Text: HF02419 Text: HF02421 Text: HF02400 - HF02499 Text: HF Index Bills and Amendments: General Index Bill History: General Index
PAG LIN
1 1 Section 1. NEW SECTION. 514I.1 TITLE.
1 2 This Act shall be known and may be cited as the "Managed
1 3 Care Consumer Protection Act".
1 4 Sec. 2. NEW SECTION. 514I.2 PURPOSE AND INTENT.
1 5 The purpose of this chapter is to ensure that enrollees
1 6 receive adequate health care services under a managed care
1 7 system. The intent of this chapter is to ensure all of the
1 8 following:
1 9 1. That enrollees have full and timely access to
1 10 clinically and culturally appropriate health care personnel
1 11 and facilities.
1 12 2. That enrollees have adequate choice among health care
1 13 professionals who are accessible and qualified.
1 14 3. Open communication between physicians and enrollees.
1 15 4. That enrollees have access to comprehensive
1 16 pharmaceutical services.
1 17 5. That enrollees have access to information regarding
1 18 limits on coverage for experimental treatments.
1 19 6. High quality care within a managed care plan.
1 20 7. Medical decisions are made by the appropriate medical
1 21 personnel.
1 22 8. That health care professionals within a plan are
1 23 practitioners in good standing.
1 24 9. That managed care plan data is available as
1 25 appropriate.
1 26 10. Full public access to information regarding health
1 27 care service delivery within a managed care plan.
1 28 11. State authority to oversee all managed care plans.
1 29 12. Sufficient and timely enrollee grievance and appeal
1 30 procedures.
1 31 Sec. 3. NEW SECTION. 514I.3 DEFINITIONS.
1 32 As used in this chapter, unless the context otherwise
1 33 requires:
1 34 1. "Appeal" means a formal process which an enrollee whose
1 35 care has been reduced, denied, or terminated, or who deems the
2 1 care inappropriate, can contest an adverse grievance decision
2 2 by the managed care plan.
2 3 2. "Emergency" means a medical condition, the onset of
2 4 which is sudden and unexpected, that manifests itself by
2 5 symptoms of sufficient severity that a prudent person who
2 6 possesses an average knowledge of health and medicine could
2 7 reasonably assume that the condition requires immediate
2 8 medical treatment and could expect the absence of medical
2 9 attention to result in serious impairment to bodily functions
2 10 or place the person's health in serious jeopardy.
2 11 3. "Enrollee" means an individual who is enrolled in a
2 12 managed care plan.
2 13 4. "Expedited review" means a review process which takes
2 14 no more than seventy-two hours.
2 15 5. "Experimental treatment" means treatment, while not
2 16 commonly used for a particular condition or illness, that
2 17 nevertheless is recognized for treatment of the particular
2 18 condition or illness, and there is no clearly superior,
2 19 nonexperimental treatment alternative available to the
2 20 enrollee.
2 21 6. "Grievance" means a written complaint submitted by or
2 22 on behalf of an enrollee.
2 23 7. "Health care provider" means a clinic, hospital,
2 24 physician organization, preferred provider organization,
2 25 independent practice association, or other appropriately
2 26 licensed provider of health care services or supplies.
2 27 8. "Health care professional" means a licensed physician
2 28 or other licensed health care practitioner providing health
2 29 care services.
2 30 9. "Health care services" means services for the
2 31 diagnosis, prevention, or treatment of a health condition,
2 32 illness, injury, or disease.
2 33 10. "Managed care entity" means a person or entity that
2 34 establishes, operates, or maintains a network of participating
2 35 health care professionals, including a licensed insurance
3 1 company, hospital or medical service plan, health maintenance
3 2 organization, limited health services organization, preferred
3 3 provider organization, or third-party administrator.
3 4 11. "Managed care plan" means a plan operated by a managed
3 5 care entity that provides for the financing and delivery of
3 6 health care services to persons enrolled in the plan, with
3 7 financial incentives for persons enrolled in the plan to use
3 8 the participating practitioners and procedures covered by the
3 9 plan.
3 10 12. "Participating practitioner" means a health care
3 11 professional who has entered into an agreement with a managed
3 12 care entity to provide health care services to enrollees.
3 13 13. "Point of service option" means an option for the
3 14 enrollee to choose to receive service from a nonparticipating
3 15 health care professional or provider.
3 16 14. "Primary care practitioner" means a health care
3 17 professional under contract with a managed care plan, who has
3 18 been designated by the plan to coordinate, supervise, or
3 19 provide ongoing care to an enrollee.
3 20 15. "Prudent person" is a person without specific medical
3 21 training for the illness or condition in question who acts as
3 22 a reasonable person would under similar circumstances.
3 23 16. "Quality assurance" means the ongoing evaluation of
3 24 the quality of health care services provided to enrollees.
3 25 Sec. 4. NEW SECTION. 514I.4 APPLICABILITY AND SCOPE.
3 26 This chapter applies to all managed care entities operating
3 27 within the state.
3 28 Sec. 5. NEW SECTION. 514I.5 ACCESS TO PERSONNEL AND
3 29 FACILITIES.
3 30 1. A managed care plan shall include a sufficient number
3 31 and type of health care professionals and specialists,
3 32 throughout the service area, to meet the needs of enrollees
3 33 and to provide meaningful choice. A managed care plan shall
3 34 demonstrate that it offers all of the following:
3 35 a. An adequate number of accessible acute care hospital
4 1 services, within a reasonable distance or travel time.
4 2 b. An adequate number of accessible participating
4 3 practitioners, within a reasonable distance or travel time.
4 4 Participating practitioners shall include family practice and
4 5 general practice physicians, internists, obstetrician and
4 6 gynecologists, and pediatricians.
4 7 c. An adequate number of accessible specialists and
4 8 subspecialists, within a reasonable distance or travel time.
4 9 When the type of medical specialist needed for a specific
4 10 condition is not represented on a specialty panel, enrollees
4 11 shall have access to nonparticipating health care
4 12 professionals.
4 13 d. The availability of specialty medical services,
4 14 including physical therapy, occupational therapy, and
4 15 rehabilitation services.
4 16 e. The availability of nonpanel specialists, when
4 17 warranted by a patient's unique medical circumstances.
4 18 2. A managed care plan shall provide for continuity of
4 19 care with established participating practitioners, when a
4 20 primary care practitioner's contract is terminated. The plan,
4 21 at no additional out-of-pocket cost, shall allow an enrollee
4 22 to continue receiving services from a primary care
4 23 practitioner whose contract with the plan is terminated
4 24 without cause. Continuation pursuant to this subsection is
4 25 effective for sixty days when the enrollee requests continued
4 26 care.
4 27 3. A managed care plan shall provide telephone access to
4 28 the managed care entity for sufficient time during business
4 29 and evening hours to ensure enrollee access for routine care,
4 30 and twenty-four hour telephone access to either the entity or
4 31 a participating provider or practitioner, for emergency care
4 32 or authorization for care.
4 33 4. A managed care plan shall provide for reasonable
4 34 standards for the waiting time to obtain an appointment for
4 35 health care services, except as otherwise provided for
5 1 emergency services. Such standards shall include appointment
5 2 scheduling guidelines based on the type of health care
5 3 service, including prenatal care appointments, well-child
5 4 visits and immunizations, routine physicals, follow-up
5 5 appointments for chronic conditions, and urgent care.
5 6 5. A managed care plan shall be required to cover and
5 7 reimburse expenses for emergency care obtained, without prior
5 8 authorization, in situations where a prudent person could
5 9 reasonably believe the condition required immediate attention
5 10 at the nearest facility.
5 11 6. A managed care plan shall demonstrate that it has
5 12 developed an access plan to meet the needs of vulnerable and
5 13 underserved populations. The plan shall provide for all of
5 14 the following:
5 15 a. Culturally appropriate services to the greatest extent
5 16 possible.
5 17 b. When a significant number of enrollees in the plan
5 18 speak a first language other than English, the plan shall
5 19 provide access to personnel fluent in languages other than
5 20 English, to the greatest extent possible.
5 21 c. Standards for continuity of care following enrollment,
5 22 including sufficient information on how to access care within
5 23 the plan.
5 24 7. A managed care plan shall hold harmless enrollees
5 25 against claims from participating practitioners in the managed
5 26 care plan for payment of the cost of covered health care
5 27 services.
5 28 Sec. 6. NEW SECTION. 514I.6 CHOICE OF HEALTH CARE
5 29 PROFESSIONAL.
5 30 1. An enrollee shall have adequate choice among
5 31 participating practitioners who are accessible and qualified.
5 32 2. A managed care plan shall permit enrollees to choose
5 33 their own primary care practitioner from a list of
5 34 participating practitioners. The list shall be updated as
5 35 health care professionals are added or removed and shall
6 1 include both of the following:
6 2 a. A sufficient number of participating practitioners who
6 3 are accepting new enrollees.
6 4 b. A sufficient mix of participating practitioners that
6 5 reflect a diversity that is adequate to meet the needs of the
6 6 enrollees' varied characteristics, including age, gender,
6 7 race, and health status.
6 8 3. A managed care entity shall develop a system to permit
6 9 enrollees to use a medical specialist primary care
6 10 practitioner under a managed care plan, when warranted by an
6 11 enrollee's medical condition. This may include enrollees
6 12 suffering from chronic diseases as well as those with other
6 13 special needs.
6 14 4. A managed care plan shall provide continuity of care
6 15 and appropriate referral to specialists within the plan, when
6 16 specialty care is warranted. An enrollee shall have access to
6 17 medical specialists on a timely basis and be provided with a
6 18 choice of specialists when a referral is made.
6 19 5. A managed care entity shall offer in each managed care
6 20 plan a point-of-service option. The point-of-service option
6 21 may require that the enrollee in the plan pay a reasonable
6 22 portion of the costs of such out-of-plan care.
6 23 6. A plan shall provide enrollees with access to a
6 24 consultation for a second opinion.
6 25 Sec. 7. NEW SECTION. 514I.7 GAG RULES.
6 26 1. A managed care entity shall not contract with a
6 27 participating practitioner to limit such practitioner's
6 28 disclosure to an enrollee or on behalf of an enrollee any
6 29 information relating to such enrollee's medical condition or
6 30 treatment options.
6 31 2. A participating practitioner shall not be penalized, or
6 32 such practitioner's contract with the managed care entity
6 33 terminated, because the participating practitioner offers
6 34 referrals, or discusses medically necessary or appropriate
6 35 care with, or on behalf of, the enrollee.
7 1 a. All treatment options may be discussed.
7 2 b. Other information, determined by the participating
7 3 practitioner to be in the best interests of the enrollee, may
7 4 be disclosed.
7 5 3. A participating practitioner shall not be penalized for
7 6 discussing financial incentives and financial arrangements
7 7 between the participating practitioner and the managed care
7 8 entity.
7 9 Sec. 8. NEW SECTION. 514I.8 DRUGS AND DEVICES.
7 10 1. A managed care plan shall provide coverage for all
7 11 drugs and devices approved by the federal food and drug
7 12 administration, whether or not that drug or device has been
7 13 approved for the specific treatment or condition, so long as
7 14 the primary care practitioner or other medical specialist
7 15 treating the enrollee determines the drug or device is
7 16 medically necessary and appropriate for the enrollee's
7 17 condition.
7 18 2. A managed care entity shall establish and operate a
7 19 drug utilization review program that includes both of the
7 20 following:
7 21 a. Retrospective review of prescription drugs furnished to
7 22 enrollees.
7 23 b. Education of physicians, enrollees, and pharmacists
7 24 regarding the appropriate use of prescription drugs.
7 25 3. A managed care entity shall provide for a drug
7 26 utilization review program with ongoing periodic examination
7 27 of data on outpatient prescription drugs to ensure quality
7 28 therapeutic outcomes for enrollees.
7 29 a. The drug utilization review program's primary emphasis
7 30 is to enhance quality of care for enrollees by assuring
7 31 appropriate drug therapy.
7 32 b. The drug utilization review program shall include all
7 33 of the following:
7 34 (1) Clinically relevant criteria and standards for drug
7 35 therapy.
8 1 (2) Nonproprietary criteria and standards, developed and
8 2 revised through an open, professional consensus process.
8 3 (3) Interventions which focus on improving therapeutic
8 4 outcomes.
8 5 4. The managed care entity shall provide for the
8 6 protection of the confidentiality of the relationship between
8 7 enrollees and health care professionals at all times.
8 8 5. A managed care entity shall provide an educational
8 9 outreach program as part of the drug utilization review
8 10 program.
8 11 a. The outreach program shall be directed to enrollees,
8 12 pharmacists, and other health care professionals.
8 13 b. The outreach program shall emphasize the appropriate
8 14 use of prescription drugs.
8 15 6. Prospective review of drug therapy may only deny
8 16 services in cases of enrollee ineligibility, coverage
8 17 limitations, or fraud.
8 18 7. The prescribing participating practitioner shall
8 19 determine the appropriate drug therapy for the enrollee.
8 20 Substitution of a drug as determined by such participating
8 21 practitioner shall not be made without the direct approval of
8 22 the participating practitioner.
8 23 Sec. 9. NEW SECTION. 514I.9 EXPERIMENTAL TREATMENTS.
8 24 1. A managed care plan which limits coverage for health
8 25 care services must define and disclose the limitation in any
8 26 agreement or certificate of coverage. The disclosure must
8 27 include the person who is authorized to make such a
8 28 determination and the criteria the plan uses to determine
8 29 whether a service is experimental.
8 30 2. A managed care entity that denies coverage under a
8 31 managed care plan for an experimental treatment, procedure,
8 32 drug, or device for an enrollee who has a terminal condition
8 33 or illness shall provide the enrollee with a denial letter
8 34 within twenty working days of the date the request is
8 35 submitted. The letter shall include all of the following:
9 1 a. The name and title of the individual making the
9 2 decision.
9 3 b. A statement setting forth the specific medical and
9 4 scientific reasons for denying coverage.
9 5 c. A description of alternative treatment, services, or
9 6 supplies covered by the plan, if any.
9 7 d. A copy of the plan's grievance and appeal procedure.
9 8 Sec. 10. NEW SECTION. 514I.10 QUALITY ASSURANCE PROGRAM.
9 9 1. A managed care entity shall develop comprehensive
9 10 quality assurance standards adequate to identify, evaluate,
9 11 and remedy problems relating to access, continuity, and
9 12 quality of care. These standards shall include all of the
9 13 following:
9 14 a. An ongoing, written, internal quality assurance
9 15 program.
9 16 b. Specific written guidelines for quality of care studies
9 17 and monitoring, including attention to vulnerable populations.
9 18 c. Performance and clinical outcomes-based criteria.
9 19 d. A procedure for remedial action to correct quality
9 20 problems, including written procedures for taking appropriate
9 21 corrective action.
9 22 e. A plan for data gathering and assessment pursuant to
9 23 section 514I.11.
9 24 f. A peer review process.
9 25 2. A managed care entity shall have a process for
9 26 selection of health care professionals who will be on the
9 27 plan's participating practitioner list, with written policies
9 28 and procedures used by the entity for such selection process.
9 29 a. The plan shall establish minimum professional
9 30 requirements.
9 31 b. The plan shall demonstrate that it has consulted with
9 32 appropriately qualified health care professionals to establish
9 33 the requirements.
9 34 c. The plan's process shall include verification of an
9 35 individual participating practitioner's license, history of
10 1 suspension or revocation, and liability claims history.
10 2 d. A managed care entity shall establish a formal,
10 3 written, ongoing process for the reevaluation of all
10 4 participating practitioners within a specified number of years
10 5 after the initial acceptance. A reevaluation shall include
10 6 updates of the previous review criteria and an assessment of
10 7 the performance pattern based on criteria including, but not
10 8 limited to, enrollee clinical outcomes, number of complaints,
10 9 and malpractice actions.
10 10 3. A managed care entity shall not use a participating
10 11 practitioner to provide services outside of such
10 12 practitioner's legally authorized scope of practice.
10 13 Sec. 11. NEW SECTION. 514I.11 DATA SYSTEMS AND
10 14 CONFIDENTIALITY.
10 15 1. A managed care entity shall provide information on a
10 16 managed care plan's structure, decision-making process, health
10 17 care benefits and exclusions, cost and cost-sharing
10 18 requirements, list of participating practitioners, and
10 19 grievance and appeal procedures to a potential enrollee, an
10 20 enrollee covered by the plan, and to the insurance division of
10 21 the department of commerce.
10 22 2. A managed care entity shall collect and report annually
10 23 to the insurance division specific data including the
10 24 following:
10 25 a. Gross outpatient and hospital utilization data.
10 26 b. Enrollee clinical outcome data.
10 27 c. The number and types of enrollee grievances or
10 28 complaints during the year, the status of decisions, and the
10 29 average time required to reach a decision.
10 30 d. The number, amount, and disposition of malpractice
10 31 claims resolved during the year by the managed care entity and
10 32 any of its participating practitioners.
10 33 3. Information required pursuant to subsection 2,
10 34 paragraphs "a" and "b", shall be reported to the insurance
10 35 division and made available to the public on a timely basis.
11 1 4. A managed care entity shall establish written policies
11 2 and procedures for the handling of medical records and
11 3 enrollee communications to ensure enrollee confidentiality.
11 4 5. A managed care entity shall ensure the confidentiality
11 5 of specified enrollee information, including, but not limited
11 6 to, prior medical history, medical record information and
11 7 claims information, except where disclosure of this
11 8 information is required by law.
11 9 6. A managed care entity shall prohibit the release of any
11 10 individual patient record information, unless such a release
11 11 is authorized in writing by the enrollee.
11 12 Sec. 12. NEW SECTION. 514I.12 CLINICAL DECISION MAKING.
11 13 1. A managed care entity shall employ a medical director
11 14 who is a licensed physician in this state. The medical
11 15 director is responsible for treatment policies, protocols,
11 16 quality assurance activities, and utilization management
11 17 decisions of the plan.
11 18 2. A managed care entity shall inform enrollees of the
11 19 financial arrangements between the entity and participating
11 20 practitioners who are physicians and pharmacists, if those
11 21 arrangements include incentives or bonuses for restriction of
11 22 services.
11 23 Sec. 13. NEW SECTION. 514I.13 OVERSIGHT AUTHORITY.
11 24 1. The insurance division in the department of commerce
11 25 shall oversee managed care entities operating within this
11 26 state.
11 27 2. A managed care entity operating in the state must be
11 28 legally authorized by the division.
11 29 3. The division shall perform audits on an annual basis,
11 30 to review enrollee clinical outcome data, enrollee service
11 31 data, operational data, and other financial data, as deemed
11 32 necessary by the division.
11 33 4. The division is not precluded from investigating
11 34 complaints, grievances, or appeals on behalf of enrollees or
11 35 participating practitioners.
12 1 5. The division, by rule, shall establish both of the
12 2 following:
12 3 a. Standards for compliance of managed care plans
12 4 regarding mandated requirements.
12 5 b. Penalties for violations.
12 6 Sec. 14. NEW SECTION. 514I.14 GRIEVANCE PROCEDURES –
12 7 REVIEWS AND APPEALS.
12 8 1. A managed care entity shall establish a grievance
12 9 procedure and provide written notification to enrollees, in a
12 10 language the enrollee understands, regarding the right to file
12 11 a grievance. At a minimum, such notification shall be given
12 12 as follows:
12 13 a. Prior to enrollment in the plan.
12 14 b. At the time care is denied or limited under the plan.
12 15 2. Notice provided as the result of a denial shall be in
12 16 writing and include the reason for denial, the name of the
12 17 individual responsible for the decision, the criteria for
12 18 determination, and notice of the enrollee's right to file a
12 19 grievance.
12 20 3. The grievance procedure shall include all of the
12 21 following:
12 22 a. Identification of the reviewing body and an explanation
12 23 of the process of review.
12 24 b. An initial investigation and review.
12 25 c. Notification within a reasonable amount of time of the
12 26 outcome of the grievance.
12 27 d. An appeal procedure.
12 28 4. A managed care entity shall set reasonable time limits
12 29 for each part of the review process, but in no case shall the
12 30 review extend beyond thirty days.
12 31 5. A managed care entity shall provide for expedited
12 32 review for cases involving an imminent, emergent, or serious
12 33 threat to the health of the enrollee.
12 34 a. The managed care entity shall immediately inform the
12 35 enrollee of this right.
13 1 b. The managed care entity shall provide the enrollee with
13 2 a written statement of the disposition or pending status of
13 3 the grievance within seventy-two hours of the commencement of
13 4 the review process.
13 5 6. A managed care entity shall report to the division the
13 6 number of grievances and appeals received by the plan within a
13 7 specified time period, including, if applicable, the outcomes
13 8 or current status of the grievances and appeals, as well as
13 9 the average time taken to resolve both grievances and appeals.
13 10 EXPLANATION
13 11 This bill creates new Code chapter 514I entitled the
13 12 "Managed Care Consumer Protection Act". The new chapter
13 13 relates to the operation and regulation of managed care health
13 14 plans.
13 15 New Code section 514I.1 sets forth the title of the chapter
13 16 as the "Managed Care Consumer Protection Act".
13 17 New Code section 514I.2 states the purpose and intent of
13 18 the chapter to ensure that enrollees receive adequate health
13 19 care services under a managed care system.
13 20 New Code section 514I.3 establishes the definitions for key
13 21 terms used in the chapter.
13 22 New Code section 514I.4 provides that the chapter applies
13 23 to all managed care entities operating in this state.
13 24 New Code section 514I.5 provides that a managed care plan
13 25 shall include a sufficient number and type of health care
13 26 professionals and specialists, throughout the service area, to
13 27 meet the needs of enrollees and to provide meaningful choice.
13 28 The plan must provide for continuity of care with established
13 29 primary care practitioners, sufficient telephone access for
13 30 routine care decisions, and reasonable standards for waiting
13 31 times to obtain services.
13 32 New Code section 514I.6 provides that an enrollee must have
13 33 adequate choice among health care professionals and that a
13 34 managed care plan must permit enrollees to use a medical
13 35 specialist primary care practitioner.
14 1 New Code section 514I.7 provides that a managed care entity
14 2 shall not contract with a health care provider to limit a
14 3 health care professional's disclosure to an enrollee or on
14 4 behalf of an enrollee any information relating to such
14 5 enrollee's medical condition or treatment options.
14 6 New Code section 514I.8 provides that a managed care plan
14 7 must provide coverage for all drugs and devices approved by
14 8 the federal food and drug administration, whether or not that
14 9 drug or device has been approved for the specific treatment or
14 10 condition, so long as the primary care practitioner or other
14 11 medical specialist treating the enrollee determines the drug
14 12 or device is medically necessary and appropriate. A managed
14 13 care plan is also required to establish a drug utilization
14 14 review program.
14 15 New Code section 514I.9 provides that a managed care entity
14 16 that denies coverage for an experimental treatment, procedure,
14 17 drug, or device for an enrollee who has a terminal condition
14 18 or illness must provide the enrollee with a denial letter
14 19 within 20 working days of the date the request is submitted.
14 20 New Code section 514.10 provides that a managed care entity
14 21 must develop comprehensive quality assurance standards,
14 22 adequate to identify, evaluate, and remedy problems relating
14 23 to access, continuity, and quality of care.
14 24 New Code section 514I.11 sets forth information which must
14 25 be provided by a managed care entity to an enrollee or
14 26 potential enrollee concerning a managed care plan.
14 27 New Code section 514I.12 provides that a managed care
14 28 entity is to employ a medical director who is a licensed
14 29 physician and who is responsible for treatment policies,
14 30 protocols, quality assurance activities, and utilization
14 31 management.
14 32 New Code section 514I.13 establishes the insurance division
14 33 of the department of commerce as the oversight agency for
14 34 managed care entities.
14 35 New Code section 514I.14 provides that a managed care
15 1 entity must establish a grievance procedure and provide
15 2 written notification to enrollees, in language the enrollee
15 3 understands, regarding the right to file a grievance.
15 4 LSB 3205YH 77
15 5 mj/cf/24
Text: HF02419 Text: HF02421 Text: HF02400 - HF02499 Text: HF Index Bills and Amendments: General Index Bill History: General Index
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