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H0228aa.........................................................by BUSINESS
MANAGED CARE - Amends existing law to provide that no managed care
organization shall require prior authorization for emergency services; to
provide for emergency services provided to a member who is unable to
reasonably reach a participating provider; to provide for medically
necessary covered services that are not reasonably available through
participating health care providers or are provided by a nonparticipating
provider; and to provide for reimbursement for services provided by a
nonparticipating provider.
02/14 House intro - 1st rdg - to printing
02/15 Rpt prt - to Bus
03/06 Rpt out - to Gen Ord
03/14 Rpt out amen - to engros
03/15 Rpt engros - 1st rdg - to 2nd rdg as amen
03/16 To Gen Ord
03/21 Ret'd to Bus
|||| LEGISLATURE OF THE STATE OF IDAHO ||||
Fifty-sixth Legislature First Regular Session - 2001
IN THE HOUSE OF REPRESENTATIVES
HOUSE BILL NO. 228
BY BUSINESS COMMITTEE
1 AN ACT
2 RELATING TO THE IDAHO MANAGED CARE REFORM ACT; AMENDING SECTION 41-3930, IDAHO
3 CODE, TO PROVIDE THAT NO MANAGED CARE ORGANIZATION SHALL REQUIRE PRIOR
4 AUTHORIZATION FOR EMERGENCY SERVICES, TO PROVIDE FOR EMERGENCY SERVICES
5 PROVIDED TO A MEMBER WHO IS UNABLE TO REASONABLY REACH A PARTICIPATING
6 PROVIDER, TO PROVIDE FOR MEDICALLY NECESSARY COVERED SERVICES THAT ARE NOT
7 REASONABLY AVAILABLE THROUGH PARTICIPATING HEALTH CARE PROVIDERS OR ARE
8 PROVIDED BY A NONPARTICIPATING PROVIDER, TO PROVIDE FOR REIMBURSEMENT FOR
9 SERVICES PROVIDED BY A NONPARTICIPATING PROVIDER AND TO PROVIDE PROCE-
10 DURES; AND DECLARING AN EMERGENCY.
11 Be It Enacted by the Legislature of the State of Idaho:
12 SECTION 1. That Section 41-3930, Idaho Code, be, and the same is hereby
13 amended to read as follows:
14 41-3930. UTILIZATION MANAGEMENT PROGRAM REQUIREMENTS. (1) All managed
15 care organizations performing utilization management or contracting with third
16 parties for the performance of utilization management shall:
17 (a) Adopt utilization management criteria based on sound patient care and
18 scientific principles developed in cooperation with licensed physicians
19 and other providers as deemed appropriate by the managed care organiza-
20 tion. Such criteria shall be sufficiently flexible to allow deviations
21 from norms when justified on a case-by-case basis;
22 (b) Adopt procedures for a timely review by a licensed physician, peer
23 provider or peer review panel when a claim has been denied as not medi-
24 cally necessary or as experimental. The procedure shall provide for a
25 written statement of the reasons the service was denied and transmittal of
26 that information to the appropriate provider for inclusion in the member's
27 permanent medical record;
28 (c) Upon enrollment, require members to provide written authorization for
29 the release of medical information to the managed care organization;
30 (d) Adopt procedures which protect the confidentiality of patient health
31 records. Such procedures may permit a managed care organization to record
32 a telephone conversation in the course of requesting patient medical
33 information only if it complies with existing state and federal laws and
34 the other party to the conversation is notified by voice message that he
35 is being recorded. Upon written request and within a reasonable time, a
36 copy of such recordings shall be provided to the other party to the con-
37 versation if the recorded conversation becomes an issue in a formal griev-
38 ance procedure, and the other party agrees to reimburse the managed care
39 organization for reasonable costs associated with providing the requested
40 copy.
41 (2) (a) If emergency services are offered, nNo managed care organization
42 shall require prior authorization for emergency services. Emergency ser-
43 vices provided to a member who is unable to reasonably reach a participat-
2
1 ing provider shall be covered as if provided by a participating provider
2 until the member can reasonably be expected to transfer to a participating
3 provider.
4 (b) In addition, a A managed care organization shall respond to member or
5 provider requests for prior authorization of a nonemergency service within
6 two (2) business days after complete member medical information is pro-
7 vided to the managed care organization unless exceptional circumstances
8 warrant a longer period to evaluate a request. Medically necessary covered
9 services that are not reasonably available through participating health
10 care providers or are provided by a nonparticipating provider to provide
11 continuity of care during brief transition periods shall be covered as if
12 provided by a participating provider until the member can reasonably be
13 expected to transfer to a participating provider. Qualified medical per-
14 sonnel shall be available during normal business hours for telephone
15 responses to inquiries about medical necessity, including certification of
16 continued length of stay.
17 (c) Reimbursement for services provided by a nonparticipating provider
18 that are required to be covered as though provided by a participating pro-
19 vider shall be based upon the usual, customary and reasonable charge for
20 such services in the managed care organization's service area or upon an
21 amount agreed to by the provider and the managed care organization. The
22 managed care organization may adopt procedures to allow for a timely noti-
23 fication to a member or the member's representative for the transition of
24 medical care to participating providers following the stabilization of the
25 presenting medical condition and the availability of a qualified partici-
26 pating provider.
27 (3) When prior approval for a covered service is required of and obtained
28 by or on behalf of a member, the approval shall be final and may not be
29 rescinded by the managed care organization after the covered service has been
30 provided except in cases of fraud, misrepresentation, nonpayment of premium,
31 exhaustion of benefits or if the member for whom the prior approval was
32 granted is not enrolled at the time the covered service was provided.
33 SECTION 2. An emergency existing therefor, which emergency is hereby
34 declared to exist, this act shall be in full force and effect on and after its
35 passage and approval.
|||| LEGISLATURE OF THE STATE OF IDAHO ||||
Fifty-sixth Legislature First Regular Session - 2001
Moved by Deal
Seconded by Henbest
IN THE HOUSE OF REPRESENTATIVES
HOUSE AMENDMENT TO H.B. NO. 228
1 AMENDMENTS TO SECTION 1
2 On page 1 of the printed bill, delete lines 42 and 43; on page 2, delete
3 lines 1 through 3, and insert: "shall require prior authorization for emer-
4 gency services. All medically necessary covered emergency services provided
5 to a member who is unable to reasonably reach a participating provider shall
6 be reimbursed by the managed care organization to the patient at a level as if
7 the covered services were provided by a participating provider until the mem-
8 ber can reasonably be expected to transfer to a participating provider.";
9 delete lines 8 through 13, and insert: "warrant a longer period to evaluate a
10 request. All medically necessary covered services that are provided by a non-
11 participating provider to provide continuity of care during a brief transition
12 period from emergency services shall be reimbursed by the managed care organi-
13 zation to the patient at a level as if the covered service was provided by a
14 participating provider until the member can reasonably be expected to transfer
15 to a participating provider. Qualified medical per-"; and delete lines 17
16 through 26.
17 CORRECTIONS TO TITLE
18 On page 1, in line 8, delete "," and insert: "AND"; in line 9, delete "AND
19 TO PROVIDE PROCE-"; and in line 10, delete "DURES".
|||| LEGISLATURE OF THE STATE OF IDAHO ||||
Fifty-sixth Legislature First Regular Session - 2001
IN THE HOUSE OF REPRESENTATIVES
HOUSE BILL NO. 228, As Amended
BY BUSINESS COMMITTEE
1 AN ACT
2 RELATING TO THE IDAHO MANAGED CARE REFORM ACT; AMENDING SECTION 41-3930, IDAHO
3 CODE, TO PROVIDE THAT NO MANAGED CARE ORGANIZATION SHALL REQUIRE PRIOR
4 AUTHORIZATION FOR EMERGENCY SERVICES, TO PROVIDE FOR EMERGENCY SERVICES
5 PROVIDED TO A MEMBER WHO IS UNABLE TO REASONABLY REACH A PARTICIPATING
6 PROVIDER, TO PROVIDE FOR MEDICALLY NECESSARY COVERED SERVICES THAT ARE NOT
7 REASONABLY AVAILABLE THROUGH PARTICIPATING HEALTH CARE PROVIDERS OR ARE
8 PROVIDED BY A NONPARTICIPATING PROVIDER AND TO PROVIDE FOR REIMBURSEMENT
9 FOR SERVICES PROVIDED BY A NONPARTICIPATING PROVIDER; AND DECLARING AN
10 EMERGENCY.
11 Be It Enacted by the Legislature of the State of Idaho:
12 SECTION 1. That Section 41-3930, Idaho Code, be, and the same is hereby
13 amended to read as follows:
14 41-3930. UTILIZATION MANAGEMENT PROGRAM REQUIREMENTS. (1) All managed
15 care organizations performing utilization management or contracting with third
16 parties for the performance of utilization management shall:
17 (a) Adopt utilization management criteria based on sound patient care and
18 scientific principles developed in cooperation with licensed physicians
19 and other providers as deemed appropriate by the managed care organiza-
20 tion. Such criteria shall be sufficiently flexible to allow deviations
21 from norms when justified on a case-by-case basis;
22 (b) Adopt procedures for a timely review by a licensed physician, peer
23 provider or peer review panel when a claim has been denied as not medi-
24 cally necessary or as experimental. The procedure shall provide for a
25 written statement of the reasons the service was denied and transmittal of
26 that information to the appropriate provider for inclusion in the member's
27 permanent medical record;
28 (c) Upon enrollment, require members to provide written authorization for
29 the release of medical information to the managed care organization;
30 (d) Adopt procedures which protect the confidentiality of patient health
31 records. Such procedures may permit a managed care organization to record
32 a telephone conversation in the course of requesting patient medical
33 information only if it complies with existing state and federal laws and
34 the other party to the conversation is notified by voice message that he
35 is being recorded. Upon written request and within a reasonable time, a
36 copy of such recordings shall be provided to the other party to the con-
37 versation if the recorded conversation becomes an issue in a formal griev-
38 ance procedure, and the other party agrees to reimburse the managed care
39 organization for reasonable costs associated with providing the requested
40 copy.
41 (2) (a) If emergency services are offered, nNo managed care organization
42 shall require prior authorization for emergency services. All medically
43 necessary covered emergency services provided to a member who is unable to
2
1 reasonably reach a participating provider shall be reimbursed by the man-
2 aged care organization to the patient at a level as if the covered ser-
3 vices were provided by a participating provider until the member can rea-
4 sonably be expected to transfer to a participating provider.
5 (b) In addition, a A managed care organization shall respond to member or
6 provider requests for prior authorization of a nonemergency service within
7 two (2) business days after complete member medical information is pro-
8 vided to the managed care organization unless exceptional circumstances
9 warrant a longer period to evaluate a request. All medically necessary
10 covered services that are provided by a nonparticipating provider to pro-
11 vide continuity of care during a brief transition period from emergency
12 services shall be reimbursed by the managed care organization to the
13 patient at a level as if the covered service was provided by a participat-
14 ing provider until the member can reasonably be expected to transfer to a
15 participating provider. Qualified medical personnel shall be available
16 during normal business hours for telephone responses to inquiries about
17 medical necessity, including certification of continued length of stay.
18 (3) When prior approval for a covered service is required of and obtained
19 by or on behalf of a member, the approval shall be final and may not be
20 rescinded by the managed care organization after the covered service has been
21 provided except in cases of fraud, misrepresentation, nonpayment of premium,
22 exhaustion of benefits or if the member for whom the prior approval was
23 granted is not enrolled at the time the covered service was provided.
24 SECTION 2. An emergency existing therefor, which emergency is hereby
25 declared to exist, this act shall be in full force and effect on and after its
26 passage and approval.
STATEMENT OF PURPOSE
RS 10914
The purpose of this legislation is to clarify the responsibilities
of managed care plans and their members with respect to emergency
health care services and health care services obtained from a
nonparticipating health care provider due to the unavailability of
a participating provider. If a participating provider is not
reasonably available, the managed care organization will be
required to cover services rendered by a nonparticipating provider
as though a participating provider rendered the services. If a
managed care organization is required to reimburse a
nonparticipating provider under this section, the reimbursement
obligation will be limited to the usual, customary, and reasonable
charge for such services in the managed care organization's service
area, or such other amount as agreed to between the managed care
organization and the provider.
FISCAL IMPACT
There will be no fiscal impact to the general fund.
CONTACT: Rep. W.W. "Bill" Deal
(208) 332-1000
STATEMENT OF PURPOSE/FISCAL NOTE H 228