H. B. 2461


(By Delegates Fleischauer, Compton, Douglas,
Doyle, Manuel, Amores and Staton)
[Introduced January 29, 1999; referred to the
Committee on Health and Human then Government Organization.]


A BILL to amend and reenact sections seven and nine, article sixteen, chapter five of the code of West Virginia, one thousand nine hundred thirty-one, as amended; to amend and reenact section fifteen, article fifteen; to amend and reenact section seven, article sixteen-a; to amend and reenact section four, article sixteen-c; to amend and reenact section five, article twenty-eight, all of chapter thirty-three of said code; to further amend said article fifteen by adding thereto a new section, designated section four-f; to amend article sixteen by adding thereto a new section, designated section thirty-one; to amend article twenty-four by adding thereto a new section, designated section seven-f; to amend article twenty-five by adding thereto a new section, designated section eight-e; and to amend article twenty-five-a by adding thereto a new section, designated section eight-e, all of said chapter thirty-three, all relating to health insurance; mandating certain benefits; and requiring all entities providing health insurance to cover any contraceptive drug or device that is approved by the United States Food and Drug Administration for use as a contraceptive and that is obtained under a prescription written by an authorized provider.

Be it enacted by the Legislature of West Virginia:
That sections seven and nine, article sixteen, chapter five of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended and reenacted; that section fifteen, article fifteen; section seven, article sixteen-a; section four, article sixteen-c; and section five, article twenty-eight, all of chapter thirty-three of said code, be amended and reenacted; that article fifteen be further amended by adding thereto a new section, designated section four-f; that article sixteen be amended by adding thereto a new section, designated section thirty-one; that article twenty-four be amended by adding thereto a new section, designated section seven-f; that article twenty-five be amended by adding thereto a new section, designated section eight-e; and that article twenty-five-a be amended by adding thereto a new section, designated section eight-e, all of said chapter thirty-three, all to read as follows:
CHAPTER 5. GENERAL POWERS AND AUTHORITY OF THE GOVERNOR,

SECRETARY OF STATE AND ATTORNEY GENERAL; BOARD

OF PUBLIC WORKS; MISCELLANEOUS AGENCIES, COMMISSIONS,

OFFICES, PROGRAMS, ETC.

ARTICLE 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.

§5-16-7. Authorization to establish group hospital and surgical insurance plan, group major medical insurance plan, group prescription drug plan and group life and accidental death insurance plan; rules for administration of plans; mandated benefits; what plans may provide; optional plans; separate rating for claims experience purposes.

(a) The agency shall establish a group hospital and surgical insurance plan or plans, a group prescription drug insurance plan or plans, a group major medical insurance plan or plans, and a group life and accidental death insurance plan or plans for those employees herein made eligible, and to establish and promulgate rules and regulations for the administration of such the plans, subject to the limitations contained in this article. Those plans shall include:
(1) Coverages and benefits for X ray and laboratory services in connection with mammograms and pap smears when performed for cancer screening or diagnostic services;
(2) Annual checkups for prostate cancer in men age fifty and over;
(3) For plans that include maternity benefits, coverages for inpatient care in a duly licensed health care facility for a mother and her newly born infant for the length of time which the attending physician deems medically necessary for the mother or her newly born child: Provided, That no such plan may deny payment for a mother or her new born child prior to forty-eight hours following a vaginal delivery, or prior to ninety-six hours following a caesarean section delivery, if the attending physician deems discharge medically inappropriate; and
(4) For plans which provide coverages for post-delivery care to a mother and her newly born child in the home, coverage for inpatient care following childbirth as provided in subdivision (3) of this subsection if such the inpatient care is determined to be medically necessary by the attending physician. Those plans may also include, among other things, medicines, medical equipment, prosthetic appliances and such other inpatient and outpatient services and expenses deemed appropriate and desirable by the agency; and
(5) For plans that include benefits and coverages for any contraceptive drug or device that is approved by the United States food and drug administration for use as a contraceptive and that is obtained under a prescription written by an authorized provider.
(b) The agency shall make available to each eligible employee, at full cost to the employee, the opportunity to purchase optional group life and accidental death insurance as established under the rules of the agency. In addition, each employee is entitled to have his or her spouse and dependents, as defined by the rules of the agency, included in the optional coverage, at full cost to the employee for each eligible dependent; and with full authorization to the agency to make the optional coverage available and provide an opportunity of purchase to each employee.
(c) The finance board may cause to be separately rated for claims experience purposes:
(1) All employees of the state of West Virginia;
(2) All teaching and professional employees of the university of West Virginia board of trustees or the board of directors of the state college system and county boards of education;
(3) All nonteaching employees of the university of West Virginia board of trustees or the board of directors of the state college system and county boards of education; or
(4) Any other categorization which would ensure the stability of the overall program.
§5-16-9. Authorization to execute contracts for group hospital and surgical insurance, group major medical insurance, group prescription drug insurance, group life and accidental death insurance and other accidental death insurance; mandated benefits; limitations; awarding of contracts; reinsurance; certificates for covered employees; discontinuance of contracts.
(a) The director is hereby given exclusive authorization to execute such contract or contracts as are necessary to carry out the provisions of this article and to provide the plan or plans of group hospital and surgical insurance coverage, group major medical insurance coverage, group prescription drug insurance coverage and group life and accidental death insurance coverage selected in accordance with the provisions of this article, such the contract or contracts to be executed with one or more agencies, corporations, insurance companies or service organizations licensed to sell group hospital and surgical insurance, group major medical insurance, group prescription drug insurance and group life and accidental death insurance in this state.
(b) The group hospital or surgical insurance coverage and group major medical insurance coverage herein provided for shall include coverages and benefits for X ray and laboratory services in connection with mammograms and pap smears when performed for cancer screening or diagnostic services and annual checkups for prostate cancer in men age fifty and over. Such These benefits shall include, but not be limited to, the following:
(1) Baseline or other recommended mammograms for women ages thirty-five to thirty-nine, inclusive;
(2) Mammograms recommended or required for women age forty to forty-nine, inclusive, every two years or as needed;
(3) A mammogram every year for women age fifty and over;
(4) A pap smear annually or more frequently based on the woman's physician's recommendation for women age eighteen and over; and
(5) A checkup for prostate cancer annually for men age fifty or over.
(c) The group life and accidental death insurance herein provided for shall be in the amount of ten thousand dollars for every employee. The amount of the group life and accidental death insurance to which an employee would otherwise be entitled shall be reduced to five thousand dollars upon such employee attaining age sixty-five.
(d) All of the insurance coverage to be provided for under this article may be included in one or more similar contracts issued by the same or different carriers.
(e) The provisions of article three, chapter five-a of this code, relating to the division of purchases of the department of finance and administration, shall do not apply to any contracts for any insurance coverage or professional services authorized to be executed under the provisions of this article. Before entering into any contract for any insurance coverage, as herein authorized, said the director shall invite competent bids from all qualified and licensed insurance companies or carriers, who may wish to offer plans for the insurance coverage desired. The director shall deal directly with insurers in presenting specifications and receiving quotations for bid purposes. No commission or finder's fee, or any combination thereof, shall be paid to any individual or agent; but this shall not preclude an underwriting insurance company or companies, at their own expense, from appointing a licensed resident agent, within this state, to service the companies' contracts awarded under the provisions of this article. Commissions reasonably related to actual service rendered for such the agent or agents may be paid by the underwriting company or companies: Provided, That in no event shall payment be made to any agent or agents when no actual services are rendered or performed. The director shall award such the contract or contracts on a competitive basis. In awarding the contract or contracts the director shall take into account the experience of the offering agency, corporation, insurance company or service organization in the group hospital and surgical insurance field, group major medical insurance field, group prescription drug field and group life and accidental death insurance field, and its facilities for the handling of claims. In evaluating these factors, the director may employ the services of impartial, professional insurance analysts or actuaries or both. Any contract executed by the director with a selected carrier shall be a contract to govern all eligible employees subject to the provisions of this article. Nothing contained in this article shall prohibit any insurance carrier from soliciting employees covered hereunder to purchase additional hospital and surgical, major medical or life and accidental death insurance coverage.
(f) The director may authorize the carrier with whom a primary contract is executed to reinsure portions of such the contract with other carriers which elect to be a reinsurer and who are legally qualified to enter into a reinsurance agreement under the laws of this state.
(g) Each employee who is covered under any such contract or contracts shall receive a statement of benefits to which such the employee, his or her spouse and his or her dependents are entitled thereunder, setting forth such the information as to whom such the benefits shall be payable, to whom claims shall be submitted, and a summary of the provisions of any such contract or contracts as they affect the employee, his or her spouse and his or her dependents.
(h) The director may at the end of any contract period discontinue any contract or contracts it has executed with any carrier and replace the same with a contract or contracts with any other carrier or carriers meeting the requirements of this article.
(i) The director shall provide by contract or contracts entered into under the provisions of this article the cost for coverage of children's immunization services from birth through age sixteen years to provide immunization against the following illnesses: Diphtheria, polio, mumps, measles, rubella, tetanus, hepatitis-b, haemophilus influenzae-b and whooping cough. Additional immunizations may be required by the commissioner of the bureau of public health for public health purposes. Any contract entered into to cover these services shall require that all costs associated with immunization, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration, be exempt from any deductible, per visit charge and/or copayment provisions which may be in force in these policies or contracts. This section does not require that other health care services provided at the time of immunization be exempt from any deductible and/or copayment provisions.
(j) The director shall provide by contract or contracts for plans that include benefits and coverages for any contraceptive drug or device that is approved by the United States food and drug administration for use as a contraceptive and that is obtained under a prescription written by an authorized provider.
CHAPTER 33. INSURANCE.

ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.

§33-15-4f. Third party reimbursement for benefits and coverage for contraceptive drug or device patients.
Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall provide as benefits to all subscribers and members coverage for any contraceptive drug or device that is approved by the United States food and drug administration for use as a contraceptive and that is obtained under a prescription written by an authorized provider.
§33-15-15. Insurance commissioner to establish minimum benefits and coverages for an individual policy design; basic policy benefits; exemptions; legislative rules; premiums; applicability.

(a) The insurance commissioner shall establish minimum benefits which may be included in any individual accident and sickness insurance policy issued pursuant to this article. The commissioner may accept bids on designs for such minimum plans and shall compile a final basic benefit plan for use by insurers within six months after the effective date of this article.
(b) The basic policy plan established by the insurance commissioner may include coverage for the services of medical physicians or surgeons, podiatrists, physician assistants, osteopathic physicians or surgeons, chiropractors, midwives, advanced nurse practitioners or any other professional health care provider as deemed appropriate by the insurance commissioner.
(c) The following shall serve as a guide to the commissioner in the design of a basic policy issued pursuant to this article:
(1) Inpatient hospital care up to twenty days per year;
(2) Outpatient hospital care including, but not limited to, surgery and anesthesia, preadmission testing, radiation therapy and chemotherapy;
(3) Accident or emergency care through emergency room care and emergency admissions to a hospital;
(4) Physician office visits for primary, preventive, well, acute or sick care, up to four visits per year, and laboratory fees, surgery and anesthesia, diagnostic X rays, physician care in a hospital inpatient or outpatient setting;
(5) Prenatal care, including a minimum of one prenatal office visit per month during the first two trimesters of pregnancy, two office visits per month during the seventh and eighth months of pregnancy, and one office visit per week during the ninth month and until term. Coverage for each such visit shall include necessary appropriate screening, including history, physical examination, and such laboratory and diagnostic procedures as may be deemed appropriate by the physician based upon recognized medical criteria for the risk group of which the patient is a member. Coverage for each office visit shall also include such prenatal counseling as the physician deems appropriate;
(6) Obstetrical care, including physician's services, delivery room and other medically necessary hospital services. (7) X ray and laboratory services in connection with mammograms or pap smears when performed for cancer screening or diagnostic purposes, at the direction of a physician, including, but not limited to, the following:
(A) Baseline or other recommended mammograms for women age thirty-five to thirty-nine, inclusive;
(B) Mammograms recommended or required for women age forty to forty-nine, inclusive, every two years or as needed;
(C) A mammogram every year for women age fifty and over; or
(D) A pap smear annually or more frequently based on the woman's physician's recommendation for women age eighteen or over. A basic policy issued pursuant to this article may apply to mammograms or pap smears the same deductibles or copayments as apply to other covered services;
(8) Medical and laboratory services in connection with annual checkups for prostate cancer in men age fifty and over; and
(9) Child immunization services as described in section five, article three, chapter sixteen of this code. This coverage will cover all costs associated with immunization, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration. These services shall be exempt from any deductible, per-visit charge and/or copayment provisions which may be in force in these policies or contracts. This section does not require that other health care services provided at the time of immunization be exempt from any deductible and/or copayment provisions; and
(10) A basic policy shall include coverage for plans that include benefits and coverages for any contraceptive drug or device that is approved by the United States food and drug administration for use as a contraceptive and that is obtained under a prescription written by an authorized provider.
(d) Notwithstanding any other provision of this code to the contrary, any basic policy issued pursuant to this section shall be exempt from all statutorily and regulatorily mandated benefits and coverages except for the minimum benefits and coverages as established by the commissioner pursuant to subsection (a) of this section.
(e) Nothing in this section shall preclude precludes an insurer from offering any other benefit or coverage under a basic policy issued pursuant to this article, for an appropriate additional premium: Provided, That any additional benefit or coverage must first be approved by the insurance commissioner.
(f) A basic policy issued pursuant to this section may include deductibles, copayments and maximum benefits: Provided, That any additional benefit must first be approved by the insurance commissioner.
(g) The insurance commissioner shall promulgate legislative rules pursuant to chapter twenty-nine-a of this code to implement the provisions of this section, including, but not limited to, rules regarding bids, forms and rates.
(h) The premiums paid for insurance provided pursuant to this article shall be exempt from the premium tax required to be paid pursuant to sections fourteen and fourteen-a, article three of this chapter.
(i) A basic policy provided by this section shall be issued only to individuals who have been without health insurance coverage for at least one year prior to application for the same.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.

§33-16-3l. Third party reimbursement for benefits and coverages for contraceptive drug or device patients.
Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall provide as benefits to all subscribers and members coverage for any contraceptive drug or device that is approved by the United States food and drug administration for use as a contraceptive and that is obtained under a prescription written by an authorized provider.
ARTICLE 16A. GROUP HEALTH INSURANCE CONVERSION.

§33-16A-7. Limits of coverage.

An insurer shall may not be required to issue a converted policy which provides benefits in excess of those provided under the group policy from which conversion is made.
A converted policy shall include coverage for plans that include benefits and coverages for any contraceptive drug or device that is approved by the United States food and drug administration for use as a contraceptive and that is obtained under a prescription written by an authorized provider.
ARTICLE 16C. EMPLOYER GROUP ACCIDENT AND SICKNESS INSURANCE POLICIES.

§33-16C-4. Insurance commissioner to establish minimum benefits and coverages; basic policy benefits.

(a) The insurance commissioner shall establish minimum benefits which shall be included in every insurance policy issued pursuant to this article. The commissioner may accept bids on designs for such minimum plans and shall compile a final basic benefit plan for use by insurers within six months after the effective date of this article.
(b) The basic policy plan established by the insurance commissioner may include coverage for the services of medical physicians or surgeons, podiatrists, physician assistants, osteopathic physicians or surgeons, chiropractors, midwives, advanced nurse practitioners or any other professional health care provider as deemed appropriate by the insurance commissioner.
(c) The following shall serve as a guide to the commissioner in the design of a basic policy issued pursuant to this article:
(1) Inpatient hospital care up to twenty days per year;
(2) Outpatient hospital care including, but not limited to, surgery and anesthesia, pre-admission testing, radiation therapy and chemotherapy;
(3) Accident or emergency care through emergency room care and emergency admissions to a hospital;
(4) Physician office visits for primary, preventive, well, acute or sick care, up to four visits per year, and laboratory fees, surgery and anesthesia, diagnostic X rays, physician care in a hospital inpatient or outpatient setting;
(5) Prenatal care, including a minimum of one prenatal office visit per month during the first two trimesters of pregnancy, two office visits per month during the seventh and eighth months of pregnancy, and one office visit per week during the ninth month and until term. Coverage for each such visit shall include necessary appropriate screening, including history, physical examination, and such laboratory and diagnostic procedures as may be deemed appropriate by the physician based upon recognized medical criteria for the risk group of which the patient is a member. Coverage for each office visit shall also include such prenatal counseling as the physician deems appropriate;
(6) Obstetrical care, including physician's services, delivery room and other medically necessary hospital services. (7) X ray and laboratory services in connection with mammograms or pap smears when performed for cancer screening or diagnostic purposes, at the direction of a physician, including, but not limited to, the following:
(A) Baseline or other recommended mammograms for women age thirty-five to thirty-nine, inclusive;
(B) Mammograms recommended or required for women age forty to forty-nine, inclusive, every two years or as needed;
(C) A mammogram every year for women age fifty and over; or
(D) A pap smear annually or more frequently based on the woman's physician's recommendation for women age eighteen or over. A basic policy issued pursuant to this article may apply to mammograms or pap smears the same deductibles or copayments as apply to other covered services;
(8) Medical and laboratory services in connection with annual checkups for prostate cancer in men age fifty and over; and
(9) Child immunization services as described in section five, article three, chapter sixteen of this code. This coverage will cover all costs associated with immunization, including the cost of the vaccine, if incurred by the health care provider, and all costs of vaccine administration. These services shall be exempt from any deductible, per-visit charge and/or copayment provisions which may be in force in these policies or contracts. This section does not require that other health care services provided at the time of immunization be exempt from any deductible and/or copayment provisions; and
(10) Benefits and coverages for plans that include benefits and coverages for any contraceptive drug or device that is approved by the United States food and drug administration for use as a contraceptive and that is obtained under a prescription written by an authorized provider.
ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH SERVICE CORPORATIONS.
§33-24-7f. Third party reimbursement for benefits and coverages for any contraceptive drug or device patients.
Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall provide as benefits to all subscribers and members coverage for any contraceptive drug or device that is approved by the United States food and drug administration for use as a contraceptive and that is obtained under a prescription written by an authorized provider.
ARTICLE 25. HEALTH CARE CORPORATIONS.
§33-25-8e. Third party reimbursement for benefits and coverages for contraceptive drug or device patients.
Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall provide as benefits to all subscribers and members coverage for any contraceptive drug or device that is approved by the United States food and drug administration for use as a contraceptive and that is obtained under a prescription written by an authorized provider.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.

§33-25A-8e. Third party reimbursement for benefits and coverages for contraceptive or device patients.
Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall provide as benefits to all subscribers and members coverage for any contraceptive drug or device that is approved by the United States food and drug administration for use as a contraceptive and that is obtained under a prescription written by an authorized provider.
ARTICLE 28. INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS.

§33-28-5. Minimum standards for benefits.

(a) The commissioner shall promulgate rules and regulations, in accordance with chapter twenty-nine-a of the code, to establish minimum standards for benefits under each of the following categories of coverage in individual policies of accident and sickness insurance and subscriber contracts of hospital, medical, dental and service corporations:
(1) Basic hospital expense coverage;
(2) Basic medical-surgical expense coverage;
(3) Hospital confinement indemnity coverage, including benefits and coverages for plans that include benefits and coverages for any contraceptive drug or device that is approved by the United States food and drug administration for use as a contraceptive and that is obtained under a prescription written by an authorized provider.
(4) Major medical expense coverage;
(5) Disability income protection coverage;
(6) Accident only coverage; and
(7) Specified disease or specified accident coverage.
(b) Nothing in this section shall preclude the issuance of any policy or subscriber contract which combines two or more of the categories of coverage enumerated in subdivisions (1) through (6) of subsection (a) of this section.
(c) No policy or subscriber contract shall be delivered or issued for delivery in this state which does not meet the prescribed minimum standards for the categories of coverage listed in subdivisions (1) through (7) of subsection (a) of this section unless the commissioner finds that such policy or subscriber contract will be in the public interest and that such policy or subscriber contract contains benefits which are reasonable in relation to the premium charged.
(d) The commissioner shall prescribe the method of identification of policies and subscriber contracts based upon coverages provided.


NOTE: The purpose of this bill is to require all entities providing health insurance to cover any contraceptive drug or device that is approved by the United States Food and Drug Administration for use as a contraceptive and that is obtained under a prescription written by an authorized provider.

Strike-throughs indicate language that would be stricken from the present law, and underscoring indicates new language that would be added.

§§33-15-4f, 33-16-3l, 33-24-7f, 33-25-8e and 33-25A-8e are new; therefore, strike-throughs and underscoring have been omitted.