H.B. 358 Enrolled

AMENDMENTS TO ACCESS TO HEALTH CARE
PROVIDERS
2004 GENERAL SESSION
STATE OF UTAH
Sponsor: Brad L. Dee
J. Stuart Adams
D. Gregg Buxton
Ben C. FerryBradley T. Johnson
Brad King
M. Susan LawrenceMichael E. Noel
Darin G. Peterson
R. Curt Webb
LONG TITLE
General Description:
This bill amends the Insurance Code provisions related to access to rural health care
providers.
Highlighted Provisions:
This bill:
. amends the definition of "independent hospitals" entitled to protection under the
access to rural health care provider provisions of the insurance code.
Monies Appropriated in this Bill:
None
Other Special Clauses:
None
Utah Code Sections Affected:
AMENDS:
31A-8-501, as last amended by Chapter 263, Laws of Utah 2001

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 Facility Licensing and 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 or critical access hospital that:
(i) is either:
(A) located 20 miles or more from any other general acute hospital or critical access
hospital; or
(B) licensed as of January 1, 2004;
[(i)] (ii) is licensed pursuant to Title 26, Chapter 21, Health Care Facility Licensing and
Inspection Act; and
[(ii)] (iii) 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 60 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

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organization to provide health care services to enrollees of the organization.
(2) Except for a health maintenance organization which is under the common ownership
or control of an entity with a hospital located within ten paved road miles of an independent
hospital, 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 prior to December 31, 2000 in a county with a
population density of less than 100 people per square mile, or the independent hospital is located
in a county with a population density of less than 30 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 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 than 30 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.

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(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 25 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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