Text: H01175 Text: H01177 Text: H01100 - H01199 Text: H Index Bills and Amendments: General Index Bill History: General Index
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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