Download Zipped Introduced WP 8.0 HB0035S2.ZIP 19,201 Bytes
[Status][Bill Documents][Fiscal Note][Bills Directory]
Second Substitute H.B. 35
Representative Judy Ann Buffmire proposes to substitute the following bill:
1
CATASTROPHIC MENTAL HEALTH
2
INSURANCE COVERAGE
3
2000 GENERAL SESSION
4
STATE OF UTAH
5
Sponsor: Judy Ann Buffmire
6
AN ACT RELATING TO INSURANCE; DEFINING TERMS; REQUIRING HEALTH
7
INSURERS TO OFFER MENTAL HEALTH COVERAGE THAT APPLIES THE SAME
8
LIFETIME LIMITS, ANNUAL PAYMENT LIMITS, AND MAXIMUM OUT-OF-POCKET
9
LIMITS TO MENTAL HEALTH CONDITIONS AS APPLY TO PHYSICAL HEALTH
10
CONDITIONS; PERMITTING THE USE OF MANAGED CARE AND CLOSED PANELS;
11
REQUIRING THAT SERVICES BE PROVIDED BY LICENSED THERAPISTS AND
12
FACILITIES; IMPOSING DUTIES ON THE COMMISSIONER TO ADOPT RULES;
13
REQUIRING AN INTERIM REVIEW AND RECOMMENDATION; IMPOSING
14
REQUIREMENTS ON STATE EMPLOYEE HEALTH PLANS; AND PROVIDING A REPEAL
15
DATE.
16
This act affects sections of Utah Code Annotated 1953 as follows:
17
AMENDS:
18
31A-22-617, as last amended by Chapters 314 and 316, Laws of Utah 1994
19
31A-22-618, as last amended by Chapter 204, Laws of Utah 1986
20
49-8-401, as last amended by Chapter 360, Laws of Utah 1998
21
63-55-231, as last amended by Chapter 131, Laws of Utah 1999
22
ENACTS:
23
31A-22-625, Utah Code Annotated 1953
24
Be it enacted by the Legislature of the state of Utah:
25
Section 1.
Section
31A-22-617
is amended to read:
26
31A-22-617. Preferred provider contract provisions.
27
Health insurance policies may provide for insureds to receive services or reimbursement
28
under the policies in accordance with preferred health care provider contracts as follows:
29
(1) Subject to restrictions under this section, any insurer or third party administrator may
30
enter into contracts with health care providers as defined in Section
78-14-3
under which the health
31
care providers agree to supply services, at prices specified in the contracts, to persons insured by
32
an insurer. The health care provider contract may require the health care provider to accept the
33
specified payment as payment in full, relinquishing the right to collect additional amounts from
34
the insured person. The insurance contract may reward the insured for selection of preferred health
35
care providers by reducing premium rates, reducing deductibles, coinsurance, or other copayments,
36
or in any other reasonable manner.
37
(2) (a) Subject to Subsections (2)(b) through (2)(f), an insurer using preferred health care
38
provider contracts shall pay for the services of health care providers not under the contract, unless
39
the illnesses or injuries treated by the health care provider are not within the scope of the insurance
40
contract. As used in this section, "class of health care providers" means all health care providers
41
licensed or licensed and certified by the state within the same professional, trade, occupational, or
42
facility licensure or licensure and certification category established pursuant to Titles 26 and 58.
43
(b) When the insured receives services from a health care provider not under contract, the
44
insurer shall reimburse the insured for at least 75% of the average amount paid by the insurer for
45
comparable services of preferred health care providers who are members of the same class of
46
health care providers. The commissioner may adopt a rule dealing with the determination of what
47
constitutes 75% of the average amount paid by the insurer for comparable services of preferred
48
health care providers who are members of the same class of health care providers.
49
(c) When reimbursing for services of health care providers not under contract, the insurer
50
may make direct payment to the insured.
51
(d) Notwithstanding Subsection (2)(b), an insurer using preferred health care provider
52
contracts may impose a deductible on coverage of health care providers not under contract.
53
(e) When selecting health care providers with whom to contract under Subsection (1), an
54
insurer may not unfairly discriminate between classes of health care providers, but may
55
discriminate within a class of health care providers, subject to Subsection (7).
56
(f) For purposes of this section, unfair discrimination between classes of health care
57
providers shall include:
58
(i) refusal to contract with class members in reasonable proportion to the number of
59
insureds covered by the insurer and the expected demand for services from class members; and
60
(ii) refusal to cover procedures for one class of providers that are:
61
(A) commonly utilized by members of the class of health care providers for the treatment
62
of illnesses, injuries, or conditions;
63
(B) otherwise covered by the insurer; and
64
(C) within the scope of practice of the class of health care providers.
65
(3) Before the insured consents to the insurance contract, the insurer shall fully disclose
66
to the insured that it has entered into preferred health care provider contracts. The insurer shall
67
provide sufficient detail on the preferred health care provider contracts to permit the insured to
68
agree to the terms of the insurance contract. The insurer shall provide at least the following
69
information:
70
(a) a list of the health care providers under contract and if requested their business
71
locations and specialties;
72
(b) a description of the insured benefits, including any deductibles, coinsurance, or other
73
copayments;
74
(c) a description of the quality assurance program required under Subsection (4); and
75
(d) a description of the grievance procedures required under Subsection (5).
76
(4) (a) An insurer using preferred health care provider contracts shall maintain a quality
77
assurance program for assuring that the care provided by the health care providers under contract
78
meets prevailing standards in the state.
79
(b) The commissioner in consultation with the executive director of the Department of
80
Health may designate qualified persons to perform an audit of the quality assurance program. The
81
auditors shall have full access to all records of the organization and its health care providers,
82
including medical records of individual patients.
83
(c) The information contained in the medical records of individual patients shall remain
84
confidential. All information, interviews, reports, statements, memoranda, or other data furnished
85
for purposes of the audit and any findings or conclusions of the auditors are privileged. The
86
information is not subject to discovery, use, or receipt in evidence in any legal proceeding except
87
hearings before the commissioner concerning alleged violations of this section.
88
(5) An insurer using preferred health care provider contracts shall provide a reasonable
89
procedure for resolving complaints and grievances initiated by the insureds and health care
90
providers.
91
(6) An insurer may not contract with a health care provider for treatment of illness or
92
injury unless the health care provider is licensed to perform that treatment.
93
(7) (a) No health care provider or insurer may discriminate against a preferred health care
94
provider for agreeing to a contract under Subsection (1).
95
(b) Any health care provider licensed to treat any illness or injury within the scope of the
96
health care provider's practice, who is willing and able to meet the terms and conditions established
97
by the insurer for designation as a preferred health care provider, shall be able to apply for and
98
receive the designation as a preferred health care provider. Contract terms and conditions may
99
include reasonable limitations on the number of designated preferred health care providers based
100
upon substantial objective and economic grounds, or expected use of particular services based
101
upon prior provider-patient profiles.
102
(8) Upon the written request of a provider excluded from a provider contract, the
103
commissioner may hold a hearing to determine if the insurer's exclusion of the provider is based
104
on the criteria set forth in Subsection (7)(b).
105
(9) Insurers are subject to the provisions of Sections
31A-22-613.5
,
31A-22-614.5
, and
106
31A-22-618
.
107
(10) Nothing in this section is to be construed as to require an insurer to offer a certain
108
benefit or service as part of a health benefit plan.
109
(11) This section does not apply to mental health coverage as provided in Section
110
31A-22-625
.
111
Section 2.
Section
31A-22-618
is amended to read:
112
31A-22-618. Nondiscrimination among health care professionals.
113
(1) Except as provided under Section
31A-22-617
, and except as to insurers licensed under
114
Chapter 8, no insurer may unfairly discriminate against any licensed class of health care providers
115
by structuring contract exclusions which exclude payment of benefits for the treatment of any
116
illness, injury, or condition by any licensed class of health care providers when the treatment is
117
within the scope of the licensee's practice and the illness, injury, or condition falls within the
118
coverage of the contract. Upon the written request of an insured alleging an insurer has violated
119
this section, the commissioner shall hold a hearing to determine if the violation exists. The
120
commissioner may consolidate two or more related alleged violations into a single hearing.
121
(2) This section does not apply to mental health coverage as provided in Section
122
31A-22-625
.
123
Section 3.
Section
31A-22-625
is enacted to read:
124
31A-22-625. Catastrophic coverage of mental health conditions.
125
(1) As used in this section:
126
(a) (i) "Mental health condition" means any condition or disorder involving mental illness
127
that falls under any of the diagnostic categories listed in the Diagnostic and Statistical Manual, as
128
periodically revised.
129
(ii) "Mental health condition" does not include the following when diagnosed as the
130
primary or substantial reason or need for treatment:
131
(A) marital or family problem;
132
(B) social, occupational, religious, or other social maladjustment;
133
(C) conduct disorder;
134
(D) chronic adjustment disorder;
135
(E) psychosexual disorder;
136
(F) chronic organic brain syndrome
137
(G) personality disorder;
138
(H) specific developmental disorder or learning disability; or
139
(I) mental retardation.
140
(b) "Term or condition" means any lifetime limit, annual payment limit, episodic limit,
141
inpatient or outpatient service limit, and maximum out-of-pocket limit.
142
(ii) "Term or condition" does not include any deductible, copayment, or coinsurance prior
143
to reaching any maximum out-of-pocket limit.
144
(iii) Out-of-pocket expenses for mental health conditions and physical health conditions
145
shall apply equally to any maximum out-of-pocket limit within a policy or contract.
146
(2) (a) At the time of purchase and renewal, an insurer shall offer to provide mental health
147
coverage to each individual or group that it insurers or seeks to insurer, which, at a minimum, shall
148
comply with Subsection (3).
149
(b) Individuals and groups may accept or reject an insurer's offer of mental health coverage
150
at the time of purchase and renewal, regardless of whether the individual or group has previously
151
accepted or rejected such coverage.
152
(3) At a minimum, a health insurance policy or health maintenance contract that provides
153
mental health coverage on or after January 1, 2001, may not establish any term or condition that
154
places a greater financial burden on an insured for the diagnosis and treatment of a mental health
155
condition than for the diagnosis and treatment of a covered physical health condition.
156
(4) (a) A policy or contract may provide coverage for the diagnosis and treatment of
157
mental health conditions through a managed care organization or system, regardless of whether
158
the policy or contract uses a managed care organization or system for the treatment of physical
159
health conditions.
160
(b) (i) Notwithstanding any other provision of this title, an insurer may:
161
(A) establish a closed panel of providers under this section; and
162
(B) refuse to provide any benefit to be paid for services rendered by a nonpanel provider
163
unless:
164
(I) the insured is referred to a nonpanel provider with the prior authorization of the insurer;
165
and
166
(II) the nonpanel provider agrees to follow the insurer's protocols and treatment guidelines.
167
(ii) If an insured receives services from a nonpanel provider in the manner permitted by
168
Subsection (4)(d)(i)(B), the insurer shall reimburse the insured for not less than 75% of the average
169
amount paid by the insurer for comparable services of panel providers under a noncapitated
170
arrangement who are members of the same class of health care providers.
171
(iii) Nothing in this Subsection (4)(b) may be construed as requiring an insurer to authorize
172
a referral to a nonpanel provider.
173
(c) To be eligible for coverage under this section, a diagnosis or treatment of a mental
174
health condition must be rendered:
175
(i) by a mental health therapist as defined in Section
58-60-102
; or
176
(ii) in a health care facility licensed or otherwise authorized to provide mental health
177
services pursuant to Title 26, Chapter 21, Health Care Facility Licensing and Inspection Act, or
178
Title 62A, Chapter 2, Licensure of Programs and Facilities, that provides a program for the
179
treatment of a mental health condition pursuant to a written plan.
180
(5) The commissioner may disapprove any policy or contract that provides mental heath
181
coverage in a manner that is inconsistent with the provisions of this section.
182
(6) The commissioner shall adopt rules as necessary to ensure compliance with this
183
section.
184
(7) The Health and Human Services Interim Committee shall review:
185
(a) the impact of this section on insurers, employers, providers, and consumers of mental
186
health services before January 1, 2004; and
187
(b) make a recommendation as to whether the cost-sharing requirements for mental health
188
conditions should be the same as for physical health conditions.
189
(8) Nothing in this section may be construed as restricting the ability of an insurer to offer
190
mental health coverage that exceeds the requirements of this section.
191
(9) This section shall be repealed in accordance with Section
63-55-231
.
192
Section 4.
Section
49-8-401
is amended to read:
193
49-8-401. Group insurance division -- Powers and duties.
194
(1) The group insurance division of the retirement office shall:
195
(a) act as a self-insurer of employee group benefit plans and administer those plans;
196
(b) enter into contracts with private insurers to underwrite employee group benefit plans
197
and to reinsure any appropriate self-insured plans;
198
(c) publish and disseminate descriptions of all employee benefit plans under this chapter
199
in cooperation with the Department of Human Resource Management and political subdivisions;
200
(d) administer the process of claims administration of all employee benefit plans under this
201
chapter or enter into contracts, after competitive bids are taken, with other benefit administrators
202
to provide for the administration of the claims process;
203
(e) obtain an annual actuarial evaluation of all self-insured benefit plans and prepare an
204
annual report for the governor and the Legislature describing the employee benefit plans being
205
administered by the retirement office detailing historical and projected program costs and the status
206
of reserve funds;
207
(f) consult with the Department of Human Resource Management and the executive bodies
208
of other political subdivisions to evaluate employee benefit plans and develop recommendations
209
for new or improved benefit plans;
210
(g) submit annually a budget which includes total projected benefit and administrative
211
costs;
212
(h) maintain reserves sufficient to liquidate the unrevealed claims liability and other
213
liabilities of the self-funded employee group benefit plans as estimated by the board's consulting
214
actuary;
215
(i) submit its recommended benefit adjustments for state employees upon approval of the
216
board to the director of the Department of Human Resource Management. The Department of
217
Human Resource Management shall include the benefit adjustments in the total compensation plan
218
recommended to the governor required by Subsection
67-19-12
(6)(a);
219
(j) adjust benefits, upon approval of the board, and upon appropriate notice to the state,
220
its educational institutions, and political subdivisions;
221
(k) for the purposes of stimulating competition, establishing better geographical
222
distribution of medical care services, and providing alternative health and dental plan coverage for
223
both active and retired employees, request proposals for alternative health and dental coverage at
224
least once every three years, proposals which meet the criteria specified in the request shall be
225
offered to active and retired state employees and may be offered to active and retired employees
226
of political subdivisions at the option of the political subdivision; [and]
227
(l) offer no less than two health plans to state employees that provide mental health
228
coverage consistent with Section
31A-22-625
; and
229
[(l)] (m) perform the same functions established in Subsections (1)(a), (b), (d), and (g) for
230
the Department of Health if the group insurance division provides program benefits to children
231
enrolled in the Utah Children's Health Insurance Program created in Title 26, Chapter 40.
232
(2) Funds budgeted and expended shall accrue from premiums paid by the various
233
employers. Administrative costs may not exceed that percentage of premium income which is
234
recommended by the board and approved by the governor and the Legislature.
235
Section 5.
Section
63-55-231
is amended to read:
236
63-55-231. Repeal dates, Title 31A.
237
(1) Section
31A-2-208.5
, Comparison tables, is repealed July 1, 2005.
238
(2) Section
31A-22-315
, Motor Vehicle Insurance Reporting, is repealed July 1, 2000.
239
(3) Title 31A, Chapter 31, Insurance Fraud Act, is repealed July 1, 2007.
240
(4) Section
31A-22-625
, Catastrophic Coverage of Mental Health Conditions, is repealed
241
July 1, 2011.
[Bill Documents][Bills Directory]