SB 313 — Requiring doula services be covered and reimbursed by Medicaid and PEIA

WEST VIRGINIA LEGISLATURE REGULAR SESSION IntroducedCommittee Substitute for Senate Bill 313 By Senators Chapman, Rucker, and Grady [Introduced[Originating Januaryin 12,the 2024;Committee on Health and Human Resources;

referredreported January 29, 2024] CS for SB 313 A BILL to amend and reenact §5-16-7 of the CommitteeCode onof HealthWest andVirginia, Human1931, Resources;as amended;

and then to the Committee on Finance] Intr SB 2024R1998 A BILL to amend and reenact §5-16-7 of the Code of West Virginia, 1931, as amended;

Intr1 CS for SB 2024R1998313 (2) Annual checkups for prostate cancer in men age 50 and over;

A "doula" means a trained professional providing continuous physical, emotional, and informational support during pregnancy, throughout the antepartum, intrapartum, and postpartum periods.

Doula services may be provided from the date of confirmed conception through 180 days after delivery, contingent on the client maintaining eligibility.

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 2 CS for SB 313 revised, under the diagnostic categories or subclassifications of:

Intr SB 2024R1998 (iv) Substance-related disorders with the exception of caffeine-related disorders and nicotine-related disorders;

Provided, That any service, even if it is related to the behavioral health, mental health, or substance use diagnosis if medical in nature, shall be reviewed as a medical 3 CS for SB 313 claim and undergo all utilization review as applicable;

Intr SB 2024R1998 (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.

(8)(8)(A) (A) All plans shall include coverage for diagnosis, evaluation, and treatment of autism spectrum disorder in individuals ages 18 months to 18 years.

Nothing in this subdivision requires reimbursement for services provided by public 4 CS for SB 313 school personnel.

In order for treatment to continue, the agency must receive objective evidence or a clinically Intr SB 2024R1998 supportable statement of expectation that:

(10)(10)(A) (A) Coverage, through the age of 20, for amino acid-based formula for the treatment of severe protein-allergic conditions or impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length, and motility of the gastrointestinal tract.

(i) Immunoglobulin E and nonimmunoglobulin E-medicated allergies to multiple food 5 CS for SB 313 proteins;

Intr SB 2024R1998 (iii) Eosinophilic disorders as evidenced by the results of a biopsy;

6 CS for SB 313 (b) The agency shall 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 Intr SB 2024R1998 under the rules of the agency.

(f) If the Public Employees Insurance Agency offers a plan that does not cover services provided by an out-of-network provider, it may provide the benefits required in paragraph (A), 7 CS for SB 313 subdivision (6), subsection (a) of this section if the services are rendered by a provider who is designated by and affiliated with the Public Employees Insurance Agency, and only if the same Intr SB 2024R1998 requirements apply for services for a physical illness.

(A) The medical necessity criteria used in determining benefits for behavioral health, 8 CS for SB 313 mental health, and substance use disorders;

Intr SB 2024R1998 (3) Identification of all nonquantitative treatment limitations that are applied to benefits for behavioral health, mental health, and substance use disorders and to medical and surgical benefits within each classification of benefits;

(C) Provide the comparative analyses, including the results of the analyses, performed to determine that the processes and strategies used to design each nonquantitative treatment limitation, as written, and the written processes and strategies used to apply each nonquantitative treatment limitation for benefits for behavioral health, mental health, and substance use disorders are comparable to, and are applied no more stringently than, the processes and strategies used to design and apply each nonquantitative treatment limitation, as written, and the written processes 9 CS for SB 313 and strategies used to apply each nonquantitative treatment limitation for medical and surgical benefits;

Intr SB 2024R1998 (D) Provide the comparative analysis, including the results of the analyses, performed to determine that the processes and strategies used to apply each nonquantitative treatment limitation, in operation, for benefits for behavioral health, mental health, and substance use disorders are comparable to, and are applied no more stringently than, the processes and strategies used to apply each nonquantitative treatment limitation, in operation, for medical and surgical benefits;

10 CS for SB 313 "Commissioner" means the commissioner of human services:

Intr SB 2024R1998 "Federal-state assistance" means and includes:

"State assistance" means and includes all forms of aid, care, assistance, services and 11 CS for SB 313 general relief made possible solely out of state, county and private appropriations to or on behalf of indigent persons, which are authorized by, and who are authorized to receive the same under and Intr SB 2024R1998 by virtue of, state division of human services’ or Department of Human Services’ rules.

"Estate" means all real and personal property and other assets included within the 12 CS for SB 313 individual’s estate as defined in the state’s probate law.

"Services" means nursing facility services, home and community-based services, and Intr SB 2024R1998 related hospital and prescription drug services for which an individual received Medicaid medical assistance.

(1) Extend Medicaid coverage to pregnant women and their newborn infants to 185 percent of the federal poverty level and to provide coverage up to 1-yearone-year postpartum care, effective July 1, 2021, or as soon as federal approval has occurred.

The health system design shall include quality assurance measures, case management, and patient outreach 13 CS for SB 313 activities.

The department shall assume responsibility for claims processing in accordance with established fee schedules and financial aspects of the program necessary to receive available Intr SB 2024R1998 federal dollars and to meet federal rules and regulations.

(6) File a state plan amendment, as preventative services, to extend Medicaid coverage to doula services.

A “doula” means a trained professional providing continuous physical, emotional, and informational support during pregnancy, throughout the antepartum, intrapartum, and postpartum periods.

Doula services may be provided from the date of confirmed conception through 180 days after delivery, contingent on the client maintaining Medicaid eligibility.

The doula services are provided to improve maternal health outcomes.

The Bureau for Medical Services shall file the state plan amendment on or before January 1, 2025.

(c) Any woman who establishes eligibility under this section shall continue to be treated as an eligible individual without regard to any change in income of the family of which she is a member until the end of the 1-yearone-year period beginning on the last day of her pregnancy.

14 CS for SB 313 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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