Text: HSB00658 Text: HSB00660 Text: HSB00600 - HSB00699 Text: HSB Index Bills and Amendments: General Index Bill History: General Index
PAG LIN
1 1 Section 1. Section 507B.4, Code Supplement 2001, is
1 2 amended by adding the following new subsections:
1 3 NEW SUBSECTION. 12A. PARTICIPATION CLAUSES. Requiring a
1 4 health care provider to participate in an insurer's benefit
1 5 programs, plans, or products as a condition of participating
1 6 in any of the insurer's other programs, plans, or products or
1 7 reducing a health care provider's payment for covered services
1 8 provided under a program, plan, or product because the health
1 9 care provider did not participate in any of the insurer's
1 10 other programs, plans, or products. It is not an unfair
1 11 practice under this subsection for an insurer to develop a
1 12 single contract with terms and conditions applicable to more
1 13 than one benefit program, plan, or product as long as the
1 14 health care provider is not required by that single contract
1 15 to participate in a program, plan, or product as a condition
1 16 of participation in any other program, plan, or product.
1 17 For purposes of this subsection, "insurer" means the same
1 18 as defined in subsection 12. "Health care provider" means the
1 19 same as defined in section 514C.13, subsection 1.
1 20 NEW SUBSECTION. 12B. PRICING RESTRICTIONS. Requiring a
1 21 health care provider providing covered services under a
1 22 benefit plan, program, or product of an insurer to accept as
1 23 payment for those covered services the lowest price, including
1 24 discounts and incentives charged by or paid to the health care
1 25 provider for the same services by any other person, as defined
1 26 in section 4.1.
1 27 For purposes of this subsection, "insurer" means the same
1 28 as defined in subsection 12. "Health care provider" means the
1 29 same as defined in section 514C.13, subsection 1.
1 30 NEW SUBSECTION. 12C. LACK OF SPECIFICITY IN CONTRACT
1 31 TERMS AND CONDITIONS. Failure of an insurer to clearly
1 32 specify in each agreement with a health care provider under
1 33 which a health care provider provides covered services, what
1 34 benefit plans, programs, or products the health care provider
1 35 has agreed to participate in pursuant to the agreement, and
2 1 the terms and conditions, including payment for each covered
2 2 service, applicable to each program, plan, or product included
2 3 under the agreement. An insurer must have and make available
2 4 to a health care provider a method or process that enables a
2 5 health care provider to determine the amount paid for each
2 6 covered service and that does not reduce or attempt to reduce
2 7 the amount paid to a health care provider for a covered
2 8 service by using an amount, discount, or payment reduction
2 9 formula or methodology that the insurer and health care
2 10 provider have not directly and specifically agreed upon as
2 11 applicable to the covered service in question. The
2 12 commissioner of insurance shall adopt rules pursuant to
2 13 chapter 17A to administer this subsection.
2 14 For purposes of this subsection, "insurer" means the same
2 15 as defined in subsection 12. "Health care provider" means the
2 16 same as defined in section 514C.13, subsection 1.
2 17 EXPLANATION
2 18 This bill amends Code section 507B.4 to designate certain
2 19 insurance practices related to health care providers as unfair
2 20 methods of competition and practice. The bill makes it an
2 21 unfair practice for an insurer to require a health care
2 22 provider to participate in an insurer's benefit programs,
2 23 plans, or products as a condition of participating in any of
2 24 the insurer's other programs, plans, or products or reducing a
2 25 health care provider's payment for covered services provided
2 26 under a program, plan, or product because the health care
2 27 provider did not participate in any of the insurer's other
2 28 programs, plans, or products.
2 29 The bill also makes it an unfair practice for an insurer to
2 30 require a health care provider providing covered services
2 31 under a benefit plan, program, or product to accept as payment
2 32 for those covered services the lowest price charged by or paid
2 33 to the health care provider for the same services by any other
2 34 person.
2 35 The bill also makes it an unfair practice to an insurer to
3 1 fail to clearly specify in each agreement with a health care
3 2 provider what plans, programs, or products the health care
3 3 provider has agreed to participate in pursuant to the
3 4 agreement and the terms and conditions, including payment for
3 5 each covered service, applicable to each program, plan, or
3 6 product included in the agreement. In addition, an insurer
3 7 must have and make available to a health care provider a
3 8 method or process that enables a health care provider to
3 9 determine the amount paid for each covered service and that
3 10 does not reduce the amount paid to a health care provider by
3 11 using a formula or methodology that the insurer and the health
3 12 care provider have not specifically agreed upon. The
3 13 commissioner of insurance is directed to adopt rules pursuant
3 14 to Code chapter 17A to administer this provision.
3 15 For purposes of the bill, an "insurer" means an entity
3 16 providing a plan of health insurance, health care benefits, or
3 17 health care services, or an entity performing utilization
3 18 review, including an insurance company offering sickness and
3 19 accident plans, a health maintenance organization, an
3 20 organized delivery system, a nonprofit health service
3 21 corporation, a plan established pursuant to Code chapter 509A
3 22 for public employees, or any other entity providing a plan of
3 23 health insurance, health care benefits, or health care
3 24 services. A "health care provider" means a hospital licensed
3 25 pursuant to Code chapter 135B, a person licensed under Code
3 26 chapter 148, 148C, 149, 150, 150A, 151, or 154, or a person
3 27 licensed as an advanced registered nurse practitioner under
3 28 Code chapter 152.
3 29 LSB 6656HC 79
3 30 av/sh/8
Text: HSB00658 Text: HSB00660 Text: HSB00600 - HSB00699 Text: HSB Index Bills and Amendments: General Index Bill History: General Index
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