Text: HF00024 Text: HF00026 Text: HF00000 - HF00099 Text: HF Index Bills and Amendments: General Index Bill History: General Index
PAG LIN
1 1 Section 1. Section 514B.1, subsection 5, Code 1999, is
1 2 amended by adding the following new paragraphs:
1 3 NEW PARAGRAPH. f. (1) Notwithstanding section 514C.6,
1 4 the health care services available to an enrollee under a
1 5 prepaid group plan shall include a provision that if a
1 6 contract between the prepaid group plan, in connection with
1 7 the health care services provided, and a provider is
1 8 terminated, or a benefit or coverage provided by a provider is
1 9 terminated because of a change in the terms of provider
1 10 participation in the prepaid group plan, and the enrollee is
1 11 undergoing a course of treatment related to a pregnancy at the
1 12 time of the termination, the prepaid group plan shall notify
1 13 the enrollee on a timely basis of the termination and shall,
1 14 if the enrollee so chooses, permit the enrollee to continue to
1 15 be covered with respect to the course of treatment related to
1 16 the pregnancy provided by the provider through the provision
1 17 of postpartum care directly related to the delivery.
1 18 (2) Notwithstanding section 514C.6, if a contract for
1 19 provision of health insurance coverage between a prepaid group
1 20 plan and a health insurance issuer is terminated and, as a
1 21 result of the termination, coverage of services of a provider
1 22 is terminated with respect to an enrollee who is undergoing a
1 23 course of treatment related to a pregnancy at the time of the
1 24 termination, coverage by the health insurance issuer shall
1 25 continue if the enrollee so chooses and the health care
1 26 services provided shall continue as if there had been a
1 27 contract between the prepaid group plan and the provider which
1 28 had been terminated, and the enrollee shall continue to be
1 29 covered with respect to the course of treatment related to the
1 30 pregnancy with the provider through the provision of
1 31 postpartum care directly related to the delivery.
1 32 NEW PARAGRAPH. g. Notwithstanding section 514C.6, the
1 33 health care services available to an enrollee under a prepaid
1 34 group plan shall include a provision that if emergency health
1 35 care services are provided under a prepaid group plan, the
2 1 plan shall cover emergency health care services received by an
2 2 enrollee, without regard to other contrary terms or conditions
2 3 of coverage, if the enrollee seeks emergency health care
2 4 services for an emergency medical condition based on a prudent
2 5 layperson standard. For purposes of this paragraph,
2 6 "emergency medical condition based on a prudent layperson
2 7 standard" means that a person suffers from a medical condition
2 8 manifesting itself by acute symptoms of sufficient severity,
2 9 which may include severe pain, such that a prudent layperson,
2 10 who possesses an average knowledge of health and medicine,
2 11 could reasonably expect the absence of immediate medical
2 12 attention to result in a condition described in 42 U.S.C. }
2 13 1396u-2(b)(2)(cc)(i), (ii), or (iii). For the purposes of
2 14 this section, "emergency health care services" means a medical
2 15 screening examination that is within the capability of the
2 16 emergency department of a hospital, including ancillary
2 17 services routinely available to the emergency department to
2 18 evaluate an emergency medical condition and within the
2 19 capabilities of the staff and facilities available at the
2 20 hospital, such further medical examination and treatment as
2 21 are required under 42 U.S.C. } 1396u-2(b)(2) to stabilize the
2 22 patient.
2 23 Sec. 2. NEW SECTION. 514B.14A EXTERNAL APPEAL PROCESS.
2 24 1. A health maintenance organization shall establish and
2 25 maintain an external appeals process to address denials of
2 26 claims by the health maintenance organization. The health
2 27 maintenance organization shall contract with an external
2 28 appeal entity approved by the commissioner of insurance.
2 29 2. The external appeal process shall provide for all of
2 30 the following:
2 31 a. A fair, de novo determination of the claim in dispute.
2 32 b. Each party may submit and review evidence related to
2 33 the claim in dispute, may use the assistance or representation
2 34 of an attorney, and may make oral presentations.
2 35 c. The health maintenance organization shall provide
3 1 timely access to all records relating to the claim and to all
3 2 provisions of the plan or coverage relating to the claim.
3 3 d. A timely decision made orally or in writing which is
3 4 binding on the health maintenance organization. The decision
3 5 shall be described in layperson's language and shall inform
3 6 the enrollee of any rights to seek further review by the
3 7 courts or other process.
3 8 Sec. 3. NEW SECTION. 514B.14B MEDICAL COMMUNICATIONS.
3 9 1. A health maintenance organization shall not prohibit or
3 10 restrict a provider from engaging in medical communications
3 11 with an enrollee.
3 12 2. For the purposes of this section, "medical
3 13 communications" means any communication made by a provider
3 14 with an enrollee regarding any of the following:
3 15 a. The enrollee's health status, medical care, or
3 16 treatment options.
3 17 b. Any utilization review requirements that may affect
3 18 treatment options for the enrollee.
3 19 c. Any financial incentives that may affect the treatment
3 20 of the enrollee.
3 21 "Medical communications" does not include a communication
3 22 by a provider with an enrollee if the communication involves a
3 23 knowing or willful misrepresentation by the provider.
3 24 EXPLANATION
3 25 This bill provides certain requirements of and restrictions
3 26 on health maintenance organizations, notwithstanding the
3 27 state-imposed federal conformity provision of Code section
3 28 514C.6. The bill provides that if an enrollee is receiving
3 29 treatment for a pregnancy and either the health maintenance
3 30 organization or the issuer of insurance terminate its contract
3 31 or the provider terminates the provider's contract with the
3 32 health maintenance organization, the enrollee may choose to
3 33 continue to receive health care services from the provider
3 34 through the time of provision of postpartum care directly
3 35 related to the delivery.
4 1 The bill also provides that if an enrollee receives
4 2 emergency health care services, the plan is to cover the costs
4 3 of the emergency care if the enrollee meets the "prudent
4 4 layperson standard" for seeking the emergency care,
4 5 notwithstanding contrary conditions of coverage of the plan.
4 6 The bill requires health maintenance organizations to
4 7 provide an external appeal process to address claims that are
4 8 denied.
4 9 The bill also prohibits a health maintenance organization
4 10 from prohibiting or restricting medical communications between
4 11 a provider and an enrollee. "Medical communications" include
4 12 communications regarding health status, medical care,
4 13 treatment options, utilization review requirements that may
4 14 affect treatment options, and any financial incentives that
4 15 may affect the treatment of an enrollee.
4 16 Current law provides for examination of the affairs of a
4 17 health maintenance organization (HMO) as deemed necessary by
4 18 the commissioner of insurance and at least every three years;
4 19 treats HMOs as insurers for the purpose of supervision,
4 20 prohibition, and liquidation (Code chapter 507C); provides
4 21 administrative procedures, and judicial review for denying,
4 22 suspending, or revoking a certificate of authority of an HMO;
4 23 allows the commissioner of insurance to maintain an action for
4 24 injunction or other process for violation of an HMO; and
4 25 provides that if no other penalty applies, a person who
4 26 violates the HMO chapter is guilty of a simple misdemeanor.
4 27 LSB 1363YH 78
4 28 pf/jw/5
Text: HF00024 Text: HF00026 Text: HF00000 - HF00099 Text: HF Index Bills and Amendments: General Index Bill History: General Index
© 1999 Cornell College and League of Women Voters of Iowa
Comments about this site or page?
webmaster@legis.iowa.gov.
Please remember that the person listed above does not vote on bills. Direct all comments concerning legislation to State Legislators.
Last update: Wed Jan 12 05:55:23 CST 2000
URL: /DOCS/GA/78GA/Legislation/HF/00000/HF00025/990111.html
jhf