§5-16-7. Authorization to establish group hospital and surgical insurance plan, group major medical insurance plan, group prescription drug plan and group life and accidental death insurance plan; rules for administration of plans; mandated benefits;...


Published: 2015

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WVC 5 - 16 - 7

§5-16-7. Authorization to establish group hospital and surgical

insurance plan, group major medical insurance plan,

group prescription drug plan and group life and

accidental death insurance plan; rules for

administration of plans; mandated benefits; what

plans may provide; optional plans; separate rating

for claims experience purposes.

     (a) The agency shall establish a group hospital and surgical

insurance plan or plans, a group prescription drug insurance plan

or plans, a group major medical insurance plan or plans and a group

life and accidental death insurance plan or plans for those

employees herein made eligible and establish and promulgate rules

for the administration of these plans subject to the limitations

contained in this article. These plans shall include:

     (1) Coverages and benefits for x-ray and laboratory services

in connection with mammograms when medically appropriate and

consistent with current guidelines from the United States

Preventive Services Task Force; pap smears, either conventional or

liquid-based cytology, whichever is medically appropriate, and

consistent with the current guidelines from either the United

States Preventive Services Task Force or The American College of

Obstetricians and Gynecologists; and a test for the human papilloma

virus (HPV) when medically appropriate and consistent with current

guidelines from either the United States Preventive Services Task

Force or The American College of Obstetricians and Gynecologists, when performed for cancer screening or diagnostic services on a

woman age eighteen or over;

     (2) Annual checkups for prostate cancer in men age fifty and

over;

     (3) Annual screening for kidney disease as determined to be

medically necessary by a physician using any combination of blood

pressure testing, urine albumin or urine protein testing and serum

creatinine testing as recommended by the National Kidney

Foundation;

     (4) For plans that include maternity benefits, coverage for

inpatient care in a duly licensed health care facility for a mother

and her newly born infant for the length of time which the

attending physician considers medically necessary for the mother or

her newly born child. No plan may deny payment for a mother or her

newborn child prior to forty-eight hours following a vaginal

delivery or prior to ninety-six hours following a caesarean section

delivery if the attending physician considers discharge medically

inappropriate;

     (5) For plans which provide coverages for post-delivery care

to a mother and her newly born child in the home, coverage for

inpatient care following childbirth as provided in subdivision (4)

of this subsection if inpatient care is determined to be medically

necessary by the attending physician. These plans may include,

among other things, medicines, medical equipment, prosthetic

appliances and any other inpatient and outpatient services and expenses considered appropriate and desirable by the agency; and

     (6) Coverage for treatment of serious mental illness:

     (A) The coverage does 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. With regard to a covered individual

who has not yet attained the age of nineteen years, "serious mental

illness" also includes attention deficit hyperactivity disorder,

separation anxiety disorder and conduct disorder.

     (B) Notwithstanding any other provision in this section to the

contrary, if the agency demonstrates that its total costs for the

treatment of mental illness for any plan exceeds two percent of the

total costs for such plan in any experience period, then the agency

may apply whatever additional cost-containment measures may be

necessary in order to maintain costs below two percent of the total

costs for the plan for the next experience period. These measures

may include, but are not limited to, limitations on inpatient and

outpatient benefits.

     (C) The agency 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, limitations on

inpatient and outpatient benefits, utilization review,

implementation of cost-containment measures, preauthorization for

certain treatments, setting coverage levels, setting maximum number

of visits within certain time periods, using capitated benefit

arrangements, using fee-for-service arrangements, using third-party

administrators, using provider networks and using patient cost

sharing in the form of copayments, deductibles and coinsurance.

     (7) Coverage for general anesthesia for dental procedures and

associated outpatient hospital or ambulatory facility charges

provided by appropriately licensed health care individuals in

conjunction with dental care if the covered person is:

     (A) Seven years of age or younger or is developmentally

disabled and is an individual for whom a successful result cannot

be expected from dental care provided under local anesthesia

because of a physical, intellectual or other medically compromising

condition of the individual and for whom a superior result can be

expected from dental care provided under general anesthesia;

     (B) A child who is twelve years of age or younger with

documented phobias or with documented mental illness and with

dental needs of such magnitude that treatment should not be delayed or deferred and for whom lack of treatment can be expected to

result in infection, loss of teeth or other increased oral or

dental morbidity and for whom a successful result cannot be

expected from dental care provided under local anesthesia because

of such condition and for whom a superior result can be expected

from dental care provided under general anesthesia.

     (8) (A) Any plan issued or renewed on or after January 1,

2012, shall include coverage for diagnosis, evaluation and

treatment of autism spectrum disorder in individuals ages eighteen

months to eighteen years. To be eligible for coverage and benefits

under this subdivision, the individual must be diagnosed with

autism spectrum disorder at age eight or younger. Such plan shall

provide coverage for treatments that are medically necessary and

ordered or prescribed by a licensed physician or licensed

psychologist and in accordance with a treatment plan developed from

a comprehensive evaluation by a certified behavior analyst for an

individual diagnosed with autism spectrum disorder.

     (B) The coverage shall include, but not be limited to, applied

behavior analysis which shall be provided or supervised by a

certified behavior analyst. The annual maximum benefit for applied

behavior analysis required by this subdivision shall be in an

amount not to exceed $30,000 per individual for three consecutive

years from the date treatment commences. At the conclusion of the

third year, coverage for applied behavior analysis required by this

subdivision shall be in an amount not to exceed $2,000 per month, until the individual reaches eighteen years of age, as long as the

treatment is medically necessary and in accordance with a treatment

plan developed by a certified behavior analyst pursuant to a

comprehensive evaluation or reevaluation of the individual. This

subdivision does not limit, replace or affect any obligation to

provide services to an individual under the Individuals with

Disabilities Education Act, 20 U. S. C. 1400 et seq., as amended

from time to time or other publicly funded programs. Nothing in

this subdivision requires reimbursement for services provided by

public school personnel.

     (C) The certified behavior analyst shall file progress reports

with the agency semiannually. In order for treatment to continue,

the agency must receive objective evidence or a clinically

supportable statement of expectation that:

     (i) The individual's condition is improving in response to

treatment;

     (ii) A maximum improvement is yet to be attained; and

     (iii) There is an expectation that the anticipated improvement

is attainable in a reasonable and generally predictable period of

time.

     (D) On or before January 1 each year, the agency shall file an

annual report with the Joint Committee on Government and Finance

describing its implementation of the coverage provided pursuant to

this subdivision. The report shall include, but not be limited to,

the number of individuals in the plan utilizing the coverage required by this subdivision, the fiscal and administrative impact

of the implementation and any recommendations the agency may have

as to changes in law or policy related to the coverage provided

under this subdivision. In addition, the agency shall provide such

other information as required by the Joint Committee on Government

and Finance as it may request.

     (E) For purposes of this subdivision, the term:

     (i) "Applied behavior analysis" means the design,

implementation and evaluation of environmental modifications using

behavioral stimuli and consequences in order to produce socially

significant improvement in human behavior and includes the use of

direct observation, measurement and functional analysis of the

relationship between environment and behavior.

     (ii) "Autism spectrum disorder" means any pervasive

developmental disorder including autistic disorder, Asperger's

Syndrome, Rett Syndrome, childhood disintegrative disorder or

Pervasive Development Disorder as defined in the most recent

edition of the Diagnostic and Statistical Manual of Mental

Disorders of the American Psychiatric Association.

     (iii) "Certified behavior analyst" means an individual who is

certified by the Behavior Analyst Certification Board or certified

by a similar nationally recognized organization.

     (iv) "Objective evidence" means standardized patient

assessment instruments, outcome measurements tools or measurable

assessments of functional outcome. Use of objective measures at the beginning of treatment, during and after treatment is

recommended to quantify progress and support justifications for

continued treatment. The tools are not required but their use will

enhance the justification for continued treatment.

     (F) To the extent that the application of this subdivision for

autism spectrum disorder causes an increase of at least one percent

of actual total costs of coverage for the plan year, the agency may

apply additional cost containment measures.

     (G) To the extent that the provisions of this subdivision

require benefits that exceed the essential health benefits

specified under section 1302(b) of the Patient Protection and

Affordable Care Act, Pub. L. No. 111-148, as amended, the specific

benefits that exceed the specified essential health benefits shall

not be required of insurance plans offered by the Public Employees

Insurance Agency.

     (9) For plans that include maternity benefits, coverage for

the same maternity benefits for all individuals participating in or

receiving coverage under plans that are issued or renewed on or

after January 1, 2014: Provided, That to the extent that the

provisions of this subdivision require benefits that exceed the

essential health benefits specified under section 1302(b) of the

Patient Protection and Affordable Care Act, Pub. L. No. 111-148, as

amended, the specific benefits that exceed the specified essential

health benefits shall not be required of a health benefit plan when

the plan is offered in this state.

     (b) The agency shall, with full authorization, make available

to each eligible employee, at full cost to the employee, the

opportunity to purchase optional group life and accidental death

insurance as established under the rules of the agency. In

addition, each employee is entitled to have his or her spouse and

dependents, as defined by the rules of the agency, included in the

optional coverage, at full cost to the employee, for each eligible

dependent.

     (c) The finance board may cause to be separately rated for

claims experience purposes:

     (1) All employees of the State of West Virginia;

     (2) All teaching and professional employees of state public

institutions of higher education and county boards of education;

     (3) All nonteaching employees of the Higher Education Policy

Commission, West Virginia Council for Community and Technical

College Education and county boards of education; or

     (4) Any other categorization which would ensure the stability

of the overall program.

     (d) The agency shall maintain the medical and prescription

drug coverage for Medicare eligible retirees by providing coverage

through one of the existing plans or by enrolling the Medicare

eligible retired employees into a Medicare specific plan,

including, but not limited to, the Medicare/Advantage Prescription

Drug Plan. If a Medicare specific plan is no longer available or

advantageous for the agency and the retirees, the retirees remain eligible for coverage through the agency.





Note: WV Code updated with legislation passed through the 2015 Regular Session

The WV Code Online is an unofficial copy of the annotated WV Code, provided as a convenience. It has NOT been edited for publication, and is not in any way official or authoritative.