§ 2-814. Health insurance appeal board.

(a)

Creation; appeal process.

(1)

Creation. There shall be a health insurance appeal board to hear appeals regarding the decision of the employee health plan administrator.

(2)

Appeal process. For appeal after a claim is denied:

a.

The first level of appeal shall be conducted at the claims administrator level and the decision will be rendered to the claimant within 30 days from receipt of the claim.

b.

The second level of appeal shall go to the plan administrator (county government) who shall establish an appeal board. The appeal board shall make the final determination and respond to the claimant within 30 days of the final appeal. The board may consult with, or seek participation of, medical experts and/or a professional third-party benefit consultant as part of the appeals process.

c.

The third level of appeal shall remain with the claims administrator allowing for a response to the claimant to be given within 60 days from receipt of the appeal.

d.

In cases where the situation requires urgent care, the decision shall be expedited at each step with an oral response within 72 hours, followed up in writing. For first and third level appeals, the claims administrator's medical director and the treating physician shall decide if an expedited appeal is necessary. For third level appeals, the treating physician shall make the determination.

e.

Claimants shall make requests for second-level appeals in writing and submit such to the benefits manager or human resources director. Claimants shall present their positions in writing, including all relevant documentation. All of claimant's identifying information shall be redacted prior to submission to the board.

(b)

Composition of the appeal board. The board shall consist of seven voting members:

(1)

Two citizen members with substantive professional experience in benefits administration for a large organization. The county commission shall appoint these citizen members.

(2)

Two citizen members each with substantive professional experience in financial management for a large organization. The county commission shall appoint these citizen members.

(3)

Three members elected by the employees who are enrolled in a county government medical insurance plan. One member shall be elected by the enrolled employees who report to the county mayor (seat A); one member shall be elected by the enrolled employees who report to the county sheriff (seat B); and one member shall be elected by the enrolled employees who report to constitutional or fee officers, not including the sheriff (seat C).

(4)

The privacy officer (HIPAA) for the county government shall serve as a non-voting ex officio member of the board.

(5)

No elected officials shall serve on the appeal board.

(6)

Board members shall elect one member to serve as chairperson and one member to serve as vice-chairperson for a one-year term.

(7)

All board members shall follow all federal and state laws regarding confidentiality and failure to do so shall result in immediate removal.

(c)

Terms of office.

(1)

Members of the health insurance appeal board shall serve staggered, four-year terms.

(2)

Appointed members shall serve no more than two full terms, not including an initial one- or two-year appointment. Elected members shall not be subject to term limits.

(d)

Elections of employee members.

(1)

An election for employee members shall be held every four years and shall coincide with the election of the employee elected representatives on the county retirement and pension board. The terms of elected employee members shall begin on March 1. Elected employee members serving on the health insurance appeal board as of the effective date of the ordinance from which this section derives shall continue to serve until their terms are affected by these requirements.

(2)

Member seats are designated by representative groups:

a.

Seat A. One member elected representing the enrolled employees in a county government medical insurance plan who report to the county mayor.

b.

Seat B. One member elected representing the enrolled employees in a county government medical insurance plan who report to the county sheriff.

c.

Seat C. One member elected representing the enrolled employees in a county government medical insurance plan who report to constitutional or fee officers, not including the sheriff.

(3)

All candidates running for employee member shall be employed in an office from their representative group. Further, they shall qualify for nomination by submitting a nominating petition containing signatures of 25 employees enrolled in a county government medical insurance plan and employed in an office from their representative group.

(4)

The insurance committee shall appoint an election committee. A candidate may not serve on the election committee. The election committee shall have the responsibility of conducting the elections: determining the voting places, election hours, number of voting booths, canvas and count votes and report the results in writing to the insurance committee.

(5)

Those candidates receiving the most votes in each representative category will be elected. In case of a tie vote, the election committee shall conduct a run-off election.

(6)

Posting and distribution of campaign materials in public buildings must be in accordance with the policies of the building. The county government materials may not be used by candidates in campaigning.

(e)

Meetings, quorum and vacancies.

(1)

The board shall hold such meetings as may be required for the transaction of business by the board.

(2)

The insurance committee shall provide secretarial support for meeting minutes if requested by the appeal board. The secretary shall have no voting authority.

(3)

A quorum for the transaction of business at such meeting shall be a majority of the duly-appointed and acting members of the board. Decisions shall be by simple majority.

(4)

In the event of vacancies on the board, the appeal board shall appoint acting members until such vacancies are filled through the regular appointment or election process. Vacancy appointments shall be made from the same pool as the vacating member (i.e., same professional criteria or same employee group).

(f)

Powers and duties.

(1)

The board shall hear appeals from the decisions of the claims administrator in accordance with the provisions of this policy, and such additional rules as it shall adopt.

(2)

The board shall have exclusive original jurisdiction to receive, hear, determine and rule upon all appeals from decisions of the claims administrator. The decision of the board shall be in writing, and the board shall take and preserve the evidence on any claim.

(3)

The board shall have the power to prescribe rules and regulations, not inconsistent with state laws or this policy, to govern and control the hearing, consideration and disposition of all appeals.

(4)

Members shall be removed for just cause as determined by the board.

(Ord. No. O-16-8-101 , § 1(Exh. A), 9-26-16)