Text: HF00382 Text: HF00384 Text: HF00300 - HF00399 Text: HF Index Bills and Amendments: General Index Bill History: General Index
PAG LIN
1 1 Section 1. NEW SECTION. 514F.4 MANAGED CARE DELIVERY
1 2 SYSTEM REIMBURSEMENT.
1 3 1. None of the provisions contained in Title XIII,
1 4 subtitle 1, shall be construed to authorize or permit a
1 5 managed care delivery system to deny a claim and refuse to pay
1 6 benefits for health care services otherwise covered under the
1 7 system solely because the services are provided by a licensed
1 8 health care provider other than one under contract or
1 9 otherwise designated by the system to provide the services to
1 10 persons covered by the system. Notwithstanding section
1 11 514C.6, payment to a licensed health care provider pursuant to
1 12 this section shall be made in the same manner and amount and
1 13 under the same conditions as a payment would be made to a
1 14 health care provider under contract or otherwise designated by
1 15 the system. This section does not apply to a health care
1 16 provider who does not agree to accept the conditions,
1 17 restrictions, and reimbursement levels provided by the system.
1 18 2. For purposes of this section, "managed care delivery
1 19 system" means a health maintenance organization, individual
1 20 practice arrangements, preferred provider organization,
1 21 exclusive provider organization, organized delivery system, or
1 22 another similar entity as defined in rules adopted by the
1 23 commissioner.
1 24 Sec. 2. NEW SECTION. 514I.1 DEFINITION.
1 25 As used in this chapter, "managed care delivery system"
1 26 means an entity, whether or not licensed by the state, which
1 27 offers to provide health care benefits to persons in this
1 28 state through prearrangements with providers of health care
1 29 services, including, but not limited to, health maintenance
1 30 organizations, individual practice arrangements, preferred
1 31 provider organizations, exclusive provider organizations, and
1 32 organized delivery systems.
1 33 Sec. 3. NEW SECTION. 514I.2 EXPANDED PROVIDER NETWORK &endash;
1 34 REQUEST BY ENROLLEE OR SUBSCRIBER.
1 35 Upon the written request of an enrollee or a subscriber
2 1 under a managed care delivery system, the managed care
2 2 delivery system shall establish an expanded network of
2 3 physicians licensed under chapter 148, 150, or 150A, or
2 4 hospitals licensed under chapter 135B, as requested by the
2 5 enrollee or subscriber, which shall be in addition to the
2 6 managed care delivery system's existing provider network. The
2 7 managed care delivery system shall accept as a provider in the
2 8 expanded network any licensed physician or licensed hospital
2 9 as requested by the enrollee or subscriber which satisfies all
2 10 of the following:
2 11 1. Satisfies the managed care delivery system's approved
2 12 credentialing standards, without regard to quotas or numerical
2 13 limitations of any kind as established by the managed care
2 14 delivery system.
2 15 2. Agrees to the terms of the managed care delivery
2 16 system's approved provider contract, which shall be the same
2 17 as the contract offered to the health care providers currently
2 18 participating in the managed care delivery system's existing
2 19 provider network.
2 20 3. Agrees to comply with the managed care delivery
2 21 system's approved clinical protocols, which shall be the same
2 22 as those clinical protocols which apply to the health care
2 23 providers currently participating in the managed care delivery
2 24 system's existing provider network.
2 25 Sec. 4. NEW SECTION. 514I.3 COMPLAINT PROCESS
2 26 ESTABLISHED.
2 27 The commissioner of insurance and the director of public
2 28 health shall review and approve and disapprove the
2 29 credentialing standards, provider contracts, and clinical
2 30 protocols relating to physicians and hospitals as applied to
2 31 the expanded network. A managed care delivery system shall
2 32 establish and maintain a complaint process affording due
2 33 process to any enrollee or subscriber making a request for an
2 34 expanded provider network pursuant to this chapter as well as
2 35 to any licensed physician or hospital denied acceptance into
3 1 the expanded provider network. The complaint process shall be
3 2 reviewed and approved or disapproved by the commissioner and
3 3 the director.
3 4 EXPLANATION
3 5 This bill creates a new chapter 514I concerning managed
3 6 care delivery systems and a new section 514F.4 concerning
3 7 reimbursement of health care providers by managed care
3 8 delivery systems.
3 9 New section 514F.4 prohibits a managed care plan from
3 10 denying a claim and refusing to pay benefits for health care
3 11 services otherwise covered under the plan solely because the
3 12 services are provided by a licensed health care provider other
3 13 than one under contract or otherwise designated by the plan to
3 14 provide the services to persons covered by the plan. Payment
3 15 to a licensed health care provider pursuant to this section
3 16 shall be made in the same manner and amount and under the same
3 17 conditions as a payment would be made to a health care
3 18 provider under contract or otherwise designated by the plan.
3 19 For purposes of this new section, "managed care plan" is
3 20 defined to include a health maintenance organization,
3 21 preferred provider organization, organized delivery system,
3 22 restricted access network, or other entity as defined in rules
3 23 adopted by the commissioner of insurance.
3 24 New section 514I.1 establishes a definition for managed
3 25 care delivery systems.
3 26 New section 514I.2 provides that upon the written request
3 27 of an enrollee or a subscriber under a managed care delivery
3 28 system, the managed care delivery system is to establish an
3 29 expanded network of physicians licensed under chapter 148,
3 30 150, or 150A, or hospitals licensed under chapter 135B, as
3 31 requested by the enrollee or subscriber. The managed care
3 32 delivery system must accept as a provider in the expanded
3 33 network any licensed physician or licensed hospital as
3 34 requested by the enrollee or subscriber which satisfies
3 35 requirements established in that section.
4 1 New section 514I.3 requires a managed care delivery system
4 2 to establish and maintain a complaint process affording due
4 3 process to any enrollee or subscriber making a request for an
4 4 expanded provider network pursuant to the chapter as well as
4 5 to any licensed physician or hospital denied acceptance into
4 6 the expanded provider network.
4 7 LSB 2187HH 76
4 8 mj/cf/24
Text: HF00382 Text: HF00384 Text: HF00300 - HF00399 Text: HF Index Bills and Amendments: General Index Bill History: General Index
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