Text: HF02297 Text: HF02299 Text: HF02200 - HF02299 Text: HF Index Bills and Amendments: General Index Bill History: General Index
PAG LIN
1 1 Section 1. NEW SECTION. 514C.11 PATIENT ACCESS TO TYPES
1 2 OF PHYSICIANS UNDER MANAGED CARE HEALTH PLAN OR INDEMNITY PLAN
1 3 WITH LIMITED PROVIDER NETWORK.
1 4 Notwithstanding section 514C.6, a managed care health plan
1 5 or indemnity plan with a limited provider network shall
1 6 provide patients direct access to each type of physician, as
1 7 defined in section 135.1 and licensed under chapter 148, 150A,
1 8 or 151. Such direct access to a physician licensed under
1 9 chapter 151 shall not be conditioned upon a referral by a
1 10 provider licensed under another chapter. Access to a
1 11 specialist may be conditioned upon a referral by a primary
1 12 care provider physician licensed under chapter 148, 150A, or
1 13 151. If a physician licensed under chapter 151 determines
1 14 that a referral should be made to a physician licensed under
1 15 another chapter, a managed care health plan or indemnity plan
1 16 with a limited provider network may require that the referral
1 17 be made first to a provider designated by the plan. Any
1 18 copayment deductible, cost containment mechanism, or premium
1 19 rate shall not discriminate directly or indirectly upon the
1 20 basis of the license held by the physician. Access to a
1 21 specialist may be subject to a different copayment or
1 22 deductible than access to a primary care provider. Access to
1 23 a nonparticipating physician may be restricted or may be
1 24 subject to different copayments, deductibles, or premium
1 25 rates, or may be excluded, provided that a plan shall not
1 26 differentiate or exclude a physician directly or indirectly
1 27 upon the basis of the license held by the physician.
1 28 Each plan must demonstrate that it is capable of serving
1 29 appropriately the needs of the subscriber population in the
1 30 service area of the plan with regard to patient access to each
1 31 type of physician. The commissioner of insurance shall adopt
1 32 rules as necessary to administer this paragraph.
1 33 For purposes of this section, "managed care health plan or
1 34 indemnity plan with a limited provider network" means a health
1 35 maintenance organization, organized delivery system,
2 1 accountable health plan, health care insurance plan which
2 2 limits the number of licensed physicians who can provide
2 3 services under the plan, preferred provider organization,
2 4 exclusive provider organization, restricted access network, or
2 5 similar health-care plan. For purposes of this section,
2 6 "physician" means physician as defined in section 135.1 and
2 7 licensed under chapter 148, 150A, or 151.
2 8 EXPLANATION
2 9 This bill creates a new section 514C.11 which provides that
2 10 a managed care health plan or indemnity plan with a limited
2 11 provider network is to provide patients direct access to each
2 12 type of physician, as defined in section 135.1 and licensed
2 13 under chapter 148, 150A, or 151. The access required pursuant
2 14 to this section is not to be conditioned upon a referral by a
2 15 physician licensed under another chapter. However, if a
2 16 physician licensed under chapter 151 determines that a
2 17 referral should be made to a physician licensed under another
2 18 chapter, such health plan may require that the referral be
2 19 made first to a provider designated by the plan. Access to a
2 20 specialist may be conditioned upon a referral by a primary
2 21 care provider licensed under the same chapter. A copayment,
2 22 deductible, cost containment mechanism, or premium rate under
2 23 such plan shall not discriminate directly or indirectly upon
2 24 the basis of the license held by a physician. Access to a
2 25 specialist may be subject to a different copayment or
2 26 deductible than access to a primary care provider. Access to
2 27 a nonparticipating physician under such plan may be restricted
2 28 or may be subject to different copayments, deductibles, or
2 29 premium rates, or may be excluded under the plan, so long as
2 30 the differentiation or exclusion is not upon the basis of the
2 31 license held by the physician.
2 32 The bill requires that each plan demonstrate that it
2 33 appropriately serves the needs of the subscriber population in
2 34 the service area of the plan with regard to patient access to
2 35 physicians of each type.
3 1 LSB 3432HV 76
3 2 mj/jw/5
Text: HF02297 Text: HF02299 Text: HF02200 - HF02299 Text: HF Index Bills and Amendments: General Index Bill History: General Index
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