State Law

West Virginia Code-Chapter 33-Article 25C. Health Maintenance Organization Patient Bill of Rights

08/28/2023 West Virginia Section 33-25C-3

Notice of certain enrollee rights

Anti-gag clause, Directories

See sections in bold below:

All managed care plans must on or after the  July 1, 2002, provide to enrollees a notice of certain enrollee rights. The notice shall be provided to enrollees on a yearly basis on a form prescribed by the commissioner and shall include, but not be limited to:

(a) The enrollee’s rights to a description of his or her rights and responsibilities, plan benefits, benefit limitations, premiums, and individual cost-sharing requirements;

(b) The enrollee’s right to a description of the plan’s grievance procedure and the right to pursue grievance and hearing procedures without reprisal from the managed care plan;


(c) A description of the method in which an enrollee can obtain a listing of the plan’s provider network, including the names and credentials of all participating providers, and the method in which an enrollee may choose providers within the plan;

(d) The enrollee’s right to privacy and confidentiality;

(e) The right to full disclosure from the enrollee’s health care provider of any information relating to his or her medical condition or treatment plan, and the ability to examine and offer corrections to the enrollee’s medical records;

(f) The enrollee’s right to be informed of plan policies and any charges for which the enrollee will be responsible;

(g) The right of enrollees to have coverage denials involving medical necessity or experimental treatment reviewed by appropriate medical professionals who are knowledgeable about the recommended or requested health service, as part of an external review as provided in this article;

(h) A description of the method in which an enrollee can obtain access to a summary of the plan’s accreditation report;

Anti-gag Clause

(i) The right of an enrollee to have medical advice or options communicated to him or her without any limitations or restrictions being placed upon the provider or primary care physician by the managed care plan;

(j) A list of all other legally mandated benefits to which the enrollee is entitled, including coverage for services provided pursuant to sections eight-a [§ 33-25A-8a], eight-b [§ 33-25A-8b], eight-c [§ 33-25A-8c], eight-d [§ 33-25A-8d], eight-e [§ 33-25A-8e], article twenty-five-a of this chapter, article twenty-five-e [§§ 33-25E-1 et seq.] of this chapter, and article forty-two [§§ 33-42-1 et seq.] of this chapter, and all rules promulgated pursuant to this chapter regulating managed care plans.

(k) Any other areas the commissioner may propose in accordance with section nine [§ 33-25C-9] of this article.