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7 LONG TITLE
8 General Description:
9 This bill amends the Insurance Code.
10 Highlighted Provisions:
11 This bill:
12 ▸ repeals an exclusion from preferred provider nondiscrimination provisions for
13 athletic trainer services; and
14 ▸ makes technical changes.
15 Money Appropriated in this Bill:
16 None
17 Other Special Clauses:
18 None
19 Utah Code Sections Affected:
20 AMENDS:
21 31A-22-617, as last amended by Laws of Utah 2014, Chapters 290 and 300
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23 Be it enacted by the Legislature of the state of Utah:
24 Section 1. Section 31A-22-617 is amended to read:
25 31A-22-617. Preferred provider contract provisions.
26 Health insurance policies may provide for insureds to receive services or
27 reimbursement under the policies in accordance with preferred health care provider contracts as
28 follows:
29 (1) Subject to restrictions under this section, an insurer or third party administrator may
30 enter into contracts with health care providers as defined in Section 78B-3-403 under which the
31 health care providers agree to supply services, at prices specified in the contracts, to persons
32 insured by an insurer.
33 (a) (i) A health care provider contract may require the health care provider to accept the
34 specified payment in this Subsection (1) as payment in full, relinquishing the right to collect
35 additional amounts from the insured person.
36 (ii) In a dispute involving a provider's claim for reimbursement, the same shall be
37 determined in accordance with applicable law, the provider contract, the subscriber contract,
38 and the insurer's written payment policies in effect at the time services were rendered.
39 (iii) If the parties are unable to resolve their dispute, the matter shall be subject to
40 binding arbitration by a jointly selected arbitrator. Each party [
41 expense, except that the cost of the jointly selected arbitrator shall be equally shared. This
42 Subsection (1)(a)(iii) does not apply to the claim of a general acute hospital to the extent it is
43 inconsistent with the hospital's provider agreement.
44 (iv) An organization may not penalize a provider solely for pursuing a claims dispute
45 or otherwise demanding payment for a sum believed owing.
46 (v) If an insurer permits another entity with which it does not share common ownership
47 or control to use or otherwise lease one or more of the organization's networks of participating
48 providers, the organization shall ensure, at a minimum, that the entity pays participating
49 providers in accordance with the same fee schedule and general payment policies as the
50 organization would for that network.
51 (b) The insurance contract may reward the insured for selection of preferred health care
52 providers by:
53 (i) reducing premium rates;
54 (ii) reducing deductibles;
55 (iii) coinsurance;
56 (iv) other copayments; or
57 (v) any other reasonable manner.
58 (c) If the insurer is a managed care organization, as defined in Subsection
59 31A-27a-403(1)(f):
60 (i) the insurance contract and the health care provider contract shall provide that in the
61 event the managed care organization becomes insolvent, the rehabilitator or liquidator may:
62 (A) require the health care provider to continue to provide health care services under
63 the contract until the earlier of:
64 (I) 90 days after the date of the filing of a petition for rehabilitation or [
65 for liquidation; or
66 (II) the date the term of the contract ends; and
67 (B) subject to Subsection (1)(c)(v), reduce the fees the provider is otherwise entitled to
68 receive from the managed care organization during the time period described in Subsection
69 (1)(c)(i)(A);
70 (ii) the provider is required to:
71 (A) accept the reduced payment under Subsection (1)(c)(i)(B) as payment in full; and
72 (B) relinquish the right to collect additional amounts from the insolvent managed care
73 organization's enrollee, as defined in Subsection 31A-27a-403(1)(b);
74 (iii) if the contract between the health care provider and the managed care organization
75 has not been reduced to writing, or the contract fails to contain the requirements described in
76 Subsection (1)(c)(i), the provider may not collect or attempt to collect from the enrollee:
77 (A) sums owed by the insolvent managed care organization; or
78 (B) the amount of the regular fee reduction authorized under Subsection (1)(c)(i)(B);
79 (iv) the following may not bill or maintain an action at law against an enrollee to
80 collect sums owed by the insolvent managed care organization or the amount of the regular fee
81 reduction authorized under Subsection (1)(c)(i)(B):
82 (A) a provider;
83 (B) an agent;
84 (C) a trustee; or
85 (D) an assignee of a person described in Subsections (1)(c)(iv)(A) through (C); and
86 (v) notwithstanding Subsection (1)(c)(i):
87 (A) a rehabilitator or liquidator may not reduce a fee by less than 75% of the provider's
88 regular fee set forth in the contract; and
89 (B) the enrollee shall continue to pay the copayments, deductibles, and other payments
90 for services received from the provider that the enrollee was required to pay before the filing
91 of:
92 (I) a petition for rehabilitation; or
93 (II) a petition for liquidation.
94 (2) (a) Subject to Subsections (2)(b) through (2)(e), an insurer using preferred health
95 care provider contracts is subject to the reimbursement requirements in Section 31A-8-501 on
96 or after January 1, 2014.
97 (b) When reimbursing for services of health care providers not under contract, the
98 insurer may make direct payment to the insured.
99 (c) An insurer using preferred health care provider contracts may impose a deductible
100 on coverage of health care providers not under contract.
101 (d) When selecting health care providers with whom to contract under Subsection (1),
102 an insurer may not unfairly discriminate between classes of health care providers, but may
103 discriminate within a class of health care providers, subject to Subsection (7).
104 (e) For purposes of this section, unfair discrimination between classes of health care
105 providers includes:
106 (i) refusal to contract with class members in reasonable proportion to the number of
107 insureds covered by the insurer and the expected demand for services from class members; and
108 (ii) refusal to cover procedures for one class of providers that are:
109 (A) commonly used by members of the class of health care providers for the treatment
110 of illnesses, injuries, or conditions;
111 (B) otherwise covered by the insurer; and
112 (C) within the scope of practice of the class of health care providers.
113 (3) Before the insured consents to the insurance contract, the insurer shall fully disclose
114 to the insured that it has entered into preferred health care provider contracts. The insurer shall
115 provide sufficient detail on the preferred health care provider contracts to permit the insured to
116 agree to the terms of the insurance contract. The insurer shall provide at least the following
117 information:
118 (a) a list of the health care providers under contract, and if requested their business
119 locations and specialties;
120 (b) a description of the insured benefits, including deductibles, coinsurance, or other
121 copayments;
122 (c) a description of the quality assurance program required under Subsection (4); and
123 (d) a description of the adverse benefit determination procedures required under
124 Subsection (5).
125 (4) (a) An insurer using preferred health care provider contracts shall maintain a quality
126 assurance program for [
127 under contract meets prevailing standards in the state.
128 (b) The commissioner, in consultation with the executive director of the Department of
129 Health, may designate qualified persons to perform an audit of the quality assurance program.
130 The auditors shall have full access to all records of the organization and its health care
131 providers, including medical records of individual patients.
132 (c) The information contained in the medical records of individual patients shall
133 remain confidential. All information, interviews, reports, statements, memoranda, or other data
134 furnished for purposes of the audit and any findings or conclusions of the auditors are
135 privileged. The information is not subject to discovery, use, or receipt in evidence in any legal
136 proceeding except hearings before the commissioner concerning alleged violations of this
137 section.
138 (5) An insurer using preferred health care provider contracts shall provide a reasonable
139 procedure for resolving complaints and adverse benefit determinations initiated by the insureds
140 and health care providers.
141 (6) An insurer may not contract with a health care provider for treatment of illness or
142 injury unless the health care provider is licensed to perform that treatment.
143 (7) (a) A health care provider or insurer may not discriminate against a preferred health
144 care provider for agreeing to a contract under Subsection (1).
145 (b) A health care provider licensed to treat an illness or injury within the scope of the
146 health care provider's practice, who is willing and able to meet the terms and conditions
147 established by the insurer for designation as a preferred health care provider, shall be able to
148 apply for and receive the designation as a preferred health care provider. Contract terms and
149 conditions may include reasonable [
150 health care providers based upon substantial objective and economic grounds, or expected use
151 of particular services based upon prior provider-patient profiles.
152 (8) Upon the written request of a provider excluded from a provider contract, the
153 commissioner may hold a hearing to determine if the insurer's exclusion of the provider is
154 based on the criteria set forth in Subsection (7)(b).
155 (9) Nothing in this section [
156 certain benefit or service as part of a health benefit plan.
157 (10) This section does not apply to catastrophic mental health coverage provided in
158 accordance with Section 31A-22-625.
159 [
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Legislative Review Note
Office of Legislative Research and General Counsel