2004 Legislation
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HOUSE BILL NO. 808 – Insurers, health care policy, reqmt


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Bill Status

H0808...........................................................by BUSINESS
INSURERS - HEALTH CARE POLICIES - Adds to and amends existing law to set
forth requirements and limitations for insurers offering health care
policies that do not meet the definition of managed care plans; and to
revise the definition for "managed care plan."
03/04    House intro - 1st rdg - to printing
03/05    Rpt prt - to 2nd rdg
03/08    2nd rdg - to 3rd rdg
03/09    3rd rdg - PASSED - 64-0-6
      AYES -- Andersen, Barraclough, Barrett, Bauer, Bayer, Bedke, Bell,
      Black, Block, Boe, Bolz, Bradford, Campbell, Cannon, Clark, Collins,
      Crow, Cuddy, Deal, Douglas, Eberle, Ellsworth, Eskridge, Field(18),
      Field(23), Gagner, Garrett, Henbest, Jaquet, Kellogg, Kulczyk, Lake,
      Langford, Langhorst, Martinez, McGeachin, Meyer, Miller, Mitchell,
      Moyle, Naccarato, Nielsen, Pasley-Stuart, Raybould, Ridinger, Ring,
      Ringo, Roberts, Robison, Rydalch, Sali, Sayler, Schaefer, Shepherd,
      Shirley, Skippen, Smith(30), Smith(24), Smylie, Snodgrass, Stevenson,
      Trail, Wood, Mr. Speaker
      NAYS -- None
      Absent and excused -- Denney, Edmunson, Harwood, Jones, McKague,
    Floor Sponsor - Gagner
    Title apvd - to Senate
03/10    Senate intro - 1st rdg - to Com/HuRes
03/12    Rpt out - rec d/p - to 2nd rdg
03/15    2nd rdg - to 3rd rdg
03/19    3rd rdg - PASSED - 35-0-0
      AYES -- Andreason, Bailey, Brandt, Bunderson, Burkett(Maxand),
      Burtenshaw, Calabretta, Cameron, Compton, Darrington, Davis, Gannon,
      Geddes, Goedde, Hill, Ingram, Kennedy, Keough, Little, Lodge,
      Malepeai, Marley, McKenzie, McWilliams, Noble, Noh, Pearce,
      Richardson, Schroeder, Sorensen, Stegner, Stennett, Sweet, Werk,
      NAYS -- None
      Absent and excused -- None
    Floor Sponsor - Malepeai
    Title apvd - to House
03/20    To enrol - Rpt enrol - Sp signed - Pres signed
03/22    To Governor
03/23    Governor signed
         Session Law Chapter 283
         Effective: 07/01/04 on all health policies
         renewing or written on or after 07-01-04

Bill Text

  ]]]]              LEGISLATURE OF THE STATE OF IDAHO             ]]]]
 Fifty-seventh Legislature                 Second Regular Session - 2004
                              IN THE HOUSE OF REPRESENTATIVES
                                     HOUSE BILL NO. 808
                                   BY BUSINESS COMMITTEE
  1                                        AN ACT
  8    Be It Enacted by the Legislature of the State of Idaho:
  9        SECTION 1.  That Chapter 18, Title 41, Idaho Code, be,  and  the  same  is
 10    hereby  amended by the addition thereto of a NEW SECTION, to be known and des-
 11    ignated as Section 41-1846, Idaho Code, and to read as follows:
 13    insurer  offering  a health care policy that does not meet the definition of a
 14    managed care plan as provided in section 41-3903(15), Idaho Code:
 15        (a)  Must have the intent to render and the capability  for  rendering  or
 16        providing  coverage  for  good quality health care services, which will be
 17        and are readily available and accessible to its insureds both  within  and
 18        outside  the  state of Idaho, and such services must be reasonably respon-
 19        sive to the needs of insureds;
 20        (b)  When "emergency services" are provided, they shall be provided as set
 21        forth in section 41-3903(7), Idaho  Code,  and  shall  not  require  prior
 22        authorization;
 23        (c)  Shall  include on its website and/or send annually to its policyhold-
 24        ers:
 25             (i)   A statement as to whether the plan includes a limited formulary
 26             of medications and a statement that the formulary will be made avail-
 27             able to any member on request;
 28             (ii)  Notification of any change in benefits; and
 29             (iii) A description of all prior authorization review procedures  for
 30             health care services;
 31        (d)  Shall  adopt  procedures for a timely review by a licensed physician,
 32        peer provider or peer review panel when a claim has  been  denied  as  not
 33        medically  necessary or as experimental. The procedure shall provide for a
 34        written statement of the reasons the service was denied and transmittal of
 35        that  information  to  the  appropriate  provider  for  inclusion  in  the
 36        insured's permanent medical record;
 37        (e)  When prior approval for a covered service is required of and obtained
 38        by or on behalf of an insured, the approval  for  the  specific  procedure
 39        shall be final and may not be rescinded after the covered service has been
 40        provided  except  in cases of fraud, misrepresentation, nonpayment of pre-
 41        mium, exhaustion of benefits or if the insured for whom the prior approval
 42        was granted is not enrolled at the time the covered service was  provided;
 43        and
  1        (f)  Shall  not  offer  a  provider any incentive that includes a specific
  2        payment made, in any type or form, to the provider  as  an  inducement  to
  3        deny, reduce, limit, or delay specific, medically necessary, and appropri-
  4        ate services covered by the health care policy.
  5        (2)  No  health  care provider shall require an insured to make additional
  6    payments for covered services under a policy subject to subsection (1) of this
  7    section, other than specified deductibles, copayments or  coinsurance  once  a
  8    provider  has  agreed in writing to accept the insurer's reimbursement rate to
  9    provide a covered service.
 10        SECTION 2.  That Section 41-3903, Idaho Code, be, and the same  is  hereby
 11    amended to read as follows:
 12        41-3903.  DEFINITIONS.  (1) "Basic health care services" means the follow-
 13    ing services: preventive care, emergency care, inpatient and outpatient hospi-
 14    tal and  physician care, hospital-based rehabilitation  treatment,  diagnostic
 15    laboratory  and diagnostic and therapeutic radiological services.  It does not
 16    include mental health services or services for alcohol or drug  abuse,  dental
 17    or vision services or long-term rehabilitation treatment.
 18        (2)  "Coinsurance"  means  a  percentage amount a member is responsible to
 19    pay out-of-pocket for health care services after satisfaction of  any applica-
 20    ble deductibles or copayments, or both.
 21        (3)  "Copayment" means an amount a member must pay to a provider  in  pay-
 22    ment for a specific health care service which is not fully prepaid.
 23        (4)  "Deductible"  means  the  amount of expense a member must first incur
 24    before the managed care organization begins payment for covered services.
 25        (5)  "Director" means the director of the department of insurance  of  the
 26    state of Idaho.
 27        (6)  "Emergency facility" means any hospital or other facility where emer-
 28    gency  services  are  provided  to  a  member including, but not limited to, a
 29    physician's office.
 30        (7)  "Emergency services" means those health care services that  are  pro-
 31    vided  in  a hospital or other emergency facility after the sudden onset of  a
 32    medical condition that manifests itself by  symptoms  of  sufficient  severity
 33    including, but not limited to, severe pain, that the absence of immediate med-
 34    ical  attention could reasonably be expected by a prudent person who possesses
 35    an average knowledge of health and medicine, to result in:
 36        (a)  Placing the patient's health in serious jeopardy;
 37        (b)  Serious impairment to bodily functions; or
 38        (c)  Serious dysfunction of any bodily organ or part.
 39        (8)  "Employer" means any person, firm, corporation, partnership or  asso-
 40    ciation.
 41        (9)  "Enrollee"  means a person who either individually or through a group
 42    has entered into a contract for services under a managed care plan.
 43        (10) "General managed care plan" means a managed care plan which  provides
 44    directly  or arranges to provide, at a minimum, basic health care services.  A
 45    general managed care plan shall include basic health care services.
 46        (11) "Health care contract" means a contract entered  into  by  a  managed
 47    care organization and an enrollee.
 48        (12) "Health  care  services"  means those services offered or provided by
 49    health care facilities and health care providers relating to  the  prevention,
 50    cure or treatment of illness, injury or disease.
 51        (13) "Limited  managed care plan" means a managed care plan which provides
 52    dental care services, vision care services, mental health services,  substance
 53    abuse services, pharmaceutical services, podiatric care services or such other
  1    services  as the director may establish by rule to be limited health care ser-
  2    vices. Limited health care services shall not include hospital, medical,  sur-
  3    gical  or emergency services except as those services are provided incident to
  4    limited health care services.
  5        (14) "Managed care organization" means a public or private person or orga-
  6    nization which offers a managed  care  plan.   Unless  otherwise  specifically
  7    stated, the provisions  of this chapter shall apply to any person or organiza-
  8    tion  offering  a managed care plan, whether or not a certificate of authority
  9    to offer the plan is required under this chapter.
 10        (15) "Managed care plan" means a contract of coverage given to an individ-
 11    ual, family or group of covered individuals pursuant  to  which  a  member  is
 12    entitled to receive a defined set of health care benefits through an organized
 13    system  of  health  care  providers  in exchange for defined consideration and
 14    which requires the member to use, or creates financial incentives for the mem-
 15    ber to use, health care providers owned, managed, employed by  or  under  con-
 16    tract with the managed care organization. A person holding a license to trans-
 17    act  disability insurance offering a health plan that creates financial incen-
 18    tives to use contracting providers may elect to file the plan as a  nonmanaged
 19    care  plan  not  subject  to the provisions of this chapter if the health plan
 20    reimburses providers solely on a fee for service basis and  does  not  require
 21    the  selection  of a primary care provider. The election to file a health plan
 22    as a nonmanaged care plan shall be made in writing at the  time  the  plan  is
 23    filed with the director pursuant to chapter 18, title 41, Idaho Code.
 24        (16) "Member"  means a policyholder, enrollee or other individual partici-
 25    pating in a managed care plan.
 26        (17) "Person" means any natural or artificial person  including,  but  not
 27    limited  to,  individuals,  partnerships,  associations, corporations or other
 28    legally recognized entities.
 29        (18) "Provider" means any physician, hospital, or other person licensed or
 30    otherwise authorized to furnish health care services.
 31        (19) "Utilization management program" means a system of reviewing the med-
 32    ical necessity, appropriateness, or quality of health care services  and  sup-
 33    plies  provided  under  a managed care plan using specified guidelines. Such a
 34    system may include, but is not limited  to,  preadmission  certification,  the
 35    application of practice guidelines, continued stay review, discharge planning,
 36    preauthorization of ambulatory procedures and retrospective review.
 37        SECTION  3.  This  act shall be in full force and effect on and after July
 38    1, 2004, and shall apply to health care policies  renewing  or  written  after
 39    July 1, 2004.

Statement of Purpose / Fiscal Impact

                      STATEMENT OF PURPOSE
                            RS 14240
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

                          FISCAL NOTE
This legislation will have no impact to the General Fund.

Contact:  Woody Richards
          Blue Cross of Idaho
STATEMENT OF PURPOSE/FISCAL NOTE                     H 808