Text: SF02305 Text: SF02307 Text: SF02300 - SF02399 Text: SF Index Bills and Amendments: General Index Bill History: General Index
PAG LIN 1 1 Section 1. NEW SECTION. 514L.1 LIABILITY OF A MANAGED 1 2 CARE HEALTH PLAN OR HEALTH MAINTENANCE ORGANIZATION. 1 3 1. For purposes of this section, unless the context 1 4 otherwise requires: 1 5 a. "Managed care health plan" means a health benefit plan 1 6 that selects and contracts with health care providers; manages 1 7 and coordinates health care delivery; monitors necessity, 1 8 appropriateness, and quality of health care delivered by 1 9 health care providers; and performs utilization review and 1 10 cost control. 1 11 b. "Health maintenance organization" means a health 1 12 maintenance organization as defined in section 514B.1, 1 13 subsection 6. 1 14 2. a. A managed care health plan or health maintenance 1 15 organization shall exercise ordinary care when making health 1 16 care treatment decisions and is liable for damages for harm to 1 17 an insured or enrollee proximately caused by its failure to 1 18 exercise ordinary care. An insured or enrollee may bring an 1 19 action against a managed care health plan or health 1 20 maintenance organization for a breach of the duty to exercise 1 21 ordinary care. 1 22 For purposes of this section, a managed care health plan or 1 23 health maintenance organization includes an employee, agent, 1 24 or other person acting on behalf of the managed care health 1 25 plan or health maintenance organization. 1 26 b. In any action brought under this section against a 1 27 managed care health plan or health maintenance organization, 1 28 the managed care health plan or health maintenance 1 29 organization may assert as a defense either of the following: 1 30 (1) The managed care health plan or health maintenance 1 31 organization did not control, influence, or participate in the 1 32 health care treatment decision. 1 33 (2) The managed care health plan or health maintenance 1 34 organization did not deny or delay payment for any treatment 1 35 prescribed or recommended by a health care provider. 2 1 c. This section does not create a duty on the part of the 2 2 managed care health plan or health maintenance organization to 2 3 provide treatment which is not covered by the health care plan 2 4 of the managed care health plan or health maintenance 2 5 organization. 2 6 d. In an action against a managed care health plan or 2 7 health maintenance organization, a finding that a physician or 2 8 other health care provider is an employee, agent, or 2 9 representative of such managed care health plan or health 2 10 maintenance organization shall not be based solely on proof 2 11 that such person's name appears in a listing of approved 2 12 health care providers made available to insureds or enrollees. 2 13 EXPLANATION 2 14 This bill creates new Code section 514L.1 which provides 2 15 that a managed care health plan or health maintenance 2 16 organization shall exercise ordinary care when making health 2 17 care treatment decisions and is liable for damages for harm to 2 18 an insured or enrollee proximately caused by its failure to 2 19 exercise such ordinary care. The bill provides that an 2 20 insured or enrollee may bring an action against a managed care 2 21 health plan or health maintenance organization for a breach of 2 22 the duty to exercise ordinary care. The bill provides that it 2 23 is a defense in any action brought against a managed care 2 24 health plan or health maintenance organization, that the 2 25 managed care health plan or health maintenance organization 2 26 did not control, influence, or participate in the health care 2 27 treatment decision, or did not deny or delay payment for any 2 28 treatment prescribed or recommended by a health care provider. 2 29 The bill provides that the new Code section does not create a 2 30 duty on the part of the managed care health plan or health 2 31 maintenance organization to provide treatment which is not 2 32 covered by the health care plan of the managed care health 2 33 plan or health maintenance organization. 2 34 LSB 5933XS 78 2 35 mj/as/5
Text: SF02305 Text: SF02307 Text: SF02300 - SF02399 Text: SF Index Bills and Amendments: General Index Bill History: General Index
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