Legislative Session number- 82

Bill Name: SF0796

E Modifying certain health insurance coverage and treatment requirements;
prohibiting health carriers from denying payment for services or treatments
after preauthorization approval except in cases of fraud; prohibiting
retaliation against health care providers for the disclosure of information
relating to the care, services or conditions affecting enrollees to an
appropriate public regulatory agency, private accreditation body or management
personnel of the health plan company, for initiating, cooperating or
participating in a utilization review or investigation or for providing
testimony, evidence, records or other assistance to enrollees, advocating on
behalf of enrollees bringing claims against health carriers or referring a
patient for a second opinion; requiring utilization review organizations
conducting prior authorization of services to follow existing standards and
utilization review organizations, health plan companies or claims administrators
determining inappropriate, unreasonable or medically unnecessary care to provide
a copy of written procedures for prior authorization to the enrollees seeking
care; defining medically necessary care for health plan company requirements
purposes; modifying certain health plan company continuity of care requirements,
specifying certain covered services termination limits and certain notice and
disclosure requirements; defining specialist for access to specialty care
purposes, expanding referral procedures information disclosure requirements and
requiring health plan companies to promptly evaluate the treatment needs of
enrollees seeking treatment for problems relating to medical conditions
including mental health and chemical dependency conditions and to pay the costs
of second opinions, defining second opinion; requiring and providing for
prospective enrollee access to evidences of coverage and drug formularies;
requiring continued coverage of prescription drugs removed from formularies
during term of the contract under certain conditions; modifying the standards
for external review of adverse determinations(mk, ja)