Senate Bill No. 15
(By Senator Hunter)
____________
[Introduced January 9, 2002; 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-f, 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 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-f,
to read as follows:
ARTICLE 25F. MANAGED CARE OMBUDSMAN PROGRAM.
§33-25F-1. Short title.
This article may be known and cited as the "West Virginia
Managed Care Ombudsman Program Act."
§33-25F-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.
§33-25F-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;
(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.
§33-25F-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 authority.
§33-25F-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.
§33-25F-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.
§33-25F-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 after receipt.
§33-25F-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.
§33-25F-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 five, 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.