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
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
CHAPTER 16. PUBLIC HEALTH.
ARTICLE 1A. RURAL HEALTH INFRASTRUCTURE PRESERVATION AND
§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.
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
(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
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
(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
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.