REPORT TITLE:
Creates HMO Ombudsman


DESCRIPTION:
Creates office of the HMO ombudsman to receive complaints and act
as advocate for HMO consumers and participants of the Hawaii
health QUEST program regarding quality of care, cost, payment,
access, or delivery of health services provided by health
maintenance organizations and the QUEST program.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                        
THE SENATE                              S.B. NO.           101
TWENTIETH LEGISLATURE, 1999                                
STATE OF HAWAII                                            
                                                             
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                   A  BILL  FOR  AN  ACT

RELATING TO HEALTH MAINTENANCE ORGANIZATIONS.



BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

 1      SECTION 1.  Chapter 432E, Hawaii Revised Statutes, is
 
 2 amended by adding a new part to be appropriately designated and
 
 3 to read as follows:
 
 4       "PART .  HEALTH MAINTENANCE ORGANIZATIONS OMBUDSMAN
 
 5      �432E-A  Office of health maintenance organizations
 
 6 ombudsman; purpose; established; appointment.(a)  The purpose
 
 7 of this part is to:
 
 8      (1)  Establish the office of the health maintenance
 
 9           organizations ombudsman for consumers of health
 
10           maintenance organizations as provided under chapter
 
11           432D and for participants in the Hawaii health QUEST
 
12           program, as provided by rules;
 
13      (2)  Ensure that each complaint is directed to the health
 
14           maintenance organizations ombudsman; and
 
15      (3)  Establish a system for the receipt and timely
 
16           investigation of complaints of enrollees of health
 
17           maintenance organizations and participants of the
 
18           Hawaii health QUEST program concerning the operation of
 
19           any health maintenance organization or the Hawaii
 

 
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 1           health QUEST program in this State.
 
 2      (b)  There is established the office of the health
 
 3 maintenance organizations ombudsman, to be attached to the
 
 4 department of commerce and consumer affairs for administrative
 
 5 purposes only, and to be headed by a single executive to be known
 
 6 as the health maintenance organizations ombudsman.  The governor
 
 7 shall appoint the health maintenance organizations ombudsman in
 
 8 the same manner and in accordance with section 26-34, as if the
 
 9 health maintenance organizations ombudsman were a member of a
 
10 board or commission.  A health maintenance organizations
 
11 ombudsman may be reappointed but may not serve for more than a
 
12 total of twelve years.
 
13      (c)  No person may serve as the health maintenance
 
14 organizations ombudsman within two years of the last day on which
 
15 the person served as a member of the legislature, or while the
 
16 person is a candidate for or holds any other state office, or
 
17 while the person is engaged in any other occupation for reward or
 
18 profit.  Effective January 1, 2000, the salary of the health
 
19 maintenance organizations ombudsman shall be $       a year.  The
 
20 salary of the health maintenance organizations ombudsman shall
 
21 not be diminished during the health maintenance organizations
 
22 ombudsman's term of office, unless by general law applying to all
 
23 salaried officers of the State.
 

 
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 1      (d)  If the health maintenance organizations ombudsman dies,
 
 2 resigns, becomes ineligible to serve, or is removed or suspended
 
 3 from office, the first assistant to the health maintenance
 
 4 organizations ombudsman shall become the acting health
 
 5 maintenance organizations ombudsman until a new health
 
 6 maintenance organizations ombudsman is appointed for a full term.
 
 7      �432E-B  Assistance; staff; delegation.(a)  The health
 
 8 maintenance organizations ombudsman shall appoint a first
 
 9 assistant and any other officers and employees that may be
 
10 necessary to carry out this part.  All employees, including the
 
11 first assistant, shall be hired by the health maintenance
 
12 organizations ombudsman and shall serve at the health maintenance
 
13 organizations ombudsman's pleasure.  In determining the salary of
 
14 each employee, the health maintenance organizations ombudsman
 
15 shall consult with the department of human resources development
 
16 and shall follow as closely as possible the recommendations of
 
17 the department.  Effective January 1, 2000, the first assistant's
 
18 salary shall be $        a year.  The health maintenance
 
19 organizations ombudsman and the health maintenance organizations
 
20 ombudsman's full-time staff shall be entitled to participate in
 
21 any employee benefit plan.
 
22      (b)  The health maintenance organizations ombudsman may
 
23 delegate to the health maintenance organizations ombudsman's
 

 
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                                     S.B. NO.           101
                                                        
                                                        

 
 1 appointees any of the health maintenance organizations
 
 2 ombudsman's duties.
 
 3      �432E-C  Duties and procedures.(a)  The office of the
 
 4 health maintenance organizations ombudsman shall:
 
 5      (1)  Act as a consumer protection and advocacy organization
 
 6           on behalf of all health care consumers in the State
 
 7           receiving services through health maintenance
 
 8           organizations as defined in section 432D-1 and all
 
 9           participants in the Hawaii health QUEST program;
 
10      (2)  Work in conjunction with the department of health in
 
11           protecting the public health, safety, and welfare;
 
12      (3)  Receive complaints regarding quality of care, cost,
 
13           payment, access, or delivery of health services
 
14           provided by health maintenance organizations or through
 
15           the Hawaii health QUEST program;
 
16      (4)  Investigate all complaints regarding quality of care,
 
17           cost, payment, access, or delivery of health services
 
18           provided by a health maintenance organization or
 
19           through the Hawaii health QUEST program;
 
20      (5)  Conduct unannounced site visits as necessary; and
 
21      (6)  Review existing and new or revised health maintenance
 
22           organization quality assurance programs and the quality
 
23           assurance program of the Hawaii health QUEST program
 

 
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                                     S.B. NO.           101
                                                        
                                                        

 
 1           and make recommendations as to how the rights of health
 
 2           maintenance organization enrollees and QUEST
 
 3           participants are affected by these programs.
 
 4      (b)  The office of the health maintenance organizations
 
 5 ombudsman shall implement a complaint system that shall include:
 
 6      (1)  A procedure for the timely acknowledgment of receipt of
 
 7           a complaint; and
 
 8      (2)  Criteria for determining the appropriate level of
 
 9           investigation for a complaint concerning quality of
 
10           care, cost, payment, access, or delivery of health
 
11           services including:
 
12           (A)  A determination as to whether a health maintenance
 
13                organization's enrollee or QUEST participant
 
14                making the complaint previously attempted to have
 
15                the complaint resolved; and
 
16           (B)  A determination as to whether a complaint should
 
17                be sent to the enrollee's health maintenance
 
18                organization or to the QUEST program for
 
19                resolution prior to investigation under this
 
20                section.
 
21      (c)  If a determination is made to investigate a complaint
 
22 under this section prior to the health maintenance organization's
 
23 enrollee or subscriber, health maintenance organization's
 

 
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                                     S.B. NO.           101
                                                        
                                                        

 
 1 provider, QUEST participant, or the department of human services
 
 2 acting as the administrator of the QUEST program, attempting to
 
 3 otherwise resolve the complaint, the reasons for that
 
 4 determination shall be documented.
 
 5      (d)  Notice of the complaint system and existence and
 
 6 operation of the office of the health maintenance organizations
 
 7 ombudsman established under this part shall be included in all
 
 8 contracts between a health maintenance organization and an
 
 9 enrollee or subscriber of a health maintenance organization, in
 
10 all contracts between a health maintenance organization and a
 
11 provider, and in a notice to all QUEST participants.
 
12      �432E-D Report.  At least twenty days prior to the
 
13 convening of each regular session, the office of the health
 
14 maintenance organizations ombudsman shall report to the insurance
 
15 commissioner, the director of health, and the legislature
 
16 regarding systemic problems or issues affecting the quality of
 
17 care, cost, payment, access, or delivery of health services
 
18 provided by health maintenance organizations or through the
 
19 Hawaii health QUEST program.  The report shall also include
 
20 findings and recommendations to resolve any reported problems or
 
21 issues.
 
22      �432E-E Rules.  The health maintenance organizations
 
23 ombudsman shall adopt rules in accordance with chapter 91 to
 

 
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                                     S.B. NO.           101
                                                        
                                                        

 
 1 implement this part."
 
 2      SECTION 2.  In codifying the new part added to chapter 432E,
 
 3 Hawaii Revised Statutes, by section 1 of this Act, the revisor of
 
 4 statutes shall substitute appropriate section numbers for the
 
 5 letters used in the new sections' designations in this Act.
 
 6      SECTION 3.  This Act shall take effect upon its approval.
 
 7 
 
 8                           INTRODUCED BY:  _______________________