H. B. 2601
(By Delegates Marshall, Hatfield, Kuhn,
Fleischauer, Compton and Perdue)
[Introduced March 1, 2001; referred to the
Committee on Banking and Insurance then Finance.]
A BILL to amend and reenact section seven, article sixteen, chapter
five of the code of West Virginia, one thousand nine hundred
thirty-one, as amended; to amend and reenact section three-a,
article sixteen, chapter thirty-three of said code; and to
amend and reenact section two, article twenty-five-a of said
chapter, all relating to requiring insurance coverage by the
public employees insurance agency and health care insurers for
mental illness.
Be it enacted by the Legislature of West Virginia:
That section seven, article sixteen, chapter five of the code
of West Virginia, one thousand nine hundred thirty-one, as amended,
be amended and reenacted;
that section three-a, article sixteen,
chapter thirty-three of said code be amended and reenacted; and
that section two, article twenty-five-a of said chapter be amended
and reenacted, 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 for the administration of such these 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, coverage 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 considers 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 considers 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 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 any other inpatient and outpatient
services and expenses deemed considered
appropriate and desirable
by the agency; and
(5) Coverage for serious mental illness identical to that set
forth in section three-a, article sixteen, chapter thirty-three of
this code.
(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.
CHAPTER 33. INSURANCE.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-3a. Same -- Mental health.
(a)(1) Any policy Notwithstanding the requirements of
subsection (b) of this section, any health benefits plan described
in this article which shall be that is delivered, or issued or
renewed in this state shall make available as provide benefits to
all individual subscribers and members and to all group members if so elected by the subscriber or group, for expenses arising from
mental or nervous conditions as hereinafter set forth. Such
benefits shall be as described in the standard nomenclature of the
American psychiatric association which are at least equal to the
following minimum requirements:
(a) In the case of benefits based upon confinement as an
inpatient in a mental hospital under the direction and supervision
of the department of mental health, or in a private mental hospital
licensed by the department of mental health, the period of
confinement for which benefits shall be payable shall be at least
forty-five days in any calendar year.
(b) In the case of benefits based upon confinement as an
inpatient in a licensed or accredited general hospital, such
benefits shall be no different than for any other illness.
(c) In the case of outpatient benefits, these shall cover
fifty percent of eligible expenses up to five hundred dollars over
a twelve-month period services furnished: (1) By a comprehensive
health service organization; (2) by a licensed or accredited
hospital; or (3) subject to the approval of the department of
mental health, services furnished by a community mental health
center or other mental health clinic or day care center which
furnishes mental health services; or (4) consultations or
diagnostic or treatment sessions, provided that such services are
rendered by a psychotherapist or by a psychologist and do not
exceed fifty such sessions over a twelve-month period. serious mental illness. The expenses do not include custodial care,
residential care or schooling. For purposes of this section,
"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: (i) Schizophrenia and other
psychotic disorders; (ii) bipolar disorders; (iii) depressive
disorders; (iv) substance abuse; and (v) anxiety disorders. With
regard to substance abuse, there shall be at least two cycles
during a covered period. With regard to any covered individual who
has not yet attained the age of nineteen years, "serious mental
illness" also includes attention deficit hyperactivity disorder,
attachment disorder, disruptive behavior disorder, eating disorders
and oppositional defiance disorder.
(2) This subsection does not apply to a health plan if its
application results in an increase of at least two percent in the
cost of the plan.
(3) The health insurer shall make determinations of medical
necessity and appropriateness.
(4) Upon the effective date of the amendments made to this
section during the regular session of the Legislature in the year
two thousand one, 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 section. Following the first day of January, two thousand
four, 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
section. All insurers shall collect, keep and report baseline data
and data as required and in the form required by the insurance
commissioner. Not later than the first day of January, two
thousand five, the insurance commissioner shall report to the joint
committee on government and finance on the effect of the amendments
made to this section during the regular session of the Legislature
in the year two thousand one
. 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.
(5) The mandate established by the amendments made to this
subsection during the regular session of the Legislature in the
year two thousand one,
that all health benefits policies must
provide coverage for mental illness terminates on the first day of
July, two thousand six, unless sooner terminated, continued or
reestablished by act of the Legislature enacted prior to the
termination date.
(d) (b) With respect to mental health benefits furnished before the thirtieth day of September, two thousand one, to an
enrollee of a health benefit plan offered in connection with a
group health plan, for a plan year beginning on or after the first
day of January, one thousand nine hundred ninety-eight:
(1) Aggregate lifetime limits:
(A) If the health benefit plan does not include an aggregate
lifetime limit on substantially all medical and surgical benefits,
as defined under the terms of the plan but not including mental
health benefits, the plan may not impose any aggregate lifetime
limit on mental health benefits;
(B) If the health benefit plan limits the total amount that
may be paid with respect to an individual or other coverage unit
for substantially all medical and surgical benefits (in this
paragraph, "applicable lifetime limit"), the plan shall either
apply the applicable lifetime limit to medical and surgical
benefits to which it would otherwise apply and to mental health
benefits, as defined under the terms of the plan, and not
distinguish in the application of the limit between medical and
surgical benefits and mental health benefits, or not include any
aggregate lifetime limit on mental health benefits that is less
than the applicable lifetime limit;
(C) If a health benefit plan not previously described in this
subdivision includes no or different aggregate lifetime limits on
different categories of medical and surgical benefits, the
commissioner shall propose rules for legislative approval in accordance with the provisions of article three, chapter
twenty-nine-a of this code under which paragraph (B) of this
subdivision shall apply, substituting an average aggregate lifetime
limit for the applicable lifetime limit.
(2) Annual limits:
(A) If a health benefit plan does not include an annual limit
on substantially all medical and surgical benefits, as defined
under the terms of the plan but not including mental health
benefits, the plan may not impose any annual limit on mental health
benefits, as defined under the terms of the plan;
(B) If the health benefit plan limits the total amount that
may be paid in a twelve-month period with respect to an individual
or other coverage unit for substantially all medical and surgical
benefits (in this paragraph, "applicable annual limit"), the plan
shall either apply the applicable annual limit to medical and
surgical benefits to which it would otherwise apply and to mental
health benefits, as defined under the terms of the plan, and not
distinguish in the application of the limit between medical and
surgical benefits and mental health benefits, or not include any
annual limit on mental health benefits that is less than the
applicable annual limit;
(C) If a health benefit plan not previously described in this
subdivision includes no or different annual limits on different
categories of medical and surgical benefits, the commissioner shall
propose rules for legislative approval in accordance with the provisions of article three, chapter twenty-nine-a of this code
under which paragraph (B) of this subdivision shall apply,
substituting an average annual limit for the applicable annual
limit.
(3) For purposes of this subsection, mental health benefits do
not include benefits with respect to treatment of substance abuse
or chemical dependency. This subsection shall does not apply to a
health benefit plan if its application results in an increase of
at least one percent in the cost under the plan.
(4) If a group health plan or a health insurer offers a
participant or beneficiary two or more benefit package options,
this subsection shall apply separately with respect to coverage
under each option.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-2. Definitions.
(1) "Basic health care services" means physician, hospital,
out-of-area, podiatric, chiropractic, laboratory, X ray, emergency,
short-term mental health services not exceeding twenty outpatient
visits in any twelve-month period, and cost-effective preventive
services including immunizations, well-child care, periodic health
evaluations for adults, voluntary family planning services,
infertility services, and children's eye and ear examinations
conducted to determine the need for vision and hearing corrections
and mental health benefits as provided in section three-a, article
sixteen of this chapter, which services need not necessarily include all procedures or services offered by a service provider.
(2) "Capitation" means the fixed amount paid by a health
maintenance organization to a health care provider under contract
with the health maintenance organization in exchange for the
rendering of health care services.
(3) "Commissioner" means the commissioner of insurance.
(4) "Consumer" means any person who is not a provider of care
or an employee, officer, director or stockholder of any provider of
care.
(5) "Copayment" means a specific dollar amount, except as
otherwise provided for by statute, that the subscriber must pay
upon receipt of covered health care services and which is set at an
amount consistent with allowing subscriber access to health care
services.
(6) "Employee" means a person in some official employment or
position working for a salary or wage continuously for no less than
one calendar quarter and who is in such a relation to another
person that the latter may control the work of the former and
direct the manner in which the work shall be done.
(7) "Employer" means any individual, corporation, partnership,
other private association, or state or local government that
employs the equivalent of at least two full-time employees during
any four consecutive calendar quarters.
(8) "Enrollee", "subscriber" or "member" means an individual
who has been voluntarily enrolled in a health maintenance organization, including individuals on whose behalf a contractual
arrangement has been entered into with a health maintenance
organization to receive health care services.
(9) "Evidence of coverage" means any certificate, agreement or
contract issued to an enrollee setting out the coverage and other
rights to which the enrollee is entitled.
(10) "Health care services" means any services or goods
included in the furnishing to any individual of medical, mental or
dental care, or hospitalization or incident to the furnishing of
the care or hospitalization, osteopathic services, chiropractic
services, podiatric services, home health, health education or
rehabilitation, as well as the furnishing to any person of any and
all other services or goods for the purpose of preventing,
alleviating, curing or healing human illness or injury.
(11) "Health maintenance organization" or "HMO" means a public
or private organization which provides, or otherwise makes
available to enrollees, health care services, including at a
minimum basic health care services which:
(a) Receives premiums for the provision of basic health care
services to enrollees on a prepaid per capita or prepaid aggregate
fixed sum basis, excluding copayments;
(b) Provides physicians' services primarily: (i) Directly
through physicians who are either employees or partners of the
organization; or (ii) through arrangements with individual
physicians or one or more groups of physicians organized on a group practice or individual practice arrangement; or (iii) through some
combination of paragraphs (i) and (ii) of this subdivision;
(c) Assures the availability, accessibility and quality,
including effective utilization, of the health care services which
it provides or makes available through clearly identifiable focal
points of legal and administrative responsibility; and
(d) Offers services through an organized delivery system in
which a primary care physician is designated for each subscriber
upon enrollment. The primary care physician is responsible for
coordinating the health care of the subscriber and is responsible
for referring the subscriber to other providers when necessary:
Provided, That when dental care is provided by the health
maintenance organization the dentist selected by the subscriber
from the list provided by the health maintenance organization shall
coordinate the covered dental care of the subscriber, as approved
by the primary care physician or the health maintenance
organization.
(12) "Impaired" means a financial situation in which, based
upon the financial information which would be required by this
chapter for the preparation of the health maintenance
organization's annual statement, the assets of the health
maintenance organization are less than the sum of all of its
liabilities and required reserves including any minimum capital and
surplus required of the health maintenance organization by this
chapter so as to maintain its authority to transact the kinds of business or insurance it is authorized to transact.
(13) "Individual practice arrangement" means any agreement or
arrangement to provide medical services on behalf of a health
maintenance organization among or between physicians or between a
health maintenance organization and individual physicians or groups
of physicians, where the physicians are not employees or partners
of the health maintenance organization and are not members of or
affiliated with a medical group.
(14) "Insolvent" or "insolvency" means a financial situation
in which, based upon the financial information that would be
required by this chapter for the preparation of the health
maintenance organization's annual statement, the assets of the
health maintenance organization are less than the sum of all of its
liabilities and required reserves.
(15) "Medical group" or "group practice" means a professional
corporation, partnership, association or other organization
composed solely of health professionals licensed to practice
medicine or osteopathy and of other licensed health professionals,
including podiatrists, dentists and optometrists, as are necessary
for the provision of health services for which the group is
responsible: (a) A majority of the members of which are licensed
to practice medicine or osteopathy; (b) who as their principal
professional activity engage in the coordinated practice of their
profession; (c) who pool their income for practice as members of
the group and distribute it among themselves according to a prearranged salary, drawing account or other plan; and (d) who
share medical and other records and substantial portions of major
equipment and professional, technical and administrative staff.
(16) "Premium" means a prepaid per capita or prepaid aggregate
fixed sum unrelated to the actual or potential utilization of
services of any particular person which is charged by the health
maintenance organization for health services provided to an
enrollee.
(17) "Primary care physician" means the general practitioner,
family practitioner, obstetrician/gynecologist, pediatrician or
specialist in general internal medicine who is chosen or designated
for each subscriber who will be responsible for coordinating the
health care of the subscriber, including necessary referrals to
other providers: Provided, That a certified nurse-midwife may be
chosen or designated in lieu of as a subscriber's primary care
physician during the subscriber's pregnancy and for a period
extending through the end of the month in which the sixty-day
period following termination of pregnancy ends: Provided, however,
That nothing in this subsection shall expand the scope of practice
for certified nurse-midwives as defined in article fifteen, chapter
thirty of this code.
(18) "Provider" means any physician, hospital or other person
or organization which is licensed or otherwise authorized in this
state to furnish health care services.
(19) "Uncovered expenses" means the cost of health care services that are covered by a health maintenance organization, for
which a subscriber would also be liable in the event of the
insolvency of the organization.
(20) "Service area" means the county or counties approved by
the commissioner within which the health maintenance organization
may provide or arrange for health care services to be available to
its subscribers.
(21) "Statutory surplus" means the minimum amount of
unencumbered surplus which a corporation must maintain pursuant to
the requirements of this article.
(22) "Surplus" means the amount by which a corporation's
assets exceeds its liabilities and required reserves based upon the
financial information which would be required by this chapter for
the preparation of the corporation's annual statement except that
assets pledged to secure debts not reflected on the books of the
health maintenance organization shall not be included in surplus.
(23) "Surplus notes" means debt which has been subordinated to
all claims of subscribers and general creditors of the
organization.
(24) "Qualified independent actuary" means an actuary who is
a member of the American academy of actuaries or the society of
actuaries and has experience in establishing rates for health
maintenance organizations and who has no financial or employment
interest in the health maintenance organization.
(25) "Quality assurance" means an ongoing program designed to objectively and systematically monitor and evaluate the quality and
appropriateness of the enrollee's care, pursue opportunities to
improve the enrollee's care and to resolve identified problems at
the prevailing professional standard of care.
(26) "Utilization management" means a system for the
evaluation of the necessity, appropriateness and efficiency of the
use of health care services, procedures and facilities.
NOTE: The purpose of this bill is to require insurance
coverage for the treatment of serious mental illness.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.