Senate Bill No. 47
(By Senator Hunter)
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[Introduced February 14, 2001; referred to the Committee on
Health and Human Resources; and then to the Committee on
Finance.]
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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 of said code 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 of said code 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:
(1) That health care delivery and financing systems are
rapidly changing;
(2) That competitive managed care models may not be the best
models 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 essential services would force residents in rural areas of West Virginia to travel long distances for certain
health care services, thereby placing the physical health and
safety of 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:
(1) "Agreement" means a rural health network care coordination
agreement as that term is defined in this section.
(2) "Essential community provider" means: (A) Sole community
provider hospitals as designated by the federal health care
financing authority; (B) 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;
(C) rural primary care hospitals as designated by the federal health care financing authority as critical access hospitals; (D)
primary care providers in federally designated medically
underserved or health-professional-shortage areas which are part of
a rural health network; (E) school health programs which are linked
to an existing provider; (F) public health departments; (G)
federally qualified health centers and rural health clinics; (H)
nonprofit primary care centers designated by the office of
community and rural health services; (I) county aging programs
operating personal care services; (J) home health agencies; (K)
hospice agencies; (L) emergency medical services agencies; and (M)
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.
(3) "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.
§16-1A-3. Essential community providers.
(a) Before the thirtieth day of June, two thousand three, 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.
(b) 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 prevents a health care insurer from
voluntarily approving any provider as a participating provider in any health benefit plan.
(c) 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 the
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.
(d) 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.
On or before the first day of January, two thousand two, 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 within forty-five minutes and access to
tertiary care within 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
health maintenance organization's network;
(4) Provide access to services seven days per week and
twenty-four hours per day; and
(5) Allow recognition of medicare certification for critical
access hospitals and other health agencies in lieu of joint
commission accreditation of health organizations.
NOTE: The purpose of this bill is to enhance and preserve
rural health care services and ensure adequate and prompt access to
care.
§16-1A and §33-25A-4a are new; therefore, strike-throughs and
underscoring have been omitted.