Source: http://www.wvlegislature.gov/Bill_Text_HTML/2000_SESSIONS/RS/Bills/HB2901%20INTR.htm
Timestamp: 2018-03-18 06:49:09
Document Index: 36394826

Matched Legal Cases: ['§33', '§33', '§33', '§33', '§33', '§33', '§33', '§33', '§33']

HB2901 INTR
(By Delegates Fleischauer, Compton,
Coleman, Caputo and Collins)
A BILL to amend and reenact sections one, two and three, article twenty-five-c, chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty-one, as amended; and to further amend said article by adding thereto fourteen new sections, designated sections two-a, two-b, four, five, six, seven, eight, nine, ten, eleven, twelve, thirteen, fourteen and fifteen, all relating to the patients' bill of rights; defining additional terms; stating legislative purpose and intent; providing that the article applies to all managed care entities operating within the state; providing for notice of certain subscribers' rights; providing for access to personnel and facilities; providing for standards regarding emergency services; providing for choice of health care professionals; providing for the prohibition of gag rules; providing for coverage for drugs and devices; requiring disclosures regarding experimental treatments; providing for quality assurance programs; providing for data systems and confidentiality; providing for clinical decisionmaking; providing for oversight authority; and establishing a grievance procedure, review and appeals.
That sections one, two and 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; and that said article be further amended by adding thereto fourteen new sections, designated sections two-a, two-b, four, five, six, seven, eight, nine, ten, eleven, twelve, thirteen, fourteen and fifteen, all to read as follows:
ARTICLE 25C. HEALTH MAINTENANCE ORGANIZATION 1999 PATIENT BILL OF RIGHTS.
This article may be referred to as the "1999 Patients' Bill of Rights."
(o) "Primary care practitioner" means a fully licensed health care professional under contract with the plan, who has been designated by the plan to coordinate, supervise, and/or provide ongoing care to the enrollee and includes: (i) Primary care physicians; and (ii) physician assistants and nurse practitioners.
(2) (3) A description of the plan's provider network, including the names and credentials of all participating physicians in the network, which further details how the subscriber may choose providers within the plan;
(3) (4) The subscriber's right to privacy and confidentiality;
(4) (5) The subscriber's ability to examine and offer corrections to their his or her own medical records;
(5) (6) The subscriber's right to be informed of plan policies and any charges for which the subscriber will be responsible;
(6) (7) The subscriber's ability to obtain evidence of the medical credentials of a plan provider such as diploma and board certifications;
(7) (8) The right of subscriber's subscribers to have coverage denials reviewed by appropriate medical professionals consistent with plan review procedures;
(9) A description of procedures to obtain emergency services and out of area services;
(10) The right of an enrollee to disenroll from the plan if his or her physician or specialist leaves the plan; and
(8) (11) Any other areas the commissioner may by rule require.
(1) An adequate number of accessible acute care hospital services, within a reasonable distance and/or travel time;
(2) An adequate number of accessible primary care practitioners, within a reasonable distance and/or travel time: Provided, That primary care practitioners include family practice and general practice physicians, internists, obstetrician/gynecologists, pediatricians, physician assistants and nurse practitioners;
(3) An adequate number of accessible specialists and subspecialists, within a reasonable distance and/or travel time: Provided, That when the type of medical specialist needed for a specific condition is not represented on the specialty panel, enrollees shall be afforded access to nonparticipating health care professionals at no additional cost to the enrollee;
(1) When the health care professional's contract is terminated, the plan shall allow enrollees, at no additional out-of-pocket cost, to continue receiving services from a primary care practitioner whose contract with the plan is terminated without cause. This continuance shall be effective for sixty days when the enrollee requests continued care;
(2) When the employer of the enrollee switches plans, the plan shall allow enrollees, at no additional out-of-pocket cost, to continue receiving services from his or her primary care practitioner. This continuance shall be effective for sixty days when the enrollee requests continued care;
(3) When either the employer of the enrollee switches plans, or when the health care professional's contract is terminated by the plan, the plan shall permit enrollees undergoing active treatment for an episode of illness or at anytime during a pregnancy, to continue to receive medically necessary covered services from the physician for up to sixty days or through post- partum care related to delivery: Provided, That the provider who is rendering services to an enrollee covered by this subsection shall agree: To accept reimbursement from the managed care plan at rates established by the managed care plan for applicable providers; to provide information to the managed care plan on services provided to an enrollee; and to adhere to the utilization review and care management protocols established by the plan;
(4) When a managed care plan becomes insolvent or ceases operations, covered services to enrollees will continue through the period for which a premium has been paid to the managed care plan on behalf of the covered person or until the covered person's discharge from an inpatient facility, whichever is greater. At no time may a participating provider collect or attempt to collect from a covered person any money owed to the provider by the terminated managed care plan; and
§33-25C-8. Drugs and devices.
(a) Each managed care plan shall provide coverage for all drugs and devices approved by the United States food and drug administration, whether or not that drug or device has been approved for the specific treatment or condition, so long as the primary care practitioner or other medical specialist treating the enrollee determines the drug or device is medically necessary and appropriate for the enrollee's condition.
(b) Each managed care service plan shall establish and operate a drug utilization review program that includes the following:
(1) Retrospective review of prescription drugs furnished to enrollees; and
(2) Education of physicians, enrollees and pharmacists regarding the appropriate use of prescription drugs.
(c) Each managed care plan shall provide for a drug utilization review program with ongoing periodic examination of data on outpatient prescription drugs to ensure quality therapeutic outcomes for enrollees:
(1) The drug utilization review program's primary emphasis shall be to enhance quality of care for enrollees by assuring appropriate drug therapy; and
(2) The drug utilization review program shall include the following:
(A) Clinically relevant criteria and standards for drug therapy;
(B) Nonproprietary criteria and standards, developed and revised through an open, professional consensus process; and
(C) Interventions which focus on improving therapeutic outcomes.
(3) The confidentiality of the relationship between enrollees and health care professionals shall be protected at all times.
(d) The health care services plan shall provide an educational outreach program as part of the drug utilization review program:
(1) The outreach program shall be directed to enrollees, pharmacists and other health care professionals; and
(2) The outreach program shall emphasize the appropriate use of prescription drugs.
(e) Prospective review of drug therapy may only deny services in cases of enrollee ineligibility, coverage limitations or fraud; and
(f) The prescribing health care professional shall determine the appropriate drug therapy for the enrollee; no substitutions shall be made without the direct approval of the prescriber.
§33-25C-9. Experimental treatments.
§33-25C-10. Quality assurance program.
§33-25C-11. Distribution of consumer guides.
Each plan shall publish and widely distribute on an annual basis a consumer guide on managed care plan performance to assist consumers, employers, and government purchasers in the selection of managed care plans. The comparative performance information in the consumer guide must include, at a minimum: Premium prices; cost-sharing requirements; benefit coverage descriptions; benefit limitations; clinical and service quality indicators; disenrollment rates; and enrollee satisfaction rates.
§33-25C-12. Data systems and confidentiality.
(a) The managed care plan shall provide information on a plan's structure, decision making process, health care benefits and exclusions, cost and cost-sharing requirements, list of contracting providers and health care professionals as well as grievance and appeal procedures to all potential enrollees, all enrollees covered by the plan, and to the state oversight agency.
§33-25C-13. Clinical decision making.
§33-25C-14. Oversight authority.
§33-25C-15. Grievance procedures, reviews and appeals.
(1) Identification of the reviewing body and an explanation of the process of review;
(2) An initial investigation and review;
(f) The managed care plan shall report to the state oversight agency the number of grievances and appeals received by the plan within a specified time period including, if applicable, the outcomes or current status of the grievances and/or appeals as well as the average time taken to resolve both grievances and appeals.
NOTE: The purpose of this bill is to amend the "Patient's Bill of Rights" to enhance statutory protection for consumers of managed health care plans.
§§33-25C-2a, 2b and 4 through 15 are new; therefore, strike-throughs and underscoring have been omitted.