Text: SF00194 Text: SF00196 Text: SF00100 - SF00199 Text: SF Index Bills and Amendments: General Index Bill History: General Index
PAG LIN
1 1 Section 1. NEW SECTION. 514J.1 PURPOSE AND INTENT.
1 2 The purpose of this chapter is to ensure that enrollees
1 3 receive adequate health care services under a managed care
1 4 plan. The intent of this chapter is to ensure that:
1 5 1. Enrollees have full and timely access to clinically and
1 6 culturally appropriate health care personnel and facilities.
1 7 2. Enrollees can choose from an adequate selection of
1 8 accessible and qualified health care professionals.
1 9 3. Open communication between health care professionals
1 10 and enrollees is ensured.
1 11 4. Enrollees have access to comprehensive pharmaceutical
1 12 services.
1 13 5. Enrollees have access to information regarding limits
1 14 on coverage of experimental treatments.
1 15 6. The quality of care is high within a managed care plan.
1 16 7. Medical decisions are made by the appropriate medical
1 17 personnel.
1 18 8. Health care professionals within a plan are in good
1 19 standing in their profession.
1 20 9. Managed care plan data is available to consumers.
1 21 10. Full public access to information regarding health
1 22 care service delivery exists within plans.
1 23 11. The proper state entities are authorized to oversee
1 24 all managed care plans.
1 25 12. A mechanism exists in a managed care plan for timely
1 26 and fair resolution of enrollee complaints, grievances, and
1 27 appeals.
1 28 Sec. 2. NEW SECTION. 514J.2 DEFINITIONS.
1 29 As used in this chapter, unless the context otherwise
1 30 requires:
1 31 1. "Appeal" means a formal process whereby an enrollee,
1 32 whose care has been reduced, denied, or terminated, or whereby
1 33 the enrollee deems the care inappropriate, can contest an
1 34 adverse grievance decision by the managed care plan.
1 35 2. "Emergency" means a medical condition, the onset of
2 1 which is sudden and unexpected, that manifests itself by
2 2 symptoms of sufficient severity, that a prudent layperson, who
2 3 possesses an average knowledge of health and medicine, could
2 4 reasonably assume that the condition requires immediate
2 5 medical treatment, and could expect the absence of medical
2 6 attention to result in serious impairment to bodily functions
2 7 or place the person's health in serious jeopardy.
2 8 3. "Enrollee" means an individual who is enrolled in a
2 9 managed care plan.
2 10 4. "Expedited review" means a review process which results
2 11 in a decision no more than seventy-two hours after the review
2 12 is commenced.
2 13 5. "Experimental treatment" means treatment that, while
2 14 not commonly used for a particular condition or illness, is
2 15 recognized for treatment of the particular condition or
2 16 illness, a treatment for which there is no clearly superior,
2 17 nonexperimental treatment alternative available to the
2 18 enrollee, or a treatment that is considered an experimental
2 19 treatment under Title XVIII or Title XIX of the federal Social
2 20 Security Act and follows Medicare and Medicaid guidelines.
2 21 6. "Grievance" means a written complaint submitted by or
2 22 on behalf of the enrollee.
2 23 7. "Health care professional" means a physician or other
2 24 person providing health care services.
2 25 8. "Health care provider" means a clinic, hospital,
2 26 physician organization, preferred provider organization,
2 27 independent practice association, or other appropriately
2 28 licensed provider of health care services or supplies.
2 29 9. "Health care services" means services for the
2 30 diagnosis, prevention, or treatment of a health condition,
2 31 illness, injury, or disease deemed medically necessary under
2 32 Title XIX of the federal Social Security Act.
2 33 10. "Managed care entity" means any entity including an
2 34 insurer, hospital, or medical service plan, health maintenance
2 35 organization, limited health services organization, preferred
3 1 provider organization, third party administrator, or any
3 2 person or entity that establishes, operates, or maintains a
3 3 network of participating health care professionals that is
3 4 licensed by the state.
3 5 11. "Managed care plan" or "plan" means a plan operated by
3 6 a managed care entity that provides for the financing and
3 7 delivery of health care services to persons enrolled in the
3 8 plan, with financial incentives for persons enrolled in the
3 9 plan to use the participating health care professionals and
3 10 procedures covered by the plan.
3 11 12. "Participating" means a health care professional who
3 12 has entered into an agreement with a managed care entity to
3 13 provide health care services to an enrollee in a managed care
3 14 plan.
3 15 13. "Point-of-service option" means an option for the
3 16 enrollee to choose to receive health care services from a
3 17 nonparticipating health care professional or health care
3 18 provider.
3 19 14. "Primary care practitioner" means a health care
3 20 professional under contract with a managed care plan, who has
3 21 been designated by the plan to coordinate, supervise, or
3 22 provide ongoing health care services to an enrollee.
3 23 15. "Prudent layperson" is a person without specific
3 24 medical training for the illness or condition in question who
3 25 acts as a reasonable person would under similar circumstances.
3 26 16. "Quality assurance" means the ongoing evaluation of
3 27 the quality of health care services provided to enrollees.
3 28 Sec. 3. NEW SECTION. 514J.3 ACCESS TO PERSONNEL AND
3 29 FACILITIES.
3 30 1. A managed care plan shall include a sufficient number
3 31 and type of primary care practitioners and specialists,
3 32 throughout the service area, to meet the needs of enrollees
3 33 and to provide meaningful choice. A managed care plan shall
3 34 demonstrate that the managed care plan offers all of the
3 35 following:
4 1 a. An adequate number of accessible acute care hospital
4 2 services, within a reasonable distance or travel time.
4 3 b. An adequate number of accessible primary care
4 4 practitioners, within a reasonable distance or travel time.
4 5 For the purposes of this requirement, primary care
4 6 practitioners shall include family practice and general
4 7 practice physicians, internists, obstetricians and
4 8 gynecologists, and pediatricians.
4 9 c. An adequate number of accessible specialists and
4 10 subspecialists, within a reasonable distance or travel time.
4 11 When the type of medical specialists needed for a specific
4 12 condition is not offered, enrollees shall have access to
4 13 nonparticipating health care professionals.
4 14 d. The availability of specialty health care services,
4 15 including physical therapy, occupational therapy, and
4 16 rehabilitation services.
4 17 e. The availability of nonparticipating health care
4 18 professional specialists, when a patient's unique medical
4 19 circumstances so warrant.
4 20 2. A managed care plan shall provide for continuity of
4 21 care with established primary care practitioners, when a
4 22 health care professional's contract is terminated.
4 23 3. A managed care plan shall provide telephone access to
4 24 the managed care plan during business and evening hours to
4 25 ensure enrollee access for routine care, and twenty-four-hour
4 26 telephone access to either the managed care plan or a
4 27 participating health care provider or health care professional
4 28 for emergencies.
4 29 4. A managed care plan shall establish standards for
4 30 reasonable waiting times to obtain appointments, except as
4 31 otherwise provided for emergency services. Such standards
4 32 shall include appointment scheduling guidelines based on the
4 33 type of health care service, including prenatal care
4 34 appointments, well-child visits and immunizations, routine
4 35 physicals, follow-up appointments for chronic conditions, and
5 1 urgent care.
5 2 5. A managed care plan shall cover and reimburse expenses
5 3 for emergency services obtained without prior authorization.
5 4 6. A managed care plan shall demonstrate that it has
5 5 developed an access plan to meet the needs of vulnerable and
5 6 underserved populations.
5 7 a. The plan shall provide culturally appropriate health
5 8 care services to the greatest extent possible.
5 9 b. When a significant number of enrollees in the plan do
5 10 not speak English, the plan shall provide access to personnel
5 11 fluent in languages other than English, to the greatest extent
5 12 possible.
5 13 c. The plan shall develop standards for continuity of care
5 14 following enrollment, including sufficient information on how
5 15 to access care within the plan.
5 16 7. A managed care plan shall hold enrollees harmless
5 17 against claims for payment of the cost of covered health care
5 18 services from participating health care providers and health
5 19 care professionals in the managed care plan.
5 20 Sec. 4. NEW SECTION. 514J.4 CHOICE OF HEALTH CARE
5 21 PROFESSIONAL.
5 22 1. A managed care plan shall offer an adequate selection
5 23 of health care professionals who are accessible and qualified
5 24 under the managed care plan.
5 25 2. A managed care plan shall permit enrollees to choose
5 26 their own primary care practitioner from a list of health care
5 27 professionals within the plan. This list shall be updated as
5 28 health care professionals are added or removed and shall
5 29 include all of the following:
5 30 a. A sufficient number of primary care practitioners who
5 31 are accepting new enrollees as patients.
5 32 b. A sufficient combination of primary care practitioners
5 33 that reflects a diversity that is adequate to meet the needs
5 34 of the enrolled population's varied characteristics including
5 35 age, gender, race, and health status.
6 1 3. A managed care plan shall develop a system to permit
6 2 enrollees to use a health care professional specialist as a
6 3 primary care practitioner when the enrollee's medical
6 4 condition so warrants.
6 5 4. A managed care plan shall provide continuity of care
6 6 and appropriate referral to health care professional
6 7 specialists within the plan, when speciality care is
6 8 warranted.
6 9 a. Enrollees shall have access to health care professional
6 10 specialists on a timely basis.
6 11 b. Enrollees shall be provided with a choice of health
6 12 care professional specialists when a referral is made.
6 13 c. Children with special health care needs shall be
6 14 managed by pediatric health care professional subspecialists.
6 15 5. A managed care plan shall offer a point-of-service
6 16 option. The point-of-service option may require that the
6 17 enrollee in the plan pay a reasonable portion of the costs of
6 18 such health care services provided by nonparticipating health
6 19 care providers or health care professionals.
6 20 6. A managed care plan shall provide enrollees with access
6 21 to consultation for a second opinion.
6 22 Sec. 5. NEW SECTION. 514J.5 INFORMATION DISCLOSURE
6 23 RULES.
6 24 1. A managed care plan shall not contract with a health
6 25 care provider to limit a health care professional's disclosure
6 26 to an enrollee or on behalf of an enrollee of any information
6 27 relating to the enrollee's medical condition or treatment
6 28 options.
6 29 2. A health care professional shall not be penalized and a
6 30 health care professional's contract with a managed care plan
6 31 shall not be terminated because the health care professional
6 32 offers referrals, or discusses medically necessary or
6 33 appropriate care with, or on behalf of, an enrollee. The
6 34 following information shall be permitted to be disclosed under
6 35 all managed care plans:
7 1 a. All treatment options.
7 2 b. Other information, determined by the health care
7 3 professional to be in the best interest of the enrollee.
7 4 3. A health care professional shall not be penalized for
7 5 discussing financial incentives and financial arrangements
7 6 between the health care professional and the managed care
7 7 entity.
7 8 Sec. 6. NEW SECTION. 514J.6 DRUGS AND DEVICES.
7 9 1. A managed care plan shall provide coverage for all
7 10 drugs and devices approved by the United States food and drug
7 11 administration, whether or not any such drug or device has
7 12 been approved for the specific treatment or condition, if the
7 13 primary care practitioner or other health care professional
7 14 treating an enrollee determines the drug or device to be
7 15 medically necessary and appropriate for the enrollee's
7 16 treatment or condition.
7 17 2. The prescribing health care professional shall
7 18 determine the appropriate drug therapy for an enrollee.
7 19 Substitutions shall not be made without the direct approval of
7 20 the prescriber.
7 21 3. A managed care plan shall establish and operate a drug
7 22 utilization review program. The primary emphasis of the
7 23 program shall be to enhance quality health care services
7 24 provided to enrollees by ensuring appropriate drug therapy.
7 25 The program shall provide all of the following:
7 26 a. Education of health care professionals, enrollees, and
7 27 pharmacists regarding the appropriate use of prescription
7 28 drugs.
7 29 b. Retrospective review of prescription drugs furnished to
7 30 enrollees.
7 31 c. Ongoing periodic examination of data on prescription
7 32 drugs used in the outpatient setting to ensure quality
7 33 therapeutic outcomes for enrollees.
7 34 d. The use of clinically relevant criteria and standards
7 35 for drug therapy; nonproprietary criteria and standards
8 1 developed and revised through an open, professional consensus
8 2 process; and interventions which focus on improving
8 3 therapeutic outcomes.
8 4 Sec. 7. NEW SECTION. 514J.7 EXPERIMENTAL TREATMENTS.
8 5 1. A managed care plan that limits coverage for health
8 6 care services shall define the limitation and disclose the
8 7 limits in any agreement or certificate of coverage. The
8 8 disclosure shall include the person authorized to make such a
8 9 determination and the criteria used to determine whether a
8 10 health care service is experimental.
8 11 2. A managed care plan that denies coverage for an
8 12 experimental treatment, procedure, drug, or device, for an
8 13 enrollee who has a terminal condition or illness shall provide
8 14 the enrollee with a denial letter within twenty working days
8 15 of receipt of a request submitted by the enrollee or on behalf
8 16 of the enrollee. The letter shall include all of the
8 17 following:
8 18 a. The name and title of the individual who made the
8 19 decision.
8 20 b. A statement setting forth the specific medical and
8 21 scientific reasons for denying coverage.
8 22 c. A description of alternative treatment, services, or
8 23 supplies covered by the plan, if any.
8 24 d. A copy of the plan's grievance and appeal procedures.
8 25 Sec. 8. NEW SECTION. 514J.8 QUALITY ASSURANCE PROGRAM.
8 26 1. A managed care plan shall establish comprehensive
8 27 quality assurance standards, adequate to identify, evaluate,
8 28 and remedy problems relating to access, continuity, and
8 29 quality of health care services. These standards shall
8 30 include all of the following:
8 31 a. An ongoing, written, internal quality assurance
8 32 program.
8 33 b. Specific written guidelines for quality of health care
8 34 services studies and monitoring, including attention to
8 35 vulnerable populations.
9 1 c. Performance-based and clinical outcomes-based criteria.
9 2 d. A procedure for remedial action to correct quality
9 3 problems, including written procedures for taking appropriate
9 4 corrective action.
9 5 e. A plan for data gathering and assessment.
9 6 f. A peer review process.
9 7 2. A managed care plan shall have a process for selection
9 8 of health care professionals as the plan's participating
9 9 health care professionals, with written policies and
9 10 procedures for review and approval used by the plan.
9 11 a. The plan shall establish minimum health care
9 12 professional requirements.
9 13 b. The plan shall demonstrate that the plan has consulted
9 14 with appropriately qualified health care professionals to
9 15 establish the requirements.
9 16 c. The plan's process shall include verification of the
9 17 individual health care professional's license, history of
9 18 suspension or revocation, and liability claims history.
9 19 d. The plan shall establish a formal, written, ongoing
9 20 process for the reevaluation of all participating health care
9 21 professionals within a specified number of years following
9 22 initial acceptance. Reevaluations shall include updates of
9 23 the previous evaluation criteria and an assessment of the
9 24 performance pattern based on criteria including enrollee
9 25 clinical outcomes, number of complaints, and malpractice
9 26 actions.
9 27 3. The plan shall not require a health care professional
9 28 to provide health care services beyond, or outside of, the
9 29 health care professional's scope of practice.
9 30 Sec. 9. NEW SECTION. 514J.8 DATA SYSTEMS AND
9 31 CONFIDENTIALITY.
9 32 1. A managed care plan shall provide information on the
9 33 plan's structure, decision-making process, health care
9 34 services coverages and exclusions, cost and cost-sharing
9 35 requirements, participating health care professionals, and
10 1 grievance and appeal procedures, to all potential enrollees,
10 2 to all enrollees covered by the plan, and to the insurance
10 3 division of the department of commerce.
10 4 2. A managed care plan shall collect and report annually
10 5 to the insurance division of the department of commerce
10 6 specified data to be available to the public including all of
10 7 the following:
10 8 a. Gross outpatient and hospital utilization data.
10 9 b. Enrollee clinical outcome data.
10 10 c. The number and types of enrollee grievances or
10 11 complaints filed during the year, the status of decisions, and
10 12 the average time required to reach a decision.
10 13 d. The number, amount, and disposition of malpractice
10 14 claims resolved during the year by the managed care plan and
10 15 any of its participating health care professionals.
10 16 3. A managed care plan shall establish written policies
10 17 and procedures for the handling of medical records and
10 18 enrollee communications to ensure enrollee confidentiality.
10 19 4. A managed care plan shall ensure the confidentiality of
10 20 specified enrollee information, including, but not limited to,
10 21 prior medical history, medical record information, and claims
10 22 information, except where disclosure of this information is
10 23 authorized by law.
10 24 5. A managed care plan shall be prohibited from releasing
10 25 any individual patient record information, unless such a
10 26 release is authorized in writing by the enrollee or the
10 27 enrollee's designee or is otherwise required or authorized by
10 28 law.
10 29 Sec. 10. NEW SECTION. 514J.9 CLINICAL DECISION MAKING.
10 30 1. A managed care plan shall appoint a medical director
10 31 who is a licensed health care professional in Iowa. The
10 32 medical director is responsible for treatment policies,
10 33 protocols, quality assurance activities, and utilization
10 34 management decisions of the plan.
10 35 2. A managed care plan shall inform enrollees, upon
11 1 request, of the financial arrangements between the plan and
11 2 participating health care professionals and pharmacists, if
11 3 those arrangements include incentives or bonuses for
11 4 restriction of services.
11 5 Sec. 11. NEW SECTION. 514J.10 OVERSIGHT AUTHORITY –
11 6 INSURANCE DIVISION.
11 7 1. The insurance division of the department of commerce
11 8 shall perform audits on an annual basis, to review enrollee
11 9 clinical outcome data, enrollee service data, and operational
11 10 and financial data.
11 11 2. This chapter shall not preclude the insurance division
11 12 from investigating complaints, grievances, or appeals on
11 13 behalf of enrollees or health care professionals.
11 14 Sec. 12. NEW SECTION. 514J.11 CITATION.
11 15 This chapter shall be known and may be cited as the
11 16 "Managed Care Consumer Protection Act".
11 17 EXPLANATION
11 18 This bill establishes a new Code chapter 514J which
11 19 provides protections for consumers of managed care. The Code
11 20 chapter may be referred to as the "Managed Care Consumer
11 21 Protection Act".
11 22 The bill states the purposes and intent of the chapter,
11 23 including providing access and choice with regard to health
11 24 care and providers of health care, providing quality health
11 25 care services through appropriate providers who are in good
11 26 standing professionally, providing for open communication
11 27 between patients and providers, and providing a process for
11 28 timely resolution of complaints and grievances.
11 29 The bill provides definitions of terms used in the new Code
11 30 chapter. The bill requires that a managed care plan provide
11 31 adequate access to sufficient numbers and types of providers,
11 32 facilities, and specialists; provide for continuity of care
11 33 when a provider's contract is terminated; provide adequate
11 34 telephone access to the managed care plan by consumers;
11 35 provide standards for waiting times to obtain appointments;
12 1 provide coverage for emergency health care services when the
12 2 situation meets the prudent lay person standard defined in the
12 3 bill; develop an access plan for underserved populations; and
12 4 hold harmless enrollees against claims of providers for
12 5 payment of costs of covered health care services.
12 6 With regard to choice of health care professionals, the
12 7 bill requires the managed care plan to provide for adequate
12 8 choice among accessible and qualified providers; requires that
12 9 an enrollee be allowed to choose the enrollee's own primary
12 10 care practitioner from the list of practitioners within the
12 11 plan; requires that an enrollee may choose a specialist as a
12 12 primary care provider if the enrollee's medical condition so
12 13 warrants; requires provision of continuity of care and
12 14 referrals to specialists within the plan; requires provision
12 15 of a point-of-service option and for consultation for a second
12 16 opinion.
12 17 The bill prohibits a managed care plan from contracting
12 18 with a provider to limit disclosures to an enrollee or on
12 19 behalf of an enrollee or to penalize a provider for relaying
12 20 any information relating to the enrollee's condition or
12 21 treatment options, and prohibits the plan from penalizing a
12 22 provider for discussing financial incentives and arrangements
12 23 between the plan and the provider.
12 24 The bill requires a plan to provide coverage for any United
12 25 States federal drug administration (FDA)-approved drugs or
12 26 devices if the drugs or devices are medically necessary as
12 27 determined by the provider; requires a drug utilization review
12 28 program which includes education and periodic examination of
12 29 data related to outcomes.
12 30 The bill requires the plan to define and disclose any
12 31 limitations of the plan and requires notice and information to
12 32 the enrollee of any denial of coverage for experimental
12 33 treatment for an enrollee who has a terminal condition or
12 34 illness.
12 35 The bill requires each managed care plan to have quality
13 1 assurance standards, have a process for selection of providers
13 2 participating in the plan, have a formal, written, ongoing
13 3 process of evaluation for all participating providers, and
13 4 limits providers to providing care only within the provider's
13 5 scope of practice.
13 6 The bill requires that the managed care plan provide
13 7 certain information to enrollees and the division of
13 8 insurance; collect and report specified data to the division
13 9 of insurance annually; provide the data to the public on a
13 10 timely basis; ensure enrollee confidentiality through written
13 11 policies and procedures for the handling of medical records
13 12 and enrollee communications; ensure confidentiality of
13 13 specified enrollee information; and prohibits the plan from
13 14 releasing the enrollee's individual patient records without
13 15 written authorization by the enrollee or the enrollee's
13 16 designee, or unless otherwise authorized by law.
13 17 The bill requires each managed care plan to appoint a
13 18 medical director who is a licensed health care professional in
13 19 Iowa. A plan is required to inform enrollees of financial
13 20 arrangements between the plan and participating health care
13 21 professionals and pharmacists if incentives or bonuses are
13 22 involved.
13 23 The bill provides that the division of insurance is to
13 24 annually audit the plan and does not preclude the division
13 25 from investigating complaints, grievances, or appeals of
13 26 enrollees and providers.
13 27 LSB 1331SS 78
13 28 pf/cf/24.1
Text: SF00194 Text: SF00196 Text: SF00100 - SF00199 Text: SF 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 05:55:00 CST 2000
URL: /DOCS/GA/78GA/Legislation/SF/00100/SF00195/990223.html
jhf