ENGROSSED
COMMITTEE SUBSTITUTE
FOR
Senate Bill No. 361
(By Senators Hunter, White, Kessler and Ball)
_________
[Originating in the Committee on Banking and Insurance;
reported February 26, 1998.]
__________
A BILL to amend and reenact section twenty-four, article twenty- five-a, chapter thirty-three of the code of West Virginia, one
thousand nine hundred thirty-one, as amended; and to further
amend said chapter by adding thereto a new article, designated
article twenty-five-c, all relating to managed care plans and
their patients' rights.
Be it enacted by the Legislature of West Virginia:
That section twenty-four, article twenty-five-a, chapter
thirty-three of the code of West Virginia, one thousand nine
hundred thirty-one, as amended, be amended and reenacted; and that
said chapter be further amended by adding thereto a new article,
designated article twenty-five-c, all to read as follows:
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-24. Statutory construction and relationship to other laws.
(a) Except as otherwise provided in this article, provisions of the insurance laws and provisions of hospital or medical service
corporation laws are not applicable to any health maintenance
organization granted a certificate of authority under this article.
The provisions of this article shall not apply to an insurer or
hospital or medical service corporation licensed and regulated
pursuant to the insurance laws or the hospital or medical service
corporation laws of this state except with respect to its health
maintenance corporation activities authorized and regulated
pursuant to this article. The provisions of this article shall not
apply to an entity properly licensed by a reciprocal state to
provide health care services to employer groups, where residents of
West Virginia are members of an employer group, and the employer
group contract is entered into in the reciprocal state. For
purposes of this subsection, a "reciprocal state" means a state
which physically borders West Virginia and which has subscriber or
enrollee hold harmless requirements substantially similar to those
set out in section seven-a of this article.
(b) Factually accurate advertising or solicitation regarding
the range of services provided, the premiums and copayments
charged, the sites of services and hours of operation, and any
other quantifiable, nonprofessional aspects of its operation by a
health maintenance organization granted a certificate of authority,
or its representative shall not be construed to violate any
provision of law relating to solicitation or advertising by health
professions: Provided, That nothing contained in this subsection
shall be construed as authorizing any solicitation or advertising which identifies or refers to any individual provider or makes any
qualitative judgment concerning any provider.
(c) Any health maintenance organization authorized under this
article shall not be considered to be practicing medicine and is
exempt from the provisions of chapter thirty of this code, relating
to the practice of medicine.
(d) The provisions of sections fifteen and twenty, article
four (general provisions); section seventeen, article six
(noncomplying forms); article six-c (guaranteed loss ratio);
article seven (assets and liabilities); article eight
(investments); article nine (administration of deposits); article
twelve (agents, brokers, solicitors and excess line); section
fourteen, article fifteen (individual accident and sickness
insurance); section sixteen, article fifteen (coverage of
children); section eighteen, article fifteen (equal treatment of
state agency); section nineteen, article fifteen (coordination of
benefits with medicaid); article fifteen-b (uniform health care
administration act); section three, article sixteen (required
policy provisions); section three-f, article sixteen (treatment of
temporomandibular disorder and craniomandibular disorder); section
eleven, article sixteen (coverage of children); section thirteen,
article sixteen (equal treatment of state agency); section
fourteen, article sixteen (coordination of benefits with medicaid);
article sixteen-a (group health insurance conversion); article
sixteen-c (small employer group policies); article sixteen-d
(marketing and rate practices for small employers); article twenty-five-c (health maintenance organization patient bill of rights);
article twenty-seven (insurance holding company systems); article
thirty-four-a (standards and commissioner's authority for companies
deemed to be in hazardous financial condition); article thirty-five
(criminal sanctions for failure to report impairment); article
thirty-seven (managing general agents); article thirty-nine
(disclosure of material transactions); and article forty-one
(privileges and immunity) shall be applicable to any health
maintenance organization granted a certificate of authority under
this article. In circumstances where the code provisions made
applicable to health maintenance organizations by this section
refer to the "insurer", the "corporation" or words of similar
import, the language shall be construed to include health
maintenance organizations.
(e) Any long-term care insurance policy delivered or issued
for delivery in this state by a health maintenance organization
shall comply with the provisions of article fifteen-a of this
chapter.
(f) A health maintenance organization granted a certificate of
authority under this article shall be exempt from paying municipal
business and occupation taxes on gross income it receives from its
enrollees, or from their employers or others on their behalf, for
health care items or services provided directly or indirectly by
the health maintenance organization. This exemption applies to all
taxable years through the thirty-first day of December, one
thousand nine hundred ninety-six. The commissioner and the tax department shall conduct a study of the appropriations of
imposition of the municipal business and occupation tax or other
tax on health maintenance organizations, and shall report to the
regular session of the Legislature, one thousand nine hundred
ninety-seven, on their findings, conclusions and recommendations,
together with drafts of any legislation necessary to effectuate
their recommendations.
ARTICLE 25C. HEALTH MAINTENANCE ORGANIZATION PATIENT BILL OF
RIGHTS.
§33-25C-1. Short title.
This article may be referred to as the "Patients' Bill of
Rights".
§33-25C-2. Definitions.
(a) "Commissioner" means the commissioner of insurance.
(b) "Managed care plan" or "plan" means any health maintenance
organization or prepaid limited health care organization.
(c) "Provider" means any physician, hospital or other person
or organization which is licensed or otherwise authorized in this
state to provide health care services or supplies.
§33-25C-3. Notice of certain subscriber rights.
All managed care plans must provide to subscribers on a form
prescribed by the commissioner a notice of certain subscriber
rights. The notice shall address the following areas:
(1) The ability of the subscriber to pursue grievance and
hearing procedures without reprisal from the managed care plan;
(2) How the subscriber may choose providers within the plan;
(3) The subscriber's right to privacy and confidentiality;
(4) The subscriber's ability to examine and offer corrections
to their own medical records;
(5) The subscriber's right to be informed of plan policies and
any charges for which the subscriber will be responsible;
(6) The subscriber's ability to obtain evidence of the medical
credentials of a plan provider such as diploma and board
certifications;
(7) The right of subscriber's to have coverage denials reviewed
by appropriate medical professionals consistent with plan review
procedures;
(8) Any other areas the commissioner may by rule require.