1     
HEALTH INSURANCE ATHLETIC TRAINER SERVICES

2     
AMENDMENTS

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2019 GENERAL SESSION

4     
STATE OF UTAH

5     
Chief Sponsor: Paul Ray

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Senate Sponsor: ____________

7     

8     LONG TITLE
9     General Description:
10          This bill repeals exclusions of a licensed athletic trainer from certain provisions of the
11     insurance code.
12     Highlighted Provisions:
13          This bill:
14          ▸     repeals exclusions of a licensed athletic trainer from:
15               •     the definition of "health care provider" in the Health Discount Program
16     Consumer Protection Act; and
17               •     preferred provider nondiscrimination provisions for a managed care
18     organization; and
19          ▸     makes technical changes.
20     Money Appropriated in this Bill:
21          None
22     Other Special Clauses:
23          None
24     Utah Code Sections Affected:
25     AMENDS:
26          31A-8a-102, as last amended by Laws of Utah 2018, Chapter 319
27          31A-22-618.5, as last amended by Laws of Utah 2017, Chapter 292
28          31A-27a-403, as last amended by Laws of Utah 2018, Chapters 281 and 391
29          31A-45-303, as last amended by Laws of Utah 2017, Chapter 168 and renumbered and
30     amended by Laws of Utah 2017, Chapter 292
31     ENACTS:
32          58-40a-306, Utah Code Annotated 1953
33     

34     Be it enacted by the Legislature of the state of Utah:
35          Section 1. Section 31A-8a-102 is amended to read:
36          31A-8a-102. Definitions.
37          As used in this chapter:
38          (1) "Fee" means any periodic charge for use of a discount program.
39          (2) "Health care provider" means a health care provider as defined in Section
40     78B-3-403[, with the exception of "licensed athletic trainer,"] who:
41          (a) is practicing within the scope of the provider's license; and
42          (b) has agreed either directly or indirectly, by contract or any other arrangement with a
43     health discount program operator, to provide a discount to enrollees of a health discount
44     program.
45          (3) (a) "Health discount program" means a business arrangement or contract in which a
46     person pays fees, dues, charges, or other consideration in exchange for a program that provides
47     access to health care providers who agree to provide a discount for health care services.
48          (b) "Health discount program" does not include a program that does not charge a
49     membership fee or require other consideration from the member to use the program's discounts
50     for health services.
51          (4) "Health discount program marketer" means a person, including a private label
52     entity, that markets, promotes, sells, or distributes a health discount program but does not
53     operate a health discount program.
54          (5) "Health discount program operator" means a person that provides a health discount
55     program by entering into a contract or agreement, directly or indirectly, with a person or
56     persons in this state who agree to provide discounts for health care services to enrollees of the
57     health discount program and determines the charge to members.
58          (6) "Marketing" means making or causing to be made any communication that contains
59     information that relates to a product or contract regulated under this chapter.
60          (7) "Value-added benefit" means a discount offering with no additional charge made by
61     a health insurer or health maintenance organization that is licensed under this title, in
62     connection with existing contracts with the health insurer or health maintenance organization.
63          Section 2. Section 31A-22-618.5 is amended to read:
64          31A-22-618.5. Coverage of insurance mandates imposed after January 1, 2009.
65          (1) The purpose of this section is to increase the range of health benefit plans available
66     in the small group, small employer group, large group, and individual insurance markets.
67          (2) A health maintenance organization that is subject to Chapter 8, Health Maintenance
68     Organizations and Limited Health Plans:
69          (a) shall offer to potential purchasers at least one health benefit plan that is subject to
70     the requirements of Chapter 8, Health Maintenance Organizations and Limited Health Plans;
71     and
72          (b) may offer to a potential purchaser one or more health benefit plans that:
73          (i) are not subject to one or more of the following:
74          (A) the limitations on insured indemnity benefits in Subsection 31A-8-105(4);
75          (B) except as provided in Subsection (2)(b)(ii), basic health care services as defined in
76     Section 31A-8-101; or
77          (C) coverage mandates enacted after January 1, 2009 that are not required by federal
78     law, provided that the insurer offers one plan under Subsection (2)(a) that covers the mandate
79     enacted after January 1, 2009; and
80          (ii) when offering a health plan under this section, provide coverage for an emergency
81     medical condition as required by Section 31A-22-627.
82          (3) An insurer that offers a health benefit plan that is not subject to Chapter 8, Health
83     Maintenance Organizations and Limited Health Plans:
84          (a) may offer a health benefit plan that is not subject to Section 31A-22-618 and
85     Subsection [31A-45-303(3)(b)(iii)] 31A-45-303(4);
86          (b) when offering a health plan under this Subsection (3), shall provide coverage of
87     emergency care services as required by Section 31A-22-627; and
88          (c) is not subject to coverage mandates enacted after January 1, 2009 that are not
89     required by federal law, provided that an insurer offers one plan that covers a mandate enacted
90     after January 1, 2009.
91          (4) Section 31A-8-106 does not prohibit the offer of a health benefit plan under
92     Subsection (2)(b).
93          (5) (a) Any difference in price between a health benefit plan offered under Subsections
94     (2)(a) and (b) shall be based on actuarially sound data.
95          (b) Any difference in price between a health benefit plan offered under Subsection
96     (3)(a) shall be based on actuarially sound data.
97          (6) Nothing in this section limits the number of health benefit plans that an insurer may
98     offer.
99          Section 3. Section 31A-27a-403 is amended to read:
100          31A-27a-403. Continuance of coverage -- Health maintenance organizations.
101          (1) As used in this section:
102          (a) "Basic health care services" [is as] means the same as that term is defined in
103     Section 31A-8-101.
104          [(b) "Enrollee" is as defined in Section 31A-8-101.]
105          [(c)] (b) "Health care" [is as] means the same as that term is defined in Section
106     31A-1-301.
107          [(d)] (c) "Health maintenance organization" [is as] means the same as that term is
108     defined in Section 31A-8-101.
109          [(e)] (d) "Limited health plan" [is as] means the same as that term is defined in Section
110     31A-8-101.
111          [(f)] (e) (i) "Managed care organization" means an entity licensed by, or holding a
112     certificate of authority from, the department to furnish health care services or health insurance.
113          (ii) "Managed care organization" includes:
114          (A) a limited health plan;
115          (B) a health maintenance organization;
116          (C) a preferred provider organization;
117          (D) a fraternal benefit society; or
118          (E) an entity similar to an entity described in Subsections (1)[(f)](e)(ii)(A) through (D).
119          (iii) "Managed care organization" does not include:
120          (A) an insurer or other person that is eligible for membership in a guaranty association
121     under Chapter 28, Guaranty Associations;
122          (B) a mandatory state pooling plan;
123          (C) a mutual assessment company or an entity that operates on an assessment basis; or
124          (D) an entity similar to an entity described in Subsections (1)[(f)](e)(iii)(A) through
125     (C).
126          [(g)] (f) "Participating provider" means a provider who, under a contract with a
127     managed care organization authorized under Section 31A-8-407, agrees to provide health care
128     services to enrollees with an expectation of receiving payment:
129          (i) directly or indirectly, from the managed care organization; and
130          (ii) other than a copayment.
131          [(h)] (g) "Participating provider contract" means the agreement between a participating
132     provider and a managed care organization authorized under Section 31A-8-407.
133          [(i)] (h) "Preferred provider" means a provider who agrees to provide health care
134     services under an agreement authorized under Subsection 31A-45-303(2).
135          [(j)] (i) "Preferred provider contract" means the written agreement between a preferred
136     provider and a managed care organization authorized under Subsection 31A-45-303(2).
137          [(k)] (j) (i) Except as provided in Subsection (1)[(k)](j)(ii), "preferred provider
138     organization" means a person that:
139          (A) furnishes at a minimum, through a preferred provider, basic health care services to
140     an enrollee in return for prepaid periodic payments in an amount agreed to before the time
141     during which the health care may be furnished;
142          (B) is obligated to the enrollee to arrange for the services described in Subsection
143     (1)[(k)](j)(i)(A); and
144          (C) permits the enrollee to obtain health care services from a provider who is not a
145     preferred provider.
146          (ii) "Preferred provider organization" does not include:
147          (A) an insurer licensed under Chapter 7, Nonprofit Health Service Insurance
148     Corporations; or
149          (B) an individual who contracts to render professional or personal services that the
150     individual performs.
151          [(l)] (k) "Provider" [is as defined in Section 31A-8-101.] means any person who:
152          (i) furnishes health care directly to the enrollee; and
153          (ii) is licensed or otherwise authorized to furnish the health care in this state.
154          [(m)] (l) "Uncovered expenditure" means a cost of health care services that is covered
155     by an organization for which an enrollee is liable in the event of the managed care
156     organization's insolvency.
157          (2) The rehabilitator or liquidator may take one or more of the actions described in
158     Subsections (2)(a) through (g) to assure continuation of health care coverage for enrollees of an
159     insolvent managed care organization.
160          (a) (i) Subject to Subsection (2)(a)(ii), a rehabilitator or liquidator may require a
161     participating provider or preferred provider to continue to provide the health care services the
162     provider is required to provide under the provider's participating provider contract or preferred
163     provider contract until the earlier of:
164          (A) 90 days after the day on which the following is filed:
165          (I) a petition for rehabilitation; or
166          (II) a petition for liquidation; or
167          (B) the day on which the term of the contract ends.
168          (ii) A requirement by the rehabilitator or liquidator under Subsection (2)(a)(i) that a
169     participating provider or preferred provider continue to provide health care services under the
170     provider's participating provider contract or preferred provider contract expires when health
171     care coverage for all enrollees of the insolvent managed care organization is obtained from
172     another managed care organization or insurer.
173          (b) (i) Subject to Subsection (2)(b)(ii), a rehabilitator or liquidator may reduce the fees
174     a participating provider or preferred provider is otherwise entitled to receive from the managed
175     care organization under the provider's participating provider contract or preferred provider
176     contract during the time period in Subsection (2)(a)(i).
177          (ii) Notwithstanding Subsection (2)(b)(i), a rehabilitator or liquidator may not reduce a
178     fee to less than 75% of the regular fee set forth in the provider's participating provider contract
179     or preferred provider contract.
180          (iii) An enrollee shall continue to pay the same copayments, deductibles, and other
181     payments for services received from a participating provider or preferred provider that the
182     enrollee is required to pay before the day on which the following is filed:
183          (A) the petition for rehabilitation; or
184          (B) the petition for liquidation.
185          (c) A participating provider or preferred provider shall:
186          (i) accept the amounts specified in Subsection (2)(b) as payment in full; and
187          (ii) relinquish the right to collect additional amounts from the insolvent managed care
188     organization's enrollee.
189          (d) Subsections (2)(b) and (c) apply to the fees paid to a provider who agrees to
190     provide health care services to an enrollee but is not a preferred or participating provider.
191          (e) This Subsection (2)(e) applies to a managed care organization that is a health
192     maintenance organization for a delinquency proceeding under this chapter that is initiated
193     before May 8, 2018.
194          (i) A solvent health maintenance organization licensed under Chapter 8, Health
195     Maintenance Organizations and Limited Health Plans, shall extend to the enrollees of an
196     insolvent health maintenance organization all rights, privileges, and obligations of being an
197     enrollee in the accepting health maintenance organization:
198          (A) subject to Subsections (2)(e)(ii), (iii), and (v);
199          (B) upon notification from and subject to the direction of the rehabilitator or liquidator
200     of an insolvent health maintenance organization licensed under Chapter 8, Health Maintenance
201     Organizations and Limited Health Plans; and
202          (C) if the solvent health maintenance organization operates within a portion of the
203     insolvent health maintenance organization's service area.
204          (ii) Notwithstanding Subsection (2)(e)(i), the accepting health maintenance
205     organization shall give credit to an enrollee for any waiting period already satisfied under the
206     enrollee's contract with the insolvent health maintenance organization.
207          (iii) A health maintenance organization accepting an enrollee of an insolvent health
208     maintenance organization under Subsection (2)(e)(i) shall charge the enrollee the premiums
209     applicable to the existing business of the accepting health maintenance organization.
210          (iv) A health maintenance organization's obligation to accept an enrollee under
211     Subsection (2)(e)(i) is limited in number to the accepting health maintenance organization's pro
212     rata share of all health maintenance organization enrollees in this state, as determined after
213     excluding the enrollees of the insolvent insurer.
214          (v) (A) The rehabilitator or liquidator of an insolvent health maintenance organization
215     shall take those measures that are possible to ensure that no health maintenance organization is
216     required to accept more than its pro rata share of the adverse risk represented by the enrollees
217     of the insolvent health maintenance organization.
218          (B) If the methodology used by the rehabilitator or liquidator to assign an enrollee is
219     one that can be expected to produce a reasonably equitable distribution of adverse risk, that
220     methodology and its results are acceptable under this Subsection (2)(e)(v).
221          (vi) (A) Notwithstanding Section 31A-27a-402, the rehabilitator or liquidator may
222     require all solvent health maintenance organizations to pay for the covered claims incurred by
223     the enrollees of the insolvent health maintenance organization.
224          (B) As determined by the rehabilitator or liquidator, payments required under this
225     Subsection (2)(e)(vi) may:
226          (I) begin as of the day on which the following is filed:
227          (Aa) the petition for rehabilitation; or
228          (Bb) the petition for liquidation; and
229          (II) continue for a maximum period through the time all enrollees are assigned pursuant
230     to this section.
231          (C) If the rehabilitator or liquidator makes an assessment under this Subsection
232     (2)(e)(vi), the rehabilitator or liquidator shall assess each solvent health maintenance
233     organization its pro rata share of the total assessment based upon its premiums from the
234     previous calendar year.
235          (D) (I) A solvent health maintenance organization required to pay for covered claims
236     under this Subsection (2)(e)(vi) may file a claim against the estate of the insolvent health
237     maintenance organization.
238          (II) Any claim described in Subsection (2)(e)(vi)(D)(I), if allowed by the rehabilitator
239     or liquidator, shall share in any distributions from the estate of the insolvent health
240     maintenance organization as a Class 3 claim.
241          (f) (i) A rehabilitator or liquidator may transfer, through sale or otherwise, the group
242     and individual health care obligations of the insolvent managed care organization to one or
243     more other managed care organizations or other insurers, if those other managed care
244     organizations and other insurers:
245          (A) are licensed to provide the same health care services in this state that are held by
246     the insolvent managed care organization; or
247          (B) have a certificate of authority to provide the same health care services in this state
248     that is held by the insolvent managed care organization.
249          (ii) The rehabilitator or liquidator may combine group and individual health care
250     obligations of the insolvent managed care organization in any manner the rehabilitator or
251     liquidator considers best to provide for continuous health care coverage for the maximum
252     number of enrollees of the insolvent managed care organization.
253          (iii) If the terms of a proposed transfer of the same combination of group and
254     individual policy obligations to more than one other managed care organization or insurer are
255     otherwise equal, the rehabilitator or liquidator shall give preference to the transfer of the group
256     and individual policy obligations of an insolvent managed care organization as follows:
257          (A) from one category of managed care organization to another managed care
258     organization of the same category, as follows:
259          (I) from a limited health plan to a limited health plan;
260          (II) from a health maintenance organization to a health maintenance organization;
261          (III) from a preferred provider organization to a preferred provider organization;
262          (IV) from a fraternal benefit society to a fraternal benefit society; and
263          (V) from an entity similar to an entity described in this Subsection (2)(f)(iii)(A) to a
264     category that is similar;
265          (B) from one category of managed care organization to another managed care
266     organization, regardless of the category of the transferee managed care organization; and
267          (C) from a managed care organization to a nonmanaged care provider of health care
268     coverage, including insurers.
269          (g) If an insolvent managed care organization has required surplus, a rehabilitator or
270     liquidator may use the insolvent managed care organization's required surplus to continue to
271     provide coverage for the insolvent managed care organization's enrollees, including paying
272     uncovered expenditures.
273          Section 4. Section 31A-45-303 is amended to read:
274          31A-45-303. Network provider contract provisions.
275          (1) Managed care organizations may provide for enrollees to receive services or
276     reimbursement under the health benefit plans in accordance with this section.
277          (2) (a) Subject to restrictions under this section, a managed care organization may enter
278     into contracts with health care providers under which the health care providers agree to be a
279     network provider and supply services, at prices specified in the contracts, to enrollees.
280          (b) A network provider contract shall require the network provider to accept the
281     specified payment in [this] Subsection (2)(a) as payment in full, relinquishing the right to
282     collect amounts other than copayments, coinsurance, and deductibles from the enrollee.
283          (c) The insurance contract may reward the enrollee for selection of network providers
284     by:
285          (i) reducing premium rates;
286          (ii) reducing deductibles;
287          (iii) coinsurance;
288          (iv) other copayments; or
289          (v) any other reasonable manner.
290          (3) [(a)] When reimbursing for services of health care providers that are not network
291     providers, the managed care organization may:
292          [(i)] (a) make direct payment to the enrollee; and
293          [(ii)] (b) impose a deductible on coverage of health care providers not under contract.
294          [(b) (i) Subsections (3)(b)(iii) and (c) apply to a managed care organization licensed
295     under:]
296          [(A) Chapter 5, Domestic Stock and Mutual Insurance Corporations;]
297          [(B) Chapter 7, Nonprofit Health Service Insurance Corporations; or]
298          [(C) Chapter 14, Foreign Insurers; and]
299          [(ii) Subsections (3)(b)(iii) and (c) and Subsection (6)(b) do not apply to a managed
300     care organization licensed under Chapter 8, Health Maintenance Organizations and Limited
301     Health Plans.]
302          [(iii)] (4) (a) When selecting health care providers with whom to contract under
303     Subsection (2), a managed care organization [described in Subsection (3)(b)(i)] may not
304     unfairly discriminate between classes of health care providers, but may discriminate within a
305     class of health care providers, subject to [Subsection (6)] Subsections (7) and (8).
306          [(c)] (b) For purposes of this section, unfair discrimination between classes of health
307     care providers includes:
308          (i) refusal to contract with class members in reasonable proportion to the number of
309     insureds covered by the insurer and the expected demand for services from class members; and
310          (ii) refusal to cover procedures for one class of providers that are:
311          (A) commonly used by members of the class of health care providers for the treatment
312     of illnesses, injuries, or conditions;
313          (B) otherwise covered by the managed care organization; and
314          (C) within the scope of practice of the class of health care providers.
315          [(4)] (5) (a) Before the enrollee consents to the insurance contract, the managed care
316     organization shall fully disclose to the enrollee that the managed care organization has entered
317     into network provider contracts.
318          (b) The managed care organization shall provide sufficient detail on the network
319     provider contracts to permit the enrollee to agree to the terms of the insurance contract.
320          (c) The managed care organization shall provide at least the following information:
321          [(a)] (i) a list of the health care providers under contract, and if requested their business
322     locations and specialties;
323          [(b)] (ii) a description of the insured benefits, including deductibles, coinsurance, or
324     other copayments;
325          [(c)] (iii) a description of the quality assurance program required under Subsection
326     [(5)] (6); and
327          [(d)] (iv) a description of the adverse benefit determination procedures required under
328     Section 31A-22-629.
329          [(5)] (6) (a) A managed care organization using network provider contracts shall
330     maintain a quality assurance program for [assuring] ensuring that the care provided by the
331     network providers meets prevailing standards in the state.
332          (b) (i) The commissioner in consultation with the executive director of the Department
333     of Health may designate qualified persons to perform an audit of the quality assurance
334     program.
335          (ii) The auditors shall have full access to all records of the managed care organization
336     and the managed care organization's health care providers, including medical records of
337     individual patients.
338          (c) (i) The information contained in the medical records of individual patients shall
339     remain confidential.
340          (ii) All information, interviews, reports, statements, memoranda, or other data
341     furnished for purposes of the audit and any findings or conclusions of the auditors are
342     privileged.
343          (iii) The information is not subject to discovery, use, or receipt in evidence in any legal
344     proceeding except hearings before the commissioner concerning alleged violations of this
345     section.
346          [(6) (a)] (7) A health care provider or managed care organization may not discriminate
347     against a network provider for agreeing to a contract under Subsection (2).
348          [(b) (i) Subsections (6)(b) and (c) apply to a managed care organization that is
349     described in Subsection (3)(b)(i) and do not apply to a managed care organization described in
350     Subsection (3)(b)(ii).]
351          [(ii) A] (8) (a) Except as provided in Subsection (8)(b), a health care provider licensed
352     to treat an illness or injury within the scope of the health care provider's practice, that is willing
353     and able to meet the terms and conditions established by the managed care organization for
354     designation as a network provider, shall be able to apply for and receive the designation as a
355     network provider.
356          (b) Contract terms and conditions may include reasonable [limitations] limits on the
357     number of designated network providers based upon substantial objective and economic
358     grounds, or expected use of particular services based upon prior provider-patient profiles.
359          (c) Upon the written request of a provider excluded from a network provider contract,
360     the commissioner may hold a hearing to determine if the managed care organization's exclusion
361     of the provider is based on the criteria [set forth in] described in this Subsection [(6)(b)] (8).
362          (9) Subsections (4) and (8):
363          (a) apply to a managed care organization licensed under:
364          (i) Chapter 5, Domestic Stock and Mutual Insurance Corporations;
365          (ii) Chapter 7, Nonprofit Health Service Insurance Corporations; or
366          (iii) Chapter 14, Foreign Insurers; and
367          (b) do not apply to a managed care organization licensed under Chapter 8, Health
368     Maintenance Organizations and Limited Health Plans.
369          [(7)] (10) Nothing in this section [is to] may be construed as [to require] requiring a
370     managed care organization to offer a certain benefit or service as part of a health benefit plan.
371          [(8) Notwithstanding Subsection (2) or Subsection (6)(b), a managed care organization
372     described in Subsection (3)(b)(i) or third party administrator is not required to, but may, enter
373     into a contract with a licensed athletic trainer, licensed under Title 58, Chapter 40a, Athletic
374     Trainer Licensing Act.]
375          Section 5. Section 58-40a-306 is enacted to read:
376          58-40a-306. Insurance coverage not mandated.
377          This chapter does not mandate health insurance coverage, or reimbursement by an
378     insurer, for athletic trainer services.