Senate Bill No. 70

(By Senators Hunter, Minard, Mitchell, Walker, Kessler and Snyder)


[Originating in the Committee on Health and Human Resources; reported February 29, 2000.]


A BILL to amend and reenact section three, article twenty-five-c, chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty-one, as amended, relating to the patients' bill of rights; and providing for notice of certain enrollees' rights.

Be it enacted by the Legislature of West Virginia:
That section three, article twenty-five-c, chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended and reenacted to read as follows:

§33-25C-3. Notice of certain enrollee rights.

All managed care plans must provide on a yearly basis to subscribers enrollees, on a form prescribed by the commissioner which he or she shall provide to all health maintenance organizations by the first day of January each year, a notice of certain subscriber enrollee rights. The notice shall address the following areas:
(1) A description of an enrollee's rights and responsibilities, plan benefits, benefit limitations, premiums and individual cost-sharing requirements;
(1) (2) The ability of the subscriber enrollee to pursue grievance and hearing procedures without reprisal from the managed care plan, along with an explanation of the plan's enrollee complaint procedure, including the appeals procedure for care denied, terminated or reduced;
(2) (3) A description of how the enrollee can obtain a listing of the plan's provider network, including the names and credentials of all participating physicians in the network which further details how the subscriber enrollee may choose providers within the plan;
(4) The enrollee's right to a consumer's guide, as published by the insurance commissioner, and procedures for obtaining a copy of the guide;
(3) (5) The subscriber's enrollee's right to privacy and confidentiality;
(4) (6) The subscriber's enrollee's ability to examine and offer corrections to their his or her own medical records;
(5) (7) The subscriber's enrollee's right to be informed of plan policies and any charges for which the subscriber enrollee will be responsible;
(6) (8) The subscriber's enrollee's ability to obtain evidence of the medical credentials of a plan provider such as diploma and board certifications;
(7) (9) The right of subscriber's enrollees to have coverage denials reviewed by appropriate medical professionals consistent with plan review procedures;
(10) A description of procedures to obtain emergency services, experimental treatment, if covered, and out-of-area services;
(11) The right of the enrollee to services as provided under sections two through seven, article forty-two of this chapter;
(12) The right of the enrollee to full disclosure from his or her health care provider of any information relating to his or her medical condition or treatment plan;
(13) A description of the procedures for obtaining access to a summary of the accreditation report as set forth in section seventeen-a, article twenty-five-a of this chapter;
(14) The right of the enrollee to emergency services without prior authorization in accordance with section eight-d, article twenty-five-a of this chapter, if a prudent person acting reasonably would have believed that an emergency medical condition existed; and
(8) (15) Any other areas the commissioner may by rule require.

(NOTE: The purpose of this bill is to amend the "patients' bill of rights" to provide for mandatory notice of enrollees rights under managed health care plans.

Strike-throughs indicate language that would be stricken from the present law, and underscoring indicates new language that would be added.)