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Introduced Version Senate Bill 15 History

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Key: Green = existing Code. Red = new code to be enacted


Senate Bill No. 15

(By Senator Hunter)

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[Introduced January 9, 2002; referred to the Committee on Banking and Insurance; and then to the Committee on Finance.]

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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.
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