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PAG LIN
1 1 Section 1. NEW SECTION. 13.35 HEALTH EDUCATION AND
1 2 ADVOCACY PROGRAM ESTABLISHED.
1 3 1. A health education and advocacy program is established
1 4 in the department of justice which shall do all of the
1 5 following:
1 6 a. Assist health care consumers to make more informed
1 7 choices in the health care marketplace, and to be able to
1 8 participate in decisions concerning the consumers' health
1 9 care.
1 10 b. Promote the interest of health care consumers in this
1 11 state in the health care marketplace.
1 12 2. a. The program shall provide assistance to health care
1 13 consumers for all of the following:
1 14 (1) Understanding their health care bills and third-party
1 15 coverage.
1 16 (2) Identifying improper billing or coverage
1 17 determinations.
1 18 (3) Reporting billing or coverage problems to appropriate
1 19 entities, including the attorney general, insurance division,
1 20 or other appropriate government agencies.
1 21 b. If a billing or coverage issue concerns the adequacy or
1 22 propriety of a service or treatment, the program shall refer
1 23 the matter to an appropriate professional, licensing, or
1 24 disciplinary body, as applicable. The program shall monitor
1 25 the progress of the concerns raised by health care consumers
1 26 through the referrals.
1 27 c. If a billing or coverage issue concerns a matter within
1 28 the jurisdiction of the commissioner of insurance, the program
1 29 shall refer the matter to the commissioner. The program shall
1 30 monitor the progress of the concerns raised by health care
1 31 consumers through the referrals.
1 32 d. The program shall work with the appropriate state
1 33 agency to assist with the resolution of billing or coverage
1 34 questions as necessary.
1 35 3. a. The program shall recommend to the attorney
2 1 general, the governor, the general assembly, or any other
2 2 appropriate state agency, any measure that will promote the
2 3 interests of health care consumers in the health marketplace.
2 4 b. The program shall present for consideration relevant
2 5 information on the effects of the program on health care
2 6 consumers generally in any agency proceeding open to the
2 7 public.
2 8 Sec. 2. NEW SECTION. 514I.1 TITLE.
2 9 This chapter shall be known and may be cited as the
2 10 "Consumer Health Insurance Protection Act".
2 11 Sec. 3. NEW SECTION. 514I.2 DEFINITION.
2 12 "Insurer" means any insurer issuing an individual or group
2 13 accident and sickness insurance policy on an expense-incurred
2 14 basis and any individual or group hospital or medical service
2 15 contract issued pursuant to chapter 509, 514, or 514A, or any
2 16 individual or group health maintenance organization contract
2 17 under chapter 514B, or any organized delivery system licensed
2 18 by the department of public health or any other person
2 19 providing a plan of health insurance subject to state
2 20 regulation.
2 21 Sec. 4. NEW SECTION. 514I.3 REQUIRED DISCLOSURE.
2 22 1. An insurer shall make disclosure in solicitation and
2 23 sales materials provided to the general public of any
2 24 provisions in a policy or contract relating to the following:
2 25 a. Preexisting condition provision.
2 26 b. Renewability of coverage.
2 27 c. Preauthorization of covered services, the person
2 28 conducting the preauthorization, the address and telephone
2 29 number of the person conducting the preauthorization, the
2 30 average time for such preauthorization to be completed, and
2 31 the annual percentage of preauthorizations which are declined.
2 32 d. An appeals procedure related to such preauthorization.
2 33 e. A restricted network provision or any exceptions to
2 34 services or providers which are not covered under the policy
2 35 or contract, as applicable.
3 1 f. The number of insureds or subscribers per physician, if
3 2 applicable.
3 3 g. The annual percentage of claims or expenses denied, as
3 4 appropriate.
3 5 h. An appeals procedure for claims and expenses which are
3 6 denied.
3 7 i. Incentives, financial or otherwise, for controlling
3 8 costs which are offered to providers who are reimbursed under
3 9 the policy or contract.
3 10 2. An insurer shall also disclose the information
3 11 identified in subsection 1 to an insured, enrollee, or
3 12 subscriber at the time of purchase and renewal of a policy or
3 13 contract.
3 14 3. a. An insurer shall annually disclose to the
3 15 commissioner of insurance and to each insured, enrollee, or
3 16 subscriber all of the following:
3 17 (1) The cumulative loss ratio for each class of policy or
3 18 contract offered by the insurer. The loss ratio is determined
3 19 on the basis of incurred claims and earned premiums for all
3 20 calculating or rating periods. However, where coverage under
3 21 a policy or contract is provided on a direct service rather
3 22 than indemnity basis, the loss ratio is determined on the
3 23 basis of incurred health care expenses and earned premiums for
3 24 such period. An insurer shall provide an explanation,
3 25 approved by the commissioner, which defines or describes the
3 26 cumulative loss ratio in such terms as to render the
3 27 explanation likely to be understood by an ordinary consumer.
3 28 (2) The annual percentage of claims or expenses denied, as
3 29 appropriate.
3 30 b. Information disclosed pursuant to this subsection shall
3 31 be updated at least annually pursuant to rules adopted by the
3 32 commissioner.
3 33 c. Information required to be disclosed to an insured,
3 34 enrollee, or subscriber pursuant to this section shall be
3 35 included in each billing statement of the insured, enrollee,
4 1 or subscriber.
4 2 Sec. 5. NEW SECTION. 514I.4 STANDARDS FOR LOSS RATIOS &endash;
4 3 HEALTH MAINTENANCE ORGANIZATIONS AND ORGANIZED DELIVERY
4 4 SYSTEMS.
4 5 A health maintenance organization and an organized delivery
4 6 system subject to this chapter shall return a cumulative loss
4 7 ratio of at least eighty-five percent. The loss ratio is on
4 8 the basis of incurred claims and earned income for coverage
4 9 provided by the health maintenance organization or organized
4 10 delivery system for all calculating or rating periods such
4 11 that the cumulative loss ratio from inception equals or
4 12 exceeds the eighty-five percent minimum loss ratio. Where
4 13 coverage is provided on a direct service rather than indemnity
4 14 basis, the loss ratio is on the basis of incurred health care
4 15 expenses and earned premiums for such period. For purposes of
4 16 achieving and maintaining the minimum cumulative loss ratio,
4 17 the experience of all contracts of a health maintenance
4 18 organization or organized delivery system is combined.
4 19 Sec. 6. NEW SECTION. 514I.5 USE OF PREMIUMS FOR
4 20 POLITICAL PURPOSES PROHIBITED.
4 21 An insurer subject to this chapter shall not expend or use
4 22 any amount of premium income received by the insurer for a
4 23 political purpose as defined in section 56.2, for the payment
4 24 of compensation to a lobbyist as defined in section 68B.2, or
4 25 for payment of expenses associated with any political
4 26 advertisement or the distribution of other political material.
4 27 Sec. 7. NEW SECTION. 514I.6 COMPLAINT PROCEDURE &endash;
4 28 APPROVAL BY COMMISSIONER.
4 29 1. An insurer subject to this chapter shall establish a
4 30 consumer response procedure for the purpose of responding to
4 31 consumer questions and complaints. An insurer shall file a
4 32 plan for establishing its procedure, or a proposal to change
4 33 its procedure, with the commissioner. The commissioner shall
4 34 review the procedure to ensure that the procedure will protect
4 35 the interests of insureds, enrollees, or subscribers and will
5 1 provide for an expeditious resolution or response to an
5 2 insured, enrollee, or subscriber.
5 3 2. The commissioner shall review the proposed procedure as
5 4 soon as possible after receipt of the proposal and shall
5 5 approve or disapprove the procedure. The commissioner shall
5 6 notify the insurer in writing of the approval or disapproval.
5 7 If approved the commissioner shall direct the insurer to
5 8 implement the procedure as soon as possible and shall, in
5 9 consultation with the insurer, establish a date by which the
5 10 procedure shall be in operation. If disapproved, the
5 11 commissioner shall include in the notification to the insurer
5 12 any objection of the commissioner which resulted in the
5 13 disapproval and direct the insurer to resubmit its proposal
5 14 after modification in response to such objection.
5 15 Sec. 8. NEW SECTION. 514I.7 PREAUTHORIZATION
5 16 REQUIREMENTS.
5 17 An insurer subject to this chapter which requires
5 18 preauthorization for covered services shall establish and
5 19 maintain a telephone line, which shall be available on a
5 20 twenty-four hour a day, seven-day a week basis for the purpose
5 21 of providing preauthorization to insureds, enrollees, or
5 22 subscribers. The insurer shall assure that appropriate
5 23 individuals are available to respond to preauthorization
5 24 requests received as a result of maintaining this telephone
5 25 line and assure that such requests receive a prompt response
5 26 and resolution, which response time in no case shall be longer
5 27 than twenty-four hours, pursuant to rules adopted by the
5 28 commissioner of insurance.
5 29 EXPLANATION
5 30 This bill establishes a health education and advocacy
5 31 program in the department of justice to assist health care
5 32 consumers to make more informed health care decisions and to
5 33 promote the interests of health care consumers in this state.
5 34 The program is to help consumers understand their health care
5 35 bills, identify improper billing or coverage determinations,
6 1 and report billing or coverage problems. The program is to
6 2 make recommendations to the attorney general, governor,
6 3 general assembly, or other appropriate state agency, which
6 4 will promote the interest of health care consumers.
6 5 The bill creates new chapter 514I to be cited as the
6 6 "Consumer Health Insurance Protection Act". The chapter
6 7 applies to any person who provides health insurance or health
6 8 coverage in this state, and includes a licensed insurance
6 9 company, a prepaid hospital or medical service plan, a health
6 10 maintenance organization, or any other person providing a plan
6 11 of health insurance subject to state insurance regulation.
6 12 The bill requires an insurer to disclose certain
6 13 information in the insurer's solicitation and sales materials,
6 14 and at the time a person purchases or renews a policy or
6 15 contract. The disclosure is to include policy or contract
6 16 information relating to any preexisting condition provision,
6 17 renewability of coverage, preauthorization of covered
6 18 services, the person conducting the preauthorization, and the
6 19 average time for such preauthorization to be completed, an
6 20 appeals procedure related to such preauthorization, a
6 21 restricted network provision, if applicable, the number of
6 22 insureds, enrollees, or subscribers per physician, if
6 23 applicable, the annual percentage of claims denied, and any
6 24 incentives, financial or otherwise, for controlling costs
6 25 through the use of less costly treatment alternatives. An
6 26 insurer is also required to annually disclose its cumulative
6 27 loss ratio and annual percentage of claims or expenses denied
6 28 to the insurance commissioner and each insured, enrollee, or
6 29 subscriber.
6 30 The bill provides that an insurer is to return a cumulative
6 31 loss ratio of at least 85 percent, based on incurred claims or
6 32 health care expenses and earned premiums for all calculating
6 33 or rating periods.
6 34 The bill prohibits the use by an insurer of any premium
6 35 income for a political purpose as defined in section 56.2, for
7 1 payment of compensation of a lobbyist as defined in section
7 2 68B.2, or for expenses associated with any political
7 3 advertisement or the distribution of other political material.
7 4 The bill also requires an insurer to establish a consumer
7 5 response procedure for the purpose of responding to consumer
7 6 questions and complaints.
7 7 LSB 2270XC 76
7 8 mj/cf/24
Text: SSB00210 Text: SSB00212 Text: SSB00200 - SSB00299 Text: SSB Index Bills and Amendments: General Index Bill History: General Index
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