W. Va. Code R. § 114-56-8

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 114-56-8 - Members' Rights & Responsibilities

8.1. A prepaid limited health service organization shall demonstrate a commitment to treating members with respect by developing written policies giving them the right to:

a. Voice grievances about the PLHSO or care provided;

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

c. Participate in decision-making regarding limited health services;

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

e. Permit the provider or other person designated by the member or a court of competent jurisdiction to make and enforce all health care decisions which the member could make if he or she had capacity or were competent.

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

8.3. 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 a claim for covered services;

b. How to obtain limited health services;

c. After-hours and emergency coverage including the PLHSO'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 coordinating provider and the process for selecting a new provider;

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

k. Changing providers;

l. Disenrollment of nongroup subscribers;

m. Voicing complaints, grievances and appeals;

n. Recommending changes in policies and services;

o. Points of access to limited health services;

p. The process by which a prepaid limited health service 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;

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

t. Policies and procedures for the care and treatment of minors as well as adults who are unable to give informed consent.

8.4. The prepaid limited health service organization shall make reasonable accommodations for providing to members with disabilities the PLHSO's policies on members' rights and responsibilities.

W. Va. Code R. § 114-56-8