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H.B. 146

This document includes House Committee Amendments incorporated into the bill on Mon, Mar 4, 2013 at 2:15 PM by jeyring. -->              1     

HEALTH CARE PROVIDER AMENDMENTS

             2     
2013 GENERAL SESSION

             3     
STATE OF UTAH

             4     
Chief Sponsor: Francis D. Gibson

             5     
Senate Sponsor: Gene Davis

             6     
             7      LONG TITLE
             8      General Description:
             9          This bill amends the definition of "health care provider" in the Utah Health Care
             10      Malpractice Act.
             11      Highlighted Provisions:
             12          This bill:
             13          .    expands the definition of "health care provider" to include licensed athletic trainers;
             14          .    exempts the term "licensed athletic trainer" from the definition of "health care
             15      provider" in provisions of the insurance code; and
             16          .    makes technical changes.
             17      Money Appropriated in this Bill:
             18          None
             19      Other Special Clauses:
             20          None
             21      Utah Code Sections Affected:
             22      AMENDS:
             23          31A-8a-102, as last amended by Laws of Utah 2008, Chapter 3
             24          31A-22-617, as last amended by Laws of Utah 2009, Chapter 12
             25          31A-29-103, as last amended by Laws of Utah 2011, Chapters 284 and 400
             26          78B-3-403, as last amended by Laws of Utah 2009, Chapter 220
             27     


             28      Be it enacted by the Legislature of the state of Utah:
             29          Section 1. Section 31A-8a-102 is amended to read:
             30           31A-8a-102. Definitions.
             31          For purposes of this chapter:
             32          (1) "Fee" means any periodic charge for use of a discount program.
             33          (2) "Health care provider" means a health care provider as defined in Section
             34      78B-3-403 , with the exception of "licensed athletic trainer," who:
             35          (a) is practicing within the scope of the provider's license; and
             36          (b) has agreed either directly or indirectly, by contract or any other arrangement with a
             37      health discount program operator, to provide a discount to enrollees of a health discount
             38      program.
             39          (3) "Health discount program" means a business arrangement or contract in which a
             40      person pays fees, dues, charges, or other consideration in exchange for a program that provides
             41      access to health care providers who agree to provide a discount for health care services.
             42          (4) "Operates a health discount program" or "health discount program operator" means
             43      to:
             44          (a) enter into a contract or agreement either directly or indirectly with a health care
             45      provider in this state which the health care provider agrees to provide discounts to enrollees of
             46      the health discount program;
             47          (b) enter into a contract or agreement either directly or indirectly with a person in this
             48      state to provide access to more than one health care provider who has agreed to provide
             49      discounts for medical services to enrollees of the health discount program;
             50          (c) sell or distribute a health discount program in this state; or
             51          (d) place your name on and market or promote a health discount program in this state.
             52          (5) "Value-added benefit" means a discount offering with no additional charge made by
             53      a health insurer or health maintenance organization that is licensed under this title, in
             54      connection with existing contracts with the health insurer or health maintenance organization.
             55          Section 2. Section 31A-22-617 is amended to read:
             56           31A-22-617. Preferred provider contract provisions.
             57          Health insurance policies may provide for insureds to receive services or
             58      reimbursement under the policies in accordance with preferred health care provider contracts as


             59      follows:
             60          (1) Subject to restrictions under this section, any insurer or third party administrator
             61      may enter into contracts with health care providers as defined in Section 78B-3-403 under
             62      which the health care providers agree to supply services, at prices specified in the contracts, to
             63      persons insured by an insurer.
             64          (a) (i) A health care provider contract may require the health care provider to accept the
             65      specified payment as payment in full, relinquishing the right to collect additional amounts from
             66      the insured person.
             67          (ii) In any dispute involving a provider's claim for reimbursement, the same shall be
             68      determined in accordance with applicable law, the provider contract, the subscriber contract,
             69      and the insurer's written payment policies in effect at the time services were rendered.
             70          (iii) If the parties are unable to resolve their dispute, the matter shall be subject to
             71      binding arbitration by a jointly selected arbitrator. Each party is to bear its own expense except
             72      the cost of the jointly selected arbitrator shall be equally shared. This Subsection (1)(a)(iii)
             73      does not apply to the claim of a general acute hospital to the extent it is inconsistent with the
             74      hospital's provider agreement.
             75          (iv) An organization may not penalize a provider solely for pursuing a claims dispute
             76      or otherwise demanding payment for a sum believed owing.
             77          (v) If an insurer permits another entity with which it does not share common ownership
             78      or control to use or otherwise lease one or more of the organization's networks of participating
             79      providers, the organization shall ensure, at a minimum, that the entity pays participating
             80      providers in accordance with the same fee schedule and general payment policies as the
             81      organization would for that network.
             82          (b) The insurance contract may reward the insured for selection of preferred health care
             83      providers by:
             84          (i) reducing premium rates;
             85          (ii) reducing deductibles;
             86          (iii) coinsurance;
             87          (iv) other copayments; or
             88          (v) any other reasonable manner.
             89          (c) If the insurer is a managed care organization, as defined in Subsection


             90      31A-27a-403 (1)(f):
             91          (i) the insurance contract and the health care provider contract shall provide that in the
             92      event the managed care organization becomes insolvent, the rehabilitator or liquidator may:
             93          (A) require the health care provider to continue to provide health care services under
             94      the contract until the earlier of:
             95          (I) 90 days after the date of the filing of a petition for rehabilitation or the petition for
             96      liquidation; or
             97          (II) the date the term of the contract ends; and
             98          (B) subject to Subsection (1)(c)(v), reduce the fees the provider is otherwise entitled to
             99      receive from the managed care organization during the time period described in Subsection
             100      (1)(c)(i)(A);
             101          (ii) the provider is required to:
             102          (A) accept the reduced payment under Subsection (1)(c)(i)(B) as payment in full; and
             103          (B) relinquish the right to collect additional amounts from the insolvent managed care
             104      organization's enrollee, as defined in Subsection 31A-27a-403 (1)(b);
             105          (iii) if the contract between the health care provider and the managed care organization
             106      has not been reduced to writing, or the contract fails to contain the language required by
             107      Subsection (1)(c)(i), the provider may not collect or attempt to collect from the enrollee:
             108          (A) sums owed by the insolvent managed care organization; or
             109          (B) the amount of the regular fee reduction authorized under Subsection (1)(c)(i)(B);
             110          (iv) the following may not bill or maintain any action at law against an enrollee to
             111      collect sums owed by the insolvent managed care organization or the amount of the regular fee
             112      reduction authorized under Subsection (1)(c)(i)(B):
             113          (A) a provider;
             114          (B) an agent;
             115          (C) a trustee; or
             116          (D) an assignee of a person described in Subsections (1)(c)(iv)(A) through (C); and
             117          (v) notwithstanding Subsection (1)(c)(i):
             118          (A) a rehabilitator or liquidator may not reduce a fee by less than 75% of the provider's
             119      regular fee set forth in the contract; and
             120          (B) the enrollee shall continue to pay the copayments, deductibles, and other payments


             121      for services received from the provider that the enrollee was required to pay before the filing
             122      of:
             123          (I) a petition for rehabilitation; or
             124          (II) a petition for liquidation.
             125          (2) (a) Subject to Subsections (2)(b) through (2)(f), an insurer using preferred health
             126      care provider contracts shall pay for the services of health care providers not under the contract,
             127      unless the illnesses or injuries treated by the health care provider are not within the scope of the
             128      insurance contract. As used in this section, "class of health care providers" means all health
             129      care providers licensed or licensed and certified by the state within the same professional,
             130      trade, occupational, or facility licensure or licensure and certification category established
             131      pursuant to Titles 26, Utah Health Code and 58, Occupations and Professions.
             132          (b) (i) Until July 1, 2012, when the insured receives services from a health care
             133      provider not under contract, the insurer shall reimburse the insured for at least 75% of the
             134      average amount paid by the insurer for comparable services of preferred health care providers
             135      who are members of the same class of health care providers.
             136          (ii) Notwithstanding Subsection (2)(b)(i), an insurer may offer a health plan that
             137      complies with the provisions of Subsection 31A-22-618.5 (3).
             138          (iii) The commissioner may adopt a rule dealing with the determination of what
             139      constitutes 75% of the average amount paid by the insurer under Subsection (2)(b)(i) for
             140      comparable services of preferred health care providers who are members of the same class of
             141      health care providers.
             142          (c) When reimbursing for services of health care providers not under contract, the
             143      insurer may make direct payment to the insured.
             144          (d) Notwithstanding Subsection (2)(b), an insurer using preferred health care provider
             145      contracts may impose a deductible on coverage of health care providers not under contract.
             146          (e) When selecting health care providers with whom to contract under Subsection (1),
             147      an insurer may not unfairly discriminate between classes of health care providers, but may
             148      discriminate within a class of health care providers, subject to Subsection (7).
             149          (f) For purposes of this section, unfair discrimination between classes of health care
             150      providers shall include:
             151          (i) refusal to contract with class members in reasonable proportion to the number of


             152      insureds covered by the insurer and the expected demand for services from class members; and
             153          (ii) refusal to cover procedures for one class of providers that are:
             154          (A) commonly utilized by members of the class of health care providers for the
             155      treatment of illnesses, injuries, or conditions;
             156          (B) otherwise covered by the insurer; and
             157          (C) within the scope of practice of the class of health care providers.
             158          (3) Before the insured consents to the insurance contract, the insurer shall fully disclose
             159      to the insured that it has entered into preferred health care provider contracts. The insurer shall
             160      provide sufficient detail on the preferred health care provider contracts to permit the insured to
             161      agree to the terms of the insurance contract. The insurer shall provide at least the following
             162      information:
             163          (a) a list of the health care providers under contract and if requested their business
             164      locations and specialties;
             165          (b) a description of the insured benefits, including any deductibles, coinsurance, or
             166      other copayments;
             167          (c) a description of the quality assurance program required under Subsection (4); and
             168          (d) a description of the adverse benefit determination procedures required under
             169      Subsection (5).
             170          (4) (a) An insurer using preferred health care provider contracts shall maintain a quality
             171      assurance program for assuring that the care provided by the health care providers under
             172      contract meets prevailing standards in the state.
             173          (b) The commissioner in consultation with the executive director of the Department of
             174      Health may designate qualified persons to perform an audit of the quality assurance program.
             175      The auditors shall have full access to all records of the organization and its health care
             176      providers, including medical records of individual patients.
             177          (c) The information contained in the medical records of individual patients shall
             178      remain confidential. All information, interviews, reports, statements, memoranda, or other data
             179      furnished for purposes of the audit and any findings or conclusions of the auditors are
             180      privileged. The information is not subject to discovery, use, or receipt in evidence in any legal
             181      proceeding except hearings before the commissioner concerning alleged violations of this
             182      section.


             183          (5) An insurer using preferred health care provider contracts shall provide a reasonable
             184      procedure for resolving complaints and adverse benefit determinations initiated by the insureds
             185      and health care providers.
             186          (6) An insurer may not contract with a health care provider for treatment of illness or
             187      injury unless the health care provider is licensed to perform that treatment.
             188          (7) (a) A health care provider or insurer may not discriminate against a preferred health
             189      care provider for agreeing to a contract under Subsection (1).
             190          (b) Any health care provider licensed to treat any illness or injury within the scope of
             191      the health care provider's practice, who is willing and able to meet the terms and conditions
             192      established by the insurer for designation as a preferred health care provider, shall be able to
             193      apply for and receive the designation as a preferred health care provider. Contract terms and
             194      conditions may include reasonable limitations on the number of designated preferred health
             195      care providers based upon substantial objective and economic grounds, or expected use of
             196      particular services based upon prior provider-patient profiles.
             197          (8) Upon the written request of a provider excluded from a provider contract, the
             198      commissioner may hold a hearing to determine if the insurer's exclusion of the provider is
             199      based on the criteria set forth in Subsection (7)(b).
             200          (9) Insurers are subject to the provisions of Sections 31A-22-613.5 , 31A-22-614.5 , and
             201      31A-22-618 .
             202          (10) Nothing in this section is to be construed as to require an insurer to offer a certain
             203      benefit or service as part of a health benefit plan.
             204          (11) This section does not apply to catastrophic mental health coverage provided in
             205      accordance with Section 31A-22-625 .
             206          (12) Notwithstanding the provisions of Subsection (1) H. , Subsection (7)(b), and
             206a      Section 31A-22-618 .H , an insurer or third party
             207      administrator is not required to, but may, enter into contracts with licensed athletic trainers,
             208      licensed under Title 58, Chapter 40a, Athletic Trainer Licensing Act.
             209          Section 3. Section 31A-29-103 is amended to read:
             210           31A-29-103. Definitions.
             211          As used in this chapter:
             212          (1) "Board" means the board of directors of the pool created in Section 31A-29-104 .
             213          (2) (a) "Creditable coverage" has the same meaning as provided in Section 31A-1-301 .


             214          (b) "Creditable coverage" does not include a period of time in which there is a
             215      significant break in coverage, as defined in Section 31A-1-301 .
             216          (3) "Domicile" means the place where an individual has a fixed and permanent home
             217      and principal establishment:
             218          (a) to which the individual, if absent, intends to return; and
             219          (b) in which the individual, and the individual's family voluntarily reside, not for a
             220      special or temporary purpose, but with the intention of making a permanent home.
             221          (4) "Enrollee" means an individual who has met the eligibility requirements of the pool
             222      and is covered by a pool policy under this chapter.
             223          (5) "Health benefit plan":
             224          (a) is defined in Section 31A-1-301 ; and
             225          (b) does not include a plan that:
             226          (i) (A) has a maximum actuarial value less than 100% of a health benefit plan
             227      described in Subsection (5)(c); or
             228          (B) has a maximum annual limit of $100,000 or less; and
             229          (ii) meets other criteria established by the board.
             230          (c) For purposes of Subsection (5)(b)(i)(A) the health benefit plan shall:
             231          (i) be a federally qualified high deductible health plan;
             232          (ii) have a deductible that has the lowest deductible that qualifies as a federally
             233      qualified high deductible health plan as adjusted by federal law; and
             234          (iii) not exceed an annual out-of-pocket maximum equal to three times the amount of
             235      the deductible.
             236          (6) "Health care facility" means any entity providing health care services which is
             237      licensed under Title 26, Chapter 21, Health Care Facility Licensing and Inspection Act.
             238          (7) "Health care insurance" is defined in Section 31A-1-301 .
             239          (8) "Health care provider" has the same meaning as provided in Section 78B-3-403 [.],
             240      with the exception of "licensed athletic trainer."
             241          (9) "Health care services" means:
             242          (a) any service or product:
             243          (i) used in furnishing to any individual medical care or hospitalization; or
             244          (ii) incidental to furnishing medical care or hospitalization; and


             245          (b) any other service or product furnished for the purpose of preventing, alleviating,
             246      curing, or healing human illness or injury.
             247          (10) "Health maintenance organization" has the same meaning as provided in Section
             248      31A-8-101 .
             249          (11) "Health plan" means any arrangement by which an individual, including a
             250      dependent or spouse, covered or making application to be covered under the pool has:
             251          (a) access to hospital and medical benefits or reimbursement including group or
             252      individual insurance or subscriber contract;
             253          (b) coverage through:
             254          (i) a health maintenance organization;
             255          (ii) a preferred provider prepayment;
             256          (iii) group practice;
             257          (iv) individual practice plan; or
             258          (v) health care insurance;
             259          (c) coverage under an uninsured arrangement of group or group-type contracts
             260      including employer self-insured, cost-plus, or other benefits methodologies not involving
             261      insurance;
             262          (d) coverage under a group type contract which is not available to the general public
             263      and can be obtained only because of connection with a particular organization or group; and
             264          (e) coverage by Medicare or other governmental benefit.
             265          (12) "HIPAA" means the Health Insurance Portability and Accountability Act.
             266          (13) "HIPAA eligible" means an individual who is eligible under the provisions of the
             267      Health Insurance Portability and Accountability Act.
             268          (14) "Insurer" means:
             269          (a) an insurance company authorized to transact accident and health insurance business
             270      in this state;
             271          (b) a health maintenance organization; or
             272          (c) a self-insurer not subject to federal preemption.
             273          (15) "Medicaid" means coverage under Title XIX of the Social Security Act, 42 U.S.C.
             274      Sec. 1396 et seq., as amended.
             275          (16) "Medicare" means coverage under both Part A and B of Title XVIII of the Social


             276      Security Act, 42 U.S.C. Sec. 1395 et seq., as amended.
             277          (17) "Plan of operation" means the plan developed by the board in accordance with
             278      Section 31A-29-105 and includes the articles, bylaws, and operating rules adopted by the board
             279      under Section 31A-29-106 .
             280          (18) "Pool" means the Utah Comprehensive Health Insurance Pool created in Section
             281      31A-29-104 .
             282          (19) "Pool fund" means the Comprehensive Health Insurance Pool Enterprise Fund
             283      created in Section 31A-29-120 .
             284          (20) "Pool policy" means a health benefit plan policy issued under this chapter.
             285          (21) "Preexisting condition" has the same meaning as defined in Section 31A-1-301 .
             286          (22) (a) "Resident" or "residency" means a person who is domiciled in this state.
             287          (b) A resident retains residency if that resident leaves this state:
             288          (i) to serve in the armed forces of the United States; or
             289          (ii) for religious or educational purposes.
             290          (23) "Third party administrator" has the same meaning as provided in Section
             291      31A-1-301 .
             292          Section 4. Section 78B-3-403 is amended to read:
             293           78B-3-403. Definitions.
             294          As used in this part:
             295          (1) "Audiologist" means a person licensed to practice audiology under Title 58,
             296      Chapter 41, Speech-language Pathology and Audiology Licensing Act.
             297          (2) "Certified social worker" means a person licensed to practice as a certified social
             298      worker under Section 58-60-205 .
             299          (3) "Chiropractic physician" means a person licensed to practice chiropractic under
             300      Title 58, Chapter 73, Chiropractic Physician Practice Act.
             301          (4) "Clinical social worker" means a person licensed to practice as a clinical social
             302      worker under Section 58-60-205 .
             303          (5) "Commissioner" means the commissioner of insurance as provided in Section
             304      31A-2-102 .
             305          (6) "Dental hygienist" means a person licensed to engage in the practice of dental
             306      hygiene as defined in Section 58-69-102 .


             307          (7) "Dentist" means a person licensed to engage in the practice of dentistry as defined
             308      in Section 58-69-102 .
             309          (8) "Division" means the Division of Occupational and Professional Licensing created
             310      in Section 58-1-103 .
             311          (9) "Future damages" includes a judgment creditor's damages for future medical
             312      treatment, care or custody, loss of future earnings, loss of bodily function, or future pain and
             313      suffering.
             314          (10) "Health care" means any act or treatment performed or furnished, or which should
             315      have been performed or furnished, by any health care provider for, to, or on behalf of a patient
             316      during the patient's medical care, treatment, or confinement.
             317          (11) "Health care facility" means general acute hospitals, specialty hospitals, home
             318      health agencies, hospices, nursing care facilities, assisted living facilities, birthing centers,
             319      ambulatory surgical facilities, small health care facilities, health care facilities owned or
             320      operated by health maintenance organizations, and end stage renal disease facilities.
             321          (12) "Health care provider" includes any person, partnership, association, corporation,
             322      or other facility or institution who causes to be rendered or who renders health care or
             323      professional services as a hospital, health care facility, physician, registered nurse, licensed
             324      practical nurse, nurse-midwife, licensed Direct-entry midwife, dentist, dental hygienist,
             325      optometrist, clinical laboratory technologist, pharmacist, physical therapist, physical therapist
             326      assistant, podiatric physician, psychologist, chiropractic physician, naturopathic physician,
             327      osteopathic physician, osteopathic physician and surgeon, audiologist, speech-language
             328      pathologist, clinical social worker, certified social worker, social service worker, marriage and
             329      family counselor, practitioner of obstetrics, licensed athletic trainer, or others rendering similar
             330      care and services relating to or arising out of the health needs of persons or groups of persons
             331      and officers, employees, or agents of any of the above acting in the course and scope of their
             332      employment.
             333          (13) "Hospital" means a public or private institution licensed under Title 26, Chapter
             334      21, Health Care Facility Licensing and Inspection Act.
             335          (14) "Licensed athletic trainer" means a person licensed under Title 58, Chapter 40a,
             336      Athletic Trainer Licensing Act.
             337          [(14)] (15) "Licensed Direct-entry midwife" means a person licensed under the


             338      Direct-entry Midwife Act to engage in the practice of direct-entry midwifery as defined in
             339      Section 58-77-102 .
             340          [(15)] (16) "Licensed practical nurse" means a person licensed to practice as a licensed
             341      practical nurse as provided in Section 58-31b-301 .
             342          [(16)] (17) "Malpractice action against a health care provider" means any action against
             343      a health care provider, whether in contract, tort, breach of warranty, wrongful death, or
             344      otherwise, based upon alleged personal injuries relating to or arising out of health care rendered
             345      or which should have been rendered by the health care provider.
             346          [(17)] (18) "Marriage and family therapist" means a person licensed to practice as a
             347      marriage therapist or family therapist under Sections 58-60-305 and 58-60-405 .
             348          [(18)] (19) "Naturopathic physician" means a person licensed to engage in the practice
             349      of naturopathic medicine as defined in Section 58-71-102 .
             350          [(19)] (20) "Nurse-midwife" means a person licensed to engage in practice as a nurse
             351      midwife under Section 58-44a-301 .
             352          [(20)] (21) "Optometrist" means a person licensed to practice optometry under Title 58,
             353      Chapter 16a, Utah Optometry Practice Act.
             354          [(21)] (22) "Osteopathic physician" means a person licensed to practice osteopathy
             355      under Title 58, Chapter 68, Utah Osteopathic Medical Practice Act.
             356          [(22)] (23) "Patient" means a person who is under the care of a health care provider,
             357      under a contract, express or implied.
             358          [(23)] (24) "Periodic payments" means the payment of money or delivery of other
             359      property to a judgment creditor at intervals ordered by the court.
             360          [(24)] (25) "Pharmacist" means a person licensed to practice pharmacy as provided in
             361      Section 58-17b-301 .
             362          [(25)] (26) "Physical therapist" means a person licensed to practice physical therapy
             363      under Title 58, Chapter 24b, Physical Therapy Practice Act.
             364          [(26)] (27) "Physical therapist assistant" means a person licensed to practice physical
             365      therapy, within the scope of a physical therapist assistant license, under Title 58, Chapter 24b,
             366      Physical Therapy Practice Act.
             367          [(27)] (28) "Physician" means a person licensed to practice medicine and surgery under
             368      Title 58, Chapter 67, Utah Medical Practice Act.


             369          [(28)] (29) "Podiatric physician" means a person licensed to practice podiatry under
             370      Title 58, Chapter 5a, Podiatric Physician Licensing Act.
             371          [(29)] (30) "Practitioner of obstetrics" means a person licensed to practice as a
             372      physician in this state under Title 58, Chapter 67, Utah Medical Practice Act, or under Title 58,
             373      Chapter 68, Utah Osteopathic Medical Practice Act.
             374          [(30)] (31) "Psychologist" means a person licensed under Title 58, Chapter 61,
             375      Psychologist Licensing Act, to engage in the practice of psychology as defined in Section
             376      58-61-102 .
             377          [(31)] (32) "Registered nurse" means a person licensed to practice professional nursing
             378      as provided in Section 58-31b-301 .
             379          [(32)] (33) "Relative" means a patient's spouse, parent, grandparent, stepfather,
             380      stepmother, child, grandchild, brother, sister, half brother, half sister, or spouse's parents. The
             381      term includes relationships that are created as a result of adoption.
             382          [(33)] (34) "Representative" means the spouse, parent, guardian, trustee,
             383      attorney-in-fact, person designated to make decisions on behalf of a patient under a medical
             384      power of attorney, or other legal agent of the patient.
             385          [(34)] (35) "Social service worker" means a person licensed to practice as a social
             386      service worker under Section 58-60-205 .
             387          [(35)] (36) "Speech-language pathologist" means a person licensed to practice
             388      speech-language pathology under Title 58, Chapter 41, Speech-language Pathology and
             389      Audiology Licensing Act.
             390          [(36)] (37) "Tort" means any legal wrong, breach of duty, or negligent or unlawful act
             391      or omission proximately causing injury or damage to another.
             392          [(37)] (38) "Unanticipated outcome" means the outcome of a medical treatment or
             393      procedure that differs from an expected result.




Legislative Review Note
    as of 2-13-13 1:58 PM


Office of Legislative Research and General Counsel


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