Text: H08922 Text: H08924 Text: H08900 - H08999 Text: H Index Bills and Amendments: General Index Bill History: General Index
PAG LIN 1 1 Amend Senate File 2410 as amended, passed, and 1 2 reprinted by the Senate, as follows: 1 3 #1. Page 82, by inserting after line 2 the 1 4 following: 1 5 "Sec. . NEW SECTION. 514J.1 TITLE. 1 6 This chapter shall be known and may be cited as 1 7 "Third-party Payor Liability Act". 1 8 Sec. . NEW SECTION. 514J.2 DEFINITIONS. 1 9 As used in this chapter, unless the context 1 10 otherwise requires: 1 11 1. "Appropriate and medically necessary" means the 1 12 standard for health care services as determined by a 1 13 physician or health care provider consistent with 1 14 accepted practices and standards of care provided by 1 15 the medical profession in the community. 1 16 2. "Enrollee" means an individual who is enrolled 1 17 in a health care plan, including covered dependents. 1 18 3. "Health care plan" means a plan under which a 1 19 person undertakes to provide, arrange for, pay for, or 1 20 reimburse any part of the cost of any health care 1 21 services. 1 22 4. "Health care provider" means a person licensed 1 23 or certified under chapter 147, 148, 148A, 148C, 149, 1 24 150, 150A, 151, 152, 153, 154, 154B, or 155A to 1 25 provide in this state professional health care service 1 26 to an individual during that individual's medical 1 27 care, treatment, or confinement. 1 28 5. "Health care treatment decision" means a 1 29 determination made when medical services are actually 1 30 provided by the health care plan and a decision which 1 31 affects the quality of the diagnosis, care, or 1 32 treatment provided to the plan's insureds or 1 33 enrollees. 1 34 6. "Health insurance carrier" means an entity 1 35 subject to the insurance laws and regulations of this 1 36 state, or subject to the jurisdiction of the 1 37 commissioner of insurance, that contracts or offers to 1 38 contract, or that subcontracts or offers to 1 39 subcontract, to provide, deliver, arrange for, pay 1 40 for, or reimburse any of the costs of health care 1 41 services, including an insurance company offering 1 42 sickness and accident plans, a health maintenance 1 43 organization, a nonprofit health service corporation, 1 44 or any other entity providing a plan of health 1 45 insurance, health benefits, or health services. 1 46 7. "Health maintenance organization" means a 1 47 health maintenance organization as defined in section 1 48 514B.1. 1 49 8. "Insured" means an individual who is covered by 1 50 a health care plan provided by a health insurance 2 1 carrier. 2 2 9. "Managed care entity" means an entity that 2 3 provides a health care plan that selects and contracts 2 4 with health care providers; manages and coordinates 2 5 health care delivery; monitors necessity, 2 6 appropriateness, and quality of health care delivered 2 7 by health care providers; and performs utilization 2 8 review and cost control. 2 9 10. "Ordinary care" means, in the case of a third- 2 10 party payor, that degree of care that a third-party of 2 11 ordinary prudence would provide under the same or 2 12 similar circumstances. In the case of a person who is 2 13 an employee, agent, or representative of a third-party 2 14 payor, "ordinary care" means that degree of care that 2 15 a person of ordinary prudence in the same profession, 2 16 specialty, or area of practice as such person would 2 17 use in the same or similar circumstances. 2 18 11. "Organized delivery system" means an organized 2 19 delivery system as licensed by the director of public 2 20 health. 2 21 12. "Physician" means an individual licensed under 2 22 the provisions of chapter 148, 150, or 150A to 2 23 practice medicine and surgery, osteopathy, or 2 24 osteopathic medicine and surgery. 2 25 13. "Third-party payor" means a health insurance 2 26 carrier, health maintenance organization, managed care 2 27 entity, or organized delivery system. 2 28 Sec. . NEW SECTION. 514J.3 THIRD-PARTY PAYOR 2 29 LIABILITY. 2 30 1. A third-party payor has the duty to exercise 2 31 ordinary care when making health care treatment 2 32 decisions and is liable for damages for harm to an 2 33 insured or enrollee proximately caused by the third- 2 34 party payor's failure to exercise such ordinary care. 2 35 2. A third-party payor is also liable for damages 2 36 for harm to an insured or enrollee proximately caused 2 37 by the health care treatment decisions made by an 2 38 employee, agent, or representative of the third-party 2 39 payor who is acting on behalf of the third-party payor 2 40 and over whom the third-party payor has the right to 2 41 exercise influence or control or has actually 2 42 exercised influence or control if such decision 2 43 results in the failure to exercise ordinary care. 2 44 3. It is a defense in an action brought pursuant 2 45 to this section against a third-party payor that 2 46 neither the third-party payor, nor an employee, agent, 2 47 or representative of the third-party payor controlled, 2 48 influenced, or participated in the health care 2 49 treatment decision; or that the third-party payor did 2 50 not deny or delay payment for any treatment prescribed 3 1 or recommended by a health care provider to the 3 2 insured or enrollee. 3 3 4. Subsections 1 and 2 do not create an obligation 3 4 on the part of the third-party payor to provide 3 5 treatment to an insured or enrollee which is not 3 6 covered by the health care plan offered by the third- 3 7 party payor. 3 8 5. This chapter does not create any liability on 3 9 the part of an employer, or an employer group 3 10 purchasing organization that purchases coverage or 3 11 assumes risk on behalf of its employees. 3 12 6. A third-party payor shall not remove a 3 13 physician or health care provider from its plan or 3 14 refuse to renew the physician or health care provider 3 15 under its plan for advocating appropriate and 3 16 medically necessary health care for the insured or 3 17 enrollee. 3 18 7. A third-party payor shall not enter into a 3 19 contract with a physician, hospital, or other health 3 20 care provider or pharmaceutical company which includes 3 21 an indemnification or hold harmless clause for the 3 22 acts or conduct of the third-party payor. Any such 3 23 indemnification or hold harmless clause in an existing 3 24 contract is void. 3 25 8. A provision under state law prohibiting a 3 26 third-party payor from practicing medicine or being 3 27 licensed to practice medicine shall not be asserted as 3 28 a defense by such third-party payor in an action 3 29 brought against it pursuant to this section or any 3 30 other applicable law. 3 31 9. In an action against a third-party payor, a 3 32 finding that a physician or other health care provider 3 33 is an employee, agent, or representative of such 3 34 third-party payor shall not be based solely on proof 3 35 that such person's name appears in a listing of 3 36 approved physicians or health care providers made 3 37 available to an insured or enrollee under a health 3 38 care plan. 3 39 10. This chapter does not apply to workers' 3 40 compensation coverage." 3 41 #2. By renumbering as necessary. 3 42 3 43 3 44 3 45 OSTERHAUS of Jackson 3 46 3 47 3 48 3 49 JOCHUM of Dubuque 3 50 4 1 4 2 4 3 BURNETT of Story 4 4 4 5 4 6 4 7 FOEGE of Linn 4 8 SF 2410.712 77 4 9 pf/sc/28
Text: H08922 Text: H08924 Text: H08900 - H08999 Text: H Index Bills and Amendments: General Index Bill History: General Index
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