H. B. 3307
(By Delegate Porter)
[Introduced January 13, 2010; referred to the
Committee on Banking and Insurance then the Judiciary.]
A BILL to amend and reenact §33-25C-1 and §33-25C-3 of the Code of
West Virginia, 1931, as amended; and to further amend said
code by adding thereto a new section, designated §33-25A-8i,
all relating to requiring managed care plan providers to
reimburse limited out of network medical expenses; and
permitting enrollees to seek reimbursements of out of network
medical expenses when denied.
Be it enacted by the Legislature of West Virginia:
That §33-25C-1 and §33-25C-3 of the Code of West Virginia,
1931, as amended, be amended and reenacted; and that said code be
further amended by adding thereto a new section, designated
§33-25A-8i, all to read as follows:
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-8i. Limited right of recovery.
(a) An enrollee of a health care plan under this article may recover or seek reimbursement for out of network medical expenses
up to the amount the health care plan would have paid to the same
or similar network provider.
(b) An enrollee's right to recover under this section is not
affected by the denial or refusal of a request or referral for
coverage of out of network medical treatment by a health care plan.
ARTICLE 25C. HEALTH MAINTENANCE ORGANIZATION PATIENT BILL OF
RIGHTS.
§33-25C-1. Short title and purpose.
This article may be referred to as the "Patients' Bill of
Rights." It is the intent of the Legislature that enrollees covered
by health care plans receive quality, cost-effective health care
designed to maintain and improve their health. The purpose of this
article is to ensure that health plan enrollees:
(a) Have improved access to information regarding their health
plans;
(b) Have sufficient and timely access to appropriate health
care services, and choice among health care providers;
(c) Are assured that health care decisions are made by
appropriate medical personnel;
(d) Have access to a quick and impartial process for appealing
plan decisions;
(e) Have the freedom to make medical choices when needed;
(e) (f) Are protected from unnecessary invasions of health care privacy; and
(f) (g) Are assured that personal health care information will
be used only as necessary to obtain and pay for health care or to
improve the quality of care.
§33-25C-3. Notice of certain enrollee rights.
All managed care plans must on or after July 1, 2002, provide
to enrollees a notice of certain enrollee rights. The notice shall
be provided to enrollees on a yearly basis on a form prescribed by
the commissioner and shall include, but not be limited to:
(a) The enrollee's rights to a description of his or her
rights and responsibilities, plan benefits, benefit limitations,
premiums, and individual cost-sharing requirements;
(b) The enrollee's right to a description of the plan's
grievance procedure and the right to pursue grievance and hearing
procedures without reprisal from the managed care plan;
(c) On or after July 1, 2009, a description of enrollee's
right to recover out of network medical expenses up to the amount
the enrollee would have been covered had the medical expenses been
paid to an in network provider;
(c) (d) A description of the method in which an enrollee can
obtain a listing of the plan's provider network, including the
names and credentials of all participating providers, and the
method in which an enrollee may choose providers within the plan;
(d) (e) The enrollee's right to privacy and confidentiality;
(e) (f) The right to full disclosure from the enrollee's
health care provider of any information relating to his or her
medical condition or treatment plan, and the ability to examine and
offer corrections to the enrollee's medical records;
(f) (g) The enrollee's right to be informed of plan policies
and any charges for which the enrollee will be responsible;
(g) (h) The right of enrollees to have coverage denials
involving medical necessity or experimental treatment reviewed by
appropriate medical professionals who are knowledgeable about the
recommended or requested health service, as part of an external
review as provided in this article;
(h) (i) A description of the method in which an enrollee can
obtain access to a summary of the plan's accreditation report;
(i) (j) The right of an enrollee to have medical advice or
options communicated to him or her without any limitations or
restrictions being placed upon the provider or primary care
physician by the managed care plan;
(j) (k) A list of all other legally mandated benefits to which
the enrollee is entitled, including coverage for services provided
pursuant to sections eight-a, eight-b, eight-c, eight-d, eight-e,
article twenty-five-a of this chapter, article twenty-five-e of
this chapter, and article forty-two of this chapter, and all rules
promulgated pursuant to this chapter regulating managed care plans.
(k) (l) Any other areas the commissioner may propose in accordance with section nine of this article.
NOTE: The purpose of this bill is to require managed care plan
providers to reimburse limited out of network medical expenses. It
also allows enrollees to seek payment when denied.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.
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