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Introduced Version House Bill 3022 History

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Key: Green = existing Code. Red = new code to be enacted
H. B. 3022


(By Delegates Hatfield, Guthrie, Perdue, Brown,

Hunt, Skaff, Spencer, Wells, Campbell and Canterbury)

[Introduced March 10, 2009; referred to the

Committee on Health and Human Resources then Finance.]




A BILL to amend the Code of West Virginia, 1931, as amended, by adding thereto a new article, designated §16-2L-1, §16-2L-2, §16-2L-3, §16-2L-4, §16-2L-5, §16-2L-6 and §16-2L-7, all relating to the creation of a medical home health care plan for uninsured adults providing primary and preventive care; the plan's cost would not exceed $40 per month per subscriber, medical home participating providers would be paid a capitation payment per member per month; funding to be provided by the State of West Virginia, the uninsured adult and his or her employer; providing the Director of the Public Employees Insurance Agency with the authority to develop the plan and to promulgate regulations, policies and procedures; providing for requirements for participating health care providers; and providing the Public Employees Insurance Agency with the authority to suspend, revoke or nonrenew participating providers' participation agreements.

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 §16-2L-1, §16-2L-2, §16-2L-3, §16-2L-4, §16-2L-5, §16-2L-6 and §16-2L-7, all to read as follows:

ARTICLE 2L. UNINSURED MEDICAL HOME PLAN.

§16-2L-1. Legislative findings and statement of purpose.

(a) The Legislature finds that the high number of West Virginia uninsured workers causes unnecessary morbidity and mortality, increases the cost of health insurance for employers offering health insurance and contributes to high utilization of emergency rooms. The Legislature also finds that the medical home concept is an effective delivery system for preventive care and a plan that would allow health clinics and private medical practitioners to provide medical home services including primary care and preventive health services for a monthly would improve the well-being and health status of West Virginia's uninsured adults.

(b) In carrying out this plan, it is the intent of the Legislature to eliminate legal, statutory and regulatory barriers to the establishment of a plan providing preventive and primary care services for a prepaid monthly fee, not to exceed $40 for the first two years, and modest per visit subscriber copayment; to encourage uninsured adult residents of this state to establish and use a medical home; to expand preventive and primary care services
for the adult uninsured; and to exempt the Uninsured Medical Home Plan from regulation as an insurer, the operation of insurance laws of the state and all other laws inconsistent with the purposes of this article.
§16-2L-2. Definitions.

For the purposes of this article, the following definitions apply:

(1) "Medical home" means a team approach to providing health care and care management. Care Management includes the adoption of clinical measures and standards, the development of a plan of care, the monitoring of clinical outcomes desired, facilitation and navigation of the health care system, provision of follow-up and support for achieving the clinical standards and. The medical home maintains a centralized, comprehensive record of all health related services to promote continuity and coordination of care;

(2) "Participating provider" means a provider under this article that has been granted approval to participate as a medical home for the Medical Home Plan;

(3) "Primary care" means basic or general health care which emphasizes access to assure timely intervention with acute problems, continuity of care for chronic conditions and monitoring to recall to promote appropriate preventive health services.

(4) "Provider" has the same meaning as "ambulatory health care facility" set forth in subsection (b), section two, article two-d
of this chapter or "private office practice" as set forth in subsection (a)(1), section four of that article;
(5) "Subscriber" means any adult individual who subscribes to the prepaid plan approved and operated in accordance with the provisions of this article, including an employee of any employer

that has purchased a group enrollment on behalf of its employees.

(6) "Plan Advisory Group" means a group of ten individuals who advise the Director of the Public Employees Insurance Agency (PEIA) on regulations and significant policy and procedures related to the implementation of the Uninsured Medical Home Plan. The members of the group shall serve two year terms and shall be selected by the Governor. The group's membership shall consist of two representatives from each of the following groups: employers participating in the plan; employees who are members of the plan; state consumer health advocacy groups; members of the House of Delegates or Senate Health Committees; and participating medical homes.

§16-2L-3. Authorization of Uninsured Medical Home Plan; Health
Care Authority considerations in selection of participating providers; funding.
(a) The PEIA shall develop and implement, by July 1, 2010, a plan that entitles subscribers to obtain medical home services from participating providers. The medical home shall include primary care services for acute and chronic diseases and minor injuries, preventive health services, care management services, office laboratory, twenty-four hour telephone access to a health care professional and assistance in obtaining free or discounted prescription medicines through the West Virginia Rx program, patient assistance programs offered by pharmaceutical companies or Section 340(b) pharmaceutical programs offered by certain community health centers and hospitals. Services may also include, if provided by the medical home, directly or by contract, or if provided by contract with PEIA, outpatient reference laboratory, plain film radiology, primary behavioral health services and limited prescriptions not otherwise available.
(b) Subject to the provisions of this article, the PEIA, with the advice of the Medical Home Advisory Group, is vested with authority to carry out the following functions, either directly or by contract, to implement the Uninsured Medical Home Plan: develop service and reporting requirements for participating medical homes and enter into contracts with primary care providers to provide medical home services; develop medical home capitation rates and copayment rates, including possible variations in rate levels based on the range of services provided through the medical homes; establish and revise quality performance measures, processes for collecting data on quality measures and utilization and reporting on quality measures and utilization; recruit medical home providers; market the Uninsured Medical Home Plan to employers and employees; manage member enrollment and disenrollment and the billing and collection of premiums. A portion of the medical home plan's monthly fee may be funded by the state and the remainder shall be divided between an employer and the employee
: Provided, That an unemployed adult may participate in the plan by paying one hundred percent of the fee after the state's share.
(c) The state's contribution to the cost of the Uninsured Medical Home Plan, including the cost of the administration of such a plan, may be obtained by the allocation of federal funds for preventive health care or other appropriate Federal funds or may be obtained by funds allocated from receipts from state taxes on tobacco products.
(d) In furtherance of the objectives of this article, the PEIA is authorized to accept any and all gifts, grants and matching funds whether in the form of money or services.
§16-2L-4. Director of the Public Employees Insurance Agency approval of fees, statement of services.
(a) Every subscriber is entitled to evidence of plan membership that shall contain a clear, concise and complete statement of the services provided by the participating provider and the benefits, if any, to which the subscriber is entitled; any exclusions or limitations on the service, kind of service, benefits, or kind of benefits, to be provided; and where and in what manner information is available as to how a service may be obtained.
(b) Fees paid to participating providers are not subject to premium taxes and surcharges imposed on insurance companies.
(c) Notwithstanding the provisions of chapter thirty-three of this code to the contrary, the Uninsured Medical Home Plan and participating providers in the medical home plan created and authorized pursuant to this article are not to be considered as providing insurance or as offering insurance services. The Uninsured Medical Home Plan and such medical home participating providers are specifically excluded from the definitions of "insurer" and "insurance" as defined in article one, chapter thirty-three of this code, and are not subject to regulation by the Insurance Commissioner except to the extent set forth in this article, nor are participating providers unauthorized insurers pursuant to section four, article forty-four of chapter thirty- three of this code.
§16-2L-5. Rule-making authority.
The Director of the PEIA, with advice from the Medical Home Advisory Group, shall promulgate joint rules as necessary to implement the provisions of this article, including emergency rules, promulgated pursuant to, chapter twenty-nine-a of this code.
§16-2L-6. Participating provider plan requirements; primary care services; notice of discontinuance or reduction of benefits.
In addition to the provisions of this article and any guidelines established by the Health Care Authority and Director of the PEIA, the plan offered pursuant to this article is subject to the following:
(1) Each participating provider and site must offer a minimum set of preventive and primary care services as established by the PEIA.
(2) No participating provider may offer: (i) An individual plan to any individual who currently has a health benefit plan; or (ii) an employee group plan to any employer that currently has a group health benefit plan.
(3) The Director of PEIA may, by legislative rule, permit participation by an employer with a comprehensive high deductible plan if such employer is able to demonstrate that such participation will not negatively impact the coverage currently offered by such employer.
(4) A participating provider must provide subscribers and, where applicable, subscribers' employers with a minimum of thirty days' notice of discontinuance or reduction of subscriber benefits.
§16-2L-7. Guidelines for evaluation of the plan; report to Legislative Oversight Commission on Health and Human Resources Accountability.
(a) The PEIA shall establish by guidelines criteria to evaluate the medical home plan and may require participating providers to submit such data and other information related to the plan.
(b) No later than December 1, 2010, and annually thereafter during the operation of the plan, the Health Care Authority must submit a report to the Legislative Oversight Commission of Health and Human Resources Accountability as established in article twenty-nine-e of this chapter on progress made by the medical home project including suggested changes to the plan and suggested expansion of the plan.



NOTE: The purpose of this bill is to create a health care plan for uninsured adults that provides medical home services including primary care and preventive care. The bill sets the plan's cost to not exceed $40 per month per subscriber for the first two years, plus a modest copayment by a subscriber for each visit to a participating provider. The bill provides that the plan is to be marketed through employers and the cost of the plan will be shared among participating employers and employees and the State of West Virginia. The bill requires participating providers to be health clinics or private practices who meet the program's requirements including the adoption of quality measures and standards. The bill also provides that participating providers are to be paid a monthly capitation for a predetermined range of services. The bill additionally provides that the Director of the Public Employees Insurance Agency with the authority to develop and implement the plan.
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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