Senate Bill No. 72
(By Senator Hunter)
[Introduced January 14, 2000; referred to the Committee
on Banking and Insurance; and then to the Committee on 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-e, 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; providing for ombudsman to have hearing
before commissioner on premium rates and premium rate
increases; and the powers, responsibility and authority of
the ombudsman program, including promulgation of legislative
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-e,
to read as follows:
ARTICLE 25E. MANAGED CARE OMBUDSMAN PROGRAM.
§33-25E-1. Short title.
This article may be known and cited as the "West Virginia
Managed Care Ombudsman Program Act."
§33-25E-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.
§33-25E-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;
(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) Intervening on behalf of consumers in any consideration by the commissioner of premium rates or premium rate increases of
managed care organizations in relation to issuance or maintenance
of certificates of authority.
§33-25E-4. Ombudsman to be notified of premium rates and
premium increases; hearing before commissioner
upon request by managed care ombudsman.
Any health maintenance organization seeking a certificate
of authority or seeking to maintain a certificate shall provide
notification to the ombudsman of any planned premium rate or
premium rate increase. Upon receiving notification of a premium
rate or premium rate increase relating to a health certificate of
authority or consideration of maintenance of a certificate of
authority, the ombudsman may request a hearing on the premium
rate before the commissioner. The commissioner shall provide for
the hearing in an appropriate time frame to permit consideration
of evidence presented at the hearing in reaching any decision
concerning the issuance of or maintenance of a certificate of
§33-25E-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.
§33-25E-6. Availability of legal counsel.
The insurance commissioner shall establish and maintain
procedures to ensure that 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.
§33-25E-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 may 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" revenue account
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
§33-25E-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
§33-25E-9. Termination of program.
The managed care ombudsman program shall be terminated
pursuant to the provisions of article ten, chapter four of this
code, on the first day of July, two thousand three, unless sooner
terminated, continued or reestablished pursuant to the provisions
of the 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.
This article is new; therefore, strike-throughs and
underscoring have been omitted.