Text: H08317 Text: H08319 Text: H08300 - H08399 Text: H Index Bills and Amendments: General Index Bill History: General Index
PAG LIN
1 1 Amend House File 2517 as follows:
1 2 #1. Page 13, by inserting after line 26 the
1 3 following:
1 4 "Sec. . NEW SECTION. 514J.1 TITLE.
1 5 This chapter shall be known and may be cited as
1 6 "Third-party Payor Liability Act".
1 7 Sec. . NEW SECTION. 514J.2 DEFINITIONS.
1 8 As used in this chapter, unless the context
1 9 otherwise requires:
1 10 1. "Appropriate and medically necessary" means the
1 11 standard for health care services as determined by a
1 12 physician or health care provider consistent with
1 13 accepted practices and standards of care provided by
1 14 the medical profession in the community.
1 15 2. "Enrollee" means an individual who is enrolled
1 16 in a health care plan, including covered dependents.
1 17 3. "Health care plan" means a plan under which a
1 18 person undertakes to provide, arrange for, pay for, or
1 19 reimburse any part of the cost of any health care
1 20 services.
1 21 4. "Health care provider" means a person licensed
1 22 or certified under chapter 147, 148, 148A, 148C, 149,
1 23 150, 150A, 151, 152, 153, 154, 154B, or 155A to
1 24 provide in this state professional health care service
1 25 to an individual during that individual's medical
1 26 care, treatment, or confinement.
1 27 5. "Health care treatment decision" means a
1 28 determination made when medical services are actually
1 29 provided by the health care plan and a decision which
1 30 affects the quality of the diagnosis, care, or
1 31 treatment provided to the plan's insureds or
1 32 enrollees.
1 33 6. "Health insurance carrier" means an entity
1 34 subject to the insurance laws and regulations of this
1 35 state, or subject to the jurisdiction of the
1 36 commissioner of insurance, that contracts or offers to
1 37 contract, or that subcontracts or offers to
1 38 subcontract, to provide, deliver, arrange for, pay
1 39 for, or reimburse any of the costs of health care
1 40 services, including an insurance company offering
1 41 sickness and accident plans, a health maintenance
1 42 organization, a nonprofit health service corporation,
1 43 or any other entity providing a plan of health
1 44 insurance, health benefits, or health services.
1 45 7. "Health maintenance organization" means a
1 46 health maintenance organization as defined in section
1 47 514B.1.
1 48 8. "Insured" means an individual who is covered by
1 49 a health care plan provided by a health insurance
1 50 carrier.
2 1 9. "Managed care entity" means an entity that
2 2 provides a health care plan that selects and contracts
2 3 with health care providers; manages and coordinates
2 4 health care delivery; monitors necessity,
2 5 appropriateness, and quality of health care delivered
2 6 by health care providers; and performs utilization
2 7 review and cost control.
2 8 10. "Ordinary care" means, in the case of a third-
2 9 party payor, that degree of care that a third-party of
2 10 ordinary prudence would provide under the same or
2 11 similar circumstances. In the case of a person who is
2 12 an employee, agent, or representative of a third-party
2 13 payor, "ordinary care" means that degree of care that
2 14 a person of ordinary prudence in the same profession,
2 15 specialty, or area of practice as such person would
2 16 use in the same or similar circumstances.
2 17 11. "Organized delivery system" means an organized
2 18 delivery system as licensed by the director of public
2 19 health.
2 20 12. "Physician" means an individual licensed under
2 21 the provisions of chapter 148, 150, or 150A to
2 22 practice medicine and surgery, osteopathy, or
2 23 osteopathic medicine and surgery.
2 24 13. "Third-party payor" means a health insurance
2 25 carrier, health maintenance organization, managed care
2 26 entity, or organized delivery system.
2 27 Sec. . NEW SECTION. 514J.3 THIRD-PARTY PAYOR
2 28 LIABILITY.
2 29 1. A third-party payor has the duty to exercise
2 30 ordinary care when making health care treatment
2 31 decisions and is liable for damages for harm to an
2 32 insured or enrollee proximately caused by the third-
2 33 party payor's failure to exercise such ordinary care.
2 34 2. A third-party payor is also liable for damages
2 35 for harm to an insured or enrollee proximately caused
2 36 by the health care treatment decisions made by an
2 37 employee, agent, or representative of the third-party
2 38 payor who is acting on behalf of the third-party payor
2 39 and over whom the third-party payor has the right to
2 40 exercise influence or control or has actually
2 41 exercised influence or control if such decision
2 42 results in the failure to exercise ordinary care.
2 43 3. It is a defense in an action brought pursuant
2 44 to this section against a third-party payor that
2 45 neither the third-party payor, nor an employee, agent,
2 46 or representative of the third-party payor controlled,
2 47 influenced, or participated in the health care
2 48 treatment decision; or that the third-party payor did
2 49 not deny or delay payment for any treatment prescribed
2 50 or recommended by a health care provider to the
3 1 insured or enrollee.
3 2 4. Subsections 1 and 2 do not create an obligation
3 3 on the part of the third-party payor to provide
3 4 treatment to an insured or enrollee which is not
3 5 covered by the health care plan offered by the third-
3 6 party payor.
3 7 5. This chapter does not create any liability on
3 8 the part of an employer, or an employer group
3 9 purchasing organization that purchases coverage or
3 10 assumes risk on behalf of its employees.
3 11 6. A third-party payor shall not remove a
3 12 physician or health care provider from its plan or
3 13 refuse to renew the physician or health care provider
3 14 under its plan for advocating appropriate and
3 15 medically necessary health care for the insured or
3 16 enrollee.
3 17 7. A third-party payor shall not enter into a
3 18 contract with a physician, hospital, or other health
3 19 care provider or pharmaceutical company which includes
3 20 an indemnification or hold harmless clause for the
3 21 acts or conduct of the third-party payor. Any such
3 22 indemnification or hold harmless clause in an existing
3 23 contract is void.
3 24 8. A provision under state law prohibiting a
3 25 third-party payor from practicing medicine or being
3 26 licensed to practice medicine shall not be asserted as
3 27 a defense by such third-party payor in an action
3 28 brought against it pursuant to this section or any
3 29 other applicable law.
3 30 9. In an action against a third-party payor, a
3 31 finding that a physician or other health care provider
3 32 is an employee, agent, or representative of such
3 33 third-party payor shall not be based solely on proof
3 34 that such person's name appears in a listing of
3 35 approved physicians or health care providers made
3 36 available to an insured or enrollee under a health
3 37 care plan.
3 38 10. This chapter does not apply to workers'
3 39 compensation coverage."
3 40 #2. Title page, line 1, by inserting after the
3 41 word "Act" the following: "relating to insurance and
3 42 consumers of insurance including the duties of certain
3 43 insurers to consumers and including".
3 44
3 45
3 46
3 47 JOCHUM of Dubuque
3 48 HF 2517.506 77
3 49 pf/jw/28
Text: H08317 Text: H08319 Text: H08300 - H08399 Text: H Index Bills and Amendments: General Index Bill History: General Index
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