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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, and shall not condition that access upon a referral by
1 9 a physician licensed under another chapter. Access to a
1 10 specialist may be conditioned upon a referral by a primary
1 11 care provider licensed under the same chapter. Any copayment,
1 12 deductible, cost containment mechanism, or premium rate shall
1 13 not discriminate directly or indirectly upon the basis of the
1 14 license held by the physician. Access to a specialist may be
1 15 subject to a different copayment or deductible than access to
1 16 a primary care provider. Access to a nonparticipating
1 17 physician may be restricted or may be subject to different
1 18 copayments, deductibles, or premium rates, or may be excluded,
1 19 provided that a plan shall not differentiate or exclude a
1 20 physician directly or indirectly upon the basis of the license
1 21 held by the physician.
1 22 Each plan must demonstrate that it is capable of serving
1 23 appropriately the needs of the subscriber population in the
1 24 service area of the plan with regard to patient access to each
1 25 type of physician.
1 26 For purposes of this section, "managed care health plan or
1 27 indemnity plan with a limited provider network" means a health
1 28 maintenance organization, organized delivery system,
1 29 accountable health plan, health care insurance plan which
1 30 limits the number of licensed physicians who can provide
1 31 services under the plan, preferred provider organization,
1 32 exclusive provider organization, restricted access network, or
1 33 similar health-care plan. For purposes of this section,
1 34 "physician" means physician as defined in section 135.1 and
1 35 licensed under chapter 148, 150A, or 151.
2 1 EXPLANATION
2 2 This bill creates a new section 514C.11 which provides that
2 3 a managed care health plan or indemnity plan with a limited
2 4 provider network is to provide patients direct access to each
2 5 type of physician, as defined in section 135.1 and licensed
2 6 under chapter 148, 150A, or 151. The access required pursuant
2 7 to this section is not to be conditioned upon a referral by a
2 8 physician licensed under another chapter. Access to a
2 9 specialist may be conditioned upon a referral by a primary
2 10 care provider licensed under the same chapter. A copayment,
2 11 deductible, cost containment mechanism, or premium rate under
2 12 such plan shall not discriminate directly or indirectly upon
2 13 the basis of the license held by a physician. Access to a
2 14 specialist may be subject to a different copayment or
2 15 deductible than access to a primary care provider. Access to
2 16 a nonparticipating physician under such plan may be restricted
2 17 or may be subject to different copayments, deductibles, or
2 18 premium rates, or may be excluded under the plan, so long as
2 19 the differentiation or exclusion is not upon the basis of the
2 20 license held by the physician.
2 21 The bill requires that each plan demonstrate that it
2 22 appropriately serves the needs of the subscriber population in
2 23 the service area of the plan with regard to patient access to
2 24 physicians of each type.
2 25 LSB 3432XC 76
2 26 mj/jw/5
Text: SSB02093 Text: SSB02095 Text: SSB02000 - SSB02099 Text: SSB Index Bills and Amendments: General Index Bill History: General Index
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