Legislative Session number- 81

Bill Name: SF0052

Relating to health; requiring the health data institute to collect certain
utilization and enrollee data; expanding the prohibition on agreements or
directives between health plan companies and health care providers and
clarifying the financial incentives disclosure requirement; prohibiting health
plan companies from interfering with decisions of treating physicians,
authorizing certain service and coverage limits; expanding the prohibition on
health plan company or health care provider retaliation or discrimination for
complaints; modifying the utilization review and notice process; requiring
organization procedures for independent external appeals of certain
determinations and prohibiting certain health care professional utilization
review conflicts; requiring and providing for the adequacy of preferred provider
networks, for enrollee choice of providers and for a written process for
selection of participating providers, specifying certain discrimination
prohibitions; requiring health plan companies to consult with participating
physicians on medical policy, quality and medical management procedures;
modifying and expanding certain health plan company complaint resolution process
requirements, requiring and providing for the establishment of internal and
external appeals processes, including health maintenance organizations under the
external appeals process requirement, specifying certain rulemaking requirements
of the commissioners of commerce and health and providing for certification of
external appeal entities by the commissioner of commerce; prohibiting health
plan companies from discriminating against enrollees in the delivery of health
care services; specifying certain minimum hospital stay requirements for breast
cancer treatment and specifying certain prohibited discriminatory practices;
requiring health plan companies providing coverage for mastectomies to provide
coverage for resulting reconstructive breast surgery; requiring coverage for
certain investigation uses of prescription drugs; modifying certain requirements
for the coverage of emergency services; expanding continuity of care
requirements; requiring and providing for enrollee access to specialty care and
for coverage for approved clinical trials; requiring and providing for health
plan companies to establish and maintain ongoing internal quality assurance and
continuous quality improvement and drug utilization programs; specifying certain
disclosure requirements of health plan companies and including HMOs under the
requirements; requiring and providing for the confidentiality of medical
records; reducing the time limit for preauthorization of nonemergency services
or benefits; specifying certain reference substitution requirements of the
revisor of statutes; repealing the dispute resolution procedure and the point of
service option exemption for certain smaller health plan companies (mk)