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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