Text: HF00554 Text: HF00556 Text: HF00500 - HF00599 Text: HF Index Bills and Amendments: General Index Bill History: General Index
PAG LIN 1 1 Section 1. NEW SECTION. 514J.1 DEFINITIONS. 1 2 As used in this chapter, unless the context otherwise 1 3 requires: 1 4 1. "Commissioner" means the commissioner of insurance. 1 5 2. "Director" means the director of public health. 1 6 3. "Emergency medical condition" means a medical condition 1 7 which manifests itself by acute symptoms of sufficient 1 8 severity, including severe pain, such that a prudent layperson 1 9 who possesses an average knowledge of health and medicine 1 10 could reasonably expect the absence of immediate medical 1 11 attention to result in one of the following: 1 12 a. Placing the health of the individual or, with respect 1 13 to a pregnant woman, the health of the woman or the fetus, in 1 14 serious jeopardy. 1 15 b. Serious impairment to bodily functions. 1 16 c. Serious dysfunction of any bodily organ or part. 1 17 4. "Emergency services" means, with respect to an 1 18 individual enrolled with a health maintenance organization, 1 19 organized delivery system, or preferred provider organization, 1 20 covered inpatient and outpatient services that are furnished 1 21 by a provider that is qualified to furnish such services and 1 22 are needed to evaluate or stabilize an emergency medical 1 23 condition. 1 24 5. "Enrollee" means an individual who is entitled to 1 25 coverage under a health maintenance organization, organized 1 26 delivery system, or preferred provider organization contract. 1 27 6. "Health care professional" means a person licensed to 1 28 or certified to practice a profession as defined in section 1 29 147.1 and who provides health care services. 1 30 7. "Health care provider" means a provider as defined in 1 31 section 514B.1. 1 32 8. "Health care services" means services included in the 1 33 furnishing to any individual of medical or dental care, or 1 34 hospitalization, or incident to the furnishing of such care or 1 35 hospitalization, as well as furnishing to any person of all 2 1 other services for the purposes of preventing, alleviating, 2 2 caring, or healing human illness, injury, or physical 2 3 disability. 2 4 9. "Health maintenance organization" means health 2 5 maintenance organization as defined in section 514B.1. 2 6 10. "Organized delivery system" means organized delivery 2 7 system as defined in section 513C.3. 2 8 11. "Participating" means, with respect to a health care 2 9 professional or health care provider, entering into an 2 10 agreement or arrangement with a health maintenance 2 11 organization, organized delivery system, or preferred provider 2 12 organization to provide health care services to enrollees. 2 13 12. "Physician" means a person licensed to practice 2 14 medicine and surgery, osteopathic medicine and surgery, 2 15 osteopathy, or chiropractic under the laws of this state. 2 16 13. "Preferred provider organization" means preferred 2 17 provider organization described in section 514F.3. 2 18 14. "Primary care provider" means a health care 2 19 professional who is trained in family practice, general 2 20 practice, internal medicine, obstetrics and gynecology, or 2 21 pediatrics and who is practicing within the scope of practice 2 22 authorized by state law, and designated by the health 2 23 maintenance organization, organized delivery system, or 2 24 preferred provider organization to coordinate, supervise, or 2 25 provide ongoing health care services to enrollees. 2 26 15. "Service area" means an established service area as 2 27 defined in section 513C.3. 2 28 Sec. 2. NEW SECTION. 514J.2 ACCESS TO CARE. 2 29 The commissioner shall adopt rules that address the ability 2 30 of a health maintenance organization or preferred provider 2 31 organization to serve its enrollees residing anywhere in the 2 32 service area. The rules shall address, but are not limited 2 33 to, addressing all of the following: 2 34 1. Geographic limits for travel to receive primary care, 2 35 including inpatient and outpatient health care services. 3 1 2. Health care provider networks that ensure that a 3 2 sufficient number and type of participating primary care 3 3 providers and specialists exist throughout the service area to 3 4 adequately meet the needs of enrollees. 3 5 3. Direct access, without the need for a referral, to 3 6 health care professionals trained in obstetrics and 3 7 gynecology. 3 8 4. The ability of a parent to designate a pediatrician as 3 9 the primary care provider for the parent's child. 3 10 Sec. 3. NEW SECTION. 514J.3 EMERGENCY SERVICES. 3 11 Emergency services, including both inpatient and outpatient 3 12 health care services, shall be provided by a health 3 13 maintenance organization, organized delivery system, or 3 14 preferred provider organization, through the organization's or 3 15 system's participating health care providers or through 3 16 guaranteed arrangements with other health care providers, on a 3 17 twenty-four-hour per day basis. A physician and sufficient 3 18 other licensed and ancillary personnel shall be readily 3 19 available at all times to render such services. 3 20 Sec. 4. NEW SECTION. 514J.4 PROHIBITION OF INTERFERENCE 3 21 WITH CERTAIN MEDICAL COMMUNICATIONS. 3 22 1. A health maintenance organization, organized delivery 3 23 system, or preferred provider organization shall not prohibit 3 24 a participating health care professional or health care 3 25 provider from, or penalize a participating health care 3 26 professional or health care provider for, discussing treatment 3 27 options with enrollees that do not reflect the position of the 3 28 organization or system, or from advocating on behalf of 3 29 enrollees within the utilization review or grievance processes 3 30 established under the organization's or system's contract. 3 31 2. A health maintenance organization, organized delivery 3 32 system, or preferred provider organization shall not penalize 3 33 a participating health care professional or health care 3 34 provider because the health care professional or provider, in 3 35 good faith, reports to state or federal authorities any act or 4 1 practice by the health maintenance organization, organized 4 2 delivery system, or preferred provider organization that, in 4 3 the opinion of the health care professional or health care 4 4 provider, jeopardizes patient health or welfare. 4 5 Sec. 5. NEW SECTION. 514J.5 EXTERNAL REVIEW PROCESS. 4 6 The commissioner shall adopt rules which require health 4 7 maintenance organizations and preferred provider organizations 4 8 and the director shall adopt rules which require organized 4 9 delivery systems to establish an external review process for 4 10 enrollees to appeal a denial of coverage based on medical 4 11 necessity. The rules shall include provisions for a timely 4 12 review, including provisions for expedited review for 4 13 situations in which delay could pose a serious health threat 4 14 to the enrollee. The rules shall also require the review to 4 15 be conducted by an independent review organization which 4 16 includes health care professionals with expertise in the 4 17 specific area of coverage being reviewed. 4 18 Sec. 6. NEW SECTION. 514J.6 HEALTH INFORMATION 4 19 DISCLOSURE HEALTH PROSPECTUS. 4 20 1. A health maintenance organization, organized delivery 4 21 system, or preferred provider organization shall provide, to 4 22 each of its enrollees at the time of enrollment and on an 4 23 annual basis, and shall make available to each prospective 4 24 enrollee upon request, a prospectus containing information 4 25 that allows the enrollee to determine the performance of the 4 26 health maintenance organization, organized delivery system, or 4 27 preferred provider organization. 4 28 2. The commissioner shall adopt rules for health 4 29 maintenance organizations and preferred provider organizations 4 30 and the director shall adopt rules for organized delivery 4 31 systems which establish the format and content of the 4 32 prospectus. The content requirement shall include but is not 4 33 limited to all of the following: 4 34 a. Quality assessment data. 4 35 b. The type, frequency, and outcomes of and the filing 5 1 procedure for enrollee complaints and grievances. 5 2 c. Covered and excluded benefits. 5 3 d. Compensation arrangements with participating health 5 4 care professionals and health care providers. 5 5 3. The commissioner and the director shall collect the 5 6 information provided in the prospectus and shall compile the 5 7 information in a format and manner that is useful to the 5 8 public. The compiled information shall be available to the 5 9 public in both electronic and printed formats. 5 10 EXPLANATION 5 11 This bill establishes a new chapter which provides certain 5 12 rights for enrollees of a health maintenance organization 5 13 (HMO), organized delivery system (ODS), or preferred provider 5 14 organization (PPO). The bill provides definitions used in the 5 15 new Code chapter. The bill directs the commissioner of 5 16 insurance to adopt rules for HMOs and PPOs relating to access 5 17 to care. Rules relating to access to care currently exist for 5 18 ODSs. The rules relate to access to care, include rules 5 19 relating to geographic limits for travel to receive primary 5 20 care, the requirement that a sufficient number of primary care 5 21 health care professionals and specialists be available in the 5 22 service area, the requirement of direct access to an 5 23 obstetrician and gynecologist, and the requirement that a 5 24 parent be allowed to designate a pediatrician as the primary 5 25 care health care professional for the parent's child. 5 26 The bill requires the availability of emergency services, 5 27 through a physician and ancillary personnel, on a 24-hour per 5 28 day basis for HMOs, ODSs, and PPOs. 5 29 The bill provides that a participating health care 5 30 professional or health care provider cannot be prohibited from 5 31 or penalized for discussing treatment options with an enrollee 5 32 and from advocating for an enrollee within the utilization 5 33 review or grievance processes. The bill prohibits an HMO, 5 34 ODS, or PPO from penalizing a health care professional or 5 35 health care provider from reporting an act or practice of the 6 1 HMO, ODS, or PPO to state or federal authorities if the 6 2 professional or provider believes, in good faith, that the act 6 3 or practice jeopardizes patient health or welfare. 6 4 The bill requires an external review process for enrollee 6 5 appeals. 6 6 The bill requires HMOs, ODSs, and PPOs to provide enrollees 6 7 and prospective enrollees with a prospectus containing 6 8 information required by rule of the commissioner or by rule of 6 9 the director of public health which will assist the enrollee 6 10 or prospective enrollee in determining the performance of the 6 11 HMO, ODS, or PPO. The information contained in the prospectus 6 12 submitted by each HMO, ODS, and PPO is to be compiled by the 6 13 commissioner and the director and is to be made available to 6 14 the public in both electronic and printed formats. 6 15 LSB 1524YH 78 6 16 pf/cf/24.1
Text: HF00554 Text: HF00556 Text: HF00500 - HF00599 Text: HF Index Bills and Amendments: General Index Bill History: General Index
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