Text: SF00280 Text: SF00282 Text: SF00200 - SF00299 Text: SF 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 A managed care health plan or indemnity plan with a limited
1 5 provider network shall provide patients direct access to each
1 6 type of provider that has authority under Title IV to utilize
1 7 differential diagnosis and physical examinations to determine
1 8 human ailments, and shall not condition that access upon a
1 9 referral by a provider licensed under another chapter.
1 10 Referral to a specialist may be conditioned upon referral by a
1 11 primary care provider licensed under the same chapter. Any
1 12 copayment, deductible, or premium rate shall not discriminate
1 13 upon the basis of the license held by a provider but may
1 14 differentiate or exclude providers upon a rational basis.
1 15 Access to a specialist may be subject to a different copayment
1 16 or deductible than access to a primary care provider. Access
1 17 to a nonparticipating provider may be restricted, or may be
1 18 subject to different copayments, deductibles, or premium
1 19 rates, or may be excluded, provided that a plan shall not
1 20 exclude a provider upon the basis of the license held by the
1 21 provider or the license held by members of the staff or
1 22 hospital.
1 23 For purposes of this section, a rational basis for
1 24 differentiating or excluding a provider shall relate to
1 25 outcome assessments of the provider as indicators of the cost
1 26 of the service to be provided or the effectiveness of the
1 27 service to be provided. For purposes of this section,
1 28 "managed care health plan or indemnity plan with a limited
1 29 provider network" means a health maintenance organization,
1 30 organized delivery system, preferred provider organization,
1 31 exclusive provider organization, point of service plan,
1 32 restricted access network, or similar health plan.
1 33 This section shall not apply if an employer offers
1 34 employees a choice of health plans, either directly or
1 35 indirectly through a health insurance purchasing cooperative,
2 1 provided that the offered choices include at least one
2 2 indemnity plan with unrestricted choice of provider, or at
2 3 least one managed care health plan or indemnity plan with a
2 4 limited provider network which provides access as defined in
2 5 this section.
2 6 EXPLANATION
2 7 This bill creates new section 514C.11 and provides that a
2 8 health maintenance organization, organized delivery system,
2 9 preferred provider organization, exclusive provider
2 10 organization, point of service plan, restricted access
2 11 network, or similar plan, with a limited provider network must
2 12 provide patients direct access to each type of provider
2 13 licensed under Title IV, which relates to public health and
2 14 health care providers, to utilize differential diagnosis and
2 15 physical examinations to determine human ailments. Certain
2 16 restrictions and conditions are applicable to the utilization
2 17 of health care providers who are not part of the restricted
2 18 provider network. The bill does not apply if an employer
2 19 offers employees a choice of health plans, provided that at
2 20 least one of the plans offers an unrestricted choice of
2 21 provider, or at least one plan which provides access as
2 22 defined in section 514C.11.
2 23 LSB 2242XS 76
2 24 mj/jj/8.1
Text: SF00280 Text: SF00282 Text: SF00200 - SF00299 Text: SF Index Bills and Amendments: General Index Bill History: General Index
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