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
© 1999 Cornell College and League of Women Voters of Iowa
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