Bill Summary – FastDemocracy

WEST VIRGINIA LEGISLATURE
REGULAR SESSION
                 Introduced House Bill 5580
                By Delegate Young [Introduced February 12, 2024; Referred to the Committee on Health and Human Resources then Finance]
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  A BILL to amend the Code of West Virginia, 1931, as amended, by adding thereto a new article,
            designated §9-4F-1, §9-4F-2, §9-4F-3, §9-4F-4, §9-4F-5, §9-4F-6, §9-4F-7, §9-4F-8, and
            §9-4F-9, all relating to creating the Affordable Medicaid Buy-In Program; requiring the
            Department of Health Services to develop and administer the Affordable Medicaid Buy-In
            Plan; setting eligibility criteria and coverage requirements; specifying role and duties of the
            Department of Health Services; establishing an advisory council to the Affordable
            Medicaid Buy-In Program; defining terms; setting limitations of employers; requiring a full-
            cost option be available for individuals who do not meet financial qualifications; requiring
            rule-making; and mandating application for necessary federal Medicaid options and
           innovation waivers to maximize federal funding of the Program.
     Be it enacted by the Legislature of West Virginia:
     ARTICLE           4F.     THE        AFFORDABLE            MEDICAID         BUY-IN        PROGRAM.
     §9-4F-1. Purpose.
            The purpose of the Affordable Medicaid Buy-In Program is to establish a new state option
  efficiently maximizing available federal funds to provide West Virginia residents with a choice of a
  high-quality,                 low-cost health insurance plan.
     §9-4F-2. Definitions.
            As used in this article:
            "Affordable Medicaid Buy-In Plan" or "plan" means a state-administered, health care
  coverage plan that leverages the Medicaid coverage structure;
            "Copayment" means a fixed dollar amount that an Affordable Medicaid Buy-in enrollee
  must pay directly to a health care provider or pharmacy for a service, visit or item;
            "Deductible" means a fixed dollar amount that a person enrolled in the Affordable Medicaid
  buy-in plan may be required to pay during a benefit period before the plan begins payment for
  covered benefits;
            "Department" means the Department of Health Services;
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           "Health care coverage premium cost" means the premium charged for health care
 coverage that is available or currently provided to an individual;
           "Health care provider" means any physical, mental or behavioral health provider, including
 a hospital, physician, clinic and other health facility;
           "Managed care organization" means an organization licensed or authorized through an
 agreement among state entities to manage, coordinate and receive payment for the delivery of
 specified services to enrolled members;
           "Medicaid" means the joint federal-state health coverage program pursuant to Title 19 or
 Title 21 of the federal Social Security Act, as amended, and the rules promulgated pursuant to that
 act;
           "Medicare" means coverage under Part A or Part B of Title 18 of the federal Social Security
 Act, as amended, and the rules promulgated pursuant to that act;
           "Premium" means the monthly amount that a plan enrollee must pay directly to the
 managed care organization offering the enrollee’s plan for consideration of the plan's coverage;
 and
           "Resident" means a person establishing intent to permanently reside in West Virginia.
     §9-4F-3. The plan.
            (a) By January 1, 2025, the department shall establish an Affordable Medicaid Buy-In Plan
  and shall offer the plan for purchase by a resident:
            (1) Who is ineligible for the following:
            (A) Medicaid; and
            (B) Medicare; and
            (2) Whose employer has not disenrolled or denied the resident enrollment in employer-
  sponsored health coverage on the basis that the resident would otherwise qualify for enrollment in
  Affordable Medicaid buy-in coverage.
            (b) The department shall establish benefits under the plan in accordance with federal and
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 state law to ensure that covered benefits include:
           (1) Ambulatory patient services;
           (2) Emergency services;
           (3) Hospitalization;
           (4) Maternity and newborn care;
           (5) Mental health and substance use disorder services, including behavioral health
 treatment;
           (6) Prescription drugs;
           (7) Rehabilitative and habilitative services and devices;
           (8) Laboratory services;
           (9) Preventive and wellness services, including reproductive health and chronic disease
 management; and
           (10) Pediatric services, including oral and vision care.
           (c) For services and benefits provided under this section, the department may pursue any
 available federal financial participation.
           (d) The department shall coordinate the plans enrollment and eligibility to maximize the
 continuity of coverage between the plan, Medicaid and private health plans.
           (e) Health care provider reimbursement rates shall be based on the Medicaid fee schedule.
 Contingent upon available funds, the department may increase reimbursement rates for health
 care providers, so long as these increases do not jeopardize the sustainability of Medicaid or the
 plan.
           (f) The plan shall be established in compliance with nondiscrimination mandates set forth
 in the Constitution of West Virginia, the West Virginia Human Rights Act, and the federal Civil
 Rights Act of 1964 and shall be available to residents irrespective of age, race, gender, national
 origin, immigration status, disability or geographic location.
           (g) The department shall establish an updated premium sliding scale for individuals under
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 200 percent of the federal poverty level who purchase the Medicaid Buy-in plan. The sliding scale
 shall prioritize individuals transitioning from Medicaid coverage.
     §9-4F-4. Administration.
            (a) The department shall develop a plan for administering the plan that prioritizes
  affordability for enrollees and provides opportunities to maximize federal dollars.
            (b) The department shall:
            (1) Establish an affordability scale for premiums and other cost-sharing fees, such as
  copayments and deductibles, based on household income. The department shall offer discounted
  premiums and cost-sharing fees in accordance with the affordability scale to residents eligible to
  enroll in the plan: Provided, That the financial assistance is, at a minimum, offered to residents
  with household incomes below 200 percent of the federal poverty level;
            (2) Establish fair and reasonable premium rates that should be assessed to plan enrollees,
 after an actuarial analysis, to ensure maximum access to coverage. Premiums imposed may be
 set at a level sufficient to offset the costs of health benefits under the plan and related
 administrative costs; and
           (c) The department may:
           (1) Administer the plan through the managed care organizations under contract with the
 State to provide Medicaid services and benefits; and
           (2) Set the medical loss ratio for insurers offering the plan consistent with the ratio
 applicable to Medicaid;
           (d) The department shall:
           (1) Establish a standardized benefit and cost sharing design for the plan; and
           (2) Establish a method for procuring prescription drugs. This authority includes consulting
 or contracting with other entities or states for combined purchasing power; and
           (3) Seek viable opportunities to reduce costs of the plan to consumers and the general
 fund: Provided, That such opportunities are consistent with the provisions of this article, do not
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 reduce eligibility or benefits for Medicaid enrollees and do not jeopardize federal financing for
 medical assistance.
     §9-4F-5. Financing.
            (a) The department shall apply for a Basic Health Plan Option under Section 1331
  and/or a State Innovation Waiver under Section 1332 of the Patient Protection and Affordable
  Care Act. The department shall maximize all available federal dollars to fund the Affordable
  Medicaid Buy-In Program Nothing in the waiver application may prohibit individuals and families
  from purchasing plans on the Marketplace.
            (b) Individuals who do not qualify for federal financial assistance may purchase the plan at
  full cost.
     §9-4F-6. Enrollment.
            The department and the West Virginia health insurance exchange and the West Virginia
  Navigator program shall coordinate efforts and cooperate to establish a consumer outreach
  program to assist residents with enrolling in Medicaid, the Affordable Medicaid Buy-In plan, on the
  health insurance exchange to   minimize gaps in   health insurance coverage.
     §9-4F-7. Advisory council.
            (a) The Secretary of the Department of Health Services shall establish an Affordable
  Medicaid Buy-In Program advisory council, to advise the department on implementation, plan
  affordability, marketing, enrollment, outreach and evaluation of health care access for residents
  enrolled in the plan. The advisory council consists of:
            (1) The Secretary of the Department of Health and Human Resources;
            (2) The Insurance Commissioner;
            (3) Three consumer advocates;
            (4) One health care provider;
            (5) One representative from a Medicaid managed care organization;
           (6) At least one public health expert with experience evaluating health data and utilization
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 trends; and
           (7) At least one researcher with experience in health care financing and administration.
           (b) The Governor shall appoint the members identified in subdivisions (4) through (7) of
 subsection (a) of this section.
     §9-4F-8. Rule-making authority.
            The Secretary of the Department of Health Services shall propose emergency rules in
  accordance with the provisions of §29A-3-15 of this code to implement the provisions of this
  article. Thereafter, the secretary shall propose additional rules for legislative approval in
  accordance with the provisions of §29A-3-1 et seq. of this code as may be needed to administer
  and maintain the Affordable Medicaid Buy-In Program.
     §9-4F-9. Limitation on employers.
            An employer that offers employer-sponsored health coverage as of the effective date of
  this article may not disenroll or deny enrollment to a resident covered under the employer's
  employer-sponsored health coverage on the basis that the employer believes that the resident
  would qualify for plan coverage.
               NOTE: The purpose of this bill is to create the Affordable Medicaid Buy-In Program. The bill requires the Department of Health Services to develop and administer the Affordable Medicaid Buy-In Plan. The bill creates the Health Care Affordability and Access Improvement Fund. The bill establishes an advisory council to the Affordable Medicaid Buy-
               In Program. The bill requires a study and reposts be made. The bill defines terms. The bill sets limitations of employers. The bill requires rule-making.
               Strike-throughs indicate language that would be stricken from a heading or the present law,
               and underscoring indicates new language that would be added.
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Statutes affected: 
Introduced Version: 9-4F-1, 9-4F-2, 9-4F-3, 9-4F-4, 9-4F-5, 9-4F-6, 9-4F-7, 9-4F-8, 9-4F-9