HF 2630 (LSB 5664YH (4) 88)

HOUSE FILE 2630

BY  ISENHART

A BILL FOR

An Act relating to health benefit plan network access and adequacy, and including applicability provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514M.1  Definitions.
   As used in this chapter unless the context otherwise requires:
   1.  “Authorized representative” means the same as defined in section 514J.102.
   2.  “Balance billing” means the practice of a provider billing for the difference between the provider’s charge for the provision of a health care service and a health carrier’s allowed amount for the health care service.
   3.  “Centers of excellence” means a specialized program within a facility that has an exceptionally high concentration of health care professionals with expertise and related resources centered on a particular medical area and delivered in a comprehensive, interdisciplinary fashion.
   4.  “Commissioner” means the commissioner of insurance.
   5.  “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense obligation imposed on a covered person by a health benefit plan providing for third-party payment or prepayment of health or medical expenses.
   6.  “Covered benefit” or “benefit” means the same as defined in section 514J.102.
   7.  “Covered person” means the same as defined in section 514J.102.
   8.  “Emergency medical condition” means the same as defined in section 514C.16.
   9.  “Emergency services” means the same as defined in section 514C.16.
   10.  “Essential community provider” means a provider that serves predominantly low-income, medically underserved individuals.
   11.  “Facility” means the same as defined in section 514J.102.
   12.  “Health benefit plan” means the same as defined in section 514J.102.
   13.  “Health care professional” means the same as defined in section 514J.102.
   14.  “Health care provider” or “provider” means the same as defined in section 514J.102.
   15.  “Health care services” means services for the diagnosis, prevention, treatment, cure or relief of a physical, mental or behavioral health condition, illness, injury, or disease, including mental health and substance use disorders.
   16.  “Health carrier” or “carrier” means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a health insurance company, a health maintenance organization, a hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits, or health care services.
   17.  “In-network” means a health care service that is provided to a covered person by a health care provider that is a participating provider in the covered person’s network plan.
   18.  “Intermediary” means a person authorized to negotiate and execute a provider contract with a health carrier on behalf of a health care provider or on behalf of a network.
   19.  “Network” means a group or groups of participating providers providing health care services under a network plan.
   20.  “Network plan” means a health benefit plan that either requires a covered person to use, or offers incentives for a covered person to use, health care providers managed, owned, under contract with, or employed by a specific health carrier.
   21.  “Out-of-network” means a health care service that is provided to a covered person by a health care provider that is not a participating provider in the covered person’s network plan.
   22.  “Participating provider” means a provider that, under a contract with a health carrier, or with a health carrier’s contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment directly or indirectly from the health carrier, in addition to a covered person’s cost-sharing.
   23.  “Person” means the same as defined in section 514J.102.
   24.  “Primary care” means general health care services of the type provided at the time a patient seeks preventive care or first seeks health care services for a specific health concern. “Primary care” includes all of the following:
   a.  Care that promotes and maintains mental and physical health and wellness.
   b.  Care that prevents disease.
   c.  Screening, diagnosing, and treatment of acute or chronic conditions caused by disease, injury, or illness.
   d.  Patient counseling and education.
   e.  Provision of a broad spectrum of preventive and curative health care over a period of time.
   f.  Coordination of care.
   25.  “Primary care professional” means a participating provider designated by a health carrier to supervise, coordinate, or to provide initial care or continuing care to a covered person, and who may be required by the health carrier to initiate a referral for specialty care and to maintain supervision of health care services rendered to the covered person.
   26.  “Specialist” means a health care professional who meets all of the following requirements:
   a.  Focuses on a specific area of physical, mental, or behavioral health, or focuses on a specific group of patients.
   b.  Has successfully completed required training and is recognized by the state to provide specific specialty care. 
   27.  “Specialty care” means advanced medically necessary care and treatment of a specific physical, mental, or behavioral health condition, or a health condition which may manifest in particular ages or subpopulations, that is provided by a specialist, preferably in coordination with a primary care professional or other health care professional.
   28.  “Telehealth” means the same as defined in section 514C.34.
   29.  “Tiered network” means a network that identifies and groups some or all types of participating providers into specific groups to which different provider reimbursement, covered person cost-sharing, provider access requirements, or any combination thereof, apply for the same health care services.
   30.  “To stabilize” means to provide medical treatment for an individual’s emergency medical condition as may be necessary to assure within a reasonable medical probability that no material deterioration of the individual’s emergency medical condition is likely to result from, or occur during, the transfer of the individual to or from a facility. “Transfer” means, for purposes of this subsection, the movement, including the discharge, of an individual outside of a facility at the direction of any person employed by, affiliated with, or associated with the facility directly or indirectly, but does not include the movement of an individual who meets any of the following criteria:
   a.  The individual has been declared legally dead by a health care professional.
   b.  The individual leaves the facility against medical advice.
    Sec. 2.  NEW SECTION.  514M.2  Network adequacy —— commissioner approval.
   1.  A health carrier providing a network plan shall maintain a network that is adequate in the number of participating providers and in the appropriate types of participating providers, including participating essential community providers, to assure that all covered health care services provided to covered persons will be accessible without unreasonable travel or delay. Covered persons shall have access to emergency services twenty-four hours per day, seven days per week.
   2.  The commissioner shall determine, by rules promulgated pursuant to chapter 17A, network adequacy that meets the requirements of this section and may establish network adequacy requirements by reference to any reasonable criteria which shall include but not be limited to all of the following:
   a.  The ratio of participating provider to covered persons by specialty care areas.
   b.  The ratio of participating primary care providers to covered persons.
   c.  The geographic accessibility of participating providers.
   d.  The geographic variation and population dispersion of participating providers.
   e.  The average wait time for a covered person to obtain an appointment with a participating provider.
   f.  Participating provider hours of operation.
   g.  The ability of the network to meet the needs of covered persons, including low-income individuals, children, and adults with serious, chronic, or complex health conditions, or physical or mental disabilities, or limited English proficiency.
   h.  Other health care service delivery options made available to covered persons, such as telehealth, mobile clinics, and centers of excellence.
   i.  The technological and specialty care services available to serve the medical needs of covered persons requiring technologically advanced or specialty care services.
   3.  a.  A health carrier shall establish and maintain a process, to be approved by the commissioner, to assure that a covered person obtains a covered benefit at an in-network level of benefits, including an in-network level of cost-sharing, from an out-of-network provider, or shall establish another protocol approved by the commissioner to address each of the following circumstances:
   (1)  The health carrier has a sufficient network pursuant to subsections 1 and 2, but does not have a specific type of participating provider available to provide a covered benefit to a covered person, or the health carrier does not have a specific type of participating provider available to provide a covered benefit to a covered person without unreasonable travel or delay.
   (2)  The health carrier has an insufficient number or type of participating providers pursuant to subsections 1 and 2 available to provide a covered benefit to a covered person without unreasonable travel or delay.
   b.  A health carrier shall inform covered persons of the process, pursuant to paragraph “a”, that a covered person may use to request access to a covered benefit provided by an out-of-network provider in each of the following circumstances:
   (1)  The covered person is diagnosed with a condition or disease that requires specialized health care services and the health carrier does not have a participating provider with the required specialty, or with the professional training and expertise, to provide health care services for the covered person’s condition or disease.
   (2)  The covered person is diagnosed with a condition or disease that requires specialized health care services and the health carrier cannot provide reasonable access to a participating provider with the required specialty, or with the professional training and expertise to provide health care services to the covered person for the condition or disease, without requiring unreasonable travel or delay.
   c.  A health carrier shall treat health care services a covered person receives from an out-of-network provider pursuant to paragraph “b” as if the health care services are provided by a participating provider, including counting the covered person’s cost-sharing for the health care services toward the covered person’s maximum out-of-pocket limit applicable to the same health care services if obtained from a participating provider under the covered person’s health benefit plan.
   d.  A health carrier’s process pursuant to this subsection shall ensure that a covered person’s request to obtain a covered benefit from an out-of-network provider is addressed by the health carrier in a time period that is medically appropriate for the covered person’s medical condition.
   e.  A health carrier shall establish and maintain a system that documents all requests made by covered persons to obtain a covered benefit from an out-of-network provider pursuant to this subsection and shall provide complete copies of the documentation to the commissioner within five business days of the commissioner’s request for the documentation.
   f.  The process established in this subsection shall not be construed by a health carrier as a substitute for establishing and maintaining a sufficient provider network pursuant to this section, nor shall the process be construed by a covered person as a process to circumvent the use of a participating provider to provide covered benefits available through a health carrier’s network.
   4.  Nothing in this section shall be construed to prevent a covered person from exercising the covered person’s rights and remedies relating to internal and external claims grievance and appeals processes pursuant to applicable state or federal law.
   5.  A health carrier shall monitor, on an ongoing basis, the ability, clinical capacity, and legal authority of the health carrier’s participating providers to furnish all contracted covered benefits to covered persons.
   6.  a.  Prior to or at the time a health carrier files a newly offered network in this state, the health carrier shall file with the commissioner for approval in the form and manner pursuant to rules adopted by the commissioner, an access plan that meets the requirements of this chapter.
   b.  A health carrier may request that the commissioner deem portions of the submitted access plan as proprietary or trade secret. The health carrier shall make the access plan, absent information deemed proprietary or trade secret by the commissioner, readily accessible on the health carrier’s main internet site, at all of the health carrier’s business premises, and to any individual upon request. For purposes of this paragraph, information is only proprietary or trade secret if revealing the information will allow the health carrier’s direct competitors to obtain competitive information.
   c.  A health carrier shall notify the commissioner of any material change to an existing network plan within ten business days after the date that the material change occurs. The carrier shall include in the notice a reasonable time frame, not to exceed fifteen business days, within which the carrier will submit an updated access plan to the commissioner for approval.
   7.  A health carrier’s access plan pursuant to subsection 6 shall at a minimum describe or contain all of the following:
   a.  The health carrier’s network, including how the use of telehealth or other technology will be used to meet network access standards, if applicable.
   b.  The health carrier’s procedures for making referrals and authorizing referrals within and outside of the health carrier’s network.
   c.  The health carrier’s ongoing process for monitoring and assuring the sufficiency of the health carrier’s network to meet the health care needs of all covered persons in the network plan.
   d.  The factors used by the health carrier to establish the health carrier’s network, including a description of the proposed network and the criteria used by the health carrier to select providers or to tier providers, if applicable.
   e.  The health carrier’s efforts to address the needs of all covered persons in the network plan, including individuals with limited English proficiency or illiteracy, diverse cultural or ethnic backgrounds, physical or mental disabilities, and serious, chronic, or complex medical conditions. This shall include the health carrier’s efforts, if applicable, to include various types of essential community providers in the health carrier’s network.
   f.  The health carrier’s methods for assessing the health care needs of all covered persons and the covered persons’ satisfaction with the health care services offered by the participating providers.
   g.  The health carrier’s methods of informing covered persons of covered health care services and the features of the specific health benefit plans offered by the health carrier, including but not limited to:
   (1)  The grievance and appeal procedures.
   (2)  The process for a covered person to select and to change network providers.
   (3)  The health carrier’s process for updating the health benefit plan’s provider directories for each of the health benefit plan’s networks.
   (4)  All health care services offered, including those health care services offered through a preventive care benefit, if applicable.
   (5)  The procedures for a covered person to access covered emergency, urgent, and specialty health care services.
   h.  The health carrier’s system for ensuring coordination and continuity of care in each of the following circumstances:
   (1)  For a covered person referred to a specialty provider.
   (2)  For a covered person using ancillary services, including social services and other community resources, and for ensuring appropriate discharge planning from such services.
   i.  The health carrier’s process for enabling a covered person to change primary care providers.
   j.  The health carrier’s proposed plan for providing continuity of care in the event of a contract termination between the health carrier and any of the health carrier’s participating providers, or in the event of the health carrier’s insolvency or other inability to continue operations. The proposed plan shall detail the process by which the health carrier will notify covered persons of the contract termination, the health carrier’s insolvency, or other cessation of operations; and the process by which the health carrier will transition covered persons to other health care providers in a medically appropriate manner.
   k.  The health carrier’s process for monitoring a covered person’s access to participating provider specialist services including emergency room care, anesthesiology, radiology, hospitalist care, pathology services, and laboratory services.
   l.  Any other information required by the commissioner to determine the health carrier’s compliance with this chapter.
    Sec. 3.  NEW SECTION.  514M.3  Prohibition on balance billing.
   1.  A health carrier shall establish a mechanism by which a participating provider will be notified on an ongoing basis of the specific covered health care services for which the participating provider is responsible, including any limitations or conditions on the participating provider’s provisions of the health care services.
   2.  Each contract executed between a health carrier and a participating provider shall contain a hold harmless provision that provides protection for covered persons. This requirement shall be met by including a provision that contains language substantially similar to the following:
   Provider agrees that in no event, including but not limited to nonpayment by a health carrier or an intermediary, the insolvency of a health carrier or an intermediary, or breach of this agreement, shall the provider bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any legal recourse against a covered person or another individual, other than the health carrier or intermediary, for health care services provided pursuant to this agreement. This agreement shall not be construed as prohibiting a provider from collecting a covered person’s cost-sharing as specifically provided in the covered person’s evidence of coverage, or from collecting fees for health care services delivered on a fee-for-service basis to a covered person. This agreement does not prohibit a provider, except for a health care professional who is employed full-time on the staff of a health carrier and has agreed to provide health care services exclusively to that health carrier’s covered persons, and a covered person from agreeing to the provider continuing to provide health care services solely at the expense of the covered person, as long as the provider has clearly informed the covered person that the health carrier may not cover or continue to cover a specific health care service or services. Except as provided herein, this agreement shall not prohibit the provider from pursuing any legal remedy available to the provider.

   3.  Each contract executed between a health carrier and a participating provider shall set forth that in the event of the health carrier’s or the intermediary’s insolvency or other cessation of operations, the provider’s obligation to deliver covered health care services to a covered person without balance billing the covered person shall continue until the earlier of either of the following:
   a.  The termination of the covered person’s coverage under the applicable health benefit plan including any extension of the covered person’s coverage provided under the contract terms or pursuant to applicable state or federal laws, for a covered person who is undergoing an active course of medical treatment.
   b.  The date the contract between the health carrier and the provider, including any required extension for covered persons undergoing an active course of medical treatment, would have terminated if the health carrier or an intermediary had remained in operation.
   4.  The contract provisions pursuant to subsections 2 and 3 shall be construed in favor of the covered person, shall survive the termination of the contract regardless of the reason for the termination, including the insolvency of the health carrier or intermediary, and shall supersede any oral or written contrary agreement between a provider and a covered person or the representative of a covered person.
   5.  In no event shall a participating provider collect or attempt to collect any money from a covered person owed to the provider by a health carrier.
    Sec. 4.  NEW SECTION.  514M.4  Participating providers.
   1.  A health carrier’s selection standards for selecting and tiering participating providers shall be developed for providers and each type of specialty care. The health carrier’s selection standards shall be used in determining the selection and tiering, as applicable, of participating providers by the health carrier and the health carrier’s intermediaries.
   2.  A health carrier’s selection and tiering criteria shall not be established in a manner that results in any of the following:
   a.  Allows a health carrier to discriminate against high-risk populations by excluding a provider or tiering a provider because the provider is located in a geographic area that contains populations or providers presenting a risk of higher than average claims, losses, or health care services utilization.
   b.  Excludes a provider because the provider treats or specializes in treating populations presenting a risk of higher than average claims, losses, or health care services utilization.
   c.  This subsection shall not be construed to prohibit a health carrier from declining to select a provider who fails to meet other legitimate selection criteria utilized by the health carrier developed in compliance with this chapter.
   3.  This chapter shall not be construed to require a health carrier or its intermediaries to contract with or retain more providers acting within the scope of the provider’s licenses or certifications under state law than are necessary to maintain a sufficient provider network pursuant to section 514M.2.
   4.  A health carrier shall make the health carrier’s standards for selecting and tiering participating providers available for review and approval by the commissioner pursuant to rules adopted by the commissioner. A description of the standards the health carrier uses for selecting and tiering participating providers shall be available, in plain language, on the health carrier’s publicly accessible internet site.
   5.  A health carrier shall notify participating providers of each participating provider’s responsibilities with respect to the health carrier’s applicable administrative policies and programs, including but not limited to payment terms; utilization review; quality assessment and improvement programs; credentialing; grievance and appeals procedures; data reporting requirements; reporting requirements for timely notice of changes in the participating provider’s practice; confidentiality requirements; and any applicable federal and state requirements.
   6.  A health carrier shall not offer an inducement to a participating provider to encourage or otherwise incent the participating provider to deliver less than medically necessary services to a covered person.
   7.  A health carrier shall not prohibit a participating provider from any of the following:
   a.  Discussing any specific treatment options with a covered person irrespective of the health carrier’s position on the treatment options.
   b.  From advocating on behalf of a covered person within the utilization review process, grievance process, or appeals process established by the health carrier, a person contracting with the health carrier, or in accordance with any rights or remedies available under state or federal law.
   8.  Each contract executed by a health carrier and a participating provider shall require that the participating provider comply with the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191.
    Sec. 5.  NEW SECTION.  514M.5  Participating providers —— removal or voluntary exit from a network.
   1.  As used in this section, unless the context otherwise requires:
   a.  “Active course of treatment” means, in reference to a covered person that has been treated on a regular basis by a participating provider that is either being removed from a network or that is voluntarily leaving a network, any of the following:
   (1)  An ongoing course of treatment for a life-threatening health condition.
   (2)  An ongoing course of treatment for a serious acute condition.
   (3)  The second or third trimester of pregnancy.
   (4)  An ongoing course of treatment for a health condition for which the treating health care professional attests that discontinuing care by that health care professional will allow the covered person’s condition to deteriorate or interfere with anticipated outcomes.
   b.  “Life-threatening health condition” means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted.
   c.  “Serious acute condition” means a disease or condition requiring complex ongoing care that a covered person is currently receiving, such as chemotherapy or radiation therapy.
   2.  A health carrier and a participating provider shall provide at least sixty calendar days advance written notice to the other party before the participating provider is either removed from the network by the health carrier or the participating provider voluntarily exits the network without cause.
   3.  a.  A health carrier shall provide written notice to all covered persons who have received health care services on a regular basis from a participating provider of the participating provider’s removal from the network, or of the participating provider’s voluntary exit from the network, within thirty calendar days of the date of the receipt or the issuance of a notice provided in accordance with subsection 1.
   b.  If a participating provider that is a primary care provider either gives or receives a notice pursuant to subsection 1, the participating provider shall provide the health carrier with a list of the participating provider’s patients that are covered by a health benefit plan offered by the health carrier. The health carrier shall also notify all covered persons who have received health care services provided by the primary care provider within thirty calendar days of receipt of the list from the primary care provider.
   4.  a.  If a covered person’s participating provider voluntarily leaves a network or is removed from the network, the health carrier shall establish and maintain procedures to transition the covered person, if the covered person is in an active course of treatment, to a participating provider in a manner that ensures continuity of care.
   b.  A health carrier shall provide notice pursuant to subsection 2 and shall make available to the covered person a list of available participating providers of the same provider type in the same geographic area. In addition, the health carrier shall make available to the covered person the procedure to request continuity of care. The procedure shall provide for all of the following:
   (1)  A request for continuity of care shall be made to the health carrier by the covered person or by the covered person’s authorized representative.
   (2)  A request for continuity of care shall be reviewed by the health carrier’s medical director after consultation with the treating health care professional for a covered person who meets the criteria pursuant to subsection 4, paragraph “a”, and who is under the care of a health care professional who has not been removed from the network or who is not leaving the network for cause. Any decisions made with respect to a request for continuity of care shall be subject to the health benefit plan’s internal and external grievance and appeal processes in accordance with applicable state and federal laws and regulations.
   5.  The continuity of care period for a covered person who is in the second or third trimester of pregnancy shall extend through the postpartum period. The continuity of care period for a covered person who is undergoing an active course of treatment shall extend to the earliest of all of the following:
   a.  The termination of the course of treatment by the covered person or by the treating health care professional.
   b.  Ninety days unless the medical director of the treating facility determines that a longer period is necessary.
   c.  The date that the covered person’s care is successfully transitioned to a participating provider.
   d.  The covered person’s benefit limitations under the health benefit plan are met or exceeded.
   e.  The covered person’s care is no longer medically necessary as determined by the covered person’s treating health care professional.
   6.  In addition to the requirements pursuant to subsection 5, a covered person’s continuity of care request shall only be granted by a health carrier if the following requirements are satisfied:
   a.  A new health care professional agrees in writing to accept the same payment from, and abide by the same terms and conditions with respect to, the health carrier for that covered person as provided in the covered person’s original provider’s contract with the health carrier.
   b.  A new health care professional agrees in writing not to seek any payment from the covered person for any amount for which the covered person would not be responsible if the covered person’s previous provider was still a participating provider.
    Sec. 6.  NEW SECTION.  514M.6  Health carriers and participating providers —— rights and responsibilities.
   1.  The rights and responsibilities pursuant to a contract between a health carrier and a participating provider shall not be assigned or delegated by either party without the prior written consent of the other party.
   2.  A health carrier shall be responsible for ensuring that a participating provider furnishes covered benefits to all covered persons without regard to the covered person’s enrollment in one of the health carrier’s health benefit plans as a private purchaser of the plan or as a participant in a publicly financed program of health care services. This requirement shall not apply if a participating provider should not render services to a covered person due to limitations arising from the participating provider’s lack of training, experience, skill, or licensing restrictions.
   3.  A health carrier shall notify each participating provider of the participating provider’s obligations, if any, to collect cost-sharing from a covered person pursuant to the covered person’s evidence of coverage, or of the participating provider’s obligations to notify a covered person of the covered person’s personal financial obligations for a health care service that is not a covered benefit.
   4.  A health carrier shall not penalize a participating provider because the participating provider, in good faith, reports to state or federal authorities any act or practice by the health carrier that may jeopardize a patient’s health or welfare.
   5.  A health carrier shall establish a mechanism by which a participating provider can, at the time health care services are provided, determine whether an individual is a covered person or is within a grace period for payment of a premium during which the health carrier may hold a participating provider’s claim for payment for health care services pending receipt of the covered person’s payment of the premium.
   6.  A health carrier shall establish procedures for efficient resolution of administrative, payment, or other disputes between a participating provider and the health carrier.
   7.  A contract between a health carrier and a participating provider shall not contain any provision that conflicts with the network health benefit plan or with the requirements of this chapter.
   8.  At the time a contract is executed, a health carrier and, if applicable, an intermediary shall timely notify a participating provider of all provisions and other documents incorporated by reference in the contract. During the term of the contract, the health carrier shall timely notify the participating provider of any material changes in the contract. For purposes of this subsection, “timely notice” and “material change” shall be defined in the contract.
   9.  A health carrier shall timely inform a health care provider of the provider’s network participation status for any health benefit plan in which the health carrier has included the provider as a participating provider.
    Sec. 7.  NEW SECTION.  514M.7  Participating facilities —— out-of-network facility-based providers.
   1.  For purposes of this section, “facility-based provider” means a provider who provides health care services to patients at an inpatient or ambulatory facility, including services such as pathology, anesthesiology, emergency room care, and radiology. The health care services are typically arranged with the facility-based provider by the facility by contract as part of the facility’s general business operations, and a covered person or the covered person’s health benefit plan do not have the option to select a specific provider to provide specific health care services.
   2.  At the time a participating facility schedules a procedure or seeks prior authorization from a health carrier for the provision of nonemergency services to a covered person, the participating facility shall provide the covered person with a written out-of-network services disclosure that contains all of the following information:
   a.  That certain facility-based providers may provide health care services to the covered person during the course of treatment.
   b.  That certain facility-based providers may not be participating providers and that a health care service provided by an out-of-network provider is provided on an out-of-network basis.
   c.  A detailed description of the charges for the out-of-network services for which the covered person may be responsible.
   d.  A notification that the covered person may either agree to pay any charges for health care services provided on an out-of-network basis, contact the covered person’s health carrier for additional assistance, or rely on other rights and remedies that may be available under state or federal law.
   e.  A statement indicating that the covered person may obtain a list of facility-based providers from the covered person’s health benefit plan that are participating providers and that the covered person may request a participating facility-based provider.
   3.  Upon admission at a participating facility where a covered person will obtain nonemergency services, the participating facility shall provide the covered person with the written out-of-network services disclosure pursuant to subsection 2, and obtain the covered person’s or the covered person’s authorized representative’s signature on the disclosure acknowledging that the covered person received the disclosure prior to receipt of health care services.
   4.  a.  If an out-of-network facility-based provider sends a billing notice directly to a covered person for a health care service provided by the out-of-network facility-based provider, the billing notice shall include the payment responsibility notice pursuant to paragraph “b”.
   b.  The payment responsibility notice shall state the following or contain substantially similar language:
   Payment responsibility notice —— The health care service[s] outlined below was [were] performed by a facility-based provider who is an out-of-network provider with your health benefit plan. You are responsible for paying your applicable cost-sharing just as you would be if the provider is within your health benefit plan’s network. With regard to the remaining charges for the health care services, you have three choices:
   [1]  You may choose to pay the balance of the bill.
   [2]  If the difference in the billed charge and your health benefit plan’s allowable amount is more than five hundred dollars, you must send the bill to your health benefit plan for processing pursuant to the health carrier’s out-of-network facility-based provider billing process.
   [3]  You may rely on other rights and remedies that may be available in Iowa.

   c.  Nothing in this section shall preclude a covered person from agreeing to pay a bill received from an out-of-network facility-based provider.
   5.  a.  A health carrier shall develop a program for payment of out-of-network facility-based provider’s bills that provides for all of the following:
   (1)  A health carrier may elect to pay an out-of-network facility-based provider bill as submitted by the provider, or the health carrier may elect to pay in accordance with the benchmark established in subparagraph (2).
   (2)  A payment to an out-of-network facility-based provider shall be presumed to be reasonable if the payment is based on either the higher of the health carrier’s contracted rate with the facility at which the out-of-network provider rendered the health care service, or on two hundred percent of the Medicare rate for the same or similar health care service provided in the same geographic area.
   b.  This section does not preclude a health carrier and an out-of-network facility-based provider from agreeing to a separate payment arrangement.
   c.  An out-of-network facility-based provider who objects to a payment made pursuant to paragraph “a” may elect the provider mediation process pursuant to subsection 6.
   6.  a.  A health carrier shall establish a health care provider mediation process for disputes concerning payments of an out-of-network facility-based provider bills for providers objecting to the payment pursuant to subsection 5.
   b.  The mediation process shall be established in accordance with a mediation standard established by the American arbitration association or other nationally recognized mediation organization.
   c.  The cost of mediation and the cost of the mediators shall be divided evenly and paid by the health carrier and the nonparticipating facility-based provider.
   d.  A health carrier shall maintain documentation of each request for mediation and of each mediation completed pursuant to this subsection. Upon request of the commissioner, the health carrier shall submit a report regarding all requested and completed mediations to the commissioner in the form and manner prescribed by the commissioner.
   7.  The rights and remedies pursuant to this section shall be in addition to and shall not preempt any other rights and remedies available to a covered person under state or federal law.
   8.  This section shall not apply to any of the following:
   a.  Providers or covered persons using the process established in section 514M.2, subsection 3.
   b.  Facilities that have made arrangements with facility-based providers employed by the facility that prohibit the facility-based providers from balance billing covered persons.
   c.  Providers with whom the facility contracts and prohibits from balance billing covered persons covered by a health benefit plan with which the facility contracts.
    Sec. 8.  NEW SECTION.  514M.8  Disclosure requirements —— health carriers and facilities.
   1.  A health carrier shall develop a written disclosure to be provided to a covered person or the covered person’s authorized representative at the time of precertification, if applicable, for a covered health care service to be provided at a facility that is in the covered person’s health benefit plan’s network if there is a possibility that the covered health care service or an ancillary health care service may be rendered by a health care professional that is out-of-network. The disclosure shall include all of the following:
   a.  That the covered person may be subject to higher cost-sharing as described in the covered person’s plan summary of coverage and benefits documents, or balance billing, if the covered health care services are performed by a health care professional who is not in the covered person’s health plan’s network.
   b.  The amount the covered person’s health plan will pay for the health care service if the health care service is provided by an out-of-network provider.
   c.  Options for accessing health care services from a participating provider.
   2.  For nonemergency health care services, a facility contracted with a health carrier shall develop a written disclosure to be provided to a covered person of the health carrier within ten business days of the date the covered person schedules an appointment for health care services at the facility, or at the time of a covered person’s nonemergency admission to the facility, that confirms that the facility is a participating provider of the covered person’s health benefit plan. The disclosure shall inform the covered person that a health care professional may provide services to the covered person while at the facility and may not participate in the covered person’s health benefit plan.
    Sec. 9.  NEW SECTION.  514M.9  Provider directories —— health carriers.
   1.  A health carrier shall post a current and accurate provider directory, updated at least monthly, for each of the health carrier’s network plans on the health carrier’s internet site. The health carrier shall ensure that the general public is able to view all of the current participating providers for a specific health benefit plan via a clearly identified link or tab without requiring an individual to create or to access an account, or without requiring an individual to enter a policy or a contract number. The provider directory shall contain all of the information pursuant to subsection 2.
   2.  The health carrier shall audit a statistically significant sample size of each provider directory quarterly to ensure accuracy. The health carrier shall retain documentation of each audit and make the documentation available for review by the commissioner within ten business days of the commissioner’s request for the documentation.
   3.  A health carrier shall provide a print copy of the current provider directory upon request of a covered person or a prospective covered person.
   4.  Each provider directory shall contain all of the following:
   a.  A description of the criteria the health carrier used to establish the health carrier’s network.
   b.  A description of the criteria the health carrier used to establish the health carrier’s tiered network, if applicable.
   c.  The process used by the health carrier to designate the different provider tiers in a tiered network.
   d.  For each provider and each facility in the network, identify the tier in which the provider or the facility is placed, to enable a covered person or a prospective covered person to easily identify the provider’s tier or the facility’s tier.
   e.  Designate each participating provider for which an authorization or a referral may be required for a covered person to access certain health care services.
   f.  For each health care professional:
   (1)  Name.
   (2)  Gender.
   (3)  Participating office locations.
   (4)  Specialty, if applicable.
   (5)  Medical group affiliations, if applicable.
   (6)  Facility affiliations, if applicable.
   (7)  Participating facility affiliations, if applicable.
   (8)  Languages spoken other than English, if applicable.
   (9)  Languages other than English spoken by the health professional’s clinical staff, if applicable.
   (10)  Whether the health care professional is accepting new patients.
   (11)  Contact information, including telephone number and email.
   (12)  Board certifications.
   g.  For each facility:
   (1)  Facility name.
   (2)  Facility type, including but not limited to acute, rehabilitation, children’s center, or cancer center.
   (3)  Participating facility locations.
   (4)  Facility accreditation status.
   (5)  Available health care services.
   (6)  Contact information, including telephone number and email for each location of the facility.
   (7)  Physical address for each location of the facility.
   5.  A health carrier shall include the specific name of each network plan, as marketed and issued in this state, on the corresponding provider directory.
   6.  A health carrier shall include in the carrier’s electronic and print versions of each provider directory a customer service email address, telephone number, and electronic link that covered persons and the general public may use to notify the health carrier of inaccurate provider directory information.
   7.  A provider directory, whether in electronic or print form, shall accommodate the communication needs of individuals with disabilities and include a link to, or information regarding, assistance available for individuals with limited English proficiency.
   8.  A health carrier shall include a disclosure in each print copy of a provider directory that the information included in the provider directory is accurate as of the print date and shall advise a covered person or a prospective covered person that for more recent information the covered person or prospective covered person should consult the health carrier’s internet site, or contact customer service at the telephone number provided in the print copy to obtain up-to-date provider directory information.
    Sec. 10.  NEW SECTION.  514M.10  Intermediaries.
   1.  An intermediary and a participating provider with whom the intermediary contracts shall comply with all applicable requirements of section 514M.6.
   2.  A health carrier’s responsibility to monitor the offering of covered benefits to covered persons pursuant to section 514M.6 shall not be delegated or assigned to an intermediary. Notwithstanding any other law to the contrary, to the extent a health carrier delegates the health carrier’s responsibilities to an intermediary, the health carrier shall retain legal responsibility for the intermediary’s compliance with all applicable requirements of this chapter.
   3.  A health carrier shall have the right to approve or disapprove the participation status of a subcontracted provider in the health carrier’s network or in a contracted network for the purpose of delivering covered benefits to the health carrier’s covered persons.
   4.  A health carrier shall maintain copies of all intermediary health care subcontracts at the health carrier’s principal place of business in the state, or ensure that the health carrier has access to all intermediary subcontracts, including the right to obtain copies within five calendar days of the health carrier’s written request to the intermediary.
   5.  An intermediary shall transmit utilization documentation and claims paid documentation to the health carrier pursuant to rules adopted by the commissioner. The health carrier shall monitor the timeliness and appropriateness of payments made to providers, and monitor the health care services received by covered persons.
   6.  An intermediary shall maintain the records, financial information, and documentation related to health care services provided to a health carrier’s covered persons at the intermediary’s principal place of business in this state in a manner pursuant to rules adopted by the commissioner.
   7.  An intermediary shall allow the commissioner access to the intermediary’s records, financial information, and documentation related to health care services provided to a health carrier’s covered persons as necessary to determine compliance with this chapter.
   8.  A health carrier shall have the right, in the event of an intermediary’s insolvency, to require the assignment to the health carrier of the provisions of a provider’s contract addressing the provider’s obligation to furnish health care services to the health carrier’s covered persons. If a health carrier requires such an assignment, the health carrier shall remain obligated to pay the provider for providing health care services to the health carrier’s covered persons under the same terms and conditions as the intermediary’s terms and conditions for paying the provider prior to the intermediary’s insolvency. 
    Sec. 11.  NEW SECTION.  514M.11  Filing requirements and state administration.
   1.  At the time a health carrier files an access plan pursuant to section 514M.2, subsection 6, the health carrier shall file with the commissioner, for the commissioner’s approval, sample contract forms proposed for use with the health carrier’s participating providers and intermediaries.
   2.  A health carrier shall submit any material changes to a contract that may affect a provision required under section 514M.10, or that is required pursuant to a rule adopted by the commissioner, to the commissioner for approval at least thirty business days prior to the health carrier’s change to the contract.
   3.  The health carrier shall maintain all provider and intermediary contracts at the health carrier’s principal place of business in the state, or the health carrier shall have access to all of the contracts in such a manner that the health carrier can provide copies of the contracts to the commissioner within ten calendar days of the commissioner’s request for review of the contracts.
   4.  A health carrier’s execution of a contract with an intermediary, a health care professional, or any other person shall not relieve the health carrier of its liability to any individual with whom the health carrier has contracted for the provision of health care services, or of the health carrier’s responsibility for compliance with all applicable state and federal laws and regulations.
   5.  All contracts between a health carrier and a health care professional, or a health carrier and an intermediary, shall be in writing and shall be subject to the commissioner’s review.
    Sec. 12.  NEW SECTION.  514M.12  Enforcement.
   1.  The commissioner may take any enforcement action under the commissioner’s authority to enforce compliance with this chapter.
   2.  The commissioner shall require a modification to a health carrier’s access plan, shall institute a corrective action plan for the health carrier, or shall use any of the commissioner’s other enforcement powers to obtain a health carrier’s compliance with this chapter if the commissioner finds any of the following:
   a.  That a health carrier has not contracted with a sufficient number of participating providers to assure that covered persons have accessible health care services in a geographic area.
   b.  That a health carrier’s network access plan does not assure a covered person’s reasonable access to covered health care services.
   c.  That a health carrier has entered into an intermediary contract or a provider contract that does not comply with this chapter.
   d.  That a health carrier has not complied with any provision of this chapter.
   3.  The commissioner shall not act to arbitrate, mediate, or settle a dispute regarding any of the following:
   a.  A health carrier’s decision not to include a provider in a network plan or in a provider network.
   b.  Any dispute between a health carrier and the health carrier’s intermediaries.
   c.  Any dispute between a health carrier and one or more providers arising under or by reason of a participating provider contract, or of the termination of a participating provider contract.
    Sec. 13.  NEW SECTION.  514M.13  Rules.
   The commissioner shall adopt rules pursuant to chapter 17A to administer this chapter.
    Sec. 14.  APPLICABILITY.  This Act applies to all health carrier health benefit plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2021.
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 health benefit plan network access and adequacy, and substantially conforms to the national association of insurance commissioners’ health benefit plan network access and adequacy model act.
   The bill establishes standards for health carriers’ networks, and for the adequacy, accessibility, transparency, and quality of health care services offered under a network plan. “Health carrier” is defined in the bill as an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a health insurance company, a health maintenance organization, a hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits, or health care services.
   The bill establishes requirements for written agreements between health carriers offering network plans, intermediaries, and participating providers, and requires a health carrier to obtain the insurance commissioner’s approval for the health carrier’s access plan. “Intermediary” is defined in the bill as a person authorized to negotiate and execute a provider contract with a health carrier on behalf of a health care provider or on behalf of a network. The bill defines a “participating provider” as a provider that, under a contract with a health carrier, or with a health carrier’s contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment directly or indirectly from the health carrier, in addition to a covered person’s cost-sharing. A health carrier’s access plan must ensure the ongoing sufficiency of the provider network consistent with the requirements detailed in the bill. 
   The bill prohibits balance billing except in certain circumstances as detailed in the bill. “Balance billing” is defined in the bill as the practice of a provider billing for the difference between the provider’s charge for provision of a health care service and a health carrier’s allowed amount for the health care service.
   The bill applies to all health carriers’ health benefit plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2021.