain its authority to transact the
kinds of business or insurance it is authorized to transact.
(13) "Individual practice arrangement" means any agreement
or arrangement to provide medical services on behalf of a health
maintenance organization among or between physicians or between
a health maintenance organization and individual physicians or
groups of physicians, where the physicians are not employees or
partners of the health maintenance organization and are not
members of or affiliated with a medical group.
(14) "Insolvent" or "insolvency" means a financial situation
in which, based upon the financial information that would be
required by this chapter for the preparation of the health
maintenance organization's annual statement, the assets of the
health maintenance organization are less than the sum of all of its liabilities and required reserves.
(15) "Medical group" or "group practice" means a
professional corporation, partnership, association or other
organization composed solely of health professionals licensed to
practice medicine or osteopathy and of other licensed health
professionals, including podiatrists, dentists and optometrists,
as are necessary for the provision of health services for which
the group is responsible: (a) A majority of the members of which
are licensed to practice medicine or osteopathy; (b) who as their
principal professional activity engage in the coordinated
practice of their profession; (c) who pool their income for
practice as members of the group and distribute it among
themselves according to a prearranged salary, drawing account or
other plan; and (d) who share medical and other records and
substantial portions of major equipment and professional,
technical and administrative staff.
(16) "Premium" means a prepaid per capita or prepaid
aggregate fixed sum unrelated to the actual or potential
utilization of services of any particular person which is charged
by the health maintenance organization for health services
provided to an enrollee.
(17) "Primary care physician" means the general
practitioner, family practitioner, obstetrician/gynecologist,
pediatrician or specialist in general internal medicine who is chosen or designated for each subscriber who will be responsible
for coordinating the health care of the subscriber, including
necessary referrals to other providers: Provided, That
certified nurse-midwife may be chosen or designated in lieu of as
a subscriber's primary care physician during the subscriber's
pregnancy and for a period extending through the end of the month
in which the sixty-day period following termination of pregnancy
ends: Provided, however, That nothing in this subsection shall
expand the scope of practice for certified nurse-midwives as
defined in article fifteen, chapter thirty of this code. an
advanced nurse practitioner practicing in compliance with article
seven, chapter thirty of this code, and other applicable state
and federal laws may serve in lieu of a primary care physician:
Provided, however, That a certified nurse-midwife may be chosen
or designated in lieu of a subscriber's primary care physician
during the subscriber's pregnancy and for a period extending
through the end of the month in which the sixty-day period
following termination of pregnancy ends. Nothing in this
subsection expands the scope of practice for advanced nurse
practitioners as governed by article seven, chapter thirty of
this code, or for certified nurse-midwives as defined in
article fifteen, chapter thirty of this code.
(18) "Provider" means any physician, hospital or other
person or organization which is licensed or otherwise authorized in this state to furnish health care services.
(19) "Uncovered expenses" means the cost of health care
services that are covered by a health maintenance organization,
for which a subscriber would also be liable in the event of the
insolvency of the organization.
(20) "Service area" means the county or counties approved by
the commissioner within which the health maintenance organization
may provide or arrange for health care services to be available
to its subscribers.
(21) "Statutory surplus" means the minimum amount of
unencumbered surplus which a corporation must maintain pursuant
to the requirements of this article.
(22) "Surplus" means the amount by which a corporation's
assets exceeds its liabilities and required reserves based upon
the financial information which would be required by this chapter
for the preparation of the corporation's annual statement except
that assets pledged to secure debts not reflected on the books of
the health maintenance organization shall not be included in
(23) "Surplus notes" means debt which has been subordinated
to all claims of subscribers and general creditors of the
(24) "Qualified independent actuary" means an actuary who is
a member of the American academy of actuaries or the society of actuaries and has experience in establishing rates for health
maintenance organizations and who has no financial or employment
interest in the health maintenance organization.
(25) "Quality assurance" means an ongoing program designed
to objectively and systematically monitor and evaluate the
quality and appropriateness of the enrollee's care, pursue
opportunities to improve the enrollee's care and to resolve
identified problems at the prevailing professional standard of
(26) "Utilization management" means a system for the
evaluation of the necessity, appropriateness and efficiency of
the use of health care services, procedures and facilities.
NOTE: The purpose of this bill is to provide that certain
advanced nurse practitioners may serve in lieu of an HMO
subscriber's primary care physician.
Strike-throughs indicate language that would be stricken
from the present law, and underscoring indicates new language
that would be added.