Print Friendly HOUSE BILL NO. 808 – Insurers, health care policy, reqmt
HOUSE BILL NO. 808
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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
]]]] 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
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 AND
4 LIMITATIONS FOR INSURERS OFFERING HEALTH CARE POLICIES THAT DO NOT MEET
5 THE DEFINITION OF MANAGED CARE PLANS; AMENDING SECTION 41-3903, IDAHO
6 CODE, TO REVISE THE DEFINITION FOR "MANAGED CARE PLAN"; PROVIDING AN
7 EFFECTIVE DATE AND PROVIDING FOR APPLICATION.
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:
12 41-1846. HEALTH CARE POLICIES -- APPLICABILITY -- REQUIREMENT. (1) An
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
23 (c) Shall include on its website and/or send annually to its policyhold-
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;
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-
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
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
This legislation will have no impact to the General Fund.
Contact: Woody Richards
Blue Cross of Idaho
STATEMENT OF PURPOSE/FISCAL NOTE H 808