H. B. 4340

(By Delegate Pino)

[Introduced January 31, 2002 ; 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 article six, chapter thirty-three of said code by adding thereto a new section, designated section thirty-seven; to amend article fifteen of said chapter by adding thereto a new section, designated section four-g; to amend article sixteen of said chapter by adding thereto a new section, designated section three-p; to amend article twenty-four of said chapter by adding thereto a new section, designated section seven-g; to amend article twenty-five of said chapter by adding thereto a new section, designated section eight-f; and to amend article twenty-five-a of said chapter by adding thereto a new section, designated section eight-f, all relating to health insurance; foods and food products for inherited metabolic diseases; and requiring insurance coverage of medically necessary low protein foods and medical foods (formulas) for treatment of inherited metabolic diseases as prescribed by a physician.

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 article six, chapter thirty-three of said code be amended by adding thereto a new section, designated section thirty-seven; that article fifteen of said chapter be amended by adding thereto a new section, designated section four-g; that article sixteen of said chapter be amended by adding thereto a new section, designated section three-p; that article twenty-four of said chapter be amended by adding thereto a new section, designated section seven-g; that article twenty-five of said chapter be amended by adding thereto a new section, designated section eight-f; and that article twenty-five-a of said chapter be amended by adding thereto a new section, designated section eight-f, 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) Medically necessary food products as a part of a dietary treatment of an inherited metabolic disease.
(3) (4) 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) (5) 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) (4) 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.
(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.
ARTICLE 6. THE INSURANCE POLICY.

§33-6-37. Foods and food products for inherited metabolic diseases; and requiring insurance coverage of low protein foods and medical foods (formulas) for treatment of inherited metabolic diseases to be covered by all health insurance policies.

(a) All individual and group health insurance policies, including hospital or major medical insurance policies, group or blanket health insurance policies, health maintenance organizations, nonprofit health service plans, hospital or major medical insurance policies, nonprofit health service plans

(b)

For the purpose of requiring certain health insurance policies as set forth is subsection (a) of this section to include coverage for certain foods and food products for the treatment of certain inherited metabolic diseases under certain circumstances in this section the following words have the meanings indicated:
(1) "Inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry and includes a disease for which the state screens newborn babies;
(2) "Low protein modified food product" means a food product that is: (i) Specially formulated to have less than one gram of protein per serving; and (ii) intended to be used under the direction of a physician for dietary treatment of an inherited metabolic disease; it does not include a natural food that is naturally low in protein;
(3) "Medical food" means that a food is: (i) Intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation; and (ii) formulated to be consumed or administered internally under the direction of a physician.
(c) The requirements of this section apply to all insurance polices and subscriber contracts now existing or hereafter delivered or issued for delivery in this state.

§33-15-4g. Third party reimbursement for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease.

(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement applicable to this article, reimbursement or indemnification for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease

may not be denied.
(b) The same deductibles, coinsurance, network restrictions and other limitations for covered services found in the policy, provision, contract, plan or agreement of the covered person may apply to

medically necessary food products as a part of a dietary treatment of an inherited metabolic disease.

ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.

§33-16-3p. Third party reimbursement for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease.

Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, whenever reimbursement or indemnity for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease covered, reimbursement or indemnification may not be denied for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease. A policy, provision, contract, plan or agreement may apply to medically necessary food products as a part of a dietary treatment of an inherited metabolic disease the same deductibles, coinsurance and other limitations as apply to other covered services.
ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH SERVICE CORPORATIONS.

§33-24-7g. Third party reimbursement for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease.

Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, whenever reimbursement or indemnity for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease are covered, reimbursement or indemnification may not be denied for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease for any nonsymptomatic person covered under the policy or contract. A policy, provision, contract, plan or agreement may apply to medically necessary food products as a part of a dietary treatment of an inherited metabolic disease the same deductibles, coinsurance and other limitations as apply to other covered services.

ARTICLE 25. HEALTH CARE CORPORATIONS.

§33-25-8f. Third party reimbursement for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease.

Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, whenever reimbursement or indemnity for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease are covered, reimbursement or indemnification may not be denied for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease. A policy, provision, contract, plan or agreement may apply to medically necessary food products as a part of a dietary treatment of an inherited metabolic disease the same deductibles, coinsurance and other limitations as apply to other covered services.

ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.

§33-25A-8f. Third party reimbursement for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease.

Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, whenever reimbursement or indemnity for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease are covered, reimbursement or indemnification may not be denied for medically necessary food products as a part of a dietary treatment of an inherited metabolic disease. A policy, provision, contract, plan or agreement may apply to medically necessary food products as a part of a dietary treatment of an inherited metabolic disease the same deductibles, coinsurance and other limitations as apply to other covered services.


NOTE: The purpose of this bill is to require insurance companies that provide health care coverage to provide for dietary treatment of medically necessary low protein foods and medical foods (formulas) for treatment of inherited metabolic diseases when prescribed by a physician.

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

§§33-6-37, 33-15-4g, 33-16-3p, 33-24-7g, 33-25-8f and 33-25A-8f are new; therefore, strike-throughs and underscoring have been omitted.