                                 CODE OF VIRGINIA

OFFICE OF THE MANAGED CARE OMBUDSMAN ESTABLISHED; RESPONSIBILITIES (§
38.2-5904)

A. The Commission shall create within the Bureau of Insurance the Office of the
Managed Care Ombudsman. The Office of the Managed Care Ombudsman shall promote
and protect the interests of covered persons under managed care health insurance
plans in the Commonwealth. All state agencies shall assist and cooperate with
the Office of the Managed Care Ombudsman in the performance of its duties under
this chapter. The definitions in &#xA7; 32.1-137.7 shall have the same meanings
ascribed to them in &#xA7; 32.1-137.7 when used in this section.

B. The Office of the Managed Care Ombudsman shall:

   1. Assist covered persons in understanding their rights and the processes
   available to them according to their managed care health insurance plan.

   2. Answer inquiries from covered persons and other citizens by telephone,
   mail, electronic mail and in person.

   3. Provide to covered persons and other citizens information concerning
   managed care health insurance plans and other utilization review entities upon
   request.

   4. Develop information on the types of managed care health insurance plans
   available in the Commonwealth, including mandated benefits and utilization
   review procedures and appeals, and receive and analyze the annual complaint
   data required to be filed by each health carrier providing a managed care
   health insurance plan, as provided in subsection C of &#xA7; 38.2-5804.

   5. Make available, either separately or through an existing Internet Web site
   utilized by the Bureau of Insurance, information as set forth in subdivision 4
   and such additional information as may be deemed appropriate.

   6. In conjunction with complaint and inquiry data maintained by the Bureau of
   Insurance, maintain data on inquiries received, the types of assistance
   requested, any actions taken and the disposition of each such matter.

   7. Upon request, assist covered persons in using the procedures and processes
   available to them from their managed care health insurance plan, including all
   utilization review appeals. Such assistance may require the review of
   insurance and health care records of a covered person, which shall be done
   only with that person&#8217;s express written consent. The confidentiality of
   any such medical records shall be maintained in accordance with the
   confidentiality and disclosure laws of the Commonwealth.

   8. Ensure that covered persons have access to the services provided through
   the Office of the Managed Care Ombudsman and that the covered persons receive
   timely responses from the representatives of the Office of the Managed Care
   Ombudsman to the inquiries.

   9. Upon request to the Commission by any of the standing committees of the
   General Assembly having jurisdiction over insurance or health or the Joint
   Commission on Health Care, provide to the Commission for dissemination to the
   requesting parties assessments of proposed and existing managed care health
   insurance laws and other studies of managed care health insurance plan issues.

   10. Monitor changes in federal and state laws relating to health insurance.

   11. Provide information to the Commission that will permit the Commission to
   report annually on the activities of the Office of the Managed Care Ombudsman
   to the standing committees of the General Assembly having jurisdiction over
   insurance and over health and to the Joint Commission on Health Care. The
   Commission&#8217;s report shall be filed by December 1 of each year, and shall
   include a summary of significant new developments in federal and state laws
   relating to health insurance each year.

   12. Carry out activities as the Commission determines to be appropriate.

HISTORY: 1999, cc. 643, 649; 2000, c. 922.