HB4081 H B&I AM 1-29

Archibald 3192

    The Committee on Banking and Insurance moves to amend the bill on page 2, section 1, line 5, 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 2.1, after the words “terminated” by adding a period;

    On page 2, subdivision 2.3.c, after the word “professional” by adding a semicolon;

    On page 2, subdivision 2.4.c, after the word “subdivisions” by striking out the references “2.4a and 2.4b" and inserting in lieu thereof the references “2.4.a and 2.4.b";

    On page 2, subdivision 2.4.d, after the word “subdivisions” by striking out the references “2.4a, 2.4b and 2.4c" and inserting in lieu thereof the references “2.4.a, 2.4.b and 2.4.c";

    On page 3, subsection 2.7, after the word “Commissioner” by adding a period;

    On page 3, subsection 2.12, after the words “medical condition” by striking out the single quotation mark and inserting a quotation mark;

    On page 4, subsection 2.17, 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 8, subsection 3.1, by striking out the words "A written" and inserting in lieu thereof the words "An issuer shall notify the covered person in writing of the covered person's right to request an external review. Such a written”;

    On page 8, subdivision 3.1.c, after the words “pursuant to” by striking out the words “subsection 15.1” and inserting in lieu thereof the words “section 14”;

    On page 9, paragraph 3.1.e.1, after the words “grievance process” by striking out the comma;

    On page 9, paragraph 3.1.f.1, after the word “life” by striking out the comma and inserting the words “or health or”;

    On page 10, subsection 5.3, after the words “person files a request for an expedited” by inserting the word “internal” and after the words “involving an adverse determination” by inserting the words “pursuant to W. Va. Code of St. R. §114-96”;

    On page 10, subdivision 5.3.a, after the word “Code” by inserting the word “of”;

    On page 11, subsection 6.2, after the word “consideration” by striking out the word “on” and inserting in lieu thereof the word “of”;

    On page 12, subdivision 6.5.a, after the words “five business days. Within” by striking out the words “two business days” and inserting in lieu thereof the words “one business day”;

    On page 13, subdivision 6.6.d, after the words “ensure that the” by striking out the word “internal” and inserting in lieu thereof the word “independent”;

    On page 13, subsection 6.8., after the words "receipt of the request for an external review" by inserting the words "and no later than one business day after making the decision";

    On page 17, subdivision 8.5.b, after “8.5.b.” by striking out the second period;

    On page 17, subdivision 8.5.c, after the word “subsection” by striking out the reference “8.8” and inserting in lieu thereof the reference “8.9”;

    On page 18, subsection 8.6, after the word “IRO” by striking out the comma;

    On page 18, subdivision 8.6.a, after the words “may not” by striking out the word “dely” and inserting in lieu thereof the word “delay”;

    On page 19, paragraph 8.9.a.2, after the words “services or treatments” by inserting the words “would not be substantially increased over those of available standard health care services or treatments”;

    On page 20, subdivision 8.11.b, after the word “subdivision” by striking out the reference “8.12.d” and inserting in lieu thereof the reference “8.11.d”;

    On page 21, subdivision 8.11.c, after “8.11.c” by adding a period;

    On page 21 subdivision 8.11.d, after “8.11.d” by adding a period;

    On page 21, paragraph 8.11.d.1, after “8.11.d.1" by adding a period;

    On page 21, paragraph 8.11.d.2, after “8.11.d.2" by adding a period;

    On page 21, paragraph 8.11.d.3, after “8.11.d.3" by adding a period and after the words “subsection 8.5” by striking out the words “pursuant to subdivision 8.11.a”;

    On page 22, subsection 8.12, after the words “random basis” by striking out the word “amount” and inserting in lieu thereof the word “among”;

    On page 23, subdivision 9.2.f, after the word “parties” by striking out the comma;

    On page 23, paragraph 9.2.f.1, after the words “before the IRO” by striking out the comma and the words “except that a party that unreasonably refuses to stipulate to limit the record may be taxed by the court for the additional costs involved”;

    On page 24, subsection 10.2, after the words “under this rule” by striking out the word “as” and inserting a comma;

    On page 25, subdivision 10.4.c, by striking out subdivision 10.4.c in its entirety;

    On page 27, paragraph 11.4.a.2, after the words “external review” by inserting the words “, any known relative of the covered person,”;

    On page 27, after paragraph 11.4.a.3, by inserting a new paragraph “11.4.a.4. Any administrator, fiduciary, employee or sponsor of an employee welfare benefit plan as defined in 29 U.S.C. 1002(1), if any, under which the covered person's request for external review arises;” and a new paragraph “11.4.a.5. A trade association of group health plans or issuers, or a trade association of health care providers;” and by renumbering the remaining paragraphs accordingly;

    On page 27, subdivision 11.4.b, after “11.4.b.” by striking out the remainder of the subdivision and inserting in lieu thereof the words “In determining whether an IRO or a clinical reviewer of the IRO has a material professional, familial or financial conflict of interest for purposes of subdivision 11.4.a, the Commissioner may disregard the mere appearance of a conflict of interest.”;

    On page 28, section 12, by striking out section 12 in its entirety and renumbering the remaining sections and their respective subsections, subdivisions and paragraphs accordingly;

    On page 28, subsection 13.1 (to be renumbered as subsection 12.1 pursuant to the above amendment), after the word “subdivision” by striking out the reference “13.1.a” and inserting in lieu thereof the reference “12.1.a”;

    On page 29, paragraph 13.2.b.2 (to be renumbered as paragraph 12.2.b.2 pursuant to the above amendment), after the word “paragraph” by striking out the reference “13.2.b.2” and inserting in lieu thereof the reference “12.2.b.1”;

    On page 30, subsection 15.2 (to be renumbered as subsection 14.2 pursuant to the above amendment), after the word “subsection” by striking out the reference “15.1” and inserting in lieu thereof the reference “14.1”;

    On page 30, subsection 15.3 (to be renumbered as subsection 14.3 pursuant to the above amendment), after the word “subsection” by striking out the reference “15.2” and inserting in lieu thereof the reference “14.2”;

    And,

    On page 30, after subsection 15.3 (to be renumbered as subsection 14.3 pursuant to the above amendment), by adding new section “114-97-15. Penalties. Any issuer failing to comply with the requirements of this rule is subject to the penalties prescribed in W. Va. Code §33-3-11.”