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
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
(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
(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
(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
(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
(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
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"
and used for the purposes of this article. "Managed care
provider" means, for the purposes of determining who is
responsible for the payment of the fee assessed by this section,
any health maintenance organization or any health care
corporation duly licensed and doing business in this state. The
fee collected by the commissioner must be deposited to the
"managed care ombudsman program fund"
account within fifteen days
§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
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.