2015 -- S 0382 | |
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LC001300 | |
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STATE OF RHODE ISLAND | |
IN GENERAL ASSEMBLY | |
JANUARY SESSION, A.D. 2015 | |
____________ | |
A N A C T | |
RELATING TO INSURANCE -- HEALTH BENEFIT PLAN NETWORK ACCESS AND | |
ADEQUACY ACT | |
| |
Introduced By: Senators Goldin, Ottiano, Nesselbush, and Miller | |
Date Introduced: February 25, 2015 | |
Referred To: Senate Health & Human Services | |
It is enacted by the General Assembly as follows: | |
1 | SECTION 1. Title 27 of the General Laws entitled "INSURANCE" is hereby amended |
2 | by adding thereto the following chapter: |
3 | CHAPTER 81 |
4 | THE HEALTH BENEFIT PLAN NETWORK ACCESS AND ADEQUACY ACT |
5 | 27-81-1. Title. -- This chapter shall be known and may be cited as the "Health Benefit |
6 | Plan Network Access and Adequacy Act." |
7 | 27-81-2. Purpose. -- The purpose and intent of this chapter is to: |
8 | (1) Establish standards for the creation and maintenance of networks by health carriers; |
9 | and |
10 | (2) Assure the adequacy, accessibility, and transparency of health care services offered |
11 | under a network plan by: |
12 | (i) Establishing requirements for written agreements between health carriers offering |
13 | network plans and participating providers regarding the standards, terms and provisions under |
14 | which the participating provider will provide covered benefits to covered persons; and |
15 | (ii) Requiring network plans to have and maintain publicly available access plans |
16 | consistent with § 27-81-5(b) that consist of policies and procedures for assuring the ongoing |
17 | sufficiency of provider networks. |
18 | 27-81-3. Definitions. -- For purposes of this chapter: |
| |
1 | (1) "Balance billing" means the practice of a (non-participating) provider billing for the |
2 | difference between the provider's charge and the health carrier's allowed amount. |
3 | (2) "Commissioner" means the Rhode Island office of the health insurance commissioner. |
4 | (3) "Covered benefits" or "benefits" means those health care services to which a covered |
5 | person is entitled under the terms of a health benefit plan. |
6 | (4) "Covered person" means a policyholder, subscriber, enrollee or other individual |
7 | participating in a health benefit plan. |
8 | (5) "Emergency medical condition" means the sudden and, at the time, unexpected onset |
9 | of a medical condition that manifests itself by acute symptoms of sufficient severity, including |
10 | severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine |
11 | and health, to reasonably expect, in the absence of immediate medical attention, to result in: |
12 | (i) Placing the individual's health or, with respect to a pregnant woman, the woman or her |
13 | unborn fetus in serious jeopardy; |
14 | (ii) Serious impairment to a bodily function; |
15 | (iii) Serious impairment of any bodily organ or part; or |
16 | (iv) With respect to a pregnant woman who is having contractions: |
17 | (A) That there is inadequate time to effect a safe transfer to another hospital before |
18 | delivery; or |
19 | (B) That transfer to another hospital may pose a threat to the health or safety of the |
20 | woman or fetus. |
21 | (6) "Emergency services" means, with respect to an emergency medical condition, as |
22 | defined in subsection (5) of this section: |
23 | (i) A medical screening examination that is within the capability of the emergency |
24 | department of a hospital, including ancillary services routinely available to the emergency |
25 | department to evaluate the emergency medical condition; and |
26 | (ii) Any further medical examination and treatment to the extent they are within the |
27 | capabilities of the staff and facilities available at the hospital to stabilize the patient. |
28 | (7) "Facility" means an institution providing health care services or a health care setting, |
29 | including, but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical |
30 | centers, nursing homes, hospices, home health agencies, residential treatment centers, diagnostic, |
31 | laboratory and imaging centers, and rehabilitation and other therapeutic health settings. |
32 | (8) "Health benefit plan" means a policy, contract, certificate or agreement entered into, |
33 | offered or issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of |
34 | the costs of health care services. |
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1 | (9) "Health care professional" means a physician or other health care practitioner |
2 | licensed, accredited or certified to perform specified health care services consistent with state |
3 | law. |
4 | (10) "Health care provider" or "provider" means a health care professional or a facility. |
5 | (11) "Health care services" means services for the diagnosis, prevention, treatment, cure |
6 | or relief of a health condition, illness, injury or disease. |
7 | (12) "Health carrier" means an entity subject to the insurance laws and regulations of this |
8 | state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract, or |
9 | enters into an agreement to provide, deliver, arrange for, pay for or reimburse any of the costs of |
10 | health care services, including a nonprofit service corporation, a health maintenance organization, |
11 | an entity offering a policy of accident and sickness insurance, or any other entity providing a plan |
12 | of health insurance, health benefits or health services. |
13 | (13) "Health maintenance organization" means a health maintenance organization as |
14 | defined in chapter 41 of this title. |
15 | (14) "Intermediary" means a person authorized to negotiate and execute provider |
16 | contracts with health carriers on behalf of health care providers or on behalf of a network. |
17 | (15) "Material change" is a change in the composition or structure of a health carrier's |
18 | provider network or a change in the size or demographic characteristics of the population enrolled |
19 | with the health carrier that renders the health carrier's network non-compliant with one or more of |
20 | the network adequacy standards set forth in § 27-81-5 or rules adopted pursuant to that section. |
21 | (16) "Network" means the group of participating providers providing services to a |
22 | network plan. |
23 | (17) "Network plan" means a health benefit plan that either requires a covered person to |
24 | use, or creates incentives, including financial incentives, for a covered person to use health care |
25 | providers managed, owned, under contract with or employed by the health carrier. |
26 | (18) "Nonprofit service corporation" means a nonprofit hospital service corporation as |
27 | defined in chapter 19 of this title or a nonprofit medical service corporation as defined in chapter |
28 | 20 of this title. |
29 | (19) "Participating provider" means a provider who, under a contract with the health |
30 | carrier or with its contractor or subcontractor, has agreed to provide health care services to |
31 | covered persons with an expectation of receiving payment, other than coinsurance, copayments or |
32 | deductibles, directly or indirectly from the health carrier. |
33 | (20) "Person" means an individual, a corporation, a partnership, an association, a joint |
34 | venture, a joint stock company, a trust, an unincorporated organization, any similar entity or any |
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1 | combination of the foregoing. |
2 | (21) "Primary care professional" means a participating health care professional |
3 | designated by the health carrier to supervise, coordinate or provide initial care or continuing care |
4 | to a covered person, and who may be required by the health carrier to initiate a referral for |
5 | specialty care and maintain supervision of health care services rendered to the covered person. |
6 | (22) "Telemedicine" or "telehealth" means the delivery of clinical health care services by |
7 | means of real time two-way electronic audio visual communications, including the application of |
8 | secure video conferencing or store and forward technology to provide or support health care |
9 | delivery, which facilitate the assessment, diagnosis, consultation, treatment, education, care |
10 | management and self-management of a patient's health care while such patient is at an originating |
11 | site and the health care provider is at a distant site; consistent with applicable federal law and |
12 | regulations; unless the term is otherwise defined by law with respect to the provision in which it |
13 | is used. |
14 | (23) "Tiered provider network" or "tiered network" means a network that identifies and |
15 | groups participating providers into specific groups to which different provider reimbursement, |
16 | enrollee cost-sharing, or provider access requirements, or any combination, thereof, apply as a |
17 | means to manage cost, utilization, quality, or to otherwise incentivize covered person or provider |
18 | behavior. |
19 | (24) "To stabilize" means with respect to an emergency medical condition, as defined in |
20 | subsection (5) of this section, to provide such medical treatment of the condition as may be |
21 | necessary to assure, within a reasonable medical probability, that no material deterioration of the |
22 | condition is likely to result from or occur during the transfer of the individual from a facility, or, |
23 | with respect to an emergency medical condition described in subsection (5)(iv) of this section, to |
24 | deliver, including the placenta. |
25 | (25) "Transfer" means, for purposes of subsection (5) of this section, the movement, |
26 | including the discharge, of an individual outside a hospital's facilities at the direction of any |
27 | person employed by, or affiliated or associated, directly or indirectly, with the hospital, but does |
28 | not include the movement of an individual who: |
29 | (i) Has been declared dead; or |
30 | (ii) Leaves the facility without the permission of any such person. |
31 | 27-81-4. Applicability and scope. -- This chapter applies to all health carriers that offer |
32 | network plans. |
33 | 27-81-5. Network adequacy. -- (a) A health carrier providing a network plan shall |
34 | maintain a network that is sufficient in numbers and types of providers to assure that all services |
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1 | to covered persons will be accessible without unreasonable delay. In the case of emergency |
2 | services, covered persons shall have access twenty-four (24) hours per day, seven (7) days per |
3 | week. A health carrier providing a tiered network plan shall ensure that all covered services be |
4 | accessible through a provider in the lowest cost-sharing tier. |
5 | (b)(1) Sufficiency shall be determined in accordance with the requirements adopted by |
6 | the commissioner through rulemaking. Such requirement must include quantitative criteria and |
7 | other requirements that the commissioner deems appropriate. When developing its criteria, the |
8 | commissioner must incorporate the following: |
9 | (i) Maximum travel time and distance standards in miles by city or town to access a full- |
10 | time equivalent primary care physician, specialist, facility, and other health care provider. |
11 | (ii) Minimum ratio of providers to covered persons for primary care physicians, |
12 | specialists, and other health care providers. |
13 | (iii) Minimum number and range of full-time equivalent physicians and health care |
14 | providers needed in a network to meet the needs of patients with limited English proficiency, |
15 | diverse cultural and ethnic backgrounds, and with physical and mental disabilities. |
16 | (iv) Maximum time and distance standards in miles by city to access full-time equivalent |
17 | diagnostic and ancillary services. |
18 | (v) Maximum time and distance standards in miles by city or town to access general |
19 | hospital services with emergency care. |
20 | (2) The commissioner shall consider the following factors in the access standards |
21 | identified in § 27-81-5(b)(1): |
22 | (i) Geographic variations that without regulator consideration might otherwise prevent in- |
23 | network access to specialty care. |
24 | (ii) Maximum allowable wait times for an appointment with a primary care physician, |
25 | specialist, and other health care provider. |
26 | (iii) Regular assessment of provider capacity, including the availability of providers to |
27 | accept new patients. |
28 | (iv) The breadth of hours of operation for network providers. |
29 | (v) The quality measures used to evaluate providers for network inclusion. |
30 | (vi) The degree to which in-network physicians are authorized to admit patients to, or in |
31 | the case of hospital-based physicians, practice at in-network hospitals. |
32 | (vii) New health care service delivery system options, such as telemedicine or telehealth. |
33 | (viii) The volume of technological and specialty services available to serve the needs of |
34 | covered persons required technologically advanced or specialty care. |
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1 | (3) All requirements of the regulations to be issued hereunder shall be applied to the |
2 | lowest cost-sharing tier of any tiered network. |
3 | (4) The commissioner shall conduct or review available periodic patient surveys to help |
4 | inform its monitoring of network adequacy and shall make the results publically available. |
5 | (c)(1) A health carrier shall have a process to assure that a covered person obtains a |
6 | covered benefit or shall make other arrangements acceptable to the commissioner when: |
7 | (i) The health carrier has a sufficient network, but has determined that it does not have a |
8 | type of participating provider available to provide the covered benefit to the covered person or |
9 | does not have a participating provider available to provide the covered benefit without |
10 | unreasonable travel or delay; and |
11 | (ii) The health carrier has an insufficient number or type of participating provider |
12 | available to provide the covered benefit to the covered person. |
13 | (2) The health carrier shall specify the process a covered person may use to request |
14 | access to obtain a covered benefit from a non-participating out-of-network provider when: |
15 | (i) The covered person is diagnosed with a condition or disease that requires specialized |
16 | health care services or medical services; and |
17 | (ii) The health carrier: |
18 | (A) Does not have a network provider of the required specialty or subspecialty with the |
19 | professional training, expertise and experience to treat or provide health care services for the |
20 | condition or disease; or |
21 | (B) Cannot provide reasonable access to a network provider with the professional |
22 | training, expertise and experience to treat or provide health care services for the condition or |
23 | disease without unreasonable delay. |
24 | (3) The health carrier shall ensure that the covered person's financial responsibilities are |
25 | not greater than if the service had been provided by an in-network provider, and shall include the |
26 | covered person's cost-sharing toward the maximum out-of-pocket limit. |
27 | (4) For the processes required under subsections (c)(1) and (c)(2) of this section, a |
28 | covered person and the requesting provider shall be notified of a decision to approve or decline |
29 | the request within seven (7) calendar days of receipt of the request. However, if the covered |
30 | person's life, health or ability to regain or maintain optimal function is in jeopardy, as indicated |
31 | by the requesting provider, the health carrier must notify the covered person and requesting |
32 | provider of approval or denial within twenty-four (24) hours of receipt of the request. Denials will |
33 | be subject to expedited carrier review and external review, if necessary. |
34 | (5) The carrier shall have a system in place that documents all requests to obtain a |
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1 | covered benefit from a non-participating provider. This document must include a log subject to |
2 | review at the discretion of the commissioner to be updated on no less than a monthly basis. The |
3 | frequency with which the processes described in subsections (c)(1) and (c)(2) of this section are |
4 | used may be used as a potential indicator of failure to comply with the requirements of this |
5 | chapter. |
6 | (6) Nothing in this section prevents a covered person from exercising the rights and |
7 | remedies available under applicable state or federal law relating to internal and external claims, |
8 | grievance and appeals processes. |
9 | (d)(1) A health carrier shall establish and maintain adequate arrangements to ensure |
10 | reasonable access to participating providers from the business or personal residence of covered |
11 | persons. In determining whether the health carrier has complied with this provision, the |
12 | commissioner shall give due consideration to the relative availability of health care providers in |
13 | the service area under consideration. |
14 | (2) A health carrier shall monitor, on an ongoing basis, the ability, clinical capacity, |
15 | financial capability and legal authority of its participating providers to furnish all contracted |
16 | covered benefits to covered persons. |
17 | (e) A health carrier shall ensure, at a minimum, that its networks meet the essential |
18 | community provider requirements that apply to qualified health plans under federal and state law, |
19 | regulation or guidance. |
20 | (f)(1) Beginning January 1, 2016, a health carrier shall file with the commissioner, in a |
21 | manner and form defined by rule of the commissioner, an access plan meeting the requirements |
22 | of this chapter for each of the network plans the carrier offers in this state. |
23 | (2)(i) The health carrier may request the commissioner to deem sections of the access |
24 | plan as proprietary or confidential, and such sections shall not be made public. The health carrier |
25 | shall make the access plans, absent any proprietary or confidential information, available on its |
26 | business premises and shall provide them to any person upon request. |
27 | (ii) For the purposes of this subsection, information is proprietary or confidential if |
28 | revealing the information would cause the health carrier's competitors to obtain valuable business |
29 | information. |
30 | (3) The carrier shall prepare an access plan prior to offering a new network plan, and |
31 | shall notify the commissioner of any material change to any existing network plan within fifteen |
32 | (15) business days after the change occurs. The health carrier shall include in the notice to the |
33 | commissioner a reasonable timeframe within which it will submit to the commissioner for |
34 | approval or file with the commissioner, as appropriate, an updated access plan. |
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1 | (4) The access plan shall describe or contain at least the following: |
2 | (i) The health carrier's network, including how the use of telemedicine or telehealth or |
3 | other technology may be used to meet network access standards; |
4 | (ii) The health carrier's procedures for making and authorizing referrals within and |
5 | outside its network, if applicable; |
6 | (iii) The health carrier's process for monitoring and assuring on an ongoing basis the |
7 | sufficiency of the network to meet the health care needs of populations that enroll in network |
8 | plans; |
9 | (iv) The health carrier's process for making available in consumer-friendly language the |
10 | criteria it has used to build its provider network, including information about the breadth of the |
11 | network and how it selects or tiers providers, which must be made available through the health |
12 | carrier's online and in-print provider directories; |
13 | (v) The health carrier's efforts to address the needs of covered persons with limited |
14 | English proficiency and illiteracy, with diverse cultural and ethnic backgrounds, and with |
15 | physical and mental disabilities; |
16 | (vi) The health carrier's methods for assessing the health care needs of covered persons |
17 | and their satisfaction with services; |
18 | (vii) The health carrier's method of informing covered persons of the plan's services and |
19 | features, including, but not limited to, the plan's grievance procedures, its process for choosing |
20 | and changing providers, its process for updating its provider directories for each of its network |
21 | plans, a statement of services offered, including those services offered through the preventative |
22 | care benefit, if applicable, and its procedures for providing and approving emergency and |
23 | specialty care; |
24 | (viii) The health carrier's system for ensuring the coordination and continuity of care for |
25 | covered persons referred to specialty physicians, for covered persons using ancillary services, |
26 | including social services and other community resources, and for ensuring appropriate discharge |
27 | planning; |
28 | (ix) The health carrier's process for enabling covered persons to change primary care |
29 | professionals, if applicable; |
30 | (x) The health carrier's methods for ensuring provision of health benefits in accordance |
31 | with legal requirements; |
32 | (xi) The health carrier's methods for selecting providers for networks that are offered as |
33 | "high-performance," "high-value," or any other label indicating that providers in such networks |
34 | are selectively chosen; |
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1 | (xii) The health carrier's proposed plan for providing continuity of care in the event of |
2 | contract termination between the health carrier and any of its participating providers, or in the |
3 | event of the health carrier's insolvency or other inability to continue operations. The description |
4 | shall explain how covered persons will be notified of the contract termination, or the health |
5 | carrier's insolvency or other cessation of operations, and transferred to other providers in a timely |
6 | manner; and |
7 | (xiii) Any other information required by the commissioner to determine compliance with |
8 | the provisions of this chapter. |
9 | 27-81-6. Requirements for health carriers and participating providers. -- (a) A health |
10 | carrier offering a network plan shall satisfy all the requirements contained in this section: |
11 | (1) A health carrier shall establish a mechanism by which the participating provider will |
12 | be notified on an ongoing basis of the specific covered health services for which the provider will |
13 | be responsible, including any limitations or conditions on services. |
14 | (2) Every contract between a health carrier and a participating provider shall set forth a |
15 | "hold harmless" provision specifying protection for covered persons. This requirement shall be |
16 | met by including a provision substantially similar to the following: |
17 | (i) "Provider agrees that in no event, including, but not limited to, nonpayment by the |
18 | health carrier or intermediary, insolvency of the health carrier or intermediary, or breach of this |
19 | agreement, shall the provider bill, charge, collect a deposit from, seek compensation, |
20 | remuneration or reimbursement from, or have any recourse against a covered person or a person |
21 | (other than the health carrier or intermediary) acting on behalf of the covered person for services |
22 | provided pursuant to this agreement. This agreement does not prohibit the provider from |
23 | collecting coinsurance, deductibles or copayments, as specifically provided in the evidence of |
24 | coverage, or fees for uncovered services delivered on a fee-for-service basis to covered persons. |
25 | Nor does this agreement prohibit a provider (except for a health care professional who is |
26 | employed full-time on the staff of a health carrier and has agreed to provide services exclusively |
27 | to that health carrier's covered persons and no others) and a covered person from agreeing to |
28 | continue services solely at the expense of the covered person, as long as the provider has clearly |
29 | informed the covered person that the health carrier may not cover or continue to cover a specific |
30 | service or services. Except as provided herein, this agreement does not prohibit the provider from |
31 | pursuing any available legal remedy." |
32 | (b)(1) Every contract between a health carrier and a participating provider shall set forth |
33 | that in the event of a health carrier or intermediary insolvency or other cessation of operations, |
34 | covered benefits to covered persons will continue through the period for which a premium has |
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1 | been paid to the health carrier on behalf of the covered person or until the covered person's |
2 | discharge from an inpatient facility, whichever time is greater. |
3 | (2) After the period for which premium has been paid, covered benefits to covered |
4 | persons confined in an inpatient facility on the date of insolvency or other cessation of operations |
5 | will continue until the earlier of: |
6 | (i) The effective date of new health benefit plan coverage; or |
7 | (ii) Their discharge from the inpatient facility because their continued confinement in the |
8 | inpatient facility is no longer medically necessary. |
9 | (c) The contract provisions that satisfy the requirements of subsections (a) and (b) of this |
10 | section shall be construed in favor of the covered person, shall survive the termination of the |
11 | contract regardless of the reason for termination, including the insolvency of the health carrier, |
12 | and shall supersede any oral or written contrary agreement between a provider and a covered |
13 | person or the representative of a covered person if the contrary agreement is inconsistent with the |
14 | hold harmless and continuation of covered benefits provisions required by subsections (a) and (b) |
15 | of this section. |
16 | (d) In no event shall a participating provider collect or attempt to collect from a covered |
17 | person any money owed to the provider by the health carrier. |
18 | (e)(1) Health carrier selection standards for selecting or tiering of participating providers |
19 | shall be developed for providers and each health care professional specialty. |
20 | (2) The standards shall be used in determining the selection or tiering of providers by the |
21 | health carrier, and its intermediaries with which it contracts. |
22 | (3) Selection criteria shall not be established in a manner: |
23 | (i) That would allow a health carrier to discriminate against high-risk populations by |
24 | excluding providers because they are located in geographic areas that contain populations or |
25 | providers presenting a risk of higher than average claims, losses or health care services |
26 | utilization; |
27 | (ii) That would exclude providers because they treat or specialize in treating populations |
28 | presenting a risk of higher than average claims, losses or health care services utilization; or |
29 | (iii) That fails to regard provider performance on quality metrics as a major and essential |
30 | component of provider selection criteria. |
31 | (4) Section 27-81-6(e)(3) shall not be construed to prohibit a carrier from declining to |
32 | select a provider who fails to meet the other legitimate selection criteria of the carrier developed |
33 | in compliance with this chapter. |
34 | (5) The provisions of this chapter do not require a health carrier, its intermediaries or the |
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1 | provider networks with which they contract, to employ specific providers acting within the scope |
2 | of their license or certification under applicable state law that may meet their selection criteria, or |
3 | to contract with or retain more providers acting within the scope of their license or certification |
4 | under applicable state law than are necessary to maintain sufficient provider network, as required |
5 | under § 27-81-5. |
6 | (f) A health carrier shall make its standards for selecting and tiering, as applicable, |
7 | participating providers available for review and approval by the commissioner, and the health |
8 | carrier shall make the standards available to the public on its website. Any material changes made |
9 | to the standards for selecting and tiering participating providers throughout the plan year shall be |
10 | submitted to the commissioner for review and approval prior to implementation. |
11 | (g) A health carrier shall notify participating providers of the providers' responsibilities |
12 | with respect to the health carrier's applicable administrative policies and programs, including, but |
13 | not limited to, payment terms; utilization review; quality assessment and improvement programs; |
14 | credentialing; grievance and appeals procedures; data reporting requirements; reporting |
15 | requirements for timely notice of changes in practice, such as discontinuance of accepting new |
16 | patients; confidentiality requirements; and any applicable federal or state programs. |
17 | (h) A health carrier shall not offer an inducement to a provider that would encourage or |
18 | otherwise incent the provider to furnish to provide less than medically necessary services to a |
19 | covered person. |
20 | (i) A health carrier shall not prohibit a participating provider from discussing any specific |
21 | or all treatment options with covered persons irrespective of the health carrier's position on the |
22 | treatment options, or from advocating on behalf of covered persons within the utilization review, |
23 | grievance or appeals processes established by the carrier or a person contracting with the carrier. |
24 | (j) A health carrier shall require a provider to make health records available to |
25 | appropriate state and federal authorities involved in assessing the quality of care or investigating |
26 | the grievances or complaints of covered persons, and to comply with the applicable state and |
27 | federal laws related to the confidentiality of medical or health records. |
28 | (k)(1) A health carrier and participating provider shall provide at least ninety (90) days |
29 | written notice to each other before terminating the contract without cause. |
30 | (2) The health carrier shall make a good faith effort to provide written notice of a |
31 | termination within thirty (30) days of receipt or issuance of a notice of termination to all covered |
32 | persons who are patients seen on a regular basis by the provider whose contract is terminating, |
33 | irrespective of whether the termination was for cause or without cause. When a participating |
34 | provider is reassigned to a higher cost-sharing tier during the patient's plan year, the patient may |
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1 | continue seeing the provider at the original cost-sharing level until the end of the covered person's |
2 | contract year. |
3 | (3) Where a contract termination involves a primary care professional, all covered |
4 | persons who are patients of that primary care professional shall also be notified. Within five (5) |
5 | working days of the date that the provider either gives or receives notice of termination, the |
6 | provider shall supply the health carrier with a list of those patients of the provider that are |
7 | covered by a plan of the health carrier. |
8 | (4) Whenever a provider's contract is terminated without cause, the health carrier shall |
9 | allow affected covered persons with acute or chronic medical conditions in active treatment to |
10 | continue such treatment until it is completed or for up to ninety (90) days, whichever is less. For |
11 | purposes of this paragraph, "active treatment" means regular visits with a provider to monitor the |
12 | status of an illness or disorder, provide direct treatment, prescribe medication or other treatment |
13 | or modify a treatment protocol. |
14 | (5) Each contract between a health carrier and a participating provider shall provide that |
15 | termination of the contract does not release the health carrier from the obligation of continuing to |
16 | reimburse a physician or provider providing medically necessary treatment at the time of |
17 | termination to a covered person who has a condition regarding which the treating physician or |
18 | health care provider believes that discontinuing care by the treating physician or provider could |
19 | cause harm to the covered person, and: |
20 | (i) The physician or provider requests that the covered person be permitted to continue |
21 | treatment under the physician's or provider's care; |
22 | (ii) The physician or provider agrees to accept the same reimbursement from the health |
23 | carrier for that covered person as provided under the contract between the physician or the |
24 | provider; and |
25 | (iii) The physician or provider agrees not to seek payment from the covered person of any |
26 | amount for which the covered person would not be responsible if the physician or provider were |
27 | still a participating provider. |
28 | (l) The rights and responsibilities under a contract between a health carrier and a |
29 | participating provider shall not be assigned or delegated by the health carrier without prior written |
30 | notice to the provider. |
31 | (m) A health carrier is responsible for ensuring that a participating provider furnishes |
32 | covered benefits to all covered persons without regard to the covered person's enrollment in the |
33 | plan as a private purchaser of the plan or as a participant in publicly financed programs of health |
34 | care services. This requirement does not apply to circumstances when the provider should not |
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1 | render services due to limitations arising from lack of training, experience, skill or licensing |
2 | restrictions. |
3 | (n) A health carrier shall notify the participating providers of their obligations, if any, to |
4 | collect applicable coinsurance, copayments or deductibles from covered persons pursuant to the |
5 | evidence of coverage, or of the providers' obligations, if any, to notify covered persons of their |
6 | personal financial obligations for non-covered services. |
7 | (o) A health carrier shall not penalize a provider because the provider, in good faith, |
8 | reports to state or federal authorities any act or practice by the health carrier that jeopardizes |
9 | patient health or welfare. |
10 | (p) A health carrier shall establish a mechanism by which the participating providers may |
11 | determine in a timely manner whether or not an individual is covered by the carrier. Any positive |
12 | eligibility determinations made by the health carrier using the established mechanism are binding |
13 | on the health carrier. |
14 | (q) A health carrier shall establish procedures for resolution of administrative, payment or |
15 | other disputes between providers and the health carrier. |
16 | (r) A contract between a health carrier and a provider shall not contain provisions that |
17 | conflict with the provisions contained in the network plan or the requirements of this chapter. |
18 | (s) A health carrier and, if appropriate, an intermediary shall timely notify a participating |
19 | provider of all provisions at the time the contract is executed and of any material changes in the |
20 | contract. |
21 | 27-81-7. Disclosure and notice requirements. -- (a) A health carrier, for each of its |
22 | network plans shall develop a written disclosure or notice to be provided to covered persons at the |
23 | time of pre-certification, if applicable, for a covered benefit to be provided at an in-network |
24 | hospital that there is the possibility that the covered person could be treated by a provider that is |
25 | not in the same network as the hospital. |
26 | (b) For non-emergency services, as a requirement of its provider contract with a health |
27 | carrier, a hospital shall develop a written disclosure or notice to be provided to a covered person |
28 | of the carrier within ten (10) days of an appointment for inpatient or outpatient services at the |
29 | hospital or at the time of a non-emergency admission at the hospital that confirms that the |
30 | hospital is a participating provider of the covered person's network plan and informs the covered |
31 | person that a physician or other provider who may provide services to the covered person while at |
32 | the hospital may not be a participating provider in the same network as the hospital. |
33 | 27-81-8. Provider directories. -- (a)(1) A health carrier shall post online a current |
34 | provider directory for each of its network plans with the information and search functions |
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1 | described in subsection (c) of this section. In making a directory available online, the carrier shall |
2 | do so in a manner that: |
3 | (i) Clearly indicates which provider directory applies to which network plan; and |
4 | (ii) Does not place any barriers to allowing any individual from accessing the directory. |
5 | (2) The health carrier shall update each network plan provider directory at least monthly |
6 | and shall be offered in a manner to accommodate individuals with limited-English language |
7 | proficiency or disabilities. |
8 | (3) A health carrier shall provide a print copy of a current provider directory with the |
9 | information described in subsection (b) of this section upon request of a covered person or a |
10 | prospective covered person. |
11 | (b) The health carrier shall make available in print and online the following provider |
12 | directory information for each network plan: |
13 | (1) For each network: |
14 | (i) The type of plan and the patient cost-sharing responsibilities (deductibles, co-pays, |
15 | premiums, etc.); |
16 | (ii) Whether there is out-of-network coverage, and the methodology used to determine |
17 | payment amounts for out-of-network services, if applicable; |
18 | (iii) The standards used to select or tier participating providers and the cost-sharing |
19 | differentials that may result from using a non-participating provider or a provider in a higher cost- |
20 | sharing tier; and |
21 | (iv) The email addresses and phone numbers individuals may use to report inaccuracies |
22 | to the provider directories to the plans. |
23 | (2) For health care professionals: |
24 | (i) Name; |
25 | (ii) Gender; |
26 | (iii) Contact information; |
27 | (iv) Specialty and subspecialty if applicable and indication of whether the provider may |
28 | be chosen as a primary care provider; |
29 | (v) Network tier to which the provider is assigned, if applicable, and |
30 | (vi) Whether accepting new patients. |
31 | (3) For hospitals: |
32 | (i) Hospital name and type (e.g. general acute care, children's cancer, rehab, etc.); |
33 | (ii) Hospital location and telephone number; |
34 | (iii) Network tier to which the hospital is assigned; and |
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1 | (iv) Hospital accreditation status; and |
2 | (4) Except hospitals, other facilities by type: |
3 | (i) Facility name; |
4 | (ii) Facility type; |
5 | (iii) Procedures performed; |
6 | (iv) Network tier to which the facility is assigned, if applicable; and |
7 | (v) Facility location and telephone number. |
8 | (c) For the online provider directories, for each network plan, a health carrier shall |
9 | include the information required under subsection (b) of this section and additionally: |
10 | (1) The health care professional information such as: |
11 | (i) Hospital affiliations; |
12 | (ii) Medical group affiliations; |
13 | (iii) Board certification(s); |
14 | (iv) Languages spoken by the health care professional or clinical staff; and |
15 | (v) Office location(s); |
16 | (2) For hospitals, the following information with search functions for specific data types |
17 | and instructions for searching for the following information: |
18 | (i) Hospital name; and |
19 | (ii) Hospital location; and |
20 | (3) Except hospitals, for other facilities, the following information with search functions |
21 | for specific data types and instructions for searching for the following information: |
22 | (i) Facility name; |
23 | (ii) Facility type; |
24 | (iii) Procedures performed; and |
25 | (iv) Facility location. |
26 | 27-81-9. Intermediaries. -- (a) Intermediaries and participating providers with whom |
27 | they contract shall comply with all the applicable requirements of § 27-81-6. |
28 | (b) A health carrier's statutory responsibility to monitor the offering of covered benefits |
29 | to covered persons shall not be delegated or assigned to the intermediary. |
30 | (c) A health carrier shall have the right to approve or disapprove participation status of a |
31 | subcontracted provider in its own or a contracted network for the purpose of delivering covered |
32 | benefits to the carrier's covered persons. |
33 | (d) A health carrier shall maintain copies of all intermediary health care subcontracts at |
34 | its principal place of business in the state, or ensure that it has access to all intermediary |
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1 | subcontracts, including the right to make copies to facilitate regulatory review, upon twenty (20) |
2 | days prior written notice from the health carrier. |
3 | (e) If applicable, an intermediary shall transmit utilization documentation and claims paid |
4 | documentation to the health carrier. The carrier shall monitor the timeliness and appropriateness |
5 | of payments made to providers and health care services received by covered persons. |
6 | (f) If applicable, an intermediary shall maintain the books, records, financial information |
7 | and documentation of services provided to covered persons at its principal place of business in |
8 | the state and preserve them in a manner that facilitates regulatory review. |
9 | (g) An intermediary shall allow the commissioner access to the intermediary's books, |
10 | records, financial information and any documentation of services provided to covered persons, as |
11 | necessary to determine compliance with this chapter. |
12 | (h) A health carrier shall have the right, in the event of the intermediary's insolvency, to |
13 | require the assignment to the health carrier of the provisions of a provider's contract addressing |
14 | the provider's obligation to furnish covered services. If the health carrier requires assignment, the |
15 | health carrier shall remain obligated to pay the provider for providing covered services under the |
16 | same terms and conditions as the intermediary prior to the insolvency. |
17 | (i) Notwithstanding any other provision of this section, the health carrier shall retain full |
18 | responsibility for the intermediary's compliance with the requirements of this chapter, as well as |
19 | full legal responsibility for any other entity's compliance with this chapter's requirements. |
20 | 27-81-10. Filing requirement and state administration. -- (a) Beginning January 1, |
21 | 2016, a health carrier shall file with the commissioner sample contract forms proposed for use |
22 | with its participating providers and intermediaries. |
23 | (b) A health carrier shall submit material changes to a contract that would affect a |
24 | provision required under this chapter or implementing regulations to the commissioner for |
25 | approval at least ninety (90) days prior to use. |
26 | (c) If the commissioner takes no action within ninety (90) days after submission of a |
27 | material change to a contract by a health carrier, the change is deemed approved. |
28 | (d) The health carrier shall maintain provider and intermediary contracts at its principal |
29 | place of business in the state, or the health carrier shall have access to all contracts and provide |
30 | copies to facilitate regulatory review upon twenty (20) days prior written notice from the |
31 | commissioner. |
32 | 27-81-11. Contracting. -- (a) The execution of a contract by a health carrier shall not |
33 | relieve the health carrier of its liability to any person with whom it has contracted for the |
34 | provision of services, nor of its responsibility for compliance with the law or applicable |
| LC001300 - Page 16 of 19 |
1 | regulations. |
2 | (b) All contracts shall be in writing and subject to review. |
3 | (c) All contracts shall comply with applicable requirements of the law and applicable |
4 | regulations. |
5 | 27-81-12. Enforcement. -- (a) If the commissioner determines that a health carrier has |
6 | not contracted with a sufficient number of participating providers to ensure that covered persons |
7 | have accessible health care services in a geographic area, or that a health carrier's network access |
8 | plan does not ensure reasonable access to covered benefits, or that a health carrier has entered |
9 | into a contract that does not comply with this chapter, or that a health carrier has not complied |
10 | with a provision of this chapter, the commissioner shall require a modification to the access plan |
11 | or institute a corrective action plan, as appropriate, that shall be followed by the health carrier, or |
12 | may use any of the commissioner's other enforcement powers to obtain the health carrier's |
13 | compliance with this chapter. |
14 | (b) The commissioner will not act to arbitrate, mediate or settle disputes regarding a |
15 | decision not to include a provider in a network plan or in a provider network or regarding any |
16 | other dispute between a health carrier, its intermediaries or one or more providers arising under or |
17 | by reason of a provider contract or its termination. |
18 | 27-81-13. Regulations. -- The commissioner may, after notice and hearing, promulgate |
19 | reasonable regulations to carry out the provisions of this chapter. The regulations shall be subject |
20 | to review in accordance with chapter 35 of title 42. |
21 | 27-81-14. Severability. -- If any provision of this chapter, or the application of the |
22 | provision to any person or circumstance shall be held invalid, the remainder of the chapter, and |
23 | the application of the provision to persons or circumstances other than those to which it is held |
24 | invalid, shall not be affected. |
25 | 27-81-15. Effective date. -- This chapter shall be effective January 1, 2016. |
26 | (1) All provider and intermediary contracts in effect on January 1, 2016, shall comply |
27 | with this chapter no later than eighteen (18) months after January 1, 2016. The commissioner may |
28 | extend the eighteen (18) months for an additional period not to exceed six (6) months if the health |
29 | carrier demonstrates good cause for an extension. |
30 | (2) A new provider or intermediary contract that is issued or put in force on or after July |
31 | 1, 2016 shall comply with this chapter. |
32 | (3) A provider contract or intermediary contract not described in subsection (1) or (2) of |
33 | this section shall comply with this chapter no later than eighteen (18) months after January 1, |
34 | 2016. |
35 | |
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1 | SECTION 2. This act shall take effect on January 1, 2016. |
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EXPLANATION | |
BY THE LEGISLATIVE COUNCIL | |
OF | |
A N A C T | |
RELATING TO INSURANCE -- HEALTH BENEFIT PLAN NETWORK ACCESS AND | |
ADEQUACY ACT | |
*** | |
1 | This act would establish criteria by which the office of the health insurance commissioner |
2 | shall review and regulate the adequacy of health plan networks. |
3 | This act would take effect on January 1, 2016. |
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