H. B. 2906

(By Delegates Hatfield, Susman
Collins and Marshall)
[Introduced February 25, 1999; referred to the
Committee on Government Organization then Finance.]

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-d, relating to the creation of the "West Virginia Managed Care Ombudsman Program Act"; establishing a managed care ombudsman program to assist consumers; providing for financing of the program from an assessment on premium dollars; establishing a statewide ombudsman advisory counsel to advise the state on the ombudsman program; and generally relating to the powers, responsibility and authority of the ombudsman program, including promulgation of legislative rules.

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-d, to read as follows:
ARTICLE 25D. MANAGED CARE OMBUDSMAN PROGRAM.
§33-25D-1. Short title.
This article may be known and cited as the "West Virginia Managed Care Ombudsman Program Act".
§33-25D-2. Creation of the state managed care ombudsman program.
There is hereby created the West Virginia managed care ombudsman program to assist consumers to understand and select managed care programs; assist enrollees to navigate and problem solve managed care plans and provide feedback and advocacy to improve health care delivery.
§33-25D-3. State managed care ombudsman; qualifications; duties.
(a) The insurance commissioner shall employ a state managed care ombudsman to effect the purposes of this article. The state managed care ombudsman shall have at least a master's degree in health or a related field and shall have demonstrated experience in one of the following areas: (1) The field of health care insurance; (2) health care; (3) community programs; (4) working with health care providers; (5) working with an involvement in volunteer programs; and (6) administrative and managerial experience. In lieu of the above educational and experience qualifications, the state managed care ombudsman shall have a four-year degree in health, insurance or a related field, plus five years of full-time equivalent experience in insurance, health or a related field. The state managed care ombudsman shall participate in ongoing training programs related to his or her duties or responsibilities. The state managed care ombudsman may not have been employed within the past two years prior to the date of his or her employment under this section by a managed care facility, or by any association of long-term care facilities, or by any organization or corporation that directly or indirectly regulates, owns, or operates a managed care facility.
(b) Neither the managed care ombudsman nor any member of his or her immediate family may have, or have had within the two years preceding his or her employment under this section, any pecuniary interest in the provision of managed care. For the purposes of this section, the term "immediate family" means the spouse, children, natural mother, natural father, natural brothers or natural sisters of the state managed care ombudsman.
(c) The duties of the state managed care ombudsman shall include, but are not limited to, the following:
(1) Establishing a mandatory statewide procedure to receive, investigate, and resolve complaints filed on behalf of any resident or citizen of this state, or filed on the state or regional managed care ombudsman's own initiative on behalf of residents, relating to action, inaction or decisions of providers of managed care plans by any health maintenance organization, health care corporation or other health care plan provider authorized to provide health care under the laws of this state, or the representatives of such providers;
(2) Contracting with an independent organization or organizations for an initial three-year period, through a competitive bidding process, to conduct mandated consumer assistance activities;
(3) Ensuring optimal coordination among different ombudsman organizations in the state and other citizen organizations;
(4) Coordinating the data collection and information dissemination activities of the ombudsman organizations with managed care information systems and programs established by the state;
(5) Evaluating the performance of any ombudsman organization under contract with the state and provide technical assistance and training to any ombudsman organization under contract with the state;
(6) Educating and training consumers in the use of comparative managed care plan information for the purpose of helping consumers select a managed care plan that is right for them;
(7) Assisting consumers in understanding their rights and responsibilities as plan enrollees;
(8) Identifying, investigating and resolving enrollees complaints and assist in filing; and
(9) Identifying, investigating, publicizing and promoting solutions to practices, policies, laws and rules that may adversely affect consumer access to quality health care.
(10) Monitoring the development and implementation of federal, state and local legislation, regulations and policies with respect to managed care;
(11) Establishing a mandatory statewide training program and certification procedures for regional managed care ombudsmen, excluding clerical staff, which shall include training in the following areas: (i) The review of medical records; (ii) confidentiality of records; (iii) techniques of complaint investigation; (iv) the effects of institutionalization; and (v) the special needs of the elderly; and (12) Promulgating mandatory statewide rules, regulations and training related to the use of managed care ombudsman volunteers in the program, including procedures to assure that the responsibility and authority of ombudsman volunteers shall be restricted to activities which do not involve access to confidential records, which do not involve complaint investigations other than information gathering to ascertain the nature and facts of a complaint, and which do not involve the initiation or pursuit of legal proceedings, actions or remedies.
§33-25D-4. Establishment of statewide ombudsman advisory counsel.
The insurance commissioner shall establish a statewide ombudsman advisory counsel to advise the state on the design, operation and evaluation of the ombudsman program. The advisory counsel shall be composed of no less than fifteen members and no more than thirty members. The advisory counsel shall be broadly representative of the health care community with a consumer majority and shall reflect the diversity of the state's population relative to race, ethnic origin, gender, age, economic status, physical and health condition.
§33-25D-5. Limitations on liability.
An ombudsman or any representative of any ombudsman organization created pursuant to the provisions of this article is immune from any civil liability that otherwise might result by reason of his or her advice, action or participation if the advice, action or participation is not violative of any applicable law or rule, performed within the scope of their employment and done in good faith.
§33-25D-6. Availability of legal counsel.
The insurance commissioner shall establish and maintain procedures to ensure that:
(a) Adequate legal counsel is available to the managed care ombudsman program for advice, consultation and representation as necessary in connection with the performance of the ombudsman's official duties; and
(b) The managed care ombudsman program has the ability to pursue administrative, legal and other appropriate remedies on behalf of residents of long-term care facilities.
§33-25D-7. Funding for managed care ombudsman programs.
(a) The state managed care ombudsman program shall receive such funds as are appropriated by the Legislature for the operation of the program.
(b) Any managed care ombudsman program may solicit and receive funds, gifts and contributions to support the operation of the program. No program shall solicit or receive any funds, gifts or contributions where the solicitation or receipt would jeopardize the independence and objectivity of the program.
(c) There is hereby created in the state treasury a special revenue account, which is an appropriated, interest bearing account, designated as the "managed care ombudsman program fund". All funds received by the managed care ombudsman program from any source shall be deposited into this special account. This fund may be used only for the purposes of administration, regulation, promotion and study of the managed care ombudsman program.
(d) Each managed care provider subject to the provisions of this article and chapter shall pay to the commissioner of insurance an annual fee equal to one half of one percent of all premiums paid to that managed care provider to be deposited in the special "managed care ombudsman program fund"

account within fifteen days after receipt.
§33-25D-8. Promulgation of rules.
Pursuant to chapter twenty-nine-a of this code, the state managed care ombudsman and the insurance commissioner shall promulgate rules to effectuate the purposes and provisions of this article.


NOTE: This bill creates a managed care ombudsman program to assist consumers to understand and select managed care plans. It provides for funding for the program by an assessment of fees on managed care providers.

Article 25D is new; therefore, strike-throughs and underscoring have been omitted.