Senate Bill No. 554
(By Senators Hunter, Macnaughtan and Kessler)
[Introduced February 16, 1998; referred to the
Committee on Banking and Insurance; and then to the Committee on
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 forty- two, relating to insurance coverage for serious mental
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 forty-two, to
read as follows:
ARTICLE 42. INSURANCE COVERAGE FOR SERIOUS MENTAL ILLNESS.
§33-42-1. Coverage for serious mental illness required.
Every health care insurer shall provide coverage for the medical treatment of serious mental illness under the same terms
and conditions as such coverage is provided for other illnesses
and diseases. Insurance coverage offered pursuant to this
statute shall include the same durational limits, amount limits,
deductibles and coinsurance factors for serious mental illness as
for other illnesses and diseases.
(a) "Health insurers" means all persons, firms, corporations
or other organizations offering and assuring health services on
a prepaid or primarily expense-incurred basis, including, but not
limited to: Policies of accident or sickness insurance, as
defined in this chapter; nonprofit hospital or medical service
plans, whether organized under this chapter or under any public
law or by special act of the Legislature; health maintenance
organizations; or any other entity which insures or reimburses
for diagnostic, therapeutic or preventative services to a
determined population on the basis of a periodic premium, except
for supplemental policies which only provide coverage for
(b) "Serious mental illness" means any mental disorder that
current medical science affirms is caused by a biological
disorder of the brain and that substantially limits the life
activities of the person with the illness, including, but not limited to, schizophrenia, schizo-affective disorder, delusional
disorder, bipolar affective disorders, major depression and
obsessive compulsive disorder.
(c) "Medical coverage" means inpatient hospitalization and
outpatient medication visits.
§33-42-3. Medical necessity and appropriateness of treatment.
Upon request of the reimbursing health insurers, all
providers of treatment of serious mental illness shall furnish
medical records or other necessary data which substantiates that
initial or continued treatment is at all times medically
necessary and appropriate. When the provider cannot so establish
medical necessity or appropriateness of the treatment modality
provided, neither the health insurer nor the patient shall be
obligated to reimburse for that period or type of care which was
not so established. The provider shall inform the patient of the
substance of this section in advance of providing treatment.
After the patient is informed that medical necessity or
appropriateness is not established, the patient may agree in
writing to continue receiving treatment at his or her own
expense. The health insurers shall make determinations of
medical necessity and appropriateness in a manner consistent with
that used to make the determination for treatment of other
diseases or injuries covered under the health insurance policy or agreement.
§33-42-4. Limitation of coverage.
The health care benefits set forth in this article apply
only to services delivered within this state. Inpatient coverage
in cases where continuous hospitalization is medically necessary
is limited to ninety consecutive days.
NOTE: The purpose of this bill is to require insurance
coverage for the treatment of serious mental illness.
This article is new; therefore, strike-throughs and
underscoring have been omitted.