Senate Bill No. 361
(By Senators Hunter, White, Kessler and Ball)
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[Introduced February 2, 1998; referred to the Committee
on Banking and Insurance.]
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A BILL to amend article twenty-five-a, chapter thirty-three of
the code of West Virginia, one thousand nine hundred thirty- one, as amended, by adding thereto a new section, designated
section thirty-six, relating to providing members of health
maintenance organizations with certain rights of membership;
and proposal of legislative rules.
Be it enacted by the Legislature of West Virginia:
That article twenty-five-a, chapter thirty-three of the code
of West Virginia, one thousand nine hundred thirty-one, as
amended, be amended by adding thereto a new section, designated
section thirty-six, to read as follows:
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-36. Short title; member rights.
This section shall heretofore be designated the West Virginia patients' bill of rights.
(a) A health maintenance organization shall develop and
adhere to policies regarding each of the following rights of
members:
(1) The right to timely, fair and effective redress of
grievances without retaliation by the organization or its
providers;
(2) The right to obtain, upon request, timely advance
determinations of coverage and the extent of coverage for care
and services; and the right to coverage by the organization if a
timely response to such a request has not been forthcoming;
(3) The right to confidentiality of all medical records; to
examine one's own medical records; and, consistent with federal
and state law, to copies of all medical records at cost;
(4) The right to appropriate and accessible care and
services in a timely fashion;
(5) The right to receive free of charge written standards
for coverage decisions which are not explicit in the subscriber
agreement, either upon request or automatically upon denial or
limitation of services;
(6) The right not to be discriminated against because of
certain health needs;
(7) The right to continued coverage as a nongroup member if
the member becomes ineligible to continue as part of a covered group;
(8) The right to be treated only by licensed programs and
professionals in those areas of practice for which the state
licenses individuals or programs;
(9) The right to obtain the credentials of any provider;
(10) The right to provide advance directives to the
organization and to compliance with the directives, consistent
with federal and state law;
(11) The right to refuse any treatment without jeopardizing
future treatment or coverage;
(12) The right to have prior coverage denials reviewed by a
provider with expertise in the field of coverage sought;
(13) The right to serve on a grievance review panel pursuant
to a selection process set forth in the grievance review
procedure;
(14) The right to a decision within twenty-one days on a
request for a health care service or item;
(15) The right to coverage of an independent second medical
opinion for use in grievance and hearing procedures; and
(16) The right to re-enroll in a managed care plan upon
discharge from a state psychiatric hospital or release from a
correctional facility: Provided, That the individual had been
enrolled in the managed care plan immediately prior to
hospitalization or incarceration and that he or she has a source of payment, including medical assistance.
(b) A health maintenance organization shall notify each
member, or the parent or legal guardian of a dependent insured,
of its policies upon development and at least every twelve months
thereafter.
(c) The commissioner shall, after notice and hearing,
propose rules for legislative approval in accordance with the
provisions of article three, chapter twenty-nine-a of this code,
as are necessary to carry out the provisions of this section.
(d) The public employees insurance agency shall require each
health maintenance organization or other plan authorized by the
agency to provide health services, to list all physicians
participating in their plan in the shopper's guide and to
contract with said physicians to continue to participate in the
plan until the next open enrollment period for participating
employees.
(e) The public employees insurance agency shall require all
hospitals authorized by the agency to provide health services to
provide an itemized statement of charges to any plan participant
who receives services from the hospital.
NOTE: The purpose of this bill is to require health
maintenance organizations to provide members with certain rights
of membership. Finally, the bill also requires the PEIA to
require hospitals to provide an itemized statement of services
rendered to plan participants and to require HMOs to contract with participating physicians to remain with the plan for the
same time period employees are obligated to utilize the HMO.
This section is new; therefore, strike-throughs and
underscoring have been omitted.