HB4079 H B&I AM 1-22

Archibald 3192

    The Committee on Banking and Insurance moves to amend the bill on page 2, section 1, line 4, after the word “authorized” by striking out the period and inserting in lieu thereof a comma, and the words “with the following amendments:

    On page 1, subsection 1.1, after the word “determinations” by adding a comma;

    On page 1, subsection 2.1, after the word “other” by striking out the word “healthcare” and inserting in lieu thereof the words “health care”;

    On page 2, subsection 2.6, after the word “specialty” by striking out the word “as” and inserting in lieu thereof the word “that”;

    On page 3, subsection 2.15, after the words “including but” by striking out the word “no” and inserting in lieu thereof the word “not”;

    On page 3, subsection 2.16, after the words “cost-incurred basis,” by striking out the words “except as otherwise specifically exempted in this definition” and inserting in lieu thereof the words “but excluding the excepted benefits defined in 42 U.S.C. § 300gg-91 and as otherwise specifically excepted in this rule”;

    On page 5, subsection 2.17, after the words “consistent with” by striking out the word “state” and inserting in lieu thereof the words “West Virginia”;

    On page 5, subsection 2.24, after the word “means” by striking out “in” and inserting in lieu thereof the word “an”;

    On page 6, subsection 2.28, after the words “other than” by striking out “that” and inserting in lieu thereof the words “the one”;

    On page 6, subdivision 2.30.a, after the word “jeopardize” by striking out the words “the covered person’s life, health or ability to regain maximum function or in the opinion of an attending health care professional with knowledge of the covered person’s medical condition, would subject the covered person to severe pain that cannot be adequately managed without the health care service or treatment that is the subject of the request.” and inserting in lieu thereof the words “the life or health of the covered person or the ability of the covered person to regain maximum function; or”;

    On page 6, preceding subdivision 2.30.b, by inserting a new subdivision “2.30.b.     In the opinion of an attending health care professional with knowledge of the covered person’s medical condition, would subject the covered person to severe pain that cannot be adequately managed without the health care service or treatment that is the subject of the request.”;

    On page 6, by renumbering subdivision 2.30.b as “2.30.c” and after the words “Except as provided in paragraph” by striking out the reference “2.30.a" and inserting in lieu thereof the reference “2.30.d";

    On page 7, by renumbering subdivision 2.30.c as “2.30.d”;

    On page 8, subsection 6.1, after the words “upon request by” by striking out the words “an entity” and inserting in lieu thereof the words “a person” and by inserting after the word “Commissioner” the words “or by statute or legislative rule”;

    On page 9, after subdivision 6.3.a.4, by inserting a new subdivision “6.3.a.5.    For purposes of calculating the time period for refiling the benefit request or claim, the time period shall begin to run upon the covered person’s receipt of the notice of opportunity to resubmit.”;

    On page 10, subdivision 7.1.b. after the words “within which” by striking the words “a determination is required to be made under subsections 7.2 and 7.4" and inserting in lieu thereof the words “prospective and retrospective review determinations are required to be made”;

    On page 11, paragraph 7.1.e.1, after the word “number” by inserting the word “of”;

    On page 12, subdivision 7.2.b by striking out the words “health carrier” and inserting in lieu thereof the word “issuer”;

    On page 14, subdivision 7.3.c, after the words “subdivision 7.3.a” by striking out the word “, and”;

    On page 15, subdivision 8.1.a. by striking out the words “health carrier” and inserting in lieu thereof the word “issuer”;

    On page 15, before paragraph 8.1.b.1, insert a new paragraph “8.1.b.1. If the covered person has failed to provide sufficient information for the issuer to determine whether, or to what extent, the benefits requested are covered benefits or payable under the issuer’s health benefit plan, the issuer shall notify the covered person as soon as possible, but in no event later than twenty-four (24) hours after receipt of the request, either orally or, if requested by the covered person, in writing of this failure and state what specific information is needed. The issuer shall provide the covered person a reasonable period of time to submit the necessary information, taking into account the circumstances, but in no event less than forty-eight (48) hours after notifying the covered person or the covered person's authorized representative of the failure to submit sufficient information.” and renumber the following paragraphs accordingly.

    On page 17, subparagraph 8.2.a.9.A, after the word “paragraph” by striking out the reference “8.2.a.8" and inserting in lieu thereof the reference “8.2.a.7";

    On page 17, subparagraph 8.2.a.9.B, after the words “in accordance with” by striking out the reference “subparagraph 8.2.a.9.A” and inserting in lieu thereof the reference “paragraph 8.2.a.8";

    On page 19, subdivision 9.3.d, after the words “in-network providers, paragraph” by striking out the reference “9.3.c.3" and inserting in lieu thereof the reference “9.3.c.1" and after the words “amount in paragraph” by striking out the reference “9.3.c.3" and inserting in lieu thereof the reference “9.3.c.1";

    And

    On page 19, paragraph 9.3.d.2, after the word “benefits” by inserting a period.