Senate Bill No.186

(By Senators Rowe, Mitchell and Burnette)

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[Introduced January 11, 2002; referred to the Committee

on Banking and Insurance; and then to the Committee on Finance.]

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A BILL to amend and reenact section eight, article sixteen, chapter five of the code of West Virginia, one thousand nine hundred thirty-one, as amended; and to amend article five, chapter nine of said code by adding thereto a new section, designated section twenty, all relating to requiring a copayment be made to medical providers by adult recipients of medicaid and persons covered under the public employees insurance act who have used tobacco products within the previous six months prior to receiving the subject medical attention.

Be it enacted by the Legislature of West Virginia:
That section eight, article sixteen, chapter five of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended and reenacted; and that article five, chapter nine of said code be amended by adding thereto a new section, designated section twenty, 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.
§5-16-8. Conditions of insurance program.
The insurance plans provided for in this article shall be designed by the public employees insurance agency:
(1) To provide a reasonable relationship between the hospital, surgical, medical and prescription drug benefits to be included and the expected reasonable and customary hospital, surgical, medical and prescription drug expenses as established by the director to be incurred by the affected employee, his or her spouse and his or her dependents. The establishment of reasonable and customary expenses by the public employees insurance agency pursuant to the preceding sentence is not subject to the state administrative procedures act in chapter twenty-nine-a of this code;
(2) To include reasonable controls which may include deductible and coinsurance provisions applicable to some or all of the benefits, and shall include includes other provisions, including, but not limited to, copayments, preadmission certification, case management programs and preferred provider arrangements;
(3) To prevent unnecessary utilization of the various hospital, surgical, medical and prescription drug services available;
(4) To provide reasonable assurance of stability in future years for the plans;
(5) To provide major medical insurance for the employees covered under this article;
(6) To provide certain group life and accidental death insurance for the employees covered under this article;
(7) To include provisions for the coordination of benefits payable by the terms of the plans with the benefits to which the employee, or his or her spouse or his or her dependents may be entitled by the provisions of any other group hospital, surgical, medical, major medical or prescription drug insurance or any combination thereof;
(8) To provide a cash incentive plan for employees, spouses and dependents to increase utilization of, and to encourage the use of, lower cost alternative health care facilities, health care providers and generic drugs. The plan shall be reviewed annually by the director and the advisory board;
(9) To provide "wellness" programs and activities which will include, but not be limited to, benefit plan incentives to discourage tobacco, alcohol and chemical abuse and an educational program to encourage proper diet and exercise: Provided, That on or before the first day of January, two thousand three, as a condition of coverage, an adult insured shall be required by a participating medical provider to sign a statement, whether or not they have used tobacco products within the previous six months before the date of treatment requested: Provided, however, That if the insured does not provide the statement or states that he or she has used a tobacco product within the previous six months, the insured shall be charged a copayment of ten dollars to be paid to the medical provider. The director of the public employees insurance agency shall prescribe and disseminate a form to all participating medical providers upon which an insured may verify his or her nonuse of tobacco products in accordance with this requirement. In establishing "wellness" programs, the division of vocational rehabilitation shall cooperate with the public employees insurance agency in establishing statewide wellness programs. The director of the public employees insurance agency shall contract with county boards of education for the use of facilities, equipment or any service related to that purpose. Boards of education may charge only the cost of janitorial service and increased utilities for the use of the gymnasium and related equipment. The cost of the exercise program shall be paid by county boards of education, the public employees insurance agency, or participating employees, their spouses or dependents. All exercise programs shall be made available to all employees, their spouses or dependents and shall may not be limited to employees of county boards of education;
(10) To provide a program, to be administered by the director, for a patient audit plan with reimbursement up to a maximum of one thousand dollars annually, to employees for discovery of health care provider or hospital overcharges when the affected employee brings the overcharge to the attention of the plan. The hospital or health care provider shall certify to the director that it has provided, prior to or simultaneously with the submission of the statement of charges for payments, an itemized statement of the charges to the employee participant for which payment is requested of the plan;
(11) To require that all employers give written notice to each covered employee prior to institution of any changes in benefits to employees, and to include appropriate penalty for any employer not providing the required information to any employee; and
(12)(a) To provide coverage for emergency services under offered plans. For the purposes of this subsection, "emergency services" means services provided in or by a hospital emergency facility, an ambulance providing related services under the provisions of article four-c, chapter sixteen of this code or the private office of a dentist to evaluate and treat a medical condition manifesting itself by the sudden, and at the time, unexpected onset of symptoms that require immediate medical attention and for which failure to provide medical attention would result in serious impairment to bodily function, serious dysfunction to any bodily organ or part, or would place the person's health in jeopardy.
(b) From the first day of July, one thousand nine hundred ninety-eight, plans shall provide coverage for emergency services, including any prehospital services, to the extent necessary to screen and stabilize the covered person. The plans shall reimburse, less any applicable copayments, deductibles, or coinsurance, for emergency services rendered and related to the condition for which the covered person presented. Prior authorization of coverage shall may not be required for the screening services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. Prior authorization of coverage shall may not be required for stabilization if an emergency medical condition exists. In the event that prior authorization was obtained, the authorization may not be retracted after the services have been provided except when the authorization was based on a material misrepresentation about the medical condition by the provider of the services or the insured person. The provider of the emergency services and the plan representative shall make a good faith effort to communicate with each other in a timely fashion to expedite postevaluation or poststabilization services. Payment of claims for emergency services shall be is based on the retrospective review of the presenting history and symptoms of the covered person.
(c) For purposes of this subdivision:
(A) "Emergency services" means those services required to screen for or treat an emergency medical condition until the condition is stabilized, including prehospital care;
(B) "Prudent layperson" means a person who is without medical training and who draws on his or her practical experience when making a decision regarding whether an emergency medical condition exists for which emergency treatment should be sought;
(C) "Emergency medical condition for the prudent layperson" means one that manifests itself by acute symptoms of sufficient severity, including severe pain, such that the person could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the individual's health, or, with respect to a pregnant woman, the health of the unborn child; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical condition, to provide medical treatment of the condition necessary to assure, with reasonable medical probability that no medical deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility: Provided, That this provision may not be construed to prohibit, limit or otherwise delay the transportation required for a higher level of care than that possible at the treating facility;
(E) "Medical screening examination" means an appropriate examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists; and
(F) "Emergency medical condition" means a condition that manifests itself by acute symptoms of sufficient severity including severe pain such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual's health or with respect to a pregnant woman the health of the unborn child, serious impairment to bodily functions or serious dysfunction of any bodily part or organ.
CHAPTER 9. HUMAN SERVICES.

ARTICLE 5. MISCELLANEOUS PROVISIONS.

§9-5-20. Copayment requirement for tobacco users.

The secretary of the department of health and human resources shall require adult recipients of medical assistance under the medicaid program to sign a written statement which shall be provided to them by participating medical providers for care to be billed as part of the medicaid program, whether or not they have used tobacco products within the previous six months before the date of the treatment requested. If a recipient does not provide the statement or states that he or she has used a tobacco product within the previous six months, the recipient shall be charged a copayment to be paid to the medical provider in an amount to be determined by the secretary of the department of health and human resources, as allowed by federal law but not to exceed ten dollars to any one provider in any seven-day period for any recipient. The secretary of the department of health and human resources shall prescribe and disseminate a form to all participating medical providers upon which an insured may verify his or her nonuse of tobacco products in accordance with the requirement of this section.



NOTE: The purpose of this bill is to require a copayment to be made to medical providers by recipients of medicaid and persons covered under the public employees insurance act who have used tobacco products within the previous six months prior to receiving the subject medical attention.

Strike-throughs indicate language that would be stricken from the present law, and underscoring indicates new language that would be added.

§9-5-20 is new; therefore, strike-throughs and underscoring have been omitted.