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H0675...........................................................by BUSINESS
INSURERS - HEALTH CARE POLICIES - Adds to and amends existing law to set
forth requirements for insurers offering health care policies that do not
meet the definition of managed care plans; to provide that health care
providers shall not require insureds to make additional payments for
covered services under certain plans other than specified deductibles,
copayments or coinsurance once the provider agrees in writing to accept the
insurer's reimbursement rate; and to revise the definition for "managed
care plan."
02/12 House intro - 1st rdg - to printing
02/13 Rpt prt - to Bus
]]]] LEGISLATURE OF THE STATE OF IDAHO ]]]]
Fifty-seventh Legislature Second Regular Session - 2004
IN THE HOUSE OF REPRESENTATIVES
HOUSE BILL NO. 675
BY BUSINESS COMMITTEE
1 AN ACT
2 RELATING TO INSURANCE; AMENDING CHAPTER 18, TITLE 41, IDAHO CODE, BY THE ADDI-
3 TION OF A NEW SECTION 41-1846, IDAHO CODE, TO SET FORTH REQUIREMENTS FOR
4 INSURERS OFFERING HEALTH CARE POLICIES THAT DO NOT MEET THE DEFINITION OF
5 MANAGED CARE PLANS AND TO PROVIDE THAT HEALTH CARE PROVIDERS SHALL NOT
6 REQUIRE INSUREDS TO MAKE ADDITIONAL PAYMENTS FOR COVERED SERVICES UNDER
7 CERTAIN PLANS OTHER THAN SPECIFIED DEDUCTIBLES, COPAYMENTS OR COINSURANCE
8 ONCE THE PROVIDER AGREES IN WRITING TO ACCEPT THE INSURER'S REIMBURSEMENT
9 RATE; AND AMENDING SECTION 41-3903, IDAHO CODE, TO REVISE THE DEFINITION
10 FOR "MANAGED CARE PLAN."
11 Be It Enacted by the Legislature of the State of Idaho:
12 SECTION 1. That Chapter 18, Title 41, Idaho Code, be, and the same is
13 hereby amended by the addition thereto of a NEW SECTION, to be known and des-
14 ignated as Section 41-1846, Idaho Code, and to read as follows:
15 41-1846. HEALTH CARE POLICIES -- APPLICABILITY -- REQUIREMENT. (1) An
16 insurer offering a health care policy that does not meet the definition of a
17 managed care plan as provided in section 41-3903(15), Idaho Code, must have
18 the intent to render and the capability for rendering or providing coverage
19 for good quality health care services, which will be and are readily available
20 and accessible to insureds, and such services must be reasonably responsive to
21 the needs of insureds.
22 (2) No health care provider shall require an insured to make additional
23 payments for covered services under a policy subject to subsection (1) of this
24 section, other than specified deductibles, copayments or coinsurance once a
25 provider has agreed in writing to accept the insurer's reimbursement rate to
26 provide a covered service.
27 SECTION 2. That Section 41-3903, Idaho Code, be, and the same is hereby
28 amended to read as follows:
29 41-3903. DEFINITIONS. (1) "Basic health care services" means the follow-
30 ing services: preventive care, emergency care, inpatient and outpatient hospi-
31 tal and physician care, hospital-based rehabilitation treatment, diagnostic
32 laboratory and diagnostic and therapeutic radiological services. It does not
33 include mental health services or services for alcohol or drug abuse, dental
34 or vision services or long-term rehabilitation treatment.
35 (2) "Coinsurance" means a percentage amount a member is responsible to
36 pay out-of-pocket for health care services after satisfaction of any applica-
37 ble deductibles or copayments, or both.
38 (3) "Copayment" means an amount a member must pay to a provider in pay-
39 ment for a specific health care service which is not fully prepaid.
40 (4) "Deductible" means the amount of expense a member must first incur
41 before the managed care organization begins payment for covered services.
2
1 (5) "Director" means the director of the department of insurance of the
2 state of Idaho.
3 (6) "Emergency facility" means any hospital or other facility where emer-
4 gency services are provided to a member including, but not limited to, a
5 physician's office.
6 (7) "Emergency services" means those health care services that are pro-
7 vided in a hospital or other emergency facility after the sudden onset of a
8 medical condition that manifests itself by symptoms of sufficient severity
9 including, but not limited to, severe pain, that the absence of immediate med-
10 ical attention could reasonably be expected by a prudent person who possesses
11 an average knowledge of health and medicine, to result in:
12 (a) Placing the patient's health in serious jeopardy;
13 (b) Serious impairment to bodily functions; or
14 (c) Serious dysfunction of any bodily organ or part.
15 (8) "Employer" means any person, firm, corporation, partnership or asso-
16 ciation.
17 (9) "Enrollee" means a person who either individually or through a group
18 has entered into a contract for services under a managed care plan.
19 (10) "General managed care plan" means a managed care plan which provides
20 directly or arranges to provide, at a minimum, basic health care services. A
21 general managed care plan shall include basic health care services.
22 (11) "Health care contract" means a contract entered into by a managed
23 care organization and an enrollee.
24 (12) "Health care services" means those services offered or provided by
25 health care facilities and health care providers relating to the prevention,
26 cure or treatment of illness, injury or disease.
27 (13) "Limited managed care plan" means a managed care plan which provides
28 dental care services, vision care services, mental health services, substance
29 abuse services, pharmaceutical services, podiatric care services or such other
30 services as the director may establish by rule to be limited health care ser-
31 vices. Limited health care services shall not include hospital, medical, sur-
32 gical or emergency services except as those services are provided incident to
33 limited health care services.
34 (14) "Managed care organization" means a public or private person or orga-
35 nization which offers a managed care plan. Unless otherwise specifically
36 stated, the provisions of this chapter shall apply to any person or organiza-
37 tion offering a managed care plan, whether or not a certificate of authority
38 to offer the plan is required under this chapter.
39 (15) "Managed care plan" means a contract of coverage given to an individ-
40 ual, family or group of covered individuals pursuant to which a member is
41 entitled to receive a defined set of health care benefits through an organized
42 system of health care providers in exchange for defined consideration and
43 which requires the member to use, or creates financial incentives for the mem-
44 ber to use, health care providers owned, managed, employed by or under con-
45 tract with the managed care organization. A person holding a license to trans-
46 act disability insurance offering a health plan that creates financial incen-
47 tives to use contracting providers may elect to file the plan as a nonmanaged
48 care plan not subject to the provisions of this chapter if the health plan
49 reimburses providers solely on a fee for service basis and does not require
50 the selection of a primary care provider. The election to file a health plan
51 as a nonmanaged care plan shall be made in writing at the time the plan is
52 filed with the director pursuant to chapter 18, title 41, Idaho Code.
53 (16) "Member" means a policyholder, enrollee or other individual partici-
54 pating in a managed care plan.
55 (17) "Person" means any natural or artificial person including, but not
3
1 limited to, individuals, partnerships, associations, corporations or other
2 legally recognized entities.
3 (18) "Provider" means any physician, hospital, or other person licensed or
4 otherwise authorized to furnish health care services.
5 (19) "Utilization management program" means a system of reviewing the med-
6 ical necessity, appropriateness, or quality of health care services and sup-
7 plies provided under a managed care plan using specified guidelines. Such a
8 system may include, but is not limited to, preadmission certification, the
9 application of practice guidelines, continued stay review, discharge planning,
10 preauthorization of ambulatory procedures and retrospective review.
STATEMENT OF PURPOSE
RS 13948
The purpose of this legislation is to clarify whether health care
plans are managed care plans for purposes of Title 41, Chapter 39,
Idaho Code, and to set forth requirements for insurers offering
health care plans that do not meet the definition of managed care
plans.
FISCAL NOTE
This legislation will have no impact to the General Fund.
Contact: Woody Richards
Blue Cross of Idaho
385-5451
STATEMENT OF PURPOSE/FISCAL NOTE H 675