SENATE 3rd Reading Unamended April 29, 2011 SENATE Amended 2nd Reading April 28, 2011First Regular Session Sixty-eighth General Assembly STATE OF COLORADO REENGROSSED This Version Includes All Amendments Adopted in the House of Introduction LLS NO. 11-0883.01 Christy Chase SENATE BILL 11-205 SENATE SPONSORSHIP Tochtrop, HOUSE SPONSORSHIP Miklosi, Senate Committees House Committees Health and Human Services A BILL FOR AN ACT Concerning parity in status between health care providers under health benefit plans, and, in connection therewith, specifying the conditions under which health insurance carriers must grant participating provider status to advanced practice nurses under the carriers' health benefit plans. Bill Summary (Note: This summary applies to this bill as introduced and does not reflect any amendments that may be subsequently adopted. If this bill passes third reading in the house of introduction, a bill summary that applies to the reengrossed version of this bill will be available at http://www.leg.state.co.us/billsummaries.) Current law prohibits health insurance carriers offering health benefit plans in rural areas of the state from discriminating between physicians and advanced practice nurses (APNs) when establishing reimbursement rates for covered services provided, regardless of whether the services are provided by a physician or APN. Additionally, when evaluating applications by APNs for participating provider status, the carrier is to use objective and reasonable criteria and take into account provider-to-covered-person ratios for covered benefits that an APN can provide and, if the carrier denies the application, notify the APN and provide the reason for the denial. The bill eliminates the limited applicability of the nondiscrimination provision, thereby prohibiting carriers offering health benefit plans anywhere in the state from discriminating between physicians and APNs, and extends the nondiscrimination provisions to prohibit a carrier from discriminating between physicians and APNs with regard to determining participating provider status. The bill further requires a carrier to notify an APN of its determination on a participating provider status application within 90 days after receipt of the application and, in the case of a denial, to notify the APN in writing of its specific reasons for the denial. If the APN so requests, the carrier must also provide the APN with a written, clear, and understandable explanation of the objective and reasonable criteria it used in making its determination. Carriers are prohibited from restricting the scope of practice or requiring supervision of an APN, in a manner not otherwise required by the "Nurse Practice Act", as part of granting participating provider status to the APN. For purposes of enforcing these requirements, APNs are afforded the same remedies as would be available for health care providers who enter a contract with a carrier, including a private right of action, equitable relief, reasonable attorney fees and costs if the APN prevails, and the ability to resolve the dispute through arbitration. Additionally, if the carrier violates these requirements, the carrier is subject to penalties for engaging in an unfair or deceptive act or practice in the business of insurance. Be it enacted by the General Assembly of the State of Colorado: SECTION 1. Legislative declaration. (1) The general assembly hereby finds and determines that: (a) In its 2010 report of a two-year study of the barriers that prevent nurses from effectively responding to rapidly changing health care settings and an evolving health care system, the committee of the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine recommends that nurses should practice to the full extent of their education, training, and scope of practice, which defines the activities a qualified nurse may perform; (b) With an aging population and the increased demands of an evolving health care delivery system, physicians alone will not be sufficient to meet growing demands for health care, particularly in the primary care area, and advanced practice nurses are a critical provider resource; (c) Allowing advanced practice nurses to practice to the full extent of their authority will improve access and offer consumers additional choice in necessary providers; (d) Moreover, advanced practice nurses invest heavily in their education and training so that they are able to offer a needed skill to consumers of health care, and future funding for nursing education at the state and federal level targets the need for advanced practice nurse providers; (e) The added education and training obtained by an advanced practice nurse enables that nurse to provide a wider range of care to consumers in an independent setting, and by virtue of that independent setting, advanced practice nurses are often in a position to create additional health care jobs; and (f) When health insurance carriers unreasonably restrict advanced practice nurses from participation on insurance panels, not only does that action prevent the advanced practice nurse from practicing, but the action limits the capacity and effectiveness of the health care delivery system, restricts access to care for health care consumers, and limits health care market job growth. (2) The general assembly therefore declares it to be the policy of this state that health insurance carriers must give advanced practice nurses fair opportunity to apply for participating provider status so as to meet the growing demands of the health care delivery system in this state and assist in job growth in the health care market, and in furtherance of that policy, health insurance carriers are: (a) Required to evaluate an application for participating provider status submitted by an advanced practice nurse using objective and reasonable criteria; (b) Required to respond timely and use appropriate criteria in making determinations on participating provider status applications by advanced practice nurses; (c) Required to provide advanced practice nurses access to the criteria used in making determinations; and (d) Subject to private enforcement proceedings brought by an advanced practice nurse and penalties for engaging in an unfair or deceptive act or practice in the business of insurance for violating these requirements. (3) It is not the intention of the general assembly to limit the ability of a carrier to make reasonable contracting decisions or require a carrier to approve a certain number of a specific type of provider for participation in the carrier's network. SECTION 2. 10-16-125, Colorado Revised Statutes, is amended to read: 10-16-125. Carrier requirements - advanced practice nurses - reimbursement rates - participating provider status - enforcement and penalties. (1) (a) In counties of the state that are neither part of a metropolitan statistical area nor a primary statistical area, a carrier offering a health benefit plan shall not discriminate between a physician and an advanced practice nurse not practicing under the direction of a physician when establishing reimbursement rates for covered services; that could be provided by an advanced practice nurse or a physician (b) A carrier offering a health benefit plan shall not discriminate between a physician and an advanced practice nurse when determining participating provider status. (2) (a) In order to improve access to primary care and choices of providers, a carrier providing a health benefit plan shall evaluate an application for status as a participating provider from an advanced practice nurse utilizing objective and reasonable criteria and shall take into account the provider-to-covered-person ratio pursuant to section 10-16-704 for the covered benefits that appropriately may be provided by the advanced practice nurse. The carrier shall make a determination on an application for participating provider status submitted by an advanced practice nurse, and notify the applicant of its determination, within the same period in which the carrier makes a participating provider determination for physicians ninety days after receipt of the application. If the application is denied, the carrier shall specify the reason for the denial in writing. If the application is approved, the carrier shall list the advanced practice nurse in the provider directory for the health benefit plan. (b) Upon request of the applicant, the carrier shall provide the specific objective and reasonable criteria it used in evaluating and making its determination on the application for status as a participating provider. The carrier shall provide the criteria in writing and in a clear and understandable format that is readily available to the applicant. (3) A carrier that approves an advanced practice nurse's application for participating provider status shall not limit the scope of practice or require supervision of the advanced practice nurse with an unrestricted license in a manner that is more restrictive than the requirements for the practice of advanced practice nursing as set forth in article 38 of title 12, C.R.S., and state board of nursing rules adopted pursuant to that article. (4) (a) If a carrier violates this section, an advanced practice nurse may pursue any of the remedies provided by section 25-37-114, C.R.S. (b) A violation of this section constitutes an unfair or deceptive act or practice in the business of insurance pursuant to section 10-3-1104. (5) This section does not limit the ability of a carrier to make reasonable contracting decisions or require a carrier to approve a certain number of a specific type of provider for participation in the carrier's network. SECTION 3. 10-3-1104 (1), Colorado Revised Statutes, is amended BY THE ADDITION OF A NEW PARAGRAPH to read: 10-3-1104. Unfair methods of competition - unfair or deceptive acts or practices. (1) The following are defined as unfair methods of competition and unfair or deceptive acts or practices in the business of insurance: (kk) Failing to comply with the requirements of section 10-16-125. SECTION 4. Act subject to petition - effective date. This act shall take effect January 1, 2012; except that, if a referendum petition is filed pursuant to section 1 (3) of article V of the state constitution against this act or an item, section, or part of this act within the ninety-day period after final adjournment of the general assembly, then the act, item, section, or part shall not take effect unless approved by the people at the general election to be held in November 2012 and shall take effect on January 1, 2012, or on the date of the official declaration of the vote thereon by the governor, whichever is later.