ENROLLED

H. B. 4847


(By Delegates Michael, Frederick, Proudfoot, H. K. White, Browning, Susman, Palumbo, Hall, Border, Ashley and G. White)


[Passed March 11, 2006; in effect ninety days from passage.]




AN ACT to amend the code of West Virginia, 1931, as amended, by adding thereto a new article designated §33-16F-1, §33-16F-2, §33-16F-3, §33-16F-4, §33-16F-5, §33-16F-6, §33-16F-7 and §33- 16F-8, all relating to group limited health benefits insurance plans; declaring legislative intent; requiring approval of plans by insurance commissioner; providing eligibility requirements for temporary, part time and seasonal employees under such plans; setting forth statutory or regulatory provisions that specifically do or do not apply to such plans; authorizing insurance commissioner to forbear from enforcing certain statutory and regulatory provisions; establishing criteria for filing and approval of premium rates; authorizing insurance commissioner to promulgate emergency rules; mandating disclaimer on policies; exempting plans from premium taxes; providing for severability; and providing rule of construction.

Be it enacted by the Legislature of West Virginia:
That the code of West Virginia, 1931, as amended, be amended by adding thereto a new article designated §33-16F-1, §33-16F-2, §33-16F-3, §33-16F-4, §33-16F-5, §33-16F-6, §33-16F-7 and §33-16F- 8, all to read as follows:
ARTICLE 16F. Group limited health benefits plans.
§33-16F-1. Declaration of legislative intent.
The Legislature recognizes that a significant number of West Virginia workers do not have health insurance coverage and that the lack of coverage is an issue of affordability. One of the ways affordable premiums can be obtained is by some combination of limiting benefits and increasing copays or deductibles. In order to provide greater access to such affordable plans to employees, the Legislature has determined that authorization of the sale of group policies with limited benefits that would include physician, inpatient and outpatient care, including preventive and primary care, will serve to bring insurance coverage to many of those working West Virginians and their families without any insurance coverage. It is, therefore, the intent of the Legislature to introduce flexibility in the design of group health insurance plans to allow insurers to offer basic benefits at affordable prices. This article may be known as the "Affordable Group Health Insurance Act."
§33-16F-2. Eligibility for coverage.
(a) As used in this article, "group plan" means any plan approved by the commissioner as a "group limited health benefits plan" in accordance with this article. Each such plan constitutes a health benefit plan "of a particular type" for the purposes of subsection (a), section three-l, article sixteen and subsection (d), section seven, article sixteen-d of this chapter.
(b) Notwithstanding any other provision of this code, including provisions mandating the inclusion of certain benefits in group health insurance plans, upon filing with and approval by the Commissioner as a "group limited health benefits plan," any insurer, including a health maintenance organization or health service corporation, may offer the plan and rates associated with the plan to employers, subject to the conditions of this article.
(c) The Commissioner shall only approve a proposed "group limited health benefits plan" that is limited to coverage of one or more of the following classes of employees: any class of employees that comprises part-time, temporary or seasonal employees that: (i) Are ineligible for coverage under any of the employer's group health benefits plans, or (ii) are employed by an employer that does not offer a group health benefits plan to any of its employees.
§33-16F-3. Applicability of other provisions.
(a) The following provisions of article sixteen of this chapter apply to group limited health benefits plans: Sections one-a, three, three-j, three-k, three-l, three-m, three-n, three-p, four, five, six, seven, nine, ten, eleven, thirteen, fourteen and fifteen; all other provisions of article sixteen do not apply to plans approved pursuant to this article unless and to the extent such provisions are specifically incorporated in rules promulgated by the Commissioner.
(b) With respect to any "group limited health benefits plan" offered to any "small employer," as that term is defined in section two, article sixteen-d of this chapter, the following provisions of article sixteen-d apply: Sections two, four, seven, eight, twelve and thirteen: Provided, That only the clause preceding the proviso in section thirteen, article sixteen-d of this chapter applies to group plans approved pursuant to this article. Notwithstanding any other provision of this code, all other provisions of article sixteen-d of this chapter do not apply to group plans approved pursuant to this article unless and to the extent such provisions are specifically incorporated in rules promulgated by the Commissioner.
(c) Notwithstanding any other provision of this code or of the code of state rules, the provisions of article sixteen-e of this chapter and of legislative rules regulating group accident and sickness policies, including the rule set forth in series 39, title 114 of the West Virginia Code of State Rules, do not apply to group plans approved pursuant to this article unless and to the extent specifically incorporated in rules promulgated by the Commissioner.
(d) The Commissioner may forbear from applying any other statutory or regulatory requirements to insurers offering a group plan approved pursuant to this article, including any requirements in article twenty-four and twenty-five-a, if the Commissioner determines that such forbearance furthers the legislative intent set forth in section one of this article.
(e) Nothing in this article may be construed to relieve an insurer or employer from complying with all applicable federal laws, including federal laws mandating the inclusion of benefits in an insurance plan.
§33-16F-4. Filing and approval of rates.
(a) Premium rate charges for any group plans shall:
(1) Be reasonable in relation to the benefits available under the policy; and
(2) Notwithstanding the provisions of section one, article sixteen-b of this chapter, be filed with the Commissioner for a waiting period of thirty days before the charges become effective. At the expiration of thirty days, the premium rate charges filed are deemed approved unless prior thereto the charges have been affirmatively approved or disapproved by the Commissioner.
(b) The Commissioner shall disapprove premium rates that are not in compliance with the requirements of any rule promulgated by the Commissioner. The Commissioner shall send written notice of the disapproval to the insurer. The Commissioner may approve the premium rates before the thirty-day period expires by giving written notice of approval.
(c) This section does not apply to group plans issued pursuant to this article upon which premiums are negotiated with the group policyholder and are experience rated.
§33-16F-5. Emergency rules authorized; factors to be considered in determining required benefits.

(a) The Commissioner shall promulgate emergency rules pursuant to the provisions of section fifteen, article three, chapter twenty-nine-a of this code on or before the first day of September, two thousand six, to prescribe requirements regarding ratemaking, which may include rules establishing loss ratio standards for group plans; to place further limitations on the eligibility of classes of employees or employees within a group; to determine benefits that must be included in such group plans, except that the Commissioner may not exclude from coverage any benefits mandated by federal law; and to provide for any other matters deemed necessary to further the intent of this article.
(b) In determining what medical treatments, procedures, and related health services benefits must be included in such plans, the Commissioner shall consider their effectiveness in improving the health status of individuals, their impact on maintaining and improving health and on reducing the unnecessary consumption of health care services, and their impact on the affordability of health care coverage.
§33-16F-6. Disclaimer.
Each group plan issued pursuant to this article shall include the following disclaimer printed in boldface type and located in a prominent portion of each policy, subscriber contract and certificate of coverage: "THIS LIMITED GROUP HEALTH BENEFITS PLAN DOES NOT PROVIDE COMPREHENSIVE MEDICAL COVERAGE. IT IS A BASIC OR LIMITED BENEFITS POLICY AND CONTAINS SPECIFIC DOLLAR LIMITS THAT WILL BE PAID FOR MEDICAL SERVICES WHICH MAY NOT BE EXCEEDED. IF THE COST OF SERVICES EXCEEDS THOSE LIMITS, THE BENEFICIARY AND NOT THE INSURER IS RESPONSIBLE FOR PAYMENT OF THE EXCESS AMOUNTS."
§33-16F-7. Exemption from premium taxes.
Products authorized under this article are exempt from the premium taxes and surcharges assessed under article three of this chapter.
§33-16F-8. Severability; controlling provisions.
(a) If any provision of this act or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the act and application of such provision to other persons or circumstances shall not be affected thereby.
(b) To the extent that provisions of this article differ from those contained elsewhere in this chapter, the provisions of this article control.