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S.B. 95 Enrolled

                 

ACCESS TO RURAL HEALTH CARE FACILITIES AMENDMENTS

                 
2000 GENERAL SESSION

                 
STATE OF UTAH

                 
Sponsor: Peter C. Knudson

                  AN ACT RELATING TO INSURANCE; PERMITTING A HEALTH MAINTENANCE
                  ORGANIZATION ENROLLEE IN A RURAL AREA TO OBTAIN HEALTH CARE SERVICES
                  FROM CLOSER, NONCONTRACTING PROVIDERS.
                  This act affects sections of Utah Code Annotated 1953 as follows:
                  AMENDS:
                      31A-8-501, as enacted by Chapter 44, Laws of Utah 1997
                  Be it enacted by the Legislature of the state of Utah:
                      Section 1. Section 31A-8-501 is amended to read:
                       31A-8-501. Access to health care providers.
                      (1) As used in this section:
                      (a) "Class of health care provider" means a health care provider or a health care facility
                  regulated by the state within the same professional, trade, occupational, or certification category
                  established under Title 58, Occupations and Professions, or within the same facility licensure
                  category established under Title 26, Chapter 21, Health Care [Facilities Inspection] Facility
                  Licensing and [Licensure] Inspection Act.
                      (b) "Covered health care services" or "covered services" means health care services for
                  which an enrollee is entitled to receive under the terms of a health maintenance organization
                  contract.
                      (c) "Credentialed staff member" means a health care provider with active staff privileges
                  at an independent hospital or federally qualified health center.
                      (d) "Federally qualified health center" means as defined in the Social Security Act, 42
                  U.S.C. Sec. 1395(x).
                      (e) "Independent hospital" means a general acute hospital that:
                      (i) is licensed pursuant to Title 26, Chapter 21, Health Care [Facilities Inspection] Facility
                  Licensing and [Licensure] Inspection Act; and


                      (ii) is controlled by a board of directors of which 51% or more reside in the county where
                  the hospital is located and:
                      (A) the board of directors is ultimately responsible for the policy and financial decisions of
                  the hospital; or
                      (B) the hospital is licensed for 45 or fewer beds and is not owned, in whole or in part, by an
                  entity that owns or controls a health maintenance organization if the hospital is a contracting facility
                  of the organization.
                      (f) "Noncontracting provider" means an independent hospital, federally qualified health
                  center, or credentialed staff member who has not contracted with a health maintenance organization
                  to provide health care services to enrollees of the organization.
                      (2) A health maintenance organization shall pay for covered health care services rendered to
                  an enrollee by an independent hospital, a credentialed staff member at an independent hospital, or a
                  credentialed staff member at his local practice location if:
                      (a) the enrollee:
                      (i) lives or resides within 30 paved road miles of the independent hospital; or
                      (ii) if Subsection (2)(a)(i) does not apply, lives or resides in closer proximity to the
                  independent hospital than a contracting hospital;
                      (b) the independent hospital is located in a county with a population density of less than 100
                  people per square mile; and
                      (c) the enrollee has complied with the prior authorization and utilization review requirements
                  otherwise required by the health maintenance organization contract.
                      (3) A health maintenance organization shall pay for covered health care services rendered to
                  an enrollee at a federally qualified health center if:
                      (a) the enrollee:
                      (i) lives or resides within 30 paved road miles of [a] the federally qualified health center; or
                      (ii) if Subsection (3)(a)(i) does not apply, lives or resides in closer proximity to the federally
                  qualified health center than a contracting provider;
                      (b) the federally qualified health center is located in a county with a population density of less

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                  than 100 people per square mile; and
                      (c) the enrollee has complied with the prior authorization and utilization review requirements
                  otherwise required by the health maintenance organization contract.
                      (4) (a) A health maintenance organization shall reimburse a noncontracting provider or the
                  enrollee for covered services rendered pursuant to Subsection (2) a like dollar amount as it pays to
                  contracting providers under a noncapitated arrangement for comparable services.
                      (b) A health maintenance organization shall reimburse a federally qualified health center or
                  the enrollee for covered services rendered pursuant to Subsection (3) a like amount as paid by the
                  health maintenance organization under a noncapitated arrangement for comparable services to a
                  contracting provider in the same class of health care providers as the provider who rendered the
                  service.
                      (5) A noncontracting provider may only refer an enrollee to another noncontracting provider
                  so as to obligate the enrollee's health maintenance organization to pay for the resulting services if:
                      (a) the noncontracting provider making the referral or the enrollee has received prior
                  authorization from the organization for the referral; or
                      (b) the practice location of the noncontracting provider to whom the referral is made:
                      (i) is located in a county with a population density of less than 100 people per square mile;
                  and
                      (ii) is within 30 paved road miles of:
                      (A) the place where the enrollee lives or resides; or
                      (B) the independent hospital or federally qualified health center at which the enrollee may
                  receive covered services pursuant to Subsection (2) or (3).
                      (6) Notwithstanding this section, a health maintenance organization may contract directly
                  with an independent hospital, federally qualified health center, or credentialed staff member.

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