HB2960 H B&I AM 3-20
Delegate Hartman moves to amend the bill on page 2, line 7, by
striking everything after the enacting section and inserting in
lieu thereof the following:
ARTICLE 16H. REVIEW OF ADVERSE DETERMINATIONS.
_____As used in this article:
_____(1) "Adverse determination" means a decision by or on behalf
of an issuer to:
_____(A) Rescind coverage;
_____(B) Declare an individual not eligible to participate in the
health benefit plan; or
_____(C) Deny, reduce or terminate payment for a benefit, or fail
to make payment, in whole or in part, for a benefit, based on a
_____(i) The benefit is not covered; or
_____(ii) The benefit is experimental, investigational or does not
meet the issuer's requirements for medical necessity,
appropriateness, health care setting, level of care or
_____(2) "External review" means a review of an adverse
determination by an independent review organization.
_____(3) "Final adverse determination" means an adverse
determination that has been upheld by the issuer at the completion of the internal grievance procedures or an adverse determination
with respect to which the internal grievance procedures have been
_____(4) "Health plan issuer" or "issuer" means an entity required
to be licensed under this chapter that contracts, or offers to
contract to provide, deliver, arrange for, pay for, or reimburse
any of the costs of health care services under a health benefit
plan, including an accident and sickness insurance company, a
health maintenance corporation, a health care corporation, a health
or hospital service corporation, and a fraternal benefit society.
_____(5) "Health benefit plan" means a policy, contract,
certificate or agreement entered into, offered or issued by an
issuer to provide, deliver, arrange for, pay for, or reimburse any
of the costs of health care services, including short-term and
catastrophic health insurance policies and policies that pay on a
cost-incurred basis, but excludes the excepted benefits defined in
42 U.S.C. §300gg-01 and policies, contracts, certificates or
agreements excluded by rules promulgated pursuant to section four
of this article.
_____(6) "Independent review organization" means an entity approved
by the commissioner to conduct external reviews of final adverse
_____(7) "Utilization review" means a system for the evaluation of
the necessity, appropriateness and efficiency of the use of health care services, procedure and facilities.
_____(8) "Rescission" means a discontinuance of coverage under a
health benefit plan that has a retroactive effect or a
cancellation. The term does not include a cancellation or
discontinuation that is attributable to a failure to timely pay
required premiums or contributions towards the cost of coverage.
§33-16H-2. Issuer requirements.
_____An issuer shall, in accordance with rules promulgated pursuant
to section four of this article, develop processes for utilization
review and internal grievance procedures and shall make external
review available with respect to all adverse determinations.
§33-16H-3. Binding nature of an independent review organization
decision; judicial review; enforcement; rules.
_____(a) To the extent a decision rendered by an independent review
organization in accordance with the rules promulgated pursuant to
section four of this article is adverse to the issuer, it is
binding on the issuer, not subject to further review in any
judicial or administrative forum except for fraud on the part of an
individual, and may be enforced by the commissioner in the same
manner as a decision issued by the commissioner.
_____(b) An individual may seek judicial review of a final decision
rendered by an independent review organization by filing a
petition, at the election of the petitioner, in either the circuit
court of Kanawha County, or in the circuit court of the county in which the petitioner resides, within sixty days after he or she
receives notice of the decision.
_____(c) This article does not create any new cause of action or
eliminate any presently existing cause of action.
§33-16H-4. Rule-making authority; emergency rules; applicability.
_____(a) The commissioner shall promulgate emergency rules and, in
accordance with the provisions of article three, chapter
twenty-nine-a of this code, shall propose legislative rules for
approval by the Legislature, to implement the provisions of this
article, including, but not limited to, rules to:
_____(1) Define the scope of the applicability of this article;
_____(2) Establish requirements for all issuers with regard to
utilization review and for internal grievance procedures and
external review of adverse determinations, which rules shall be
based on the corresponding model acts adopted by the National
Association of Insurance Commissioners and, with respect to
external review, shall meet or exceed the minimum consumer
protections established by the federal Patient Protection and
Affordable Care Act (Public Law 111-148), as amended by the federal
Health Care and Education Reconciliation Act of 2010 (Public Law
_____(3) Provide for judicial review pursuant to subsection (b),
section three of this article, which rules shall be based on the
provisions of this code and rules governing judicial review of contested cases under the state administrative procedures act.
_____(b) Notwithstanding the provisions of section one, article
twenty-three of this chapter; section four, article twenty-four of
this chapter; section six, article twenty-five of this chapter; and
section twenty-four, article twenty-five-a of this chapter, this
article and the rules promulgated under this article are applicable
to all health benefits plans and supersede any provisions to the
contrary in this chapter or in any rules promulgated under this