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Introduced Version Senate Bill 490 History

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

Senate Bill No. 490

(By Senators Tucker, D. Hall, Green and Barnes)

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[Introduced February 5, 2014; referred to the Committee on Banking and Insurance; and then to the Committee on the Judiciary.]

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A BILL to amend the Code of West Virginia, 1931, as amended, by adding thereto a new section, designated §33-6-38, relating to defining certain key terms; prohibiting insurers from requiring optometrists, ophthalmologists, dentists, chiropractors, podiatrists or any other health care professional to provide discounts on noncovered services; prohibiting optometrists, ophthalmologists, dentists, chiropractors, podiatrists or any other health care professional from charging more for covered persons on noncovered services than his or her customary or usual rate for such services; requiring contractual discounts that do not result in a fee that is less than what an insurer would pay an optometrist, ophthalmologist, dentist, chiropractor, podiatrist or any other health care professional for covered services and materials; and providing that insurers may not provide for a nominal reimbursement for a service in order to claim that a service or material is covered.

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 section, designated §33-6-38, to read as follows:

ARTICLE 6. THE INSURANCE POLICY.

§33-6-38. Noncovered discounts.

    (a) For the purposes of this section:

    (1) “Covered services” means services and materials for which reimbursement from a vision plan, dental plan or health benefit policy is provided by an enrollee’s plan contract, or for which a reimbursement would be available but for the application of the enrollee’s contractual limitations of deductibles, copayments, and coinsurance.

    (2) “Contractual discount” means a percentage reduction from a provider’s usual and customary rate for covered services and materials required under a participating provider agreement.

    (3) “Health benefit policy” means any individual or group plan, policy or contract providing medical, hospital or surgical coverage issued, delivered, issued for delivery or renewed in this state by an insurer, after January 1, 2014.

    (4) “Materials” includes, but is not limited to, any material or device utilized within the scope of practice of a health care professional.

    (b) No agreement between an insurer or an entity that writes a health benefit policy, vision insurance or dental insurance and an optometrist, ophthalmologist, dentist, chiropractor, podiatrist or any other health care professional for the provision of any services on a preferred or in-network basis to plan members or insurance subscribers in connection with any health benefit policy may require that such professional provide services or materials at a fee limited or set by the plan or insurer unless the services or materials are reimbursed as covered services under the contract.

    (c) An optometrist, ophthalmologist, dentist, chiropractor, podiatrist or any other health care professional may not charge more for services and materials that are noncovered services under any health benefits policy than his or her usual and customary rate for those services and materials.

    (d) The amount of a contractual discount may not result in a fee less than the health benefits policy would pay for covered services and materials but for the application of an enrollee’s contractual limitations of deductibles, copayments, and coinsurance.

    (e) Reimbursement paid by the health benefit policy, vision plan or dental plan for covered services and materials shall be reasonable and may not provide nominal reimbursement in order to claim that services and materials are covered services.

    NOTE: The purpose of this bill is to provide that insurers may not contractually require optometrists, ophthalmologists, dentists, chiropractors, podiatrists or any other health care professional to provide a discount on services such insurers do not cover under the plan; to require health care professionals to charge no more to covered persons for noncovered services and materials than his or her customary rate, requiring that discounts will not result in a fee that is less than what an insurer would pay for covered services and prohibiting insurers from paying nominal reimbursements in order to claim that services or materials are covered services.


    This section is new; therefore, strike-throughs and underscoring have been omitted.

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