Text: HSB00232 Text: HSB00234 Text: HSB00200 - HSB00299 Text: HSB Index Bills and Amendments: General Index Bill History: General Index
PAG LIN
1 1 Section 1. NEW SECTION. 514C.11 PROVIDER ACCESS UNDER
1 2 MANAGED CARE HEALTH PLAN OR INDEMNITY PLAN WITH LIMITED
1 3 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 provider that
1 7 has authority under Title IV, subtitle 3, to utilize
1 8 differential diagnosis and physical examinations to determine
1 9 human ailments, and shall not condition that access upon a
1 10 referral by a provider licensed under another chapter.
1 11 Referral to a specialist may be conditioned upon referral by a
1 12 primary care provider licensed under the same chapter. Any
1 13 copayment, deductible, or premium rate shall not discriminate
1 14 upon the basis of the license held by a provider but may
1 15 differentiate or exclude providers upon a rational basis.
1 16 Access to a specialist may be subject to a different copayment
1 17 or deductible than access to a primary care provider. Access
1 18 to a nonparticipating provider may be restricted, or may be
1 19 subject to different copayments, deductibles, or premium
1 20 rates, or may be excluded, provided that a plan shall not
1 21 exclude a provider upon the basis of the license held by the
1 22 provider or the license held by members of the staff or
1 23 hospital.
1 24 For purposes of this section, a rational basis for
1 25 differentiating or excluding a provider shall relate to
1 26 outcome assessments of the provider as indicators of the cost
1 27 of the service to be provided or the effectiveness of the
1 28 service to be provided. For purposes of this section,
1 29 "managed care health plan or indemnity plan with a limited
1 30 provider network" means a health maintenance organization,
1 31 organized delivery system, preferred provider organization,
1 32 exclusive provider organization, point of service plan,
1 33 restricted access network, or similar health plan.
1 34 This section shall not apply if an employer offers
1 35 employees a choice of health plans, either directly or
2 1 indirectly through a health insurance purchasing cooperative,
2 2 provided that the offered choices include at least one
2 3 indemnity plan with unrestricted choice of provider, or at
2 4 least one managed care health plan or indemnity plan with a
2 5 limited provider network which provides access as defined in
2 6 this section.
2 7 A managed care health plan or indemnity plan with a limited
2 8 provider network plan shall demonstrate to such plan's
2 9 regulatory authority that the plan is appropriately serving
2 10 the needs of the population in the service area of the plan
2 11 and that the plan does not discriminate against a type of
2 12 provider upon the basis of the type of license held by the
2 13 provider.
2 14 EXPLANATION
2 15 This bill creates a new section 514C.11 which provides that
2 16 a managed care health plan or indemnity plan with a limited
2 17 provider network is to provide patients with direct access to
2 18 health care providers who are authorized under Title IV,
2 19 subtitle 3, of the Code to utilize differential diagnosis and
2 20 physical examinations to determine human ailments. Access
2 21 provided under the section is not to be conditioned upon a
2 22 referral by a provider licensed under a different chapter.
2 23 The bill provides that access to a specialist may be subject
2 24 to a different copayment or deductible than a primary care
2 25 provider.
2 26 The bill defines a managed care plan or indemnity plan with
2 27 a limited provider network as a health maintenance
2 28 organization, organized delivery system, preferred provider
2 29 organization, exclusive provider organization, point of
2 30 service plan, restricted access network, or similar health
2 31 plan.
2 32 The bill provides that the requirement to provide access
2 33 does not apply if an employer offers employees a choice of
2 34 health plans, either directly or indirectly through a health
2 35 insurance purchasing cooperative, and one of the plans offered
3 1 includes unrestricted choice of provider, or one with a
3 2 limited provider network which provides access as provided in
3 3 section 514C.11.
3 4 LSB 2294HC 76
3 5 mj/sc/14
Text: HSB00232 Text: HSB00234 Text: HSB00200 - HSB00299 Text: HSB Index Bills and Amendments: General Index Bill History: General Index
Iowa General Assembly
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