Text: SF02388 Text: SF02390 Text: SF02300 - SF02399 Text: SF Index Bills and Amendments: General Index Bill History: General Index
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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 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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