H. B. 4377
(By Delegates Douglas, Compton,
Leach, Warner and Hall)
[Introduced February 3, 2000; referred to the
Committee on Banking and Insurance then Finance.]
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-three, relating to requiring insurance coverage by
health care insurers for serious mental illness;
definitions; determination of medical necessity and
appropriateness; providers providing treatment; duties of
insurers and insurance commissioner; data collection and
reporting; and termination date.
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-three, to read as follows:
ARTICLE 43. INSURANCE COVERAGE FOR SERIOUS MENTAL ILLNESS.
§33-43-1. Coverage for serious mental illness required.
(a) On and after the first day of January, two thousand one,
every health care benefits policy issued or renewed in this state
shall provide coverage for the medical treatment of serious
mental illness of adults and children under the same terms and
conditions as the coverage provided for other illnesses and
diseases under the policy's medical and surgical benefits. The
durational limits on days or visits; dollar amount limits on
out-of-pocket, annual and lifetime expenditures; deductibles; and
coinsurance factors applicable to other illnesses and diseases
under the policy's medical and surgical benefits shall apply to
serious mental illness.
(b) The provisions of subsection (a) of this section do not
apply to a health benefits policy if, based upon experience
occurring over a continuous twelve-month period, the health care
insurer demonstrates to the commissioner that its application has
resulted in an increase of at least two percent in the net cost
of the policy.
§33-43-2. Definitions.
(a) "Health benefits policy" means any group plan, policy or contract for health care services issued, delivered, issued
for delivery or renewed in this state by a health care
corporation, health maintenance organization, accident and
sickness insurer, fraternal benefit society, nonprofit hospital
service corporation, nonprofit medical service corporation,
public employee's insurance agency or similar entity when the
policy or plan covers hospital, medical or surgical expenses,
except for credit accident and sickness, long term care, medicare
supplement, champus supplement, individual major medical and
limited benefit policies as defined under article sixteen-e of
this chapter.
(b) "Serious mental illness" means an illness included in
the American psychiatric association's diagnostic and statistical
manual of mental disorders, as periodically revised, under the
diagnostic categories or subclassifications of: (1) Pervasive
developmental disorders; (2) delirium, dementia and amnestic and
other cognitive disorders; (3) schizophrenia and other psychotic
disorders; (4) bipolar disorders; and (5) depressive disorders.
With regard to any covered individual who has not yet attained
the age of nineteen years, "serious mental illness" also includes
those illnesses included under the other categories of disorders listed in the American psychiatric association's diagnostic and
statistical manual of mental disorders, as revised.
(c) "Medical treatment" means appropriate and medically
necessary evaluation, diagnosis and treatment, including
inpatient hospitalization and outpatient visits.
§33-43-3. Medical necessity and appropriateness of treatment;
providers.
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.
Nothing in this article requires an insurer to contract with all
providers willing to provide treatment for serious mental
illness.
§33-43-4. Data collection and reporting.
Upon the effective date of this article, the insurance
commissioner shall obtain baseline data relating to the numbers
of insured persons, the cost of services for treatment of mental
illnesses, the cost of all services paid for by health insurers
and other data as may be reasonably required prior to the
mandatory coverages required by this article. Following the
first day of January, two thousand one, the insurance commissioner shall obtain data relating to the numbers of insured
persons, the cost of services for treatment of mental illnesses
and the cost of all services provided by health insurers as a
result of the mandatory coverages required by this article.
The
insurance commissioner may require insurers to maintain and
provide data relating to diagnostic categories of insured persons
with serious mental illness, services or categories of services
provided, the provider categories providing those services, cost
data and other data as may be reasonably required to evaluate the
effect of this article. All insurers shall collect, keep and
report baseline data and data following the enactment of this
article as required and in the form required by the insurance
commissioner. Not later than the first day of January, two
thousand three, the insurance commissioner shall report to the
joint committee on government and finance on the effect of the
passage of this article. The insurance commissioner may
categorize the data reported in the manner he or she may
determine, except that data related to the public employees
insurance agency, even if included in aggregate data, shall also
be reported separately.
§33-2A-5. Termination date.
The mandate established by the enactment of this article
that all health benefits policies must provide coverage for
serious mental illness shall terminate on the first day of July,
two thousand three, pursuant to article ten, chapter four of this
code, unless sooner terminated, continued or reestablished by act
of the Legislature enacted prior to the termination date.
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.