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PAG LIN
1 1 Amend Senate File 276, as amended, passed, and
1 2 reprinted by the Senate, as follows:
1 3 #1. Page 14, by inserting after line 18 the
1 4 following:
1 5 "Sec. . NEW SECTION. 514K.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. 514K.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
1 26 services to an individual during that individual's
1 27 medical care, treatment, or confinement.
1 28 5. "Health care treatment decision" means a
1 29 determination made when health care services are
1 30 actually provided under the health care plan and a
1 31 decision which affects the quality of the diagnosis,
1 32 care, or 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 providing health
1 41 care 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 services delivery; monitors necessity,
2 6 appropriateness, and quality of health care services
2 7 delivered by health care providers; and performs
2 8 utilization 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 chapter 148, 150, or 150A to practice medicine and
2 23 surgery, osteopathy, or osteopathic medicine and
2 24 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. 514K.3 THIRD-PARTY PAYOR
2 29 DUTY TO EXERCISE ORDINARY CARE – 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 services treatment decisions made
2 38 by an employee, agent, or representative of the third-
2 39 party payor who is acting on behalf of the third-party
2 40 payor and over whom the third-party payor has the
2 41 right to 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 services treatment decision; or that the third-party
2 50 payor did not deny or delay payment for any health
3 1 care services prescribed or recommended by a health
3 2 care provider to the 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 any
3 5 health care services to an insured or enrollee that
3 6 are not covered by the health care plan offered by the
3 7 third-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 health care
3 11 services coverage or assumes risk on behalf of its
3 12 employees for providing health care services.
3 13 6. A third-party payor shall not remove a health
3 14 care provider from its plan or refuse to renew the
3 15 participation of a health care provider under its plan
3 16 for advocating appropriate and medically necessary
3 17 health care services for an insured or enrollee.
3 18 7. A third-party payor shall not enter into a
3 19 contract with a hospital or health care provider or
3 20 pharmaceutical company which includes an
3 21 indemnification or hold harmless clause for the acts
3 22 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 health care provider is an employee,
3 33 agent, or representative of such third-party payor
3 34 shall not be based solely on proof that such a health
3 35 care provider's name appears in a listing of approved
3 36 health care providers made available to an insured or
3 37 enrollee under a health care plan.
3 38 10. This chapter does not apply to workers'
3 39 compensation coverages."
3 40 #2. By renumbering as necessary.
3 41
3 42
3 43
3 44 OSTERHAUS of Jackson
3 45 SF 276.503 78
3 46 mj/jw
Text: H01175 Text: H01177 Text: H01100 - H01199 Text: H Index Bills and Amendments: General Index Bill History: General Index
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