Senate Bill No. 665
(By Senator Prezioso)
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[Introduced February 20, 2010; referred to the Committee on
Health and Human Resources; and then to the Committee on
Finance.]
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A BILL to amend and reenact §33-15B-1, §33-15B-2, §33-15B-3,
§33-15B-4, §33-15B-5 and §33-15B-6 of the Code of West
Virginia, 1931, as amended, all relating to health care forms
and data; explaining legislative purposes; defining scope of
article; transferring certain duties regarding uniform forms
from the Health Care Authority to the Insurance Commissioner;
defining "health insurer"; authorizing the Insurance
Commissioner to develop an all-payer database; authorizing
Insurance Commissioner to propose emergency rules; mandating
collaboration between the Insurance Commissioner and Secretary
of Health and Human Resources to manage health care data;
prescribing penalties; and renaming the article.
Be it enacted by the Legislature of West Virginia:
That §33-15B-1, §33-15B-2, §33-15B-3, §33-15B-4, §33-15B-5 and
§33-15B-6 of the Code of West Virginia, 1931, as amended, be
amended and reenacted, all to read as follows:
ARTICLE 15B. HEALTH CARE UNIFORMITY AND TRANSPARENCY ACT.
§33-15B-1. Legislative findings; purpose.
The Legislature hereby finds that there is a need to provide
guidelines promote uniformity regarding uniform health care
administration in order to best serve consumers, health care
providers and insurers. and to organize and streamline the claims
process. The One purpose of this article is to require the
transfer of the authority of the insurance authorize the Insurance
Commissioner to develop standard forms and procedures regarding
health care claims and to require that all insurers, third party
providers payers and health care providers implement and use such
the standards in a uniform manner. to the West Virginia Health
Care Authority
The West Virginia Health Care Authority is responsible for
coordinating and overseeing the Legislature also finds that
consumers must have transparent health care price and quality
information in order to make economically sound and medically
appropriate decisions and, further, that the commissioner and the
Secretary of Health and Human Resources are the appropriate
agencies to oversee health data collection in West Virginia efforts and
coordinating to coordinate database development, analysis and
reporting to facilitate cost management, utilization review, and
quality assurance efforts by
state payors, and payers, regulatory
agencies, insurers, consumers, providers and other interested
parties.
The Legislature finds that the West Virginia Health Care
Authority is the appropriate agency to oversee the development of
standard forms and procedures regarding health care claims. Thus,
the Legislature hereby transfers the responsibilities to develop
standard forms and procedures regarding health care claims and all
other requirements and procedures under this article to the West
Virginia Health Care Authority. Therefore, the second purpose of
this article is to authorize the commissioner to develop an
all-payer database comprising claims and other health care data in
order to develop, in collaboration with the Secretary of Health and
Human Resources, a health care consumer guide.
§33-15B-2. Scope of article.
The provisions of this article apply to all health care
providers in the state; including but not limited to, all health
insurers writing or issuing accident and sickness policies,
including hospital service corporations, health service
corporations, medical service corporations, dental service
corporations and HMOs; all third party providers payers; all state
agencies and departments, including, but not limited to, the Public Employees Insurance Agency
workers' compensation insurance and
providers of services under Medicare and Medicaid;
and all entities
involved in the payment of health care claims.
§33-15B-3. Insurance commissioner to propose rules; use of
standardized forms and classifications; advisory
group.
(a) The
West Virginia Health Care Authority commissioner shall
promulgate legislative rules propose rules for legislative
approval, in accordance with the provisions of chapter
twenty-nine-a of this code, regarding the implementation and use of
uniform health care administrative forms.
Such The rules shall
establish, where practicable, the acceptance and use throughout the
health care system of standard administrative forms, terms or
procedures, including, but not limited to, the following:
(1) The standard
health care financing administration fifteen
hundred (HCFA 1500) CMS 1500 health insurance claim form, as
amended, or other similar forms, terms, and definitions to be used
which are consistent with health care and insurance industry
standards.
(2) International classification of disease, ninth clinical
modifications (ICD-9-CM) and common procedural terminology (CPT)
codes, as amended, or other similar forms, terms, and definitions
to be used which are consistent with health care and insurance industry standards.
(3) National uniform billing data element specifications
(UB-92) (UB-04), as amended, and as supplemented by the West
Virginia uniform billing committee, or other similar forms, terms,
and definitions to be used which are consistent with health care
and insurance industry standards.
(4) Consideration of current practices involving reimbursement
of claims and explanation of benefits, and the implementation of
standards and guidelines regarding explanation of benefits,
including, but not limited to, consideration of line item
explanations of payments or denial of payments.
(b) The legislative rules required herein shall be developed
by the West Virginia Health Care Authority with the advice of an
advisory group to be appointed by the
board of the West Virginia
Health Care Authority commissioner. Such advisory group shall
consist of representatives of consumers, providers, payors, and
regulatory agencies, including representatives from the following:
The
office of the Insurance Commissioner; the West Virginia Health
Care Authority; West Virginia Dental Association; West Virginia
Pharmacists Association; the West Virginia Hospital Association;
commercial health insurers; third party administrators; the West
Virginia State Medical Association; the West Virginia Nurses
Association; Public Employees Insurance Agency
workers' compensation commission; and consumers.
The West Virginia Health
Care Authority shall form such advisory group after the effective
date of this section.
(c) The
West Virginia Health Care Authority commissioner and
the advisory group shall review the legislative rules
effected to
be proposed pursuant to this section as necessary and update the
same in a timely manner in order to conform to current legislation
and health care and insurance industry standards and trends.
§33-15B-4. All-payer database; collaborative development of a
health care consumer guide; rules authorized.
(a) All health care providers, insurers, third party providers
and state agencies or departments shall have one year from the date
the West Virginia Health Care Authority establishes the legislative
rules required by this article to comply with the requirements of
the same.
(a) As used in this article, the term "health insurer" means:
(1) Any entity licensed to transact accident and sickness
insurance in this state, including health care corporations;
hospital, medical and dental corporations; HMOs; and, to the extent
permitted under federal law, administrators of insured, self-
insured, or publicly funded health care benefit plans offered by
public or private entities;
(2) Any third-party administrator, pharmacy benefit manager, entity conducting administrative services for business, or similar
entity with claims data, eligibility data, provider files and other
information relating to health care provided to West Virginia
residents and health care provided by West Virginia health care
providers and facilities;
(3) Any health benefit plan offered or administered by or on
behalf of the State of West Virginia or an agency or
instrumentality of the state; and
(4) Any health benefit plan offered or administered by or on
behalf of the federal government with the agreement of the federal
government.
(b) In order to permit the development of an all-payer
database, every health insurer shall provide health insurance
claims data to the commissioner or such other person designated by
the commissioner in accordance with standards and procedures set
forth in rules.
(c) The commissioner and the Secretary of the Department of
Health and Human Resources shall adopt a set of measures to
evaluate and compare health care quality and provider performance,
coordinate the collection of health care quality data in the state
by working with other entities that collect such data to minimize
duplication and to minimize the burden on providers of data, and
collaborate in the management and oversight of the analysis, distribution and use of such data.
(d) To the extent allowed by federal law and the rules
promulgated pursuant to this section, health care data shall be
available as a resource for insurers, employers, providers,
purchasers of health care, researchers, and state agencies to
continuously review health care utilization, expenditures, and
performance in this state. In presenting data for public access,
comparative considerations shall be made regarding geography,
demographics, general economic factors and institutional size. The
collection, storage and release of health care data and statistical
information that is subject to the federal requirements of the
Health Insurance Portability and Accountability Act shall be
governed exclusively by the rules adopted thereunder in 45 CFR
Parts 160 and 164.
(e) The commissioner may promulgate emergency rules and shall
propose rules for legislative approval in accordance with the
provisions of article three, chapter twenty-nine-a of this code, to
carry out the provisions of this section.
§33-15B-5. Penalties for violation.
Any
person, partnership, corporation, limited liability
company, professional corporation, health care provider or other
entity health insurer violating any provision of this article shall
be
guilty of a misdemeanor and, upon conviction shall be punished by subject to a fine
imposed by the commissioner of not more than
$1,000
for each violation. Each day of continuing violation after
conviction shall be considered a separate offense. The West
Virginia Health Care Authority is empowered to withhold rate
approval or a certificate of need for any health care provider
violating any provision of this article.
§33-15B-6. Citation of article.
This article may be known as the
"Uniform Health Care
Administration "Health Care Uniformity and Transparency Act."
NOTE: The purpose of this bill is to transfer from the Health
Care Authority to the Insurance Commissioner certain duties
regarding the creation of uniform health care forms and to
authorize the Insurance Commissioner to develop an all-payer
database and to collaborate with the health and human resources
secretary in managing and analyzing health care data.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.