Text: HSB00168 Text: HSB00170 Text: HSB00100 - HSB00199 Text: HSB Index Bills and Amendments: General Index Bill History: General Index
PAG LIN
1 1 Section 1. NEW SECTION. 514C.14 CONTINUITY OF CARE –
1 2 PREGNANCY.
1 3 1. Except as provided under subsection 2 or 3, a carrier,
1 4 as defined in section 513B.2, an organized delivery system,
1 5 authorized under 1993 Iowa Acts, chapter 158, or a plan
1 6 established pursuant to chapter 509A for public employees,
1 7 which terminates its contract with a participating health care
1 8 provider, shall continue to provide coverage under the
1 9 contract to a covered person in the second or third trimester
1 10 of pregnancy for continued care from such health care
1 11 provider. Such persons may continue to receive such treatment
1 12 or care through postpartum care related to the child birth and
1 13 delivery. Payment for covered benefits and benefit levels
1 14 shall be according to the terms and conditions of the
1 15 contract.
1 16 2. A covered person who makes an involuntary change in
1 17 health plans may request that the new health plan cover the
1 18 services of the covered person's physician specialist who is
1 19 not a participating health care provider under the new health
1 20 plan, if the covered person is in the second or third
1 21 trimester of pregnancy. Continuation of such coverage shall
1 22 continue through postpartum care related to the child birth
1 23 and delivery. Payment for covered benefits and benefit level
1 24 shall be according to the terms and conditions of the new
1 25 health plan contract.
1 26 3. A carrier, organized delivery system, or plan
1 27 established under chapter 509A, which terminates the contract
1 28 of a participating health care provider for cause shall not be
1 29 liable to pay for health care services provided by the health
1 30 care provider to a covered person following the date of
1 31 termination.
1 32 Sec. 2. NEW SECTION. 514C.15 CONTINUITY OF CARE –
1 33 CHRONIC CONDITION.
1 34 1. Except as provided under subsection 2 or 3, if a
1 35 carrier, as defined in section 513B.2, an organized delivery
2 1 system, authorized under 1993 Iowa Acts, chapter 158, or a
2 2 plan established pursuant to chapter 509A for public
2 3 employees, terminates its contract with a participating health
2 4 care provider, a covered individual who is undergoing a
2 5 specified course of treatment for a chronic condition or a
2 6 related condition, with the recommendation of the covered
2 7 individual's treating physician licensed under chapter 148,
2 8 150, or 150A, may continue to receive treatment from the
2 9 covered individual's physician for the chronic condition or a
2 10 related condition, for a period of up to sixty days. Payment
2 11 for covered benefits and benefit level shall be according to
2 12 the terms and conditions of the contract.
2 13 2. A covered person who makes a change in health plans
2 14 involuntarily may request that the new health plan cover
2 15 services of the covered person's treating physician licensed
2 16 under chapter 148, 150, or 150A, who is not a participating
2 17 health care provider under the new health plan, if the covered
2 18 person is undergoing a specified course of treatment for a
2 19 chronic condition or a related condition. Continuation of
2 20 such coverage shall continue for up to sixty days. Payment
2 21 for covered benefits and benefit levels shall be according to
2 22 the terms and conditions of the contract.
2 23 3. A carrier, organized delivery system, or plan
2 24 established under chapter 509A which terminates the contract
2 25 of a participating health care provider for cause shall not be
2 26 liable to pay for health care services provided by the health
2 27 care provider to a covered person following the date of
2 28 termination.
2 29 Sec. 3. NEW SECTION. 514F.4 EXPERIMENTAL TREATMENT
2 30 REVIEW.
2 31 1. A carrier, as defined in section 513B.2, an organized
2 32 delivery system, authorized under 1993 Iowa Acts, chapter 158,
2 33 or a plan established pursuant to chapter 509A for public
2 34 employees, that limits coverage for experimental medical
2 35 treatment, drugs, or devices, shall develop and implement a
3 1 procedure to evaluate experimental medical treatments and
3 2 shall submit a description of the procedure to the division of
3 3 insurance. The procedure shall be in writing and must
3 4 describe the process used to determine whether the carrier,
3 5 organized delivery system, or chapter 509A plan will provide
3 6 coverage for new medical technologies and new uses of existing
3 7 technologies. The procedure, at a minimum, shall require a
3 8 review of information from appropriate government regulatory
3 9 agencies and published scientific literature concerning new
3 10 medical technologies and new uses of existing technologies. A
3 11 carrier, organized delivery system, or chapter 509A plan shall
3 12 include appropriately licensed or qualified professionals in
3 13 the evaluation process. The procedure shall provide a process
3 14 for a person covered under a plan or contract to request an
3 15 internal review of a denial of coverage because the proposed
3 16 treatment is experimental.
3 17 2. A carrier, organized delivery system, or chapter 509A
3 18 plan that limits coverage for experimental treatment, drugs,
3 19 or devices shall clearly disclose such limitations in a
3 20 contract, policy, or certificate of coverage.
3 21 3. For purposes of this section, "experimental medical
3 22 treatment" means medical technology or a new application of an
3 23 existing medical technology, including medical procedures,
3 24 drugs, and devices for treating a medical condition or illness
3 25 that is not generally by accepted informed medical
3 26 professionals in this country as effective, or has not been
3 27 proven by scientific testing or evidence to be effective in
3 28 treating the medical condition or illness for which its use is
3 29 proposed.
3 30 Sec. 4. NEW SECTION. 514J.1 LEGISLATIVE INTENT.
3 31 It is the intent of the general assembly to provide a
3 32 mechanism for the appeal of a denial of coverage based on
3 33 medical necessity.
3 34 Sec. 5. NEW SECTION. 514J.2 DEFINITIONS.
3 35 1. "Carrier" means an entity subject to the insurance laws
4 1 and regulations of this state, or subject to the jurisdiction
4 2 of the commissioner, performing utilization review, including
4 3 an insurance company offering sickness and accident plans, a
4 4 health maintenance organization, a nonprofit health service
4 5 corporation, a plan established pursuant to chapter 509A for
4 6 public employees, or any other entity providing a plan of
4 7 health insurance, health care benefits, or health care
4 8 services.
4 9 2. "Commissioner" means the commissioner of insurance.
4 10 3. "Coverage decision" means a final adverse decision
4 11 based on medical necessity. This definition does not include
4 12 a denial of coverage for a service or treatment specifically
4 13 listed in plan or evidence of coverage documents as excluded
4 14 from coverage.
4 15 4. "Enrollee" means an individual, or an eligible
4 16 dependent, who receives health care benefits coverage through
4 17 a carrier or organized delivery system.
4 18 5. "Independent review entity" means a reviewer or entity,
4 19 certified by the commissioner pursuant to section 514J.6.
4 20 6. "Organized delivery system" means an organized delivery
4 21 system authorized under 1993 Iowa Acts, chapter 158, and
4 22 licensed by the director of public health, and performing
4 23 utilization review.
4 24 Sec. 6. NEW SECTION. 514J.3 EXCLUSIONS.
4 25 This chapter does not apply to a hospital confinement
4 26 indemnity, credit, dental, vision, long-term care, disability
4 27 income insurance coverage, coverage issued as a supplement to
4 28 liability insurance, workers compensation or similar
4 29 insurance, or automobile medical payment insurance.
4 30 Sec. 7. NEW SECTION. 514J.4 EXTERNAL REVIEW REQUEST.
4 31 1. At the time of a coverage decision, the carrier or
4 32 organized delivery system shall notify the enrollee of the
4 33 right to have the coverage decision reviewed under the
4 34 external review process.
4 35 2. The enrollee, or the enrollee's treating health care
5 1 provider acting on behalf of the enrollee, may file a written
5 2 request for external review of the coverage decision with the
5 3 commissioner. The request must be filed within sixty days of
5 4 the receipt of the coverage decision.
5 5 3. The request for external review must be accompanied by
5 6 a twenty-five dollar filing fee. The commissioner may waive
5 7 the filing fee for good cause. The filing fee shall be
5 8 refunded if the enrollee prevails in the external review
5 9 process.
5 10 Sec. 8. NEW SECTION. 514J.5 ELIGIBILITY.
5 11 1. The commissioner shall have two business days from
5 12 receipt of a request for an external review to certify the
5 13 request. The commissioner shall certify the request if the
5 14 following criteria are satisfied:
5 15 a. The enrollee was covered by the carrier or organized
5 16 delivery system at the time the service or treatment was
5 17 proposed.
5 18 b. The enrollee has been denied coverage based on a
5 19 determination by the carrier or organized delivery system that
5 20 the proposed service or treatment does not meet the definition
5 21 of medical necessity as defined in the enrollee's evidence of
5 22 coverage.
5 23 c. The enrollee, or the enrollee's treating health care
5 24 provider acting on behalf of the enrollee, has exhausted all
5 25 internal appeal mechanisms provided under the carrier's or the
5 26 organized delivery system's contract.
5 27 d. The written request for external review was filed
5 28 within sixty days of receipt of the coverage decision.
5 29 2. The commissioner shall notify the enrollee, or the
5 30 enrollee's treating health care provider acting on behalf of
5 31 the enrollee, and the carrier or organized delivery system in
5 32 writing of the decision.
5 33 3. The carrier or organized delivery system has three days
5 34 to contest the eligibility of the request for external review
5 35 with the commissioner. If the commissioner finds that the
6 1 request for external review is not eligible for full review,
6 2 the commissioner shall notify the enrollee, or the enrollee's
6 3 treating health care provider acting on behalf of the
6 4 enrollee, in writing of the reasons that the request for
6 5 external review is not eligible for full review.
6 6 Sec. 9. NEW SECTION. 514J.6 INDEPENDENT REVIEW ENTITIES.
6 7 1. The commissioner shall solicit names of independent
6 8 review entities from carriers, organized delivery systems, and
6 9 medical professional associations.
6 10 2. Independent review entities include both of the
6 11 following:
6 12 a. Medical peer review organizations.
6 13 b. Nationally recognized health experts or institutions.
6 14 3. The commissioner shall certify independent review
6 15 entities to conduct external reviews. An individual who
6 16 conducts an external review as part of a certified independent
6 17 review entity shall be a health care professional and satisfy
6 18 both of the following requirements:
6 19 a. Hold a current unrestricted license to practice
6 20 medicine or a health profession in the United States. A
6 21 health care professional who is a physician shall also hold a
6 22 current certification by a recognized American medical
6 23 specialty board.
6 24 b. Have no history of disciplinary actions or sanctions,
6 25 including, but not limited to, the loss of staff privileges or
6 26 any participation restriction taken or pending by any hospital
6 27 or state or federal government regulatory agency.
6 28 4. Each independent review entity shall have a quality
6 29 assurance program on file with the commissioner that ensures
6 30 the timeliness and quality of the reviews, the qualifications
6 31 and independence of the experts, and the confidentiality of
6 32 medical records and review materials.
6 33 5. The commissioner shall certify independent review
6 34 entities every two years.
6 35 Sec. 10. NEW SECTION. 514J.7 EXTERNAL REVIEW.
7 1 The external review process shall meet the following
7 2 criteria:
7 3 1. The carrier or organized delivery system, within three
7 4 business days of a receipt of an eligible request for an
7 5 external review from the commissioner, shall do all of the
7 6 following:
7 7 a. Select an independent review entity from the list
7 8 certified by the commissioner. The independent review entity
7 9 shall be an expert in the treatment of the medical condition
7 10 under review. The independent review entity shall not be a
7 11 subsidiary of, or owned or controlled by the carrier or
7 12 organized delivery system, or owned or controlled by a trade
7 13 association of carriers or organized delivery systems of which
7 14 the carrier or organized delivery system is a member.
7 15 b. Notify the enrollee, and the enrollee's treating
7 16 physician, of the name, address, and phone number of the
7 17 independent review entity and of the enrollee's and treating
7 18 physician's right to submit additional information.
7 19 c. Provide any information submitted to the carrier or
7 20 organized delivery system by the enrollee or the enrollee's
7 21 treating health care provider in support of the request for
7 22 coverage of a service or treatment under the carrier's or
7 23 organized delivery system's appeal procedures.
7 24 d. Provide any other relevant documents used by the
7 25 carrier or organized delivery system in determining whether
7 26 the proposed service or treatment should have been provided.
7 27 2. The enrollee, or the enrollee's treating health care
7 28 provider, may provide any information submitted in support of
7 29 the internal review, and other newly discovered relevant
7 30 information. The enrollee shall have ten days from the
7 31 mailing date of the notification of the independent review
7 32 entity's selection to provide this information. Failure to
7 33 provide the information within ten days shall be ground for
7 34 rejection of consideration of the information by the
7 35 independent review entity.
8 1 3. The independent review entity shall notify the enrollee
8 2 and the enrollee's treating health care provider of any
8 3 additional medical information required to conduct the review
8 4 within five business days of receipt of the documentation
8 5 required under subsection 1. The requested information shall
8 6 be submitted within five days. Failure to provide the
8 7 information shall be ground for rejection of consideration of
8 8 the information by the independent review entity. The carrier
8 9 or organized delivery system shall be notified of this
8 10 request.
8 11 4. The independent review entity shall submit its decision
8 12 as soon as possible, but not more than thirty days from the
8 13 independent review entity's receipt of the request for review.
8 14 The decision shall be mailed to the enrollee, or the treating
8 15 health care provider acting on behalf of the enrollee, and the
8 16 carrier or organized delivery system.
8 17 5. The confidentiality of any medical records submitted
8 18 shall be maintained pursuant to applicable state and federal
8 19 laws.
8 20 Sec. 11. NEW SECTION. 514J.8 EXPEDITED REVIEW.
8 21 An expedited review shall be conducted within seventy-two
8 22 hours if the enrollee's treating health care provider states
8 23 that delay would pose an imminent or serious threat to the
8 24 enrollee.
8 25 Sec. 12. NEW SECTION. 514J.9 FUNDING.
8 26 All reasonable fees and costs of the independent review
8 27 entity in conducting an external review shall be paid by the
8 28 carrier or organized delivery system.
8 29 Sec. 13. NEW SECTION. 514J.10 REPORTING.
8 30 Each carrier and organized delivery system shall file an
8 31 annual report with the commissioner containing all of the
8 32 following:
8 33 1. The number of external reviews requested.
8 34 2. The number of the external reviews certified by the
8 35 commissioner.
9 1 3. The number of coverage decisions which were upheld by
9 2 an independent review entity.
9 3 The commissioner shall prepare a report by January 31 of
9 4 each year.
9 5 Sec. 14. NEW SECTION. 514J.11 IMMUNITY.
9 6 An independent review entity conducting a review under this
9 7 chapter is not liable for damages arising from determinations
9 8 made under the review process. This does not apply to any act
9 9 or omission by the independent review entity made in bad faith
9 10 or involving gross negligence.
9 11 Sec. 15. NEW SECTION. 514J.12 STANDARD OF REVIEW.
9 12 The standard of review to be used by an independent review
9 13 entity shall be whether the health care service or treatment
9 14 denied by the carrier or organized delivery system was
9 15 medically necessary as defined by the enrollee's evidence of
9 16 coverage, subject to Iowa law. The independent review entity
9 17 shall take into consideration factors identified in the review
9 18 record that impact the delivery of or describe the standard of
9 19 care for the medical service or treatment under review. The
9 20 medical service or treatment recommended by the enrollee's
9 21 treating health care provider shall be upheld upon review so
9 22 long as it is found to be medically necessary.
9 23 Sec. 16. NEW SECTION. 514J.13 RULES.
9 24 The commissioner shall adopt rules pursuant to chapter 17A
9 25 as are necessary to administer this chapter.
9 26 EXPLANATION
9 27 This bill creates several new Code sections relating to the
9 28 provision and evaluation of health care services to covered
9 29 individuals in this state.
9 30 The bill creates new Code section 514C.14 which provides
9 31 for continuation of coverage by a carrier, organized delivery
9 32 system, or plan established pursuant to chapter 509A for
9 33 public employees, for costs associated with a health care
9 34 provider providing continued care to a covered person who is
9 35 in the second or third trimester of pregnancy. Such coverage
10 1 is to continue through postpartum care if the carrier,
10 2 organized delivery system, or plan terminates its contract
10 3 with the health care provider. The section also provides that
10 4 a covered person who makes a change in health plan
10 5 involuntarily may request that the new health plan cover
10 6 services of the covered person's physician specialist who is
10 7 not a participating health care provider under the new health
10 8 plan, if the covered person is in the second or third
10 9 trimester of pregnancy. Such coverage shall continue through
10 10 postpartum care related to the child birth and delivery. A
10 11 carrier, organized delivery system, or chapter 509A plan which
10 12 terminates the contract of a participating health care
10 13 provider for cause is not liable for health care services
10 14 provided to a covered person following the date of
10 15 termination.
10 16 New Code section 514C.15 is created and provides that if a
10 17 carrier, an organized delivery system, or a plan established
10 18 pursuant to chapter 509A for public employees, terminates its
10 19 contract with a participating health care provider, a covered
10 20 individual who undergoing a specified course of treatment for
10 21 a chronic condition, with the recommendation of the covered
10 22 individual's treating physician licensed under chapter 148,
10 23 150, or 150A, may continue to receive treatment from the
10 24 covered individual's physician for that chronic condition or a
10 25 related condition, for a period of up to 60 days. Payment for
10 26 covered benefits and benefit level shall be according to the
10 27 terms and conditions of the contract.
10 28 The bill establishes new Code section 514F.4 and provides
10 29 that a carrier, an organized delivery system, or a plan
10 30 established pursuant to chapter 509A for public employees,
10 31 that limits coverage for experimental medical treatment,
10 32 drugs, or devices, shall develop and implement a procedure to
10 33 evaluate experimental medical treatments and shall submit a
10 34 description of the procedure to the division of insurance.
10 35 The procedure shall be in writing and must describe the
11 1 process used to determine whether the carrier, organized
11 2 delivery system, or chapter 509A plan will provide coverage
11 3 for new medical technologies and new uses of existing
11 4 technologies. The procedure, at a minimum, shall require a
11 5 review of information from appropriate government regulatory
11 6 agencies and published scientific literature concerning new
11 7 medical technologies and new uses of existing technologies.
11 8 The bill creates new Code chapter 514J relating to the
11 9 appeal by an individual receiving health benefits coverage who
11 10 is denied health care services or treatment.
11 11 New Code section 514J.1 states the intent of the general
11 12 assembly to provide a mechanism for the appeal of a denial of
11 13 coverage based on medical necessity.
11 14 New Code section 514J.2 establishes definitions for key
11 15 terms used in the chapter.
11 16 New Code section 514J.3 provides that the chapter does not
11 17 apply to a hospital confinement indemnity, credit, dental
11 18 vision, long-term care, disability income insurance coverage,
11 19 coverage issued as a supplement to liability insurance,
11 20 workers compensation or similar insurance, or automobile
11 21 medical payment insurance.
11 22 New Code section 514J.4 provides that an enrollee or the
11 23 enrollee's treating health care provider may file a written
11 24 request for external review of a denial of coverage. Such
11 25 request must be filed within 60 days of the receipt of the
11 26 denial of coverage. A $25 filing fee is provided for, which
11 27 may be waived by the commissioner for good cause. The filing
11 28 fee is to be refunded to the enrollee if the enrollee prevails
11 29 in the external review process.
11 30 New Code section 514J.5 establishes eligibility
11 31 requirements for the certification of the external review
11 32 request. The bill provides that the commissioner shall have
11 33 two business days from receipt of the request for external
11 34 review to certify the request. The commissioner must certify
11 35 the request if the enrollee was covered by the carrier or
12 1 organized delivery system at the time the service or treatment
12 2 was proposed, the enrollee has been denied coverage based on a
12 3 determination that the proposed service or treatment does not
12 4 meet the definition of medical necessity as defined in the
12 5 enrollee's evidence of coverage, the enrollee has exhausted
12 6 all internal appeal mechanisms, and the written request for
12 7 external review was filed within 60 days of receipt of the
12 8 coverage denial.
12 9 New Code section 514J.6 provides that independent review
12 10 entities include medical peer review organizations and
12 11 nationally recognized health experts or institutions as
12 12 certified by the commissioner.
12 13 New Code section 514J.7 establishes the external review
12 14 process. The bill provides that the carrier or organized
12 15 delivery system, within three business days of receipt of an
12 16 eligible request for external review, shall select an
12 17 independent review entity from the list certified by the
12 18 commissioner, notify the enrollee of the independent review
12 19 entity and of the enrollee's right to submit additional
12 20 information, provide any information submitted to the carrier
12 21 or organized delivery system by the enrollee or the enrollee's
12 22 treating health care provider in support of the request for
12 23 coverage of a service or treatment; and provide any other
12 24 relevant documents used by the carrier or organized delivery
12 25 system in determining whether the proposed service or
12 26 treatment should have been provided. The independent review
12 27 entity is to submit its decision as soon as possible.
12 28 New Code section 514J.8 provides for an expedited review to
12 29 be conducted within 72 hours when the enrollee's treating
12 30 health care provider states that delay would pose an imminent
12 31 or serious threat to the enrollee.
12 32 New Code section 514J.9 provides that all reasonable fees
12 33 and costs of the independent review entity are to be paid by
12 34 the carrier or organized delivery system.
12 35 New Code section 514J.10 directs each carrier and organized
13 1 delivery system to file with the commissioner an annual report
13 2 including the number of external reviews requested, the number
13 3 of external review requests certified by the commissioner, and
13 4 the number of coverage decisions which were upheld by an
13 5 independent review entity.
13 6 New Code section 514J.11 provides that an independent
13 7 review entity is not liable for damages arising from a
13 8 determination under the review process.
13 9 New Code section 514J.12 provides that the standard of
13 10 review to be used by an independent review entity is whether
13 11 the health care service or treatment denied by the carrier or
13 12 organized delivery system was medically necessary as evidenced
13 13 by the enrollee's evidence of coverage.
13 14 New Code section 514J.14 directs the commissioner to adopt
13 15 rules necessary to implement new Code chapter 514J.
13 16 LSB 1420DP 78
13 17 mj/jw/5
Text: HSB00168 Text: HSB00170 Text: HSB00100 - HSB00199 Text: HSB Index Bills and Amendments: General Index Bill History: General Index
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