2004 Legislation
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HOUSE BILL NO. 675 – Insurers, health care policy, reqmt

HOUSE BILL NO. 675

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Bill Status



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

Bill Text


                                                                        
                                                                        
  ]]]]              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 / Fiscal Impact


                      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