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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