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S1457aa.....................................by COMMERCE AND HUMAN RESOURCES
CONTRACTS - MANAGED CARE - Amends existing law to provide that no health
care provider shall require a member to make additional payments for
covered services under a health care contract, other than specified
deductibles, copayments or insurance, once a provider has agreed in writing
to accept the managed care organization's reimbursement rate to provide
covered service.
02/13 Senate intro - 1st rdg - to printing
02/16 Rpt prt - to Com/HuRes
02/25 Rpt out - to 14th Ord
Rpt out amen - to engros
02/26 Rpt engros - 1st rdg - to 2nd rdg as amen
02/27 2nd rdg - to 3rd rdg as amen
03/04 3rd rdg as amen - PASSED - 35-0-0
AYES -- Andreason, Boatright, Branch, Bunderson, Burtenshaw, Cameron,
Crow, Danielson, Darrington, Diede, Dunklin, Frasure, Geddes, Hansen,
Hawkins, Ingram, Ipsen, Keough, King, Lee, McLaughlin, Noh, Parry,
Richardson, Riggs, Risch, Sandy, Schroeder, Sorensen, Stennett,
Sweeney, Thorne, Twiggs, Wheeler, Whitworth
NAYS -- None
Absent and excused -- None
Floor Sponsor - Cameron
Title apvd - to House
03/05 House intro - 1st rdg as amen - to Res/Con
03/06 Rpt out - to Bus
03/20 Rpt out - rec d/p - to 2nd rdg as amen
03/20 Rls susp - PASSED - 66-0-4
AYES -- Alltus, Barraclough, Barrett, Bell, Bieter, Bivens,
Black(15), Black(23), Boe, Bruneel, Callister, Campbell, Chase,
Clark, Crane, Crow, Cuddy, Deal, Denney, Ellsworth, Field(13),
Field(20), Gagner, Geddes, Gould, Hadley, Hansen, Henbest, Hornbeck,
Jaquet, Jones(9), Jones(22), Jones(20), Judd, Kellogg, Kempton,
Kendell, Kjellander, Kunz, Lake, Linford, Loertscher, Mader, Marley,
McKague, Meyer, Miller, Mortensen, Newcomb, Pischner, Pomeroy,
Reynolds, Richman, Ridinger, Robison, Sali, Schaefer, Stevenson,
Stoicheff, Stone, Tilman, Trail, Watson, Wheeler, Wood, Zimmermann
NAYS -- None
Absent and excused -- Stubbs, Taylor, Tippets, Mr Speaker
Floor Sponsor - Black(23)
Title apvd - to Senate
03/20 To enrol - rpt enrol - Pres signed
03/23 Sp signed - to Governor
03/30 Governor signed
Session Law Chapter 421
Effective: 07/01/98
S1457|||| LEGISLATURE OF THE STATE OF IDAHO |||| Fifty-fourth Legislature Second Regular Session - 1998IN THE SENATE SENATE BILL NO. 1457, As Amended BY COMMERCE AND HUMAN RESOURCES COMMITTEE 1 AN ACT 2 RELATING TO HEALTH CARE CONTRACTS OF MANAGED CARE ORGANIZATIONS; AMENDING SEC- 3 TION 41-3915, IDAHO CODE, TO PROVIDE THAT NO HEALTH CARE PROVIDER SHALL 4 REQUIRE A MEMBER TO MAKE ADDITIONAL PAYMENTS FOR COVERED SERVICES UNDER A 5 HEALTH CARE CONTRACT, OTHER THAN SPECIFIED DEDUCTIBLES, COPAYMENTS OR 6 COINSURANCE ONCE A PROVIDER HAS AGREED IN WRITING TO ACCEPT THE MANAGED 7 CARE ORGANIZATION'S REIMBURSEMENT RATE TO PROVIDE A COVERED SERVICE. 8 Be It Enacted by the Legislature of the State of Idaho: 9 SECTION 1. That Section 41-3915, Idaho Code, be, and the same is hereby 10 amended to read as follows: 11 41-3915. HEALTH CARE CONTRACTS. (1) All health care contracts or other 12 marketing documents describing health care services offered by any managed 13 care organization shall contain: 14 (a) A complete description of the health care services and other benefits 15 to which the member is entitled; 16 (b) A description of the accessibility and availability of services, 17 including a list of the providers participating in the managed care plan 18 and of the providers who are accepting new patients, the addresses of pri- 19 mary care physicians and participating hospitals, and the specialty of 20 each physician and category of the other participating providers. The 21 information required by this subsection (1)(b) may be contained in a sepa- 22 rate document and incorporated in the contract by reference and shall be 23 amended from time to time as necessary to provide members with the most 24 current information; 25 (c) Any predetermined and prepaid rate of payment for health care ser- 26 vices and for other benefits, if any, and any services or benefits for 27 which the member is obliged to pay, including member responsibility for 28 deductibles, copayments, and coinsurance; 29 (d) All exclusions and limitations on services or other benefits includ- 30 ing all restrictions relating to preexisting conditions; 31 (e) A statement as to whether the plan includes a limited formulary of 32 medications and a statement that the formulary will be made available to 33 any member on request; 34 (f) All criteria by which a member may be terminated or denied 35 reenrollment; 36 (g) Service priorities in case of epidemic, or other emergency conditions 37 affecting demand for health care services; 38 (h) A statement that members shall not, under any circumstances, be lia- 39 ble, assessable or in any way subject to payment for the debts, liabili- 40 ties, insolvency, impairment or any other financial obligations of the 41 managed care organization; 42 (i) Grievance procedures; 43 (j) Procedures for notifying enrollees of any change in benefits; and 2 1 (k) A description of all prior authorization review procedures for health 2 care services. 3 (2) In addition to the requirements of subsection (1) of this section, an 4 organization offering a general managed care plan shall: 5 (a) Establish procedures for members to select or change primary care 6 providers; 7 (b) Establish procedures to notify members of the termination of their 8 primary care provider and the manner in which the managed care organiza- 9 tion will assist members in transferring to another participating primary 10 care provider; 11 (c) Establish referral procedures for specialty care and procedures for 12 after-hours, out-of-network, out-of-area and emergency care; 13 (d) Allow members direct access to network obstetricians and gynecolo- 14 gists for maternity care, annual visits, and follow-up gynecological care 15 for conditions diagnosed during maternity care or annual visits; 16 (e) Allow family practice and general practice physicians, general 17 internists, pediatricians, obstetricians, and gynecologists to be included 18 in the general managed care plan's listing of primary care providers. 19 (3) No managed care organization shall cancel the enrollment of a member 20 or refuse to transfer a member from a group to an individual basis for reasons 21 relating to age, sex, race, religion, occupation, or health status. However, 22 nothing contained herein shall prevent termination of a member who has vio- 23 lated any published policies of the organization, which have been approved by 24 the director. 25 (4) No managed care organization shall contract with any provider under 26 provisions which require a member to guarantee payment, other than specified 27 copayments, deductibles and coinsurance to such provider in the event of non- 28 payment by the managed care organization for any services rendered under con- 29 tract directly or indirectly between the member and the managed care organiza- 30 tion. 31 (5) No health care provider shall require a member to make additional 32 payments for covered services under a health care contract, other than speci- 33 fied deductibles, copayments, or coinsurance once a provider has agreed 34 in writing to accept the managed care organization's reimbursement rate 35 to provide a covered service .or has accepted a referral to36provide a covered service.37 (6) The rates charged by any managed care organization to its members 38 shall not be excessive, inadequate, or unfairly discriminatory. The director 39 may define by rule what constitutes excessive, inadequate or unfairly discrim- 40 inatory rates and may require a description of the actuarial assumptions and 41 analysis upon which such rates are based as well as whatever other informa- 42 tion, available to the managed care organization, he deems necessary to deter- 43 mine that a rate or proposed rate meets the requirements of this subsection. 44 If experience rating is a common health insurance practice in the area served 45 by the managed care organization, it shall have the right to experience-rate 46 its own contracts. 47 (7) No such contract form or amendment to an approved contract form shall 48 be issued unless it has been filed with the director. The contract form or 49 amendment shall become effective thirty (30) days after such filing unless 50 specifically disapproved by the director. Any such disapproval shall be based 51 on the requirements of section 41-3905, Idaho Code, or subsection (1), (2), 52 (4), (5) or (6) of this section. 53 (8) The director shall disapprove any contract which, with amendments, 54 does not constitute the entire contractual obligation between the parties 55 involved. No portion of the charter, bylaws, or other constituent document of 3 1 the managed care organization shall constitute part of such a contract unless 2 set forth in full therein or incorporated by reference as authorized in this 3 section.
STATEMENT OF PURPOSE
RS 08057
This legislation would correct an oversight in the Managed
Care Reform Act passed in 1997 which limits health care
providers who have not signed a managed care contract to
reimbursement rates contained in those contracts. Without this
legislation, a person who is enrolled in a managed care plan
may not be allowed to see a health care provider of his or her
choice even if that person is willing to pay an additional fee
to do so.
F I SCAL IMPACT
No fiscal impact.
CONTACT
Name: Ken Mc C lur e
Phone: 388-1200
STATEMENT OF PURPOSE/FISCAL IMPACT
S1457