§ 4089w - Office of health care ombudsman
§ 4089w. Office of health care ombudsman
(a) The department shall establish the office of the health care ombudsman by contract with any nonprofit organization. The office shall be administered by the state health care ombudsman, who shall be an individual with expertise and experience in the fields of health care and advocacy.
(b) The health care ombudsman office shall:
(1) Assist health insurance consumers with health insurance plan selection by providing information, referral and assistance to individuals about means of obtaining health insurance coverage and services.
(2) Assist health insurance consumers to understand their rights and responsibilities under health insurance plans.
(3) Provide information to the public, agencies, legislators and others regarding problems and concerns of health insurance consumers and shall make recommendations for resolving those problems and concerns.
(4) Identify, investigate and resolve complaints on behalf of individual health insurance consumers and assist those consumers with the filing and pursuit of complaints and appeals.
(5) Analyze and monitor the development and implementation of federal, state and local laws, regulations and policies relating to health insurance consumers, and recommend changes it deems necessary.
(6) Facilitate public comment on laws, regulations, and policies, including policies and actions of health insurers.
(7) Promote the development of citizen and consumer organizations.
(8) Ensure that health insurance consumers have timely access to the services provided by the office.
(9) Submit to the general assembly and to the governor on or before January 1 of each year a report on the activities, performance and fiscal accounts of the office during the preceding year.
(c) The state health care ombudsman may:
(1) Hire or contract with persons to fulfill the purposes of this subchapter.
(2) Review the health insurance records of a consumer who has provided written consent. Based on the written consent of the consumer or the consumer's guardian or legal representative, a health insurer shall provide the state ombudsman access to records relating to that consumer.
(3) Pursue administrative, judicial and other remedies on behalf of any individual health insurance consumer or group of consumers.
(4) Delegate to employees and contractors of the ombudsman any part of the state ombudsman's authority.
(5) Adopt policies and procedures necessary to carry out the provisions of this subchapter.
(6) Take any other actions necessary to fulfil the purposes of this subchapter.
(d) All state agencies shall comply with reasonable requests from the state ombudsman for information and assistance. The department may adopt rules necessary to assure the cooperation of state agencies under this subsection.
(e) In the absence of written consent by a complainant or an individual utilizing the services of the office, or his or her guardian or legal representative, or court order, the state ombudsman, its employees and contractors, shall not disclose the identity of the complainant or individual.
(f) The state ombudsman, its employees and contractors shall not have any conflict of interest relating to the performance of their responsibilities under this subchapter. For the purposes of this section, a conflict of interest exists whenever the state ombudsman, its employees, contractors or a person affiliated with the state ombudsman, its employees and contractors:
(1) have direct involvement in the licensing, certification, or accreditation of a health care facility, heath insurer, or a health care provider;
(2) have a direct ownership interest or investment interest in a health care facility, health insurer, or a health care provider;
(3) are employed by, or participating in the management of a health care facility, health insurer, or a health care provider; or
(4) receive or have the right to receive, directly or indirectly, remuneration under a compensation arrangement with a health care facility, health insurer or health care provider.
(g) The state ombudsman shall be able to speak on behalf of the interests of health care and health insurance consumers and to carry out all duties prescribed in this subchapter without being subject to any disciplinary or retaliatory action. Nothing in this subsection shall limit the authority of the commissioner to enforce the terms of the contract.
(h) As used in this section, "health insurance plan" means a policy, service contract or other health benefit plan offered or issued by a health insurer, as defined by subsection 9402 of Title 18, and includes the Vermont health access plan and beneficiaries covered by the Medicaid program unless such beneficiaries are otherwise provided ombudsman services. (Added 1997, No. 159 (Adj. Sess.), § 2; amended 1999, No. 79 (Adj. Sess.), § 1.)