H. B. 2956


(By Delegates L. Smith,
Hatfield and Susman)
[Introduced February 26, 1999; referred to the
Committee on Banking and Insurance then Government Organization.]


A BILL to amend chapter sixteen of the code of West Virginia, one thousand nine hundred thirty-one, as amended, by adding thereto a new article, designated article one-a; and to amend article twenty-five-a, chapter thirty-three by adding thereto a new section, designated section four-a, all relating to the preservation and enhancement of health care access; defining essential community providers; prohibiting managed care organizations from denying essential community providers an opportunity to participate in the organization's plan as a participating provider where the essential community provider meets certain criteria; and requiring the insurance commissioner to establish standards and implement reporting procedures to ensure adequate access to care.

Be it enacted by the Legislature of West Virginia:
That chapter sixteen of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended by adding thereto a new article, designated article one-a; and that article twenty-five-a, chapter thirty-three be amended by adding thereto a new section, designated section four-a, all to read as follows:
CHAPTER 16. PUBLIC HEALTH.

ARTICLE 1A. RURAL HEALTH INFRASTRUCTURE PRESERVATION AND
ENHANCEMENT ACT.
§16-1A-1. Statement of legislative intent.
The Legislature finds that the following are true: (1) That health care delivery and financing systems are rapidly changing; (2) that urban managed care models, based on competition, may not be the best model for enhancing health care delivery in rural areas of the state and may threaten the continued existence of certain essential health services; (3) that loss of such services would force residents in rural areas of West Virginia to travel long distances for primary and essential health care services, thereby placing the physical health and safety of such residents at risk; (4) that providers of health services to rural areas and consumers in those areas desire to organize and preserve essential and primary health care services in rural areas; and (5) that the state must assure that managed care practices and reimbursement policies of public and private payors do not impair access to essential health care services in rural areas.
§16-1A-2. Definitions.
For purposes of this article:
(a) "Agreement" means a rural health network care coordination agreement as that term is defined in this section.
(b) "Department" means the department of health and human resources.
(c) "Essential community provider" means: (1) Sole community provider hospitals as designated by the federal health care financing authority; (2) rural hospitals located in nonmetropolitan areas with fewer than seventy-five licensed acute care beds, which are located in communities where there is only one medical/surgical acute care facility, which derive at least fifty percent of revenue from governmental payors, and which are part of a rural network; (3) rural primary care hospitals as designated by the federal health care financing authority under the essential access community hospital program; (4) primary care providers in federally designated medically underserved or health professional shortage areas who are part of a rural health network; (5) school health programs which are linked to an existing provider; (6) public health departments; (7) federally qualified health centers and rural health clinics; (8) nonprofit primary care centers designated by the office of community and rural health services; (9) county aging programs operating personal care services; (10) home health agencies; (11) hospice agencies; (12) emergency medical services agencies; and (13) regional behavioral health agencies. In order to be designated as an essential community provider, the entity must participate in the medicare and medicaid programs and adopt and comply with a policy for the provision of health care services to indigent and charity patients.
(d) "Health benefit plan" means the health insurance policy or subscriber agreement between a covered person or policyholder and a health care insurer which defines the covered services and benefit levels available.
(e)"Secretary" means the secretary of the department of
health and human resources.
§16-1A-3. Essential community providers.
(a) Before the thirtieth day of June, two thousand two, no essential community provider may be denied the opportunity to become a participating provider in a health benefit plan. This subsection applies to any essential community provider which is willing to render health care services covered by a health benefit plan under one of the following:
(1) The same terms and conditions, including payment terms, applicable to other participating providers of the same provider category in the plan; or
(2) Such terms and conditions as may be mutually agreed upon by the provider and the health care insurer offering the health benefit plan.
In the event an essential community provider requests the opportunity to become a participating provider in any health benefit plan, the health care insurer of that plan shall conduct reasonable and good faith negotiations with the essential community provider. If the requesting essential community provider meets the terms and conditions applicable to other participating providers of the same provider category, the health care insurer shall approve the provider as a participating provider for purposes of the plan. Nothing in this subsection may be construed to prevent a health care insurer from voluntarily approving any provider as a participating provider in any health benefit plan.
To reject or terminate an essential community provider from serving as a participating provider in a health plan, the health care insurer shall:
(1) Inform the provider in writing of the basis of such rejection or termination, referring to the specific qualification or standard which the provider failed to meet; and
(2) Afford the provider a reasonable opportunity to conform to such qualification or standard.
(b) The insurance commissioner shall ensure compliance and enforcement of the provisions of this section.
CHAPTER 33. INSURANCE.

ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-4a. Commissioner to develop standards.
By the year two thousand, the commissioner of insurance shall develop written standards and shall implement reporting requirements to ensure that health maintenance organizations:
(1) Maintain a provider network sufficient in numbers and types of health care professionals and facilities to ensure that all covered benefits and services to enrollees are available, including access to primary care within thirty minutes, access to basic hospital services in forty-five minutes, and access to tertiary care in sixty minutes;
(2) Maintain adequate enrollee to primary care physician and specialty care physician ratios;
(3) Maintain adequate physician, nurse and other health professional staffing levels for all provider facilities in the HMO's network;
(4) Provide access to services seven days per week and twenty-four hours per day.



NOTE: The purpose of this bill is to enhance and preserve rural health care services and ensure adequate, prompt access to care.
Article one-a, chapter sixteen, and section four-a, article twenty-five-a, chapter thirty-three are new; therefore, strike-throughs and underscoring have been omitted.