Senate Bill No. 7
(By Senators Bailey, Minard, Bowman and Kessler)
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[Introduced February 14, 2001; referred to the Committee on
Banking and Insurance.]
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A BILL to amend chapter thirty-three of the code of West
Virginia, one thousand nine hundred thirty-one, as amended,
by adding thereto a new article, designated article
twenty-five-f, relating to patient protection; providing
that the article's provisions are applicable to all who are
involved with any form of managed care organization,
including preferred provider organizations, health
maintenance organizations and any type of organizational
practice of medicine which does not include medical
partnerships or solo practice; requiring administrators of
health benefit plans to annually file certain information
with the insurance commissioner; providing disclosure requirements related to information that is required to be
filed; requiring health care carriers to maintain networks
of providers of health care sufficient to ensure available
services for covered individuals; specifying general
responsibilities of health care carriers; requiring health
care carriers to adopt standards for the selection of
service providers; providing for a system in which to
address and resolve complaints by a review board; providing
notice requirements relating to the handling of complaints;
prohibiting the limiting of liability of a health care
carrier for actions of a physician; and requiring the
offering of a point-of-service plan designed to receive
covered services from out-of-network health care providers
without first having to obtain a referral or prior
authorization from the health care carrier.
Be it enacted by the Legislature of West Virginia:
That chapter thirty-three of the code of West Virginia, one
thousand nine hundred thirty-one, as amended, be amended by
adding thereto a new article, designated article twenty-five-f,
to read as follows:
ARTICLE 25F. PATIENT PROTECTION.
§33-25F-1. Managed care reporting and disclosure requirements.
(a) The administrator of every health benefit plan operating
under the authority of the commissioner of insurance shall
annually, on or before the first day of each year, file in the
office of the commissioner, on a form prescribed by the
commissioner, the following information, to the extent
applicable:
(1) The number of and reasons for complaints received from
plan participants regarding medical treatment;
(2) The number of participants who terminated coverage under
the plan for any reason;
(3) The number of provider contracts that were terminated in
the preceding year and the reasons for termination. This
information shall include the number of providers leaving the
plan and the number of new providers;
(4) Utilization data, including statistics relating to the
utilization, quality, availability and accessibility of services,
as defined by the commissioner; and
(5) Aggregate financial compensation data, including the
percentage of providers paid under a capitation arrangement,
discounted fee-for-service or salary, the services included in the capitation payment, and the range of compensation paid by
withhold or incentive payments.
(b) The name, or group or institutional name, of an
individual provider may not be disclosed pursuant to this
section. No civil liability arises from compliance with the
provisions of this section, provided that the acts or omissions
are made in good faith and do not constitute gross negligence,
willful or wanton misconduct or intentional wrongdoing.
(c) Each health benefit plan shall provide the following
applicable information to plan participants and prospective
participants upon request:
(1) The evidence of coverage, subscriber contract, health
insurance policy or the contract and benefit summary of any other
type of health benefit plan;
(2) An explanation for the utilization review criteria and
treatment protocol under which treatments are provided for
conditions specified by the prospective participant. This
explanation shall be in writing if so requested;
(3) In the event a recommended treatment is denied, written
reasons for the denial and an explanation of the utilization
review criteria or treatment protocol upon which the denial was based;
(4) The plan's restrictive formularies or prior approval
requirements for obtaining prescription drugs, whether a
particular drug or therapeutic class of drugs is excluded from
its formulary, and the circumstances under which a nonformulary
drug may be covered; and
(5) The plan's procedures and medically based criteria for
determining whether a specified procedure, test or treatment is
experimental.
(d) For the purposes of this article, "health benefit plan"
or "plan" means: (1) Health maintenance organization subscriber
contracts; and (2) insurance company or hospital and medical
service corporation preferred provider benefit plans in which
utilization review or quality management programs are used to
manage the provision of covered health care services, and in
which enrollees are given incentives through benefit
differentials to limit the receipt of covered health care
services to those provided by participating providers.
(e) All health maintenance organizations shall provide
emergency services on a twenty-four-hour a day basis without
prior authorization. Additionally, if, in the event of an emergency, it is not feasible because of time or geographic
constraints, or if the participant is out of the area of the
health maintenance organization, then an out-of-network provider
may be used without prior authorization. An "emergency," for the
purposes of this article, means a situation involving health that
an ordinary person would view as an emergency. This does not
include mild colds, routine aches and pains not associated with
acute trauma.
(f) Health maintenance organizations shall provide annually
pap smears, low-density radiation mammograms, routine screening
tests for prostate cancer and a routine chest X ray.
Additionally, midwife, child immunization services and
rehabilitative services, shall be covered and available for
provision in appropriate medical situations.
(g) All health maintenance organizations shall provide
psychiatric and mental health care coverage which includes, on an
annual basis, if needed, not less than one evaluation and twelve
sessions of treatment.
§33-25F-2. Network adequacy; standards; access plan required.
(a) A health-care carrier offering a managed care plan in
this state shall maintain a network that is sufficient in numbers and types of providers to ensure that all services to covered
persons are accessible without unreasonable delay. Sufficiency
in number and type of provider is determined in accordance with
the requirements of this section. Covered persons shall have
access to emergency care twenty-four-hours a day, seven days a
week. A health-care carrier providing a managed care plan shall
use reasonable criteria to determine sufficiency. The criteria
may include, but is not limited to:
(1) A ratio of specialty care providers to covered persons;
(2) A ratio of primary care providers to covered persons;
(3) Geographic accessibility;
(4) Waiting times for appointments with participating
providers; and
(5) Hours of operation.
(b) The volume of technological and specialty services
available to serve the needs of covered persons requiring
technologically advanced or specialty care shall be maintained at
a level sufficient to provide accessibility to all persons
covered under the particular plan.
(c) Whenever a health-care carrier has an insufficient
number or type of participating providers to provide a covered benefit, the health-care carrier shall ensure that the covered
person obtains the covered benefit at no greater cost to the
covered person than if the covered benefit were obtained from
participating providers or, shall otherwise make arrangements
acceptable to the department of health and human resources, in
consultation with the commissioner.
(d) The health-care carrier shall establish and maintain
adequate provider networks to ensure reasonable proximity of
participating providers to the businesses or personal residences
of covered persons. In determining whether a health-care carrier
has complied with this requirement, consideration shall be given
to the relative availability of health care providers in the
service under consideration.
(e) A health-care carrier shall monitor, on an ongoing
basis, the ability, clinical capacity, financial capacity and
legal authority of its providers to furnish all covered benefits
to covered persons. An access plan for each managed care plan
offered in this state shall describe or contain at least the
following:
(1) A listing of the names and specialties of the
health-care carrier's participating providers;
(2) The health-care carrier's procedures for making
referrals within and outside its network;
(3) The health-care carrier's process for monitoring and
ensuring, on an ongoing basis, the sufficiency of the network to
meet the health-care needs of populations that enroll in the
managed care plan;
(4) The health-care carrier's efforts to address the needs
of covered persons with limited English proficiency or, with
diverse cultural and ethnic backgrounds, or with physical and
mental disabilities;
(5) The health-care carrier's methods for assessing the
health-care needs of covered persons and their satisfaction with
services;
(6) The health-care carrier's method of informing covered
persons of the plan's services and features, including, but not
limited to, the plan's grievance procedures, its procedures
utilized for choosing and changing providers, and its procedures
for providing and approving emergency and specialty care;
(7) The health-care carrier's system for ensuring the
coordination and continuity of care for covered persons referred
to specialty physicians and for covered persons using ancillary services, including social services and other community
resources, and for ensuring appropriate discharge planning;
(8) The health-care carrier's process for enabling covered
persons to change primary care professionals;
(9) The health-care carrier's proposed plan for providing
continuity of care in the event of contract termination between
the health-care carrier and a participating provider or in the
event of the health-care carrier's insolvency or other inability
to continue operations. The description shall explain how
covered persons will be notified of the contract termination or
the health-care carrier's insolvency or other cessation of
operations and how covered services are intended to be
transferred to other providers in a timely manner; and
(10) Any other information required by the commissioner to
determine compliance with existing rules.
§33-25F-3. Health-care carriers, general responsibilities.
(a) A health-care carrier offering a managed care plan shall
notify, in writing, prospective participating providers of the
participating providers' responsibilities, concerning the
health-care carrier's administrative policies and programs,
including, but not limited to, payment terms, utilization reviews, the quality assurance programs, credentialing, grievance
procedures, data reporting requirements, confidentiality
requirements and applicable federal or state requirements.
(b) A health-care carrier may not offer an inducement under
a managed care plan to provide less than medically necessary
services to a covered person.
(c) A health-care carrier may not prohibit a participating
provider from discussing a treatment option with a covered person
or from advocating on behalf of a covered person within the
utilization review or grievance processes established by the
health-care carrier or a person contracting with the health-care
carrier.
(d) A health-care carrier shall require a participating
provider to make health records available to appropriate state
and federal authorities, in accordance with the applicable state
and federal laws related to the confidentiality of medical or
health records, when the authorities are involved in assessing
the quality of care or investigating a grievance or complaint of
a covered person.
(e) A health-care carrier and participating provider shall
provide at least sixty days' written notice to each other before terminating the contract between them without cause. The
health-care carrier shall make a good faith effort to provide
written notice of a termination, within fifteen working days of
receipt or issuance of a notice of termination from or to a
participating provider, to all covered persons who are patients
seen on a regular basis by the participating provider whose
contract is terminating, irrespective of whether the termination
is for cause or without cause. If a contract termination
involves a primary care professional, all covered persons who are
patients of that primary care professional must be notified.
(f) A health-care carrier shall ensure that a participating
provider furnishes covered benefits to all covered persons
without regard to the covered person's enrollment in the plan as
a private purchaser or as a participant in a publicly financed
program of health-care services. This requirement does not apply
to circumstances in which the participating provider should not
render services because of the participating provider's lack of
training, experience, or skill or because of restriction on the
participating provider's license.
(g) A health-care carrier shall notify the participating
providers of their obligation, if any, to collect applicable coinsurance, copayments or deductibles from covered persons under
the evidence of coverage or of the participating providers'
obligations, if any, to notify covered persons of the covered
persons' personal financial obligations for noncovered benefits.
(h) A health-care carrier may not penalize a participating
provider because the participating provider in good faith reports
to the state or federal authorities an act or practice by the
health-care carrier that may adversely affect patient health or
welfare.
(i) A health-care carrier shall establish a mechanism by
which a participating provider may determine in a timely manner
whether or not a person is covered by the health-care carrier.
(j) A health-care carrier shall establish procedures for
resolution of administrative, payment or other disputes between
the health-care carrier and participating providers.
(k) A contract between a health-care carrier and a
participating provider may not contain definitions or other
provisions that conflict with the definitions or provisions
contained in the managed care plan. A contract between a
health-care carrier and a participating provider shall set forth
all of the responsibilities and obligations of the provider either in the contract or documents referenced in the contract.
A health-care carrier shall make its best effort to furnish
copies of any reference documents, if required by a participating
provider, prior to execution of the contract.
§33-25F-4. Selection of providers; professional credentials
standards.
(a) A health-care carrier shall adopt standards for
selecting participating providers who are primary care
professionals and for each health-care professional specialty
within the health care carrier's network. The health-care
carrier shall use the standards to select health-care
professionals, the health-care carrier's intermediaries, and any
provider network with which the health-care carrier contracts.
A health-care carrier may not adopt selection criteria that
allows the health-care carrier to:
(1) Avoid high-risk populations by excluding a provider
because the provider is located in a geographic area that
contains populations presenting a risk of higher than average
claims, losses or use of health-care services; or
(2) Exclude a provider because the provider treats or
specializes in treating populations presenting a risk of higher than average claims, losses or use of health-care services.
(b) A health-care carrier may use criteria established in
accordance with the provisions of this section to select
health-care professionals allowed to participate in the
health-care carrier's managed care plan. A health-care carrier
shall make its selection standards for participating providers
available for review by the department and by each health-care
professional who is subject to the selection standards.
(c) (1) A system for resolving complaints shall include,
without limitation, an initial investigation, a review of the
complaint by a review board and a procedure for appealing a
determination regarding the complaint. The majority of the
members of the review board must be insureds who receive health-
care services from the managed care organization.
(2) Except as otherwise provided, a review board shall
complete its review regarding a complaint or appeal and notify
the insured of its determination not later than thirty days after
the complaint or appeal is filed, unless the insured and the
review board have agreed to a longer period of time.
(3) Any review board involving direct patient care or
hospitalization issues shall include a minimum of three medical doctors or doctors of osteopathic medicine, of which one must be
a specialist if the area in question involves specialty care.
(4) If a complaint involves an imminent and serious threat
to the health of the insured, the managed care organization shall
inform the insured immediately of his or her right to an
expedited review of his or her complaint. If an expedited review
is required, the review board shall notify the insured in writing
of its determination within seventy-two hours after the complaint
is filed.
(5) Notice provided to an insured by a review board
regarding a complaint must include, without limitation, an
explanation of any further rights of the insured regarding the
complaint that are available under his or her health-care plan.
(d) No contract between a health-care carrier and a
physician, for the purpose of delineating the rights and
obligations of the parties within the provider network, may limit
the liability of the health-care carrier for any actions of the
physician for which the health-care carrier might otherwise be
liable.
§33-25F-5. Point of service.
(a) A carrier which offers a managed care plan shall offer a point-of-service plan to every contract holder which would
allow a covered person to receive covered services from
out-of-network health-care providers without having to obtain a
referral or prior authorization from the carrier. The
point-of-service plan may require that a subscriber pay a higher
deductible or copayment or higher premium for the plan pursuant
to limits established by the department of health and human
resources in consultation with the insurance commissioner's
rules.
(b) A carrier shall provide each subscriber in a plan whose
contract holder elects the point-of-service plan, with the
opportunity, at the time of enrollment and during the annual open
enrollment period, to enroll in the point-of-service plan option.
The carrier shall provide written notice of the point-of-service
plan to each subscriber in a plan whose contract holder elects
the point-of-service plan and shall include in that notice a
detailed explanation of the financial costs to be incurred by a
subscriber who selects that plan.
(c) The requirements of this section do not apply to a
carrier contract which offers a managed care plan that provides
health-care services to medicaid recipients, or a federally qualified, nonprofit health maintenance organization.
(d) A carrier which offers a managed care plan utilizing a
selective contracting arrangement approved in accordance with
existing rules and that provides benefits for out-of-network
providers is in compliance with this section.
(e) A health maintenance organization affiliated with an
insurance company authorized to issue health benefit plans in
this state that offers point-of-service benefits exclusively
through a point-of-service plan provided by the affiliated
insurance company using a selective contracting arrangement is in
compliance with this section if the point-of-service plan is
offered under the requirements of subsections (a) and (b) of this
section.
NOTE: The purpose of this bill is to address coverage
matters involving all persons who are involved with any form of
managed care organization, including preferred provider
organizations, health maintenance organizations or any type of
organizational practice of medicine which does not include
medical partnerships or solo practice. The major provisions of
the bill are as follows: It requires administrators of health
benefit plans to annually file certain information with the
insurance commissioner; it sets forth disclosure requirements
related to information that is required to be filed; it requires
health-care carriers to maintain networks of providers of
health-care sufficient to ensure available services for covered
individuals; it enumerates general responsibilities of health-care carriers; it requires health-care carriers to adopt
standards for the selection of service providers; it provides for
a system in which to address and resolve complaints by a review
board; it sets forth notice requirements relating to the handling
of complaints; it prohibits the limiting of liability of a
health-care carrier for actions or omissions of a physician; and,
it requires the offering of a point-of-service plan designed to
receive covered services from out-of-network health care
providers without first having to obtain a referral or prior
authorization from the health-care carrier.
This article is new; therefore, strike-throughs and
underscoring have been omitted.
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