Senate Bill No. 115

(By Senator Hunter)


[Introduced January 14, 1998; referred to the Committee
on Health and Human Resources.]

A BILL to amend article twenty-five-a, chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty- one, as amended, by adding thereto a new section, designated section thirty-six, relating to providing members of health maintenance organizations with certain rights of membership; and proposal of legislative rules.

Be it enacted by the Legislature of West Virginia:
That article twenty-five-a, chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended by adding thereto a new section, designated section thirty-six, to read as follows:
§33-25A-36. Member rights.
(a) A health maintenance organization shall develop and adhere to policies regarding each of the following rights of members:
(1) The right to timely, fair and effective redress of grievances without retaliation by the organization or its providers;
(2) The right to obtain, upon request, timely advance determinations of coverage and the extent of coverage for care and services; and the right to coverage by the organization if a timely response to such a request has not been forthcoming;
(3) The right to confidentiality of all medical records; to examine one's own medical records; and, consistent with federal and state law, to copies of all medical records at cost;
(4) The right to appropriate and accessible care and services in a timely fashion;
(5) The right to receive free of charge written standards for coverage decisions which are not explicit in the subscriber agreement, either upon request or automatically upon denial or limitation of services;
(6) The right not to be discriminated against because of certain health needs;
(7) The right to continued coverage as a nongroup member if the member becomes ineligible to continue as part of a covered group;
(8) The right to be treated only by licensed programs and professionals in those areas of practice for which the state licenses individuals or programs;
(9) The right to obtain the credentials of any provider;
(10) The right to provide advance directives to the organization and to compliance with the directives, consistent with federal and state law;
(11) The right to refuse any treatment without jeopardizing future treatment or coverage;
(12) The right to have prior coverage denials reviewed by a provider with expertise in the field of coverage sought;
(13) The right to serve on a grievance review panel pursuant to a selection process set forth in the grievance review procedure;
(14) The right to a decision within twenty-one days on a request for a health care service or item;
(15) The right to coverage of an independent second medical opinion for use in grievance and hearing procedures; and
(16) The right to re-enroll in a managed care plan upon discharge from a state psychiatric hospital or release from a correctional facility: Provided, That the individual had been enrolled in the managed care plan immediately prior to hospitalization or incarceration and that he or she has a source of payment, including medical assistance.
(b) A health maintenance organization shall notify each member, or the parent or legal guardian of a dependent insured, of its policies upon development and at least every twelve months thereafter.
(c) The commissioner shall, after notice and hearing, propose rules for legislative approval in accordance with the provisions of article three, chapter twenty-nine-a of this code, as are necessary to carry out the provisions of this section.

NOTE: The purpose of this bill is to require health maintenance organizations to provide members with certain rights of membership.

This section is new; therefore, strike-throughs and underscoring have been omitted.