COMMITTEE SUBSTITUTE
FOR
Senate Bill No. 100
(By Senators Hunter, Mitchell and Kessler)
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[Originating in the Committee on Banking and Insurance;
reported February 28, 2000.]
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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-four, relating
to insurance coverage for serious mental illness.
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-four, to read as follows:
ARTICLE 44. INSURANCE COVERAGE FOR SERIOUS MENTAL ILLNESS.
§33-44-1. 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.
§33-44-2. Definitions.
(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 specified diseases.
(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.
§33-44-3. 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.
§33-44-4. 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.