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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 to a physician licensed under chapter 151 is
2 15 not to be conditioned upon a referral by a physician licensed
2 16 under another chapter. Access to a specialist may be
2 17 conditioned upon a referral by a primary care provider
2 18 licensed under chapter 148, 150A, or 151. If a physician
2 19 licensed under chapter 151 makes a determination that a
2 20 patient should be referred to a physician licensed under a
2 21 different chapter, the managed care health plan or indemnity
2 22 plan with a limited provider network may require the referral
2 23 to be made first to a provider designated by the plan. A
2 24 copayment, deductible, cost containment mechanism, or premium
2 25 rate under such plan shall not discriminate directly or
2 26 indirectly upon the basis of the license held by a physician.
2 27 Access to a specialist may be subject to a different copayment
2 28 or deductible than access to a primary care provider. Access
2 29 to a nonparticipating physician under such plan may be
2 30 restricted or may be subject to different copayments,
2 31 deductibles, or premium rates, or may be excluded under the
2 32 plan, so long as the differentiation or exclusion is not upon
2 33 the basis of the license held by the physician.
2 34 The bill requires that each plan demonstrate that it
2 35 appropriately serves the needs of the subscriber population in
3 1 the service area of the plan with regard to patient access to
3 2 physicians of each type.
3 3 LSB 3432SV 76
3 4 mj/jw/5
Text: SF02388 Text: SF02390 Text: SF02300 - SF02399 Text: SF Index Bills and Amendments: General Index Bill History: General Index
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