Senate Bill No. 22
(By Senator Hunter)
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[Introduced January 9, 2002; 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-c; 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-c; 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 1C. RURAL HEALTH INFRASTRUCTURE PRESERVATION AND
ENHANCEMENT ACT.
§16-1C-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.
§16-1C-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.
§16-1C-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 one, 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.
§16-1C and §33-25A-4a are new; therefore, strike-throughs
and underscoring have been omitted.