HF 349 (LSB 2239YH (5) 86)

HOUSE FILE 349

BY  KAUFMANN

A BILL FOR

An Act relating to certain health coverage that covers the essential health benefits required pursuant to the federal Patient Protection and Affordable Care Act and including applicability and penalty provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  507B.5A  Discrimination in health benefit plan design prohibited.
   1.  A carrier that offers a policy, contract, or plan that covers the essential health benefits as required pursuant to section 1302 of the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and its implementing regulations, shall not use a plan benefit design or a manner of implementing a plan benefit design for providing the essential health benefits that discriminates against an enrollee based on the enrollee’s age, expected length of life, race, color, national origin, sex, gender identity, sexual orientation, present or predicted disability, degree of medical dependency, quality of life, or present or predicted diagnosis, disease, or health condition. The commissioner may adopt rules pursuant to chapter 17A to administer this section.
   2.  For purposes of this section, unless the context otherwise requires, “carrier” means the same as defined in section 513B.2.
    Sec. 2.  NEW SECTION.  514K.2  Health carrier disclosures —— public internet sites.
   1.  A carrier that provides small group health coverage pursuant to chapter 513B or individual health coverage pursuant to chapter 513C and that offers for sale a policy, contract, or plan that covers the essential health benefits required pursuant to section 1302 of the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and its implementing regulations, shall provide to each of its enrollees at the time of enrollment, and shall make available to prospective enrollees and enrollees, insurance producers licensed under chapter 522B, and the general public, on the carrier’s internet site, all of the following information in a clear and understandable form for use in comparing policies, contracts, and plans, and coverage and premiums:
   a.  Any exclusions from coverage and any restrictions on the use or quantity of covered items and services in each category of benefits, including prescription drugs and drugs administered by a physician or clinic.
   b.  Any items or services, including prescription drugs, that have a coinsurance requirement where the cost-sharing required depends on the cost of the item or service.
   c.  The specific prescription drugs available on the carrier’s formulary, the specific prescription drugs covered when furnished by a physician or clinic, and any clinical prerequisites or prior authorization requirements for coverage of the drugs.
   d.  The specific types of specialists available in the carrier’s network and the specific physicians included in the carrier’s network.
   e.  The process for an enrollee to appeal a carrier’s denial of coverage of an item or service prescribed or ordered by the enrollee’s treating physician.
   f.  How medications will specifically be included in or excluded from the deductible, including a description of all out-of-pocket costs that may not apply to the deductible for a prescription drug.
   2.  The commissioner may adopt rules pursuant to chapter 17A to administer this section.
   3.  The commissioner may impose any of the sanctions provided under chapter 507B for a violation of this section.
    Sec. 3.  NEW SECTION.  514K.3  Health care plan internal appeals process —— disclosure requirements.
   1.  A carrier that provides small group health coverage pursuant to chapter 513B or individual health coverage pursuant to chapter 513C through the issuance of nongrandfathered health plans as defined in section 1251 of the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and in 45 C.F.R. §147.140, shall implement and maintain procedures for carrying out an effective internal claims and appeals process that meets the requirements established pursuant to section 2719 of the federal Public Health Service Act, 42 U.S.C. §300gg-19, and 45 C.F.R. §147.136. The procedures shall include but are not limited to all of the following:
   a.  Expedited notification to enrollees of benefit determinations involving urgent care.
   b.  Full and fair internal review of claims and appeals.
   c.  Avoidance of conflicts of interest.
   d.  Sufficient notice to enrollees, including a description of available internal claims and appeals procedures, as well as information about how to initiate an appeal of a denial of coverage.
   2.  a.  A carrier that provides health coverage as described in subsection 1 shall maintain written records of all requests for internal claims and appeals that are received and for which internal review was performed during each calendar year. Such records shall be maintained for at least three years.
   b.  A carrier that provides health coverage as described in subsection 1 shall submit to the commissioner, upon request, a report that includes all of the following:
   (1)  The total number of requests for internal review of claims and appeals that are received by the carrier each year.
   (2)  The average length of time for resolution of each request for internal review of a claim or appeal.
   (3)  A summary of the types of coverage or cases for which internal review of a claim or appeal was requested.
   (4)  Any other information required by the commissioner in a format specified by rule.
   3.  A carrier that provides health coverage as described in subsection 1 shall make available to consumers written notice of the carrier’s internal claims and appeals and internal review procedures and shall maintain a toll-free consumer-assistance telephone helpline that offers consumers assistance with the carrier’s internal claims and appeals and internal review procedures, including how to initiate, complete, or submit a claim or appeal.
   4.  The commissioner may adopt rules pursuant to chapter 17A to administer this section.
    Sec. 4.  APPLICABILITY.  This Act is applicable to health insurance policies, contracts, or plans that are delivered, issued for delivery, continued, or renewed on or after January 1, 2016.
EXPLANATION
The inclusion of this explanation does not constitute agreement with

the explanation’s substance by the members of the general assembly.
   This bill relates to certain health coverage offered in this state that covers the essential health benefits required by the federal Patient Protection and Affordable Care Act and includes applicability and penalty provisions.
   New Code section 507B.5A prohibits a health carrier that offers such coverage from using a plan benefit design that discriminates against an enrollee on specified bases. The commissioner of insurance may adopt rules to administer the provision. A person who violates the new Code section is subject to the enforcement provisions of Code chapter 507B including cease and desist orders and civil penalties.
   New Code section 514K.2 requires health carriers that provide small group or individual health coverage that covers the essential health benefits to make information available to prospective enrollees and enrollees, insurance producers, and the general public on the carrier’s internet site that can be used to compare policies, contracts, and plans and coverage and premiums. The bill specifies what information must be included. The commissioner may adopt rules to administer the new Code section. The commissioner may impose any of the sanctions available under Code chapter 507B for a violation of the new Code section.
   New Code section 514K.3 requires health carriers that provide small group or individual health coverage that covers the essential health benefits to implement and maintain procedures for carrying out effective internal claims and appeals and specifies what these procedures must include. The provision also requires a health carrier to maintain written records concerning internal claims and appeals received and to submit a report to the commissioner, upon request, with specified information about the internal claims and appeals. A health carrier is also required to make available to consumers written notice about the carrier’s internal claims and appeals procedures and to maintain a toll-free consumer-assistance telephone helpline that offers consumers assistance with these procedures, including how to initiate, complete, or submit a claim or appeal. The commissioner may adopt rules to administer the new Code section.
   The bill is applicable to health insurance policies, contracts, or plans that are delivered, issued for delivery, continued, or renewed on or after January 1, 2016.