W. Va. Code R. § 114-53-7

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-53-7 - Members' Rights & Responsibilities

7.1. An HMO shall demonstrate a commitment to treating members with respect by developing written policies giving them the right to:

a. Voice grievances about the HMO or care provided;

b. Have information concerning the HMO, its services, the practitioners providing care and members' rights and responsibilities;

c. Participate in decision-making regarding health care; and

d. Be treated with respect and recognition of their dignity and need for privacy.

7.2. An HMO shall develop a written policy addressing members' responsibilities for cooperating with those providing health care services by giving needed information to professional staff to ensure appropriate care and by following instructions and guidelines given by those providing health care services.

7.3. All policies on members' rights and responsibilities shall be provided in writing in clear and concise terms to all members and participating providers and, at a minimum, shall address the following procedures for, policies concerning or information regarding:

a. How to submit claim for covered services;

b. How to obtain primary and specialty care, behavioral health services and hospital services;

c. After-hours and emergency coverage including the HMO's policy on when to directly access emergency care or use 911 type services;

d. Benefits and services included and excluded from membership;

e. Obtaining out-of-area coverage;

f. Special benefit provisions such, as co-payment, higher deductibles and rejection of claims, that may apply to services outside the system;

g. Member charges;

h. Notification of termination or change in any benefits, services or delivery site/office;

i. Notification of termination of a primary care or specialty provider and the process for selecting a new provider;

j. Appealing decisions adversely affecting a member's coverage, benefits or relationship to the HMO;

k. Changing practitioners;

l. Disenrollment of nongroup subscribers;

m. Voicing complaints, grievances and appeals;

n. Recommending changes in policies and services;

o. Points of access to primary care, specialty care and hospital services;

p. The process by which a managed care organization determines whether or not to include new and emerging technology or treatment as a covered benefit;

q. Provider names, qualifications and titles;

r. Confidentiality; and

s. Member satisfaction surveys that assess patient complaints, requests to change practitioners and/or facilities and disenrollments.

7.4. The health maintenance organization shall make reasonable accommodations for providing to member's with disabilities the HMO's policies on members' rights and responsibilities.

7.5. A health maintenance organization shall have a procedure by which a member, upon diagnosis with a life-threatening, degenerative or disabling condition or disease, either of which requires specialized health care over a prolonged period of time, may receive a standing referral to a specialist with expertise in that condition or disease who will be responsible for and capable of providing and coordinating the member's specialty care. When a standing referral is made, the HMO shall periodically review the referral for continued necessity.

W. Va. Code R. § 114-53-7