Sixty-first General Assembly

LLS NO. 97­0453.01 PLC HOUSE BILL 97­1303

STATE OF COLORADO

BY REPRESENTATIVE Allen;

also SENATOR J. Johnson.

HEALTH, ENVIRONMENT,

WELFARE & INSTITUTIONS

A BILL FOR AN ACT

CONCERNING INFORMATION TO BE PROVIDED BY AN INSURER TO A PERSON SELECTING A PERSONAL INJURY PROTECTION INSURANCE POLICY CONTAINING A MANAGED CARE ARRANGEMENT.

Bill Summary

"PIP Managed Care Disclosure"

(Note: This summary applies to this bill as introduced and does not necessarily reflect any amendments which may be subsequently adopted.)

Requires an insurer to notify an insured who selects personal injury protection coverage that includes a managed care arrangement of the following:

• What benefits are provided;

• That the insured will have PIP coverage even if the managed care arrangement option is not chosen and that the managed care arrangement option is not mandatory;

• That the insured's doctor may not be in the managed care arrangement's network of health care professionals;

• That the insured will be limited to use of the managed care arrangement's network of health care professionals;

• That all medical decisions are reviewed by a case manager assigned by the managed care arrangement who may not be a health care professional;

• Whether or not there are any copayments or deductibles required to be paid by the insured, and if so, how much they are.

Provides that the required information must be provided to the insured, and a signed receipt be obtained from the insured, each time a complying policy that contains a managed care arrangement option is issued, replaced, or renewed. Also requires the information to be on a document separate and distinct from all other documents received by the insured at those times.

Be it enacted by the General Assembly of the State of Colorado:

SECTION 1.  10­4­706 (2), Colorado Revised Statutes, 1994 Repl. Vol., as amended, is amended BY THE ADDITION OF THE FOLLOWING NEW PARAGRAPHS to read:

10­4­706.  Required coverages ­ complying policies ­ PIP examination program. (2) (j)  IF AN INSURER OFFERS A COVERAGE OPTION THAT PROVIDES PERSONAL INJURY PROTECTION THROUGH A MANAGED CARE ARRANGEMENT, THE INSURER SHALL ALSO ADVISE AN INSURED IN WRITING OF THE FOLLOWING AND SHALL OBTAIN FROM THE INSURED A SIGNED ACKNOWLEDGMENT OF RECEIPT OF THE FOLLOWING INFORMATION BEFORE ISSUING, REPLACING, OR RENEWING ANY COMPLYING POLICY CONTAINING SUCH COVERAGE OPTION:

(I)  THAT THE INSURED WILL BE COVERED BY PERSONAL INJURY PROTECTION EVEN IF THE INSURED DOES NOT CHOOSE THE MANAGED CARE ARRANGEMENT COVERAGE OPTION AND THAT THE MANAGED CARE ARRANGEMENT IS NOT MANDATORY;

(II)  THE SPECIFIC DOLLAR AMOUNT THAT WILL BE SAVED BY THE INSURED BY PURCHASING THE MANAGED CARE ARRANGEMENT COVERAGE, AND WHETHER OR NOT THE INSURER'S AGENT RECEIVES ANY ADDITIONAL COMPENSATION FROM THE INSURER FOR RECOMMENDING OR ISSUING TO AN INSURED A COMPLYING POLICY WITH THE MANAGED CARE ARRANGEMENT;

(III)  THAT THE INSURED'S HEALTH CARE PROFESSIONAL OF CHOICE MAY NOT BE IN THE NETWORK OF PREFERRED HEALTH CARE PROFESSIONALS USED BY THE MANAGED CARE ARRANGEMENT, OR, IF THE HEALTH CARE PROFESSIONAL OF CHOICE IS IN THE NETWORK WHEN THE INSURED IS ISSUED A POLICY, THAT SUCH HEALTH CARE PROFESSIONAL MAY NOT REMAIN IN THE NETWORK AND THE INSURED WILL NOT BE ADVISED WHEN THAT HEALTH CARE PROFESSIONAL LEAVES THE NETWORK;

(IV)  THAT ALL DECISIONS MADE CONCERNING THE INSURED'S MEDICAL TREATMENT FOLLOWING AN ACCIDENT COVERED UNDER A COMPLYING POLICY MUST BE APPROVED BY THE MANAGED CARE ARRANGEMENT THROUGH AN ASSIGNED CASE MANAGER AND THAT SUCH CASE MANAGER IS NOT REQUIRED TO BE A HEALTH CARE PROFESSIONAL;

(V)  THAT THE INSURED WILL NOT BE REFERRED TO A HEALTH CARE PROFESSIONAL WHO IS OUTSIDE THE MANAGED CARE ARRANGEMENT'S NETWORK OF PREFERRED HEALTH CARE PROFESSIONALS WITHOUT THE APPROVAL OF THE MANAGED CARE ARRANGEMENT THROUGH AN ASSIGNED CASE MANAGER AND THAT ANY REFERRAL TO A HEALTH CARE PROFESSIONAL WHO IS A SPECIALIST IN A PARTICULAR MEDICAL DISCIPLINE MUST FIRST BE APPROVED BY THE ASSIGNED CASE MANAGER AND MUST BE MADE TO A SPECIALIST WHO IS IN THE MANAGED CARE ARRANGEMENT'S NETWORK OF PREFERRED HEALTH CARE PROFESSIONALS;

(VI)  THAT, IF THE INSURED USES A HEALTH CARE PROFESSIONAL WHO IS NOT IN THE MANAGED CARE ARRANGEMENT'S NETWORK OF PREFERRED HEALTH CARE PROFESSIONALS, THE INSURED MAY BE REQUIRED TO PAY THE HEALTH CARE PROFESSIONAL FOR THE SERVICES PROVIDED OR OTHERWISE FINANCIALLY PENALIZED;

(VII)  THAT THE MANAGED CARE ARRANGEMENT MAY HAVE SPECIFIC GUIDELINES AND LIMITS FOR CARE, TREATMENT, SERVICES, PRODUCTS, EXPENSES, OR ACCOMMODATIONS AND THAT EXCEEDING THE GUIDELINES OR LIMITS MAY AFFECT THE ABILITY OF THE INSURED TO HAVE SUCH FUTURE BENEFITS APPROVED BY THE ASSIGNED CASE MANAGER OR OF THE HEALTH CARE PROFESSIONAL, PROVIDER OF SERVICES, OR THE INSURED TO BE REIMBURSED FOR THE CARE, TREATMENT, SERVICES, PRODUCTS, EXPENSES, OR ACCOMMODATIONS;

(VIII)  WHAT CARE, TREATMENT, SERVICES , PRODUCTS, EXPENSES, OR ACCOMMODATIONS ARE COVERED BENEFITS OF THE MANAGED HEALTH CARE ARRANGEMENT AND THE EXACT AMOUNT OF THE PENALTIES, DEDUCTIBLES, OR COPAYMENTS, IF ANY;

(IX)  THAT THE INSURED IS NOT ENTITLED TO A PIP EXAMINATION IN THE EVENT OF A DISPUTED PIP CLAIM PURSUANT TO PARAGRAPH (c) OF SUBSECTION (6) OF THIS SECTION AND, IF THE INSURED REQUESTS A PIP EXAMINATION PURSUANT TO RULES PROMULGATED BY THE EXECUTIVE DIRECTOR, THE INSURED SHALL PAY FOR SUCH PIP EXAMINATION.

(k)  THE INSURER SHALL PROVIDE THE INFORMATION REQUIRED BY PARAGRAPH (j) OF THIS SUBSECTION (2), ALONG WITH THE MANAGED CARE ARRANGEMENT'S NETWORK OF PREFERRED HEALTH CARE PROFESSIONALS, TO THE INSURED EACH TIME A COMPLYING POLICY CONTAINING A MANAGED CARE ARRANGEMENT IS ISSUED, REPLACED, OR RENEWED. THE INFORMATION SHALL BE PROVIDED ON A DOCUMENT THAT IS SEPARATE AND DISTINCT FROM ALL OTHER DOCUMENTS RECEIVED BY THE INSURED AT THE TIME THE INSURED'S COMPLYING POLICY IS ISSUED, REPLACED, OR RENEWED.

SECTION 2.  10­4­706 (4) (a), Colorado Revised Statutes, 1994 Repl. Vol., as amended, is amended to read:

10­4­706.  Required coverages ­ complying policies ­ PIP examination program. (4) (a)  An insurer issuing policies providing coverages as set forth in this section shall provide written explanations of all available coverages prior to issuing any policy to an insured. After a named insured selects a policy with desired personal injury protection coverage, an insurer shall not be under any further obligation to notify such policyholder in any renewal or replacement policy of the availability of a basic personal injury protection policy or of any alternative personal injury protection coverage.

SECTION 3.  Effective date ­ applicability. This act shall take effect July 1, 1997, and shall apply to all complying personal injury protection policies that contain a managed care arrangement option issued, replaced, or renewed on or after said date.

SECTION 4.  Safety clause. The general assembly hereby finds, determines, and declares that this act is necessary for the immediate preservation of the public peace, health, and safety.