H. B. 2578
(By Delegates Kominar, Craig, Hrutkay, Mahan, Palumbo,
Webster, White, Armstead and Ellem)
[Introduced January 26, 2007; referred to the
Committee on Banking and Insurance then the Judiciary.]
A BILL to amend and reenact §33-16-3a of the Code of West Virginia,
1931, as amended, relating to extending mental health benefit
packages; removing the sunset provision for mandated insurance
parity; and removing insurance commissioner reporting
requirement.
Be it enacted by the legislature of West Virginia:
That §33-16-3a of the Code of West Virginia,1931, as amended,
be amended and reenacted to read as follows:
CHAPTER 33. INSURANCE.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-3a. Same -- Mental health.
(a)(1) Notwithstanding the requirements of subsection (b) of
this section, any health benefits plan described in this article
that is delivered, issued or renewed in this state shall provide
benefits to all individual subscribers and members and to all group members for expenses arising from treatment of serious mental
illness. The expenses do not include custodial care, residential
care or schooling. For purposes of this section, "serious mental
illness" means an illness included in the American psychiatric
association's diagnostic and statistical manual of mental
disorders, as periodically revised, under the diagnostic categories
or subclassifications of: (i) Schizophrenia and other psychotic
disorders; (ii) bipolar disorders; (iii) depressive disorders; (iv)
substance-related disorders with the exception of caffeine-related
disorders and nicotine-related disorders; (v) anxiety disorders;
and (vi) anorexia and bulimia.
(2) Notwithstanding any other provision in this section to the
contrary, in the event that an insurer can demonstrate actuarially
to the insurance commissioner that its total anticipated costs for
treatment for mental illness, for any plan will exceed or have
exceeded two percent of the total costs for such plan in any
experience period, then the insurer may apply whatever cost
containment measurers may be necessary, including, but not limited
to, limitations on inpatient and outpatient benefits, to maintain
costs below two percent of the total costs for the plan:
Provided,
That for any group with twenty-five members or less, the insurer
may apply such additional cost containment measures as may be
necessary if the total anticipated actual costs for the treatment
of mental illness will exceed one percent of the total costs for
the group.
(3) The insurer shall not discriminate between medical-
surgical benefits and mental health benefits in the administration
of its plan. With regard to both medical-surgical and mental
health benefits, it may make determinations of medical necessity
and appropriateness, and it may use recognized health care quality
and cost management tools, including, but not limited to,
utilization review, use of provider networks, implementation of
cost containment measures, preauthorization for certain treatments,
setting coverage levels including the number of visits in a given
time period, using capitated benefit arrangements, using fee-for-
service arrangements, using third-party administrators, and using
patient cost sharing in the form of copayments, deductibles and
coinsurance.
(4) The provisions of this subsection shall apply with respect
to group health plans for plan years beginning on or after the
first day of January, two thousand three.
The provisions of this
section shall cease to be effective on and after the thirty-first
day of March, two thousand seven, unless further extended by the
Legislature.
(5) The commissioner on or before the thirty-first day of
December, two thousand five, and annually thereafter, shall report
to the Legislature's joint committee on government and finance and
the committees on insurance of the respective houses of the
Legislature regarding the fiscal impact of this subsection on the
expenses of insurers affected thereby, and which insurers expenses of providing mental health benefits have exceeded the percentage
limits established by this subsection.
(b) With respect to mental health benefits furnished to an
enrollee of a health benefit plan offered in connection with a
group health plan, for a plan year beginning on or after the first
day of January, one thousand nine hundred ninety-eight, the
following requirements shall apply to aggregate lifetime limits and
annual limits.
(1) Aggregate lifetime limits:
(A) If the health benefit plan does not include an aggregate
lifetime limit on substantially all medical and surgical benefits,
as defined under the terms of the plan but not including mental
health benefits, the plan may not impose any aggregate lifetime
limit on mental health benefits;
(B) If the health benefit plan limits the total amount that
may be paid with respect to an individual or other coverage unit
for substantially all medical and surgical benefits (in this
paragraph, "applicable lifetime limit"), the plan shall either
apply the applicable lifetime limit to medical and surgical
benefits to which it would otherwise apply and to mental health
benefits, as defined under the terms of the plan, and not
distinguish in the application of the limit between medical and
surgical benefits and mental health benefits, or not include any
aggregate lifetime limit on mental health benefits that is less
than the applicable lifetime limit;
(C) If a health benefit plan not previously described in this
subdivision includes no or different aggregate lifetime limits on
different categories of medical and surgical benefits, the
commissioner shall propose rules for legislative approval in
accordance with the provisions of article three, chapter
twenty-nine-a of this code under which paragraph (B) of this
subdivision shall apply, substituting an average aggregate lifetime
limit for the applicable lifetime limit.
(2) Annual limits:
(A) If a health benefit plan does not include an annual limit
on substantially all medical and surgical benefits, as defined
under the terms of the plan but not including mental health
benefits, the plan may not impose any annual limit on mental health
benefits, as defined under the terms of the plan;
(B) If the health benefit plan limits the total amount that
may be paid in a twelve-month period with respect to an individual
or other coverage unit for substantially all medical and surgical
benefits (in this paragraph, "applicable annual limit"), the plan
shall either apply the applicable annual limit to medical and
surgical benefits to which it would otherwise apply and to mental
health benefits, as defined under the terms of the plan, and not
distinguish in the application of the limit between medical and
surgical benefits and mental health benefits, or not include any
annual limit on mental health benefits that is less than the
applicable annual limit;
(C) If a health benefit plan not previously described in this
subdivision includes no or different annual limits on different
categories of medical and surgical benefits, the commissioner shall
propose rules for legislative approval in accordance with the
provisions of article three, chapter twenty-nine-a of this code
under which paragraph (B) of this subdivision shall apply,
substituting an average annual limit for the applicable annual
limit.
(3) If a group health plan or a health insurer offers a
participant or beneficiary two or more benefit package options,
this subsection shall apply separately with respect to coverage
under each option.
This bill was recommended for passage by Select Committee or
Insurance Availability and Medical Insurance.
Note: The purpose of the bill is to continue current mental
health parity laws for group insurance plans.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.
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