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
© 1996 Cornell College and League of Women Voters of Iowa
Comments? webmaster@legis.iowa.gov.
Last update: Mon Mar 4 09:34:06 CST 1996
URL: /DOCS/GA/76GA/Legislation/HF/00300/HF00383/950313.html
jhf