2014 -- S 2503

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LC004576

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2014

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A N   A C T

RELATING TO HEALTH AND SAFETY -- HEALTH CARE ACCESSIBILITY AND

QUALITY ASSURANCE ACT

     

     Introduced By: Senators McCaffrey, Miller, Satchell, Archambault, and Gallo

     Date Introduced: February 27, 2014

     Referred To: Senate Health & Human Services

     It is enacted by the General Assembly as follows:

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     SECTION 1. Section 23-17.13-3 of the General Laws in Chapter 23-17.13 entitled

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"Health Care Accessibility and Quality Assurance Act" is hereby amended to read as follows:

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     23-17.13-3. Certification of health plans. -- (a) Certification process.

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      (1) Certification.

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      (i) The director shall establish a process for certification of health plans meeting the

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requirements of certification in subsection (b).

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      (ii) The director shall act upon the health plan's completed application for certification

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within ninety (90) days of receipt of such application for certification.

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      (2) Review and recertification. - To ensure compliance with subsection (b), the director

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shall establish procedures for the periodic review and recertification of qualified health plans not

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less than every five (5) years; provided, however, that the director may review the certification of

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a qualified health plan at any time if there exists evidence that a qualified health plan may be in

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violation of subsection (b).

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      (3) Cost of certification. - The total cost of obtaining and maintaining certification under

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this title and compliance with the requirements of the applicable rules and regulations are borne

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by the entities so certified and shall be one hundred and fifty percent (150%) of the total salaries

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paid to the certifying personnel of the department engaged in those certifications less any salary

 

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reimbursements and shall be paid to the director to and for the use of the department. That

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assessment shall be in addition to any taxes and fees otherwise payable to the state.

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      (4) Standard definitions. - To help ensure a patient's ability to make informed decisions

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regarding their health care, the director shall promulgate regulation(s) to provide for standardized

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definitions (unless defined in existing statute) of the following terms in this subdivision,

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provided, however, that no definition shall be construed to require a health care entity to add any

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benefit, to increase the scope of any benefit, or to increase any benefit under any contract:

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      (i) Allowable charge;

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      (ii) Capitation;

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      (iii) Co-payments;

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      (iv) Co-insurance;

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      (v) Credentialing;

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      (vi) Formulary;

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      (vii) Grace period;

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      (viii) Indemnity insurance;

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      (ix) In-patient care;

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      (x) Maximum lifetime cap;

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      (xi) Medical necessity;

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      (xii) Out-of-network;

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      (xiii) Out-patient;

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      (xiv) Pre-existing conditions;

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      (xv) Point of service;

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      (xvi) Risk sharing;

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      (xvii) Second opinion;

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      (xviii) Provider network;

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      (xix) Urgent care.

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      (b) Requirements for certification. - The director shall establish standards and procedures

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for the certification of qualified health plans that conduct business in this state and who have

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demonstrated the ability to ensure that health care services will be provided in a manner to assure

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availability and accessibility, adequate personnel and facilities, and continuity of service, and has

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demonstrated arrangements for ongoing quality assurance programs regarding care processes and

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outcomes; other standards shall consist of, but are not limited to, the following:

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      (1) Prospective and current enrollees in health plans must be provided information as to

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the terms and conditions of the plan consistent with the rules and regulations promulgated under

 

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chapter 12.3 of title 42 so that they can make informed decisions about accepting and utilizing the

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health care services of the health plan. This must be standardized so that customers can compare

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the attributes of the plans, and all information required by this paragraph shall be updated at

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intervals determined by the director. Of those items required under this section, the director shall

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also determine which items shall be routinely distributed to prospective and current enrollees as

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listed in this subsection and which items may be made available upon request. The items to be

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disclosed are:

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      (i) Coverage provisions, benefits, and any restriction or limitations on health care

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services, including but not limited to, any exclusions as follows: by category of service, and if

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applicable, by specific service, by technology, procedure, medication, provider or treatment

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modality, diagnosis and condition, the latter three (3) of which shall be listed by name.

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      (ii) Experimental treatment modalities that are subject to change with the advent of new

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technology may be listed solely by the broad category "Experimental Treatments". The

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information provided to consumers shall include the plan's telephone number and address where

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enrollees may call or write for more information or to register a complaint regarding the plan or

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coverage provision.

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      (2) Written statement of the enrollee's right to seek a second opinion, and reimbursement

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if applicable.

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      (3) Written disclosure regarding the appeals process described in section 23-17.12-1 et

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seq. and in the rules and regulations for the utilization review of care services, promulgated by the

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department of health, the telephone numbers and addresses for the plan's office which handles

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complaints as well as for the office which handles the appeals process under section 23-17.12-1 et

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seq. and the rules and regulations for the utilization of health.

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      (4) Written statement of prospective and current enrollees' right to confidentiality of all

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health care record and information in the possession and/or control of the plan, its employees, its

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agents and parties with whom a contractual agreement exists to provide utilization review or who

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in any way have access to care information. A summary statement of the measures taken by the

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plan to ensure confidentiality of an individual's health care records shall be disclosed.

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      (5) Written disclosure of the enrollee's right to be free from discrimination by the health

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plan and the right to refuse treatment without jeopardizing future treatment.

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      (6) Written disclosure of a plan's policy to direct enrollees to particular providers. Any

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limitations on reimbursement should the enrollee refuse the referral must be disclosed.

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      (7) A summary of prior authorization or other review requirements including

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preauthorization review, concurrent review, post-service review, post-payment review and any

 

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procedure that may lead the patient to be denied coverage for or not be provided a particular

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service.

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      (8) Any health plan that operates a provider incentive plan shall not enter into any

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compensation agreement with any provider of covered services or pharmaceutical manufacturer

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pursuant to which specific payment is made directly or indirectly to the provider as an

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inducement or incentive to reduce or limit services, to reduce the length of stay or the use of

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alternative treatment settings or the use of a particular medication with respect to an individual

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patient, provided however, that capitation agreements and similar risk sharing arrangements are

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not prohibited.

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      (9) Health plans must disclose to prospective and current enrollees the existence of

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financial arrangements for capitated or other risk sharing arrangements that exist with providers

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in a manner described in paragraphs (i), (ii), and (iii):

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      (i) "This health plan utilizes capitated arrangements, with its participating providers, or

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contains other similar risk sharing arrangements;

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      (ii) This health plan may include a capitated reimbursement arrangement or other similar

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risk sharing arrangement, and other financial arrangements with your provider;

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      (iii) This health plan is not capitated and does not contain other risk sharing

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arrangements."

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      (10) Written disclosure of criteria for accessing emergency health care services as well

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as a statement of the plan's policies regarding payment for examinations to determine if

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emergency health care services are necessary, the emergency care itself, and the necessary

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services following emergency treatment or stabilization. The health plan must respond to the

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request of the treating provider for post-stabilization treatment by approving or denying it as soon

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as possible.

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      (11) Explanation of how health plan limitations impact enrollees, including information

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on enrollee financial responsibility for payment for co-insurance, co-payment, or other non-

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covered, out-of-pocket, or out-of-plan services. This shall include information on deductibles and

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benefits limitations including, but not limited to, annual limits and maximum lifetime benefits.

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      (12) The terms under which the health plan may be renewed by the plan enrollee,

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including any reservation by the plan of any right to increase premiums.

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      (13) Summary of criteria used to authorize treatment.

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      (14) A schedule of revenues and expenses, including direct service ratios and other

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statistical information which meets the requirements set forth below on a form prescribed by the

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director.

 

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      (15) Plan costs of health care services, including but not limited to all of the following:

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      (i) Physician services;

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      (ii) Hospital services, including both inpatients and outpatient services;

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      (iii) Other professional services;

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      (iv) Pharmacy services, excluding pharmaceutical products dispensed in a physician's

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office;

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      (v) Health education;

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      (vi) Substance abuse services and mental health services.

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      (16) Plan complaint, adverse decision, and prior authorization statistics. This statistical

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data shall be updated annually:

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      (i) The ratio of the number of complaints received to the total number of covered

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persons, reported by category, listed in paragraphs (b)(15)(i) -- (vi);

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      (ii) The ratio of the number of adverse decisions issued to the number of complaints

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received, reported by category;

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      (iii) The ratio of the number of prior authorizations denied to the number of prior

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authorizations requested, reported by category;

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      (iv) The ratio of the number of successful enrollee appeals to the total number of appeals

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filed.

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      (17) Plans must demonstrate that:

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      (i) They have reasonable access to providers, so that all covered health care services will

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be provided. This requirement cannot be waived and must be met in all areas where the health

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plan has enrollees;

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      (ii) Urgent health care services, if covered, shall be available within a time frame that

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meets standards set by the director.

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      (18) A comprehensive list of participating providers listed by office location, specialty if

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applicable, and other information as determined by the director, updated annually and made

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publically available to enrollees online or in hard copy format.

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     (19) On or before July 1, 2015, and annually thereafter, plans except contracts providing

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supplemental coverage to Medicare or other governmental programs, as well as qualified health

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plans sold in the health exchange ("The Marketplace") and in the small group and individual

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markets that market a preferred provider benefit plan, shall report to the director of health and

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office of the health insurance commissioner for approval or modification, on an annual basis,

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their contracts with physicians and health care providers to assure that all medical and health care

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services and items in the package of benefits for which coverage is provided in a manner that

 

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assures both availability and accessibility of adequate, qualified personnel, specialty care and

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facilities. Plans shall provide a detailed document that shall include, but not be limited to, the

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following information:

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     (i) Process for monitoring and updating network adequacy;

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     (ii) Efforts to address enrollees with special health needs;

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     (iii) Procedures to enable enrollees to change primary care physicians;

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     (iv) A process for ensuring continuity of care in the event of a contract termination;

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     (v) Methods to assess enrollee satisfaction and provide the director with information on

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an annual basis;

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     (vi) Marketing practices,

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     (vii) Efforts and initiatives underway to address community providers in underserved

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areas; and

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     (viii) Information on quality measures for health plan performance.

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     (20) Plans that market a preferred provider benefit plan shall provide to an insured on

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request information on:

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     (i) Whether a physician or other health care provider is a participating provider in the

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insurer’s preferred provider network;

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     (ii) Whether proposed health care services are covered by the health insurance policy;

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     (iii) What the insured's personal responsibility will be for payment of applicable

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copayment or deductible amounts; and

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     (iv) Coinsurance amounts owed based on the provider’s contracted rate for in-network

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services or the insurer’s usual and customary reimbursement rate for out-of-network services.

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      (19)(21) Plans must provide to the director, at intervals determined by the director,

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enrollee satisfaction measures. The director is authorized to specify reasonable requirements for

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these measures consistent with industry standards to assure an acceptable degree of statistical

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validity and comparability of satisfaction measures over time and among plans. The director shall

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publish periodic reports for the public providing information on health plan enrollee satisfaction.

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      (c) Issuance of certification.

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      (1) Upon receipt of an application for certification, the director shall notify and afford

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the public an opportunity to comment upon the application.

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      (2) A health care plan will meet the requirements of certification, subsection (b) by

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providing information required in subsection (b) to any state or federal agency in conformance

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with any other applicable state or federal law, or in conformity with standards adopted by an

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accrediting organization provided that the director determines that the information is substantially

 

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similar to the previously mentioned requirements and is presented in a format that provides a

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meaningful comparison between health plans.

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      (3) All health plans shall be required to establish a mechanism, under which providers,

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including local providers participating in the plan, provide input into the plan's health care policy,

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including technology, medications and procedures, utilization review criteria and procedures,

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quality and credentialing criteria, and medical management procedures.

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      (4) All health plans shall be required to establish a mechanism under which local

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individual subscribers to the plan provide input into the plan's procedures and processes regarding

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the delivery of health care services.

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      (5) A health plan shall not refuse to contract with or compensate for covered services an

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otherwise eligible provider or non-participating provider solely because that provider has in good

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faith communicated with one or more of his or her patients regarding the provisions, terms or

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requirements of the insurer's products as they relate to the needs of that provider's patients.

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      (6) (i) All health plans shall be required to publicly notify providers within the health

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plans' geographic service area of the opportunity to apply for credentials. This notification

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process shall be required only when the plan contemplates adding additional providers and may

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be specific as to geographic area and provider specialty. Any provider not selected by the health

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plan may be placed on a waiting list.

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      (ii) This credentialing process shall begin upon acceptance of an application from a

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provider to the plan for inclusion.

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      (iii) Each application shall be reviewed by the plan's credentialing body.

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      (iv) All health plans shall develop and maintain credentialing criteria to be utilized in

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adding providers from the plans' network. Credentialing criteria shall be based on input from

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providers credentialed in the plan and these standards shall be available to applicants. When

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economic considerations are part of the decisions, the criteria must be available to applicants.

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Any economic profiling must factor the specialty utilization and practice patterns and general

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information comparing the applicant to his or her peers in the same specialty will be made

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available. Any economic profiling of providers must be adjusted to recognize case mix, severity

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of illness, age of patients and other features of a provider's practice that may account for higher

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than or lower than expected costs. Profiles must be made available to those so profiled.

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      (7) A health plan shall not exclude a provider of covered services from participation in

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its provider network based solely on:

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      (i) The provider's degree or license as applicable under state law; or

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      (ii) The provider of covered services lack of affiliation with, or admitting privileges at a

 

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hospital, if that lack of affiliation is due solely to the provider's type of license.

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      (8) Health plans shall not discriminate against providers solely because the provider

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treats a substantial number of patients who require expensive or uncompensated medical care.

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      (9) The applicant shall be provided with all reasons used if the application is denied.

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      (10) Plans shall not be allowed to include clauses in physician or other provider contracts

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that allow for the plan to terminate the contract "without cause"; provided, however, cause shall

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include lack of need due to economic considerations.

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      (11) (i) There shall be due process for non-institutional providers for all adverse

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decisions resulting in a change of privileges of a credentialed non-institutional provider. The

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details of the health plan's due process shall be included in the plan's provider contracts.

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      (ii) A health plan is deemed to have met the adequate notice and hearing requirement of

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this section with respect to a non-institutional provider if the following conditions are met (or are

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waived voluntarily by the non-institutional provider):

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      (A) The provider shall be notified of the proposed actions and the reasons for the

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proposed action.

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      (B) The provider shall be given the opportunity to contest the proposed action.

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      (C) The health plan has developed an internal appeals process that has reasonable time

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limits for the resolution of an internal appeal.

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      (12) If the plan places a provider or provider group at financial risk for services not

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provided by the provider or provider group, the plan must require that a provider or group has met

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all appropriate standards of the department of business regulation.

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      (13) A health plan shall not include a most favored rate clause in a provider contract.

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     SECTION 2. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO HEALTH AND SAFETY -- HEALTH CARE ACCESSIBILITY AND

QUALITY ASSURANCE ACT

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     This act would require that on or before July 1, 2015, and annually thereafter, certain

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health plans submit their contracts with physicians and healthcare providers to the director of the

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department of health and the office of the health insurance commissioner for approval or

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modification to assure the availability and accessibility of adequate, qualified personnel, specialty

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care and facilities. The act would also require a plan be submitted annually to inform, educate and

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assist all enrollees in making informed decisions as to participating physicians, healthcare

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providers, applicable co-payments, deductibles and coinsurance amounts. The act would further

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provide that a comprehensive list of participating providers be made available to enrollees online

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or in hard copy format.

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     This act would take effect upon passage.

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