Bill Text: WV HB4931 | 2024 | Regular Session | Introduced
Bill Title: Relating to Insurance carrier Requirement for Health Coverage Plans
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced) 2024-01-19 - To House Banking and Insurance [HB4931 Detail]
Download: West_Virginia-2024-HB4931-Introduced.html
WEST VIRGINIA LEGISLATURE
2024 REGULAR SESSION
Introduced
House Bill 4931
By Delegate Westfall
[Introduced January 19, 2024; Referred
to the Committee on Banking and Insurance then Health and Human Resources ]
A BILL to amend and reenact §33-6-39 of the Code of West Virginia, 1931, as amended, relating to changing insurance carrier requirements for health plans with dental coverage.
Be it enacted by the Legislature of West Virginia:
ARTICLE 6. The Insurance Policy.
§33-6-39. Prohibitions related to dental insurance plans, agreements, charges, and reimbursements; definitions.
(a) For purposes of this section:
"Covered services" means dental care services for which reimbursement is available/ under an enrollee’s plan contract, or for which reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximum, frequency limitations, alternative benefit payments, or any other limitation.
"Contractual discount" means a percentage reduction from the provider's usual and customary rate for covered dental services and materials required under a participating provider agreement.
"Dental plan" includes any policy of insurance which is issued by a health care service contractor which provides for coverage of dental services not in connection with a medical plan.
"Materials" includes, but is not limited to, any material or device utilized within the scope of practice by a licensed dentist.
(b) No contract of any health care service contractor that covers any dental services, and no contract or participating provider agreement with a dentist may require, directly or indirectly, that a dentist who is a participating provider, provide services to an enrolled participant at a fee set by, or a fee subject to the approval of, the health care services contractor unless the dental services are covered services.
(c) A health care service contractor or other person providing third-party administrator services shall not make available any providers in its dental network to a plan that sets dental fees for any services except covered services.
(d) A dentist may not charge more for services and materials that are noncovered services under a dental benefits policy than his or her usual and customary fee for those services and materials.
(e) Reimbursement paid by a 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.
(f) An "insurer," as that term is defined in §33-1-2 of this code, shall not establish rates for a dental coverage plan that excessive, inadequate, or discriminatory. To ensure compliance with this prohibition, the following shall occur:
(1) The Tax Commissioner shall promulgate rules to require rate filings and, as part of the rules, may require the submission of adequate documentation and supporting information, including actuarial opinions or certifications, and set expected benefits ratios. Additionally, the Commissioner will establish rules concerning:
(A) Expenditures for clinical dental services;
(B) Activities that improve dental care quality; and
(C) Overhead and administrative cost expenditures.
(2) The carrier shall submit expected rate increases to the commissioner at least sixty days prior to the proposed implementation of the rates. The Tax Commissioner shall then be responsible for approving the rate increase. If no response is given by the Commissioner, the insurer may then implement them subject to later changes by the Commissioner.
(3) The Commissioner shall also create mechanisms to measure the "dental loss ratio," which is defined as "the percentage of dollars collected each year for a dental coverage plan that the dental coverage plan incurs on dental services provided to an enrollee, separate from overhead and administrative costs." After establishment of an accepted measure, carries will be responsible for reporting the "dental loss ratio" beginning July 1, 2024, and every year thereafter.
(4) The Tax Commissioner will be responsible for publishing the information gathered on the "dental loss ratio" on his or her agency's website for public consumption. Carriers and plans that fall outside of a set number of standard deviations, determined by the Commissioner, will be highlighted in the data presented.
(f) (g)This section applies to dental plans, contracts, and participating provider agreements which take effect or are renewed on or after July 1, 2019 2024.
NOTE: The purpose of this bill is to change insurance carrier requirements for health plans with dental coverage.
Strike-throughs indicate language that would be stricken from a heading or the present law and underscoring indicates new language that would be added.
