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7 LONG TITLE
8 General Description:
9 This bill amends provisions of the Insurance Code relating to medical retainer
10 agreements.
11 Highlighted Provisions:
12 This bill:
13 ▸ allows a health care provider to bill an insurer for the services provided under a
14 medical retainer agreement; and
15 ▸ authorizes a managed care organization's network provider to collect fees from an
16 enrollee due under a medical retainer agreement.
17 Money Appropriated in this Bill:
18 None
19 Other Special Clauses:
20 None
21 Utah Code Sections Affected:
22 AMENDS:
23 31A-4-106.5, as enacted by Laws of Utah 2012, Chapter 50
24 31A-45-303, as last amended by Laws of Utah 2017, Chapter 168 and renumbered and
25 amended by Laws of Utah 2017, Chapter 292
26
27 Be it enacted by the Legislature of the state of Utah:
28 Section 1. Section 31A-4-106.5 is amended to read:
29 31A-4-106.5. Medical retainer agreements.
30 (1) For purposes of this section:
31 (a) "Medical retainer agreement" means a written contract:
32 (i) between:
33 (A) except as provided in Subsection (1)(b)(iii)(B), a natural person or a professional
34 corporation, alone or with others professionally associated with the natural person or
35 professional corporation; and
36 (B) an individual patient or a patient's representative; and
37 (ii) in which:
38 (A) the person described in Subsection (1)(a)(i)(A) agrees to provide routine health
39 care services to the individual patient for an agreed upon fee and period of time; and
40 (B) either party to the contract may terminate the agreement upon written notice to the
41 other party.
42 (b) "Routine health care services" include:
43 (i) screening, assessment, diagnosis, and treatment for the purpose of promotion of
44 health, and detection and management of disease or injury;
45 (ii) supplies and prescription drugs that are dispensed in a health care provider's office;
46 and
47 (iii) laboratory work, such as routine blood screening or routine pathology screening
48 performed by a laboratory that:
49 (A) is associated with the health care provider entering into the medical retainer
50 agreement; or
51 (B) if not associated with the health care provider, has entered into an agreement with
52 the health care provider to provide the laboratory work without charging a fee to the patient for
53 the laboratory work.
54 (2) A medical retainer agreement exempt from the provisions of Subsection
55 31A-4-106(2) [
56 (a) shall describe the specific routine health care services that are included in the
57 contract;
58 (b) shall prominently state in writing that the retainer agreement is not health
59 insurance; and
60 (c) may not prohibit the health care provider[
61 insurer for the services provided under the medical retainer agreement.
62 Section 2. Section 31A-45-303 is amended to read:
63 31A-45-303. Network provider contract provisions.
64 (1) Managed care organizations may provide for enrollees to receive services or
65 reimbursement under the health benefit plans in accordance with this section.
66 (2) (a) Subject to restrictions under this section, a managed care organization may enter
67 into contracts with health care providers under which the health care providers agree to be a
68 network provider and supply services, at prices specified in the contracts, to enrollees.
69 (b) A network provider contract shall require the network provider to accept the
70 specified payment in this Subsection (2) as payment in full, relinquishing the right to collect
71 from the enrollee amounts other than:
72 (i) copayments, coinsurance, and deductibles [
73 (ii) any fee due under a medical retainer agreement entered into under Section
74 31A-4-106.5.
75 (c) The insurance contract may reward the enrollee for selection of network providers
76 by:
77 (i) reducing premium rates;
78 (ii) reducing deductibles;
79 (iii) coinsurance;
80 (iv) other copayments; or
81 (v) any other reasonable manner.
82 (3) (a) When reimbursing for services of health care providers that are not network
83 providers, the managed care organization may:
84 (i) make direct payment to the enrollee; and
85 (ii) impose a deductible on coverage of health care providers not under contract.
86 (b) (i) Subsections (3)(b)(iii) and (c) apply to a managed care organization licensed
87 under:
88 (A) Chapter 5, Domestic Stock and Mutual Insurance Corporations;
89 (B) Chapter 7, Nonprofit Health Service Insurance Corporations; or
90 (C) Chapter 14, Foreign Insurers; and
91 (ii) Subsections (3)(b)(iii) and (c) and Subsection (6)(b) do not apply to a managed care
92 organization licensed under Chapter 8, Health Maintenance Organizations and Limited Health
93 Plans.
94 (iii) When selecting health care providers with whom to contract under Subsection (2),
95 a managed care organization described in Subsection (3)(b)(i) may not unfairly discriminate
96 between classes of health care providers, but may discriminate within a class of health care
97 providers, subject to Subsection (6).
98 (c) For purposes of this section, unfair discrimination between classes of health care
99 providers includes:
100 (i) refusal to contract with class members in reasonable proportion to the number of
101 insureds covered by the insurer and the expected demand for services from class members; and
102 (ii) refusal to cover procedures for one class of providers that are:
103 (A) commonly used by members of the class of health care providers for the treatment
104 of illnesses, injuries, or conditions;
105 (B) otherwise covered by the managed care organization; and
106 (C) within the scope of practice of the class of health care providers.
107 (4) Before the enrollee consents to the insurance contract, the managed care
108 organization shall fully disclose to the enrollee that the managed care organization has entered
109 into network provider contracts. The managed care organization shall provide sufficient detail
110 on the network provider contracts to permit the enrollee to agree to the terms of the insurance
111 contract. The managed care organization shall provide at least the following information:
112 (a) a list of the health care providers under contract, and if requested their business
113 locations and specialties;
114 (b) a description of the insured benefits, including deductibles, coinsurance, or other
115 copayments;
116 (c) a description of the quality assurance program required under Subsection (5); and
117 (d) a description of the adverse benefit determination procedures required under
118 Section 31A-22-629.
119 (5) (a) A managed care organization using network provider contracts shall maintain a
120 quality assurance program for assuring that the care provided by the network providers meets
121 prevailing standards in the state.
122 (b) The commissioner in consultation with the executive director of the Department of
123 Health may designate qualified persons to perform an audit of the quality assurance program.
124 The auditors shall have full access to all records of the managed care organization and the
125 managed care organization's health care providers, including medical records of individual
126 patients.
127 (c) The information contained in the medical records of individual patients shall
128 remain confidential. All information, interviews, reports, statements, memoranda, or other data
129 furnished for purposes of the audit and any findings or conclusions of the auditors are
130 privileged. The information is not subject to discovery, use, or receipt in evidence in any legal
131 proceeding except hearings before the commissioner concerning alleged violations of this
132 section.
133 (6) (a) A health care provider or managed care organization may not discriminate
134 against a network provider for agreeing to a contract under Subsection (2).
135 (b) (i) Subsections (6)(b) and (c) apply to a managed care organization that is described
136 in Subsection (3)(b)(i) and do not apply to a managed care organization described in
137 Subsection (3)(b)(ii).
138 (ii) A health care provider licensed to treat an illness or injury within the scope of the
139 health care provider's practice, that is willing and able to meet the terms and conditions
140 established by the managed care organization for designation as a network provider, shall be
141 able to apply for and receive the designation as a network provider. Contract terms and
142 conditions may include reasonable limitations on the number of designated network providers
143 based upon substantial objective and economic grounds, or expected use of particular services
144 based upon prior provider-patient profiles.
145 (c) Upon the written request of a provider excluded from a network provider contract,
146 the commissioner may hold a hearing to determine if the managed care organization's exclusion
147 of the provider is based on the criteria set forth in Subsection (6)(b).
148 (7) Nothing in this section is to be construed as to require a managed care organization
149 to offer a certain benefit or service as part of a health benefit plan.
150 (8) Notwithstanding Subsection (2) or Subsection (6)(b), a managed care organization
151 described in Subsection (3)(b)(i) or third party administrator is not required to, but may, enter
152 into a contract with a licensed athletic trainer, licensed under Title 58, Chapter 40a, Athletic
153 Trainer Licensing Act.
Legislative Review Note
Office of Legislative Research and General Counsel