First Regular Session
Sixty-second General Assembly
LLS NO. 99-0294.01 Jerry Barry SENATE BILL 99-087
STATE OF COLORADO
BY SENATOR Thiebaut;
also REPRESENTATIVE Tapia.
HEALTH, ENVIRONMENT, WELFARE & INSTITUTIONS
A BILL FOR AN ACT
101 CONCERNING THE RIGHTS OF HEALTH INSURANCE POLICY BENEFICIARIES.
Bill Summary
(Note: This summary applies to this bill as introduced and does
not necessarily reflect any amendments that may be subsequently
adopted.)
Access to emergency care. In situations where a reasonable
person would seek emergency medical services, requires health insurance
companies ("carriers") to reimburse providers without prior authorization
and to reimburse out-of-network providers in the same manner as
in-network providers. Applies these requirements to necessary follow-up
or post-stabilization care.
Point-of-service care. Requires carriers that offer health benefit
plans requiring the use of participating providers to also offer
point-of-service policies. Excludes from the requirement group health
coverage plans that offer coverage through more than one carrier or that
offer 2 or more coverage options that differ significantly in the use of
participating providers or significantly different networks of providers.
Choice of providers. Requires carriers to permit covered persons
or enrollees to receive primary care from any available participating
primary care provider. Requires such carriers to permit covered persons
or enrollees to receive speciality care from any available participating
specialist, subject to appropriate referral procedures, unless the carrier
clearly informs covered persons or enrollees of limitations on the choice
of specialty providers.
Access to specialty care. Requires carriers to allow female
covered persons or enrollees to designate their ob/gyn as their primary
care provider or to provide routine gynecological care and pregnancy
related health care services without prior authorization or referral.
Requires carriers to allow covered persons or enrollees to be
treated by a specialist if the covered person or enrollee has a condition
[ ] denotes HOUSE amendment. { } denotes SENATE amendment.
Capital letters indicate new material to be added to existing statute.
Dashes through the words indicate material to be deleted from existing statute.
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requiring treatment by a specialist and the treatment is covered under the
health benefit plan.
Provides that the carrier may require that the specialty care be
provided by an in-network specialist, unless there are no in-network
specialists available.
Information available to consumers. Requires carriers to
disclose to covered persons or enrollees or potential covered persons or
enrollees specified information concerning procedures and limitations on
coverages under the health benefit plans.
Ombudsman program. Establishes an ombudsman program in
the department of public health and environment to assist consumers in
choosing their health benefit plan and in resolving disputes with carriers.
Quality standards. Requires all carriers to establish internal
quality assurance programs meeting specified requirements.
Grievance procedures. Requires all carriers to establish internal
and external appeals procedures for grievances. Establishes requirements
for such procedures.
Protecting the relationships between patients and providers.
Prohibits carriers from contractually restricting a provider from engaging
in communications concerning a patient's health status, treatment options,
and financial incentives.
Prohibits a carrier from transferring liability for its actions or
inactions to a provider.
Requires contracts between carriers and providers to establish
reasonable procedures for participation and to consult with participating
providers regarding the procedures.
1 Be it enacted by the General Assembly of the State of Colorado:
2 SECTION 1. Part 1 of article 16 of title 10, Colorado Revised
3 Statutes, is amended BY THE ADDITION OF THE FOLLOWING NEW
4 SECTIONS to read:
5 10-16-123. Short title. SECTIONS 10-16-123 TO 10-16-135 SHALL
6 BE KNOWN AND MAY BE CITED AS THE "COLORADO PATIENT'S BILL OF
7 RIGHTS".
8 10-16-124. Definitions. AS USED IN SECTIONS 10-16-123 TO
9 10-16-135, UNLESS THE CONTEXT OTHERWISE REQUIRES:
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1 (1) "APPEALABLE DECISION" MEANS ANY OF THE FOLLOWING:
2 (a) DENIAL OF, REDUCTION IN, OR TERMINATION OF PAYMENT, OR
3 FAILURE TO PROVIDE OR MAKE PAYMENT, IN WHOLE OR IN PART, FOR A
4 BENEFIT, INCLUDING A FAILURE TO COVER AN ITEM OR HEALTH CARE
5 SERVICE FOR WHICH BENEFITS ARE OTHERWISE PROVIDED BECAUSE IT IS
6 DETERMINED TO BE NOT MEDICALLY NECESSARY OR APPROPRIATE.
7 (b) FAILURE TO PROVIDE COVERAGE OF EMERGENCY SERVICES OR
8 REIMBURSEMENT OF MAINTENANCE CARE OR POST-STABILIZATION CARE
9 UNDER SECTION 10-16-125.
10 (c) FAILURE TO PROVIDE A CHOICE OF PROVIDER UNDER SECTION
11 10-16-127.
12 (d) FAILURE TO PROVIDE ACCESS TO SPECIALTY AND OTHER CARE
13 UNDER SECTION 10-16-128.
14 (e) THE IMPOSITION OF A LIMITATION THAT IS PROHIBITED UNDER
15 SECTION 10-16-133.
16 (2) "BENEFITS" MEANS THE EXTENT OF THE COVERAGE PROVIDED
17 FOR BY A HEALTH BENEFIT PLAN.
18 (3) "EMERGENCY APPEAL" MEANS AN APPEAL FILED BY A COVERED
19 PERSON OR ENROLLEE THAT NEEDS IMMEDIATE ATTENTION FROM THE
20 CARRIER GIVEN THE URGENCY OR SEVERITY OF THE NATURE OF THE
21 MEDICAL CONDITION FOR WHICH THE APPEAL WAS FILED.
22 (4) "EMERGENCY SERVICES" MEANS A MEDICAL SCREENING
23 EXAMINATION THAT IS WITHIN THE CAPABILITY OF THE EMERGENCY
24 DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY
25 AVAILABLE TO THE EMERGENCY DEPARTMENT TO EVALUATE AN
26 EMERGENCY MEDICAL CONDITION WITHIN THE CAPABILITIES OF THE STAFF
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1 AND FACILITIES AVAILABLE AT THE HOSPITAL AND SUCH FURTHER MEDICAL
2 EXAMINATION AND TREATMENT AS ARE REQUIRED TO STABILIZE THE
3 PATIENT.
4 (5) (a) "EMERGENCY MEDICAL CONDITION" MEANS A MEDICAL
5 CONDITION MANIFESTING ITSELF BY ACUTE SYMPTOMS OF SUFFICIENT
6 SEVERITY, INCLUDING SEVERE PAIN, SUCH THAT A PRUDENT LAYPERSON,
7 WHO POSSESSES AN AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE,
8 COULD REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL
9 ATTENTION TO RESULT IN:
10 (I) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT TO
11 A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD,
12 IN SERIOUS JEOPARDY;
13 (II) SERIOUS IMPAIRMENT OF BODILY FUNCTIONS; OR
14 (III) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART; OR
15 (b) WITH RESPECT TO A PREGNANT WOMEN WHO IS HAVING
16 CONTRACTIONS, "EMERGENCY MEDICAL CONDITION" MEANS:
17 (I) THAT THERE IS INADEQUATE TIME TO EFFECT A SAFE TRANSFER
18 TO A HOSPITAL THAT IS A PARTICIPATING PROVIDER BEFORE DELIVERY OF
19 THE UNBORN CHILD; OR
20 (II) THAT TRANSFER MAY POSE A THREAT TO THE HEALTH OR
21 SAFETY OF THE WOMAN OR THE UNBORN CHILD.
22 (6) (a) "EXTERNALLY APPEALABLE DECISION" MEANS AN
23 APPEALABLE DECISION WHEN:
24 (I) THE AMOUNT INVOLVED EXCEEDS FIVE HUNDRED DOLLARS; OR
25 (II) THE PATIENT'S LIFE OR HEALTH IS JEOPARDIZED AS A
26 CONSEQUENCE OF THE DECISION.
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1 (b) THE TERM "EXTERNALLY APPEALABLE DECISION" DOES NOT
2 INCLUDE A DENIAL OF COVERAGE FOR HEALTH CARE SERVICES THAT ARE
3 SPECIFICALLY EXCLUDED IN THE HEALTH BENEFIT PLAN.
4 (7) "GROUP HEALTH BENEFIT PLAN" MEANS A PLAN THAT OFFERS
5 TWO OR MORE DIFFERENT HEALTH BENEFIT PLANS TO A GROUP OF PERSONS
6 ELIGIBLE TO CHOOSE BETWEEN THE HEALTH BENEFIT PLANS.
7 (8) (a) "MEDICAL COMMUNICATION" MEANS ANY COMMUNICATION
8 MADE BY A PROVIDER WITH A PATIENT OF THE PROVIDER OR THE GUARDIAN
9 OR LEGAL REPRESENTATIVE OF SUCH PATIENT WITH RESPECT TO:
10 (I) THE PATIENT'S HEALTH STATUS, MEDICAL CARE, OR TREATMENT
11 OPTIONS;
12 (II) ANY UTILIZATION REVIEW REQUIREMENTS THAT MAY AFFECT
13 TREATMENT OPTIONS FOR THE PATIENT; OR
14 (III) ANY FINANCIAL INCENTIVES THAT MAY AFFECT THE
15 TREATMENT OF THE PATIENT.
16 (b) "MEDICAL COMMUNICATION" DOES NOT INCLUDE A
17 COMMUNICATION BY A PROVIDER WITH A PATIENT OF THE PROVIDER OR
18 THE GUARDIAN OR LEGAL REPRESENTATIVE OF SUCH PATIENT IF THE
19 COMMUNICATION INVOLVES A KNOWING OR WILLFUL MISREPRESENTATION
20 BY SUCH PROVIDER.
21 (9) "POINT-OF-SERVICE COVERAGE" MEANS THE RIGHT TO
22 PAYMENT BY THE CARRIER FOR COVERED HEALTH CARE SERVICES WHEN
23 PROVIDED BY A NONPARTICIPATING PROVIDER. SUCH COVERAGE NEED NOT
24 INCLUDE THE RIGHT TO PAYMENTS TO PROVIDERS THAT THE CARRIER
25 EXCLUDES BECAUSE OF FRAUD, QUALITY, OR SIMILAR REASONS.
26 (10) "SPECIALIST" MEANS, WITH RESPECT TO A MEDICAL
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1 CONDITION, A PROVIDER, FACILITY, OR CENTER THAT HAS ADEQUATE
2 EXPERTISE THROUGH APPROPRIATE TRAINING AND EXPERIENCE,
3 INCLUDING, IN THE CASE OF A CHILD, APPROPRIATE PEDIATRIC EXPERTISE,
4 TO PROVIDE HIGH QUALITY CARE IN TREATING THE MEDICAL CONDITION.
5 (11) "SPECIALTY CARE" MEANS HEALTH CARE SERVICES PROVIDED
6 BY A PROVIDER WHO IS A SPECIALIST AND THAT CAN ONLY BE PROVIDED BY
7 A SPECIALIST QUALIFIED TO TREAT THE MEDICAL CONDITION FOR WHICH
8 THE COVERED PERSON OR ENROLLEE IS SEEKING HEALTH CARE SERVICES.
9 10-16-125. Access to emergency care - care after stabilization.
10 (1) IF A HEALTH BENEFIT PLAN OFFERED BY A CARRIER PROVIDES ANY
11 BENEFITS WITH RESPECT TO EMERGENCY SERVICES, THE CARRIER SHALL
12 COVER EMERGENCY SERVICES FURNISHED UNDER THE HEALTH BENEFIT
13 PLAN:
14 (a) WITHOUT THE NEED FOR ANY PRIOR AUTHORIZATION
15 DETERMINATION;
16 (b) WHETHER OR NOT THE PROVIDER FURNISHING SUCH HEALTH
17 CARE SERVICES IS A PARTICIPATING PROVIDER WITH RESPECT TO SUCH
18 HEALTH CARE SERVICES;
19 (c) IN A MANNER SO THAT, IF SUCH HEALTH CARE SERVICES ARE
20 PROVIDED TO A COVERED PERSON OR ENROLLEE BY A NONPARTICIPATING
21 PROVIDER:
22 (I) THE COVERED PERSON OR ENROLLEE IS NOT LIABLE FOR
23 AMOUNTS THAT EXCEED THE AMOUNTS OF LIABILITY THAT WOULD BE
24 INCURRED IF THE HEALTH CARE SERVICES WERE PROVIDED BY A
25 PARTICIPATING PROVIDER; AND
26 (II) THE CARRIER PAYS AN AMOUNT THAT IS NOT LESS THAN THE
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1 AMOUNT PAID TO A PARTICIPATING PROVIDER FOR THE SAME HEALTH CARE
2 SERVICES; AND
3 (d) WITHOUT REGARD TO ANY OTHER TERM OR CONDITION OF SUCH
4 COVERAGE, OTHER THAN EXCLUSION OR COORDINATION OF BENEFITS, AND
5 AFFILIATION OR WAITING PERIOD OR OTHER APPLICABLE COST-SHARING.
6 (2) IN THE CASE OF HEALTH CARE SERVICES, OTHER THAN
7 EMERGENCY SERVICES, FOR WHICH BENEFITS ARE AVAILABLE UNDER A
8 HEALTH BENEFIT PLAN OFFERED BY A CARRIER, THE CARRIER SHALL
9 PROVIDE FOR REIMBURSEMENT WITH RESPECT TO SUCH HEALTH CARE
10 SERVICES PROVIDED TO A COVERED PERSON OR ENROLLEE OTHER THAN
11 THROUGH A PARTICIPATING PROVIDER IN A MANNER CONSISTENT WITH
12 SUBSECTION (1) OF THIS SECTION IF THE HEALTH CARE SERVICES ARE
13 REASONABLY NECESSARY MAINTENANCE CARE OR POST-STABILIZATION
14 CARE.
15 10-16-126. Point-of-service coverage. (1) EXCEPT AS PROVIDED
16 IN SUBSECTION (2) OF THIS SECTION, IF A HEALTH BENEFIT PLAN OFFERED
17 BY A CARRIER IN CONNECTION WITH A GROUP HEALTH BENEFIT PLAN
18 PROVIDES BENEFITS ONLY THROUGH PARTICIPATING PROVIDERS, THE
19 CARRIER SHALL OFFER A COVERED PERSON OR ENROLLEE THE OPTION TO
20 PURCHASE POINT-OF-SERVICE COVERAGE FOR ALL SUCH BENEFITS FOR
21 WHICH COVERAGE IS OTHERWISE SO LIMITED. SUCH OPTION SHALL BE
22 MADE AVAILABLE TO THE COVERED PERSON OR ENROLLEE AT THE TIME OF
23 ENROLLMENT UNDER THE HEALTH BENEFIT PLAN AND AT SUCH OTHER
24 TIMES AS THE HEALTH BENEFIT PLAN OR CARRIER OFFERS THE COVERED
25 PERSON OR ENROLLEE A CHOICE OF COVERAGE OPTIONS.
26 (2) SUBSECTION (1) OF THIS SECTION SHALL NOT APPLY TO A
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1 COVERED PERSON OR ENROLLEE IN A GROUP HEALTH BENEFIT PLAN IF THE
2 GROUP HEALTH BENEFIT PLAN OFFERS THE COVERED PERSON OR
3 ENROLLEE:
4 (a) A CHOICE OF HEALTH BENEFIT PLANS THROUGH MORE THAN
5 ONE CARRIER; OR
6 (b) TWO OR MORE HEALTH BENEFIT PLANS OF THE SAME CARRIER
7 THAT DIFFER SIGNIFICANTLY WITH RESPECT TO THE USE OF PARTICIPATING
8 PROVIDERS OR THE NETWORKS OF SUCH PROVIDERS THAT ARE USED.
9 (3) NOTHING IN THIS SECTION SHALL BE CONSTRUED:
10 (a) AS REQUIRING BENEFITS FOR A PARTICULAR TYPE OF PROVIDER;
11 (b) AS REQUIRING AN EMPLOYER TO PAY ANY COSTS AS A RESULT
12 OF THIS SECTION OR TO MAKE EQUAL CONTRIBUTIONS WITH RESPECT TO
13 DIFFERENT HEALTH BENEFIT PLANS; OR
14 (c) AS PREVENTING A CARRIER FROM IMPOSING HIGHER COSTS OR
15 COST-SHARING ON A COVERED PERSON OR ENROLLEE FOR THE EXERCISE OF
16 A POINT-OF-SERVICE COVERAGE OPTION.
17 10-16-127. Choice of providers. (1) A CARRIER THAT OFFERS A
18 HEALTH BENEFIT PLAN SHALL PERMIT EACH COVERED PERSON OR
19 ENROLLEE TO RECEIVE PRIMARY CARE FROM ANY PARTICIPATING PRIMARY
20 CARE PROVIDER WHO IS AVAILABLE TO ACCEPT SUCH INDIVIDUAL.
21 (2) (a) SUBJECT TO PARAGRAPH (b) OF THIS SUBSECTION (2), A
22 CARRIER THAT OFFERS A HEALTH BENEFIT PLAN SHALL PERMIT EACH
23 COVERED PERSON OR ENROLLEE TO RECEIVE MEDICALLY NECESSARY OR
24 APPROPRIATE SPECIALTY CARE, PURSUANT TO APPROPRIATE REFERRAL
25 PROCEDURES, FROM ANY QUALIFIED PARTICIPATING PROVIDER WHO IS
26 AVAILABLE TO ACCEPT SUCH COVERED PERSON OR ENROLLEE FOR SUCH
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1 CARE.
2 (b) PARAGRAPH (a) OF THIS SUBSECTION (2) SHALL NOT APPLY TO
3 SPECIALTY CARE IF THE CARRIER CLEARLY INFORMS COVERED PERSONS
4 AND ENROLLEES OF THE LIMITATIONS ON CHOICE OF PARTICIPATING
5 PROVIDERS WITH RESPECT TO SUCH CARE.
6 10-16-128. Access to specialty care. (1) IF, IN CONNECTION
7 WITH THE PROVISION OF A HEALTH BENEFIT PLAN, A CARRIER REQUIRES OR
8 PERMITS A COVERED PERSON OR ENROLLEE TO DESIGNATE A
9 PARTICIPATING PRIMARY CARE PROVIDER:
10 (a) THE HEALTH BENEFIT PLAN OR CARRIER SHALL PERMIT SUCH
11 COVERED PERSON OR ENROLLEE WHO IS A FEMALE TO DESIGNATE A
12 PARTICIPATING PROVIDER WHO SPECIALIZES IN OBSTETRICS AND
13 GYNECOLOGY AS THE INDIVIDUAL'S PRIMARY CARE PROVIDER; AND
14 (b) IF SUCH A COVERED PERSON OR ENROLLEE HAS NOT
15 DESIGNATED SUCH A PROVIDER AS A PRIMARY CARE PROVIDER, THE
16 HEALTH BENEFIT PLAN OR CARRIER:
17 (I) SHALL NOT REQUIRE AUTHORIZATION OR A REFERRAL BY THE
18 COVERED PERSON'S OR ENROLLEE'S PRIMARY CARE PROVIDER OR
19 OTHERWISE FOR COVERAGE OF ROUTINE GYNECOLOGICAL CARE, SUCH AS
20 PREVENTIVE WOMEN'S HEALTH EXAMINATIONS AND PREGNANCY RELATED
21 HEALTH CARE SERVICES PROVIDED BY A PARTICIPATING PROVIDER WHO
22 SPECIALIZES IN OBSTETRICS AND GYNECOLOGY TO THE EXTENT SUCH CARE
23 IS OTHERWISE COVERED; AND
24 (II) MAY TREAT THE ORDERING OF OTHER GYNECOLOGICAL CARE
25 BY SUCH A PARTICIPATING PROVIDER AS THE AUTHORIZATION OF THE
26 PRIMARY CARE PROVIDER WITH RESPECT TO SUCH CARE UNDER THE
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1 HEALTH BENEFIT PLAN.
2 (c) NOTHING IN SUBPARAGRAPH (II) OF PARAGRAPH (b) OF THIS
3 SUBSECTION (1) SHALL WAIVE ANY REQUIREMENTS OF COVERAGE
4 RELATING TO MEDICAL NECESSITY OR APPROPRIATENESS WITH RESPECT TO
5 COVERAGE OF GYNECOLOGICAL CARE SO ORDERED.
6 (2) THE HEALTH BENEFIT PLAN OR CARRIER SHALL MAKE OR
7 PROVIDE FOR A REFERRAL TO A SPECIALIST WHO IS AVAILABLE AND
8 ACCESSIBLE TO PROVIDE TREATMENT FOR A CONDITION OR DISEASE OF
9 SUFFICIENT SERIOUSNESS AND COMPLEXITY TO REQUIRE TREATMENT BY A
10 SPECIALIST IF:
11 (a) AN INDIVIDUAL IS A COVERED PERSON OR ENROLLEE UNDER A
12 HEALTH BENEFIT PLAN OFFERED BY A CARRIER; AND
13 (b) BENEFITS FOR SUCH TREATMENT ARE PROVIDED UNDER THE
14 HEALTH BENEFIT PLAN.
15 (3) (a) A CARRIER MAY REQUIRE THAT THE HEALTH CARE SERVICES
16 PROVIDED TO A COVERED PERSON OR ENROLLEE PURSUANT TO SUCH
17 REFERRAL UNDER SUBSECTION (2) OF THIS SECTION BE:
18 (I) PURSUANT TO A TREATMENT PLAN, ONLY IF THE TREATMENT
19 PLAN IS DEVELOPED BY THE SPECIALIST AND APPROVED BY THE CARRIER
20 IN CONSULTATION WITH THE DESIGNATED PRIMARY CARE PROVIDER OR
21 SPECIALIST AND THE COVERED PERSON OR ENROLLEE OR THE COVERED
22 PERSON'S OR ENROLLEE'S DESIGNEE; AND
23 (II) IN ACCORDANCE WITH APPLICABLE QUALITY ASSURANCE AND
24 UTILIZATION REVIEW STANDARDS OF THE HEALTH BENEFIT PLAN OR
25 CARRIER.
26 (b) NOTHING IN THIS SUBSECTION (3) SHALL BE CONSTRUED AS
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1 PREVENTING SUCH A TREATMENT PLAN FOR A COVERED PERSON OR
2 ENROLLEE FROM REQUIRING A SPECIALIST TO PROVIDE THE PRIMARY CARE
3 PROVIDER WITH REGULAR UPDATES ON THE SPECIALTY CARE PROVIDED, AS
4 WELL AS ALL NECESSARY MEDICAL INFORMATION.
5 (4) A CARRIER IS NOT REQUIRED UNDER SUBSECTION (2) OF THIS
6 SECTION TO PROVIDE FOR A REFERRAL TO A SPECIALIST THAT IS NOT A
7 PARTICIPATING PROVIDER, UNLESS THE HEALTH BENEFIT PLAN OR
8 NETWORK DOES NOT HAVE AN APPROPRIATE SPECIALIST THAT IS
9 AVAILABLE AND ACCESSIBLE TO TREAT THE COVERED PERSON'S OR
10 ENROLLEE'S CONDITION THAT IS A PARTICIPATING PROVIDER WITH RESPECT
11 TO SUCH TREATMENT.
12 10-16-129. Information available to consumers. (1) NO LATER
13 THAN JULY 1, 2000, A CARRIER, IN CONNECTION WITH A HEALTH BENEFIT
14 PLAN, SHALL PROVIDE FOR THE DISCLOSURE, IN A CLEAR AND ACCURATE
15 FORM, TO EACH COVERED PERSON OR ENROLLEE, OR TO A POTENTIAL
16 COVERED PERSON OR ENROLLEE UPON SUCH PERSON'S OR ENROLLEE'S
17 REQUEST, OR GROUP HEALTH BENEFIT PLAN SPONSOR WITH WHICH THE
18 HEALTH BENEFIT PLAN OR CARRIER HAS CONTRACTED, OF THE FOLLOWING
19 INFORMATION FOR EACH HEALTH BENEFIT PLAN OFFERED:
20 (a) A DESCRIPTION OF THE BENEFITS AND HEALTH CARE SERVICES
21 UNDER EACH SUCH HEALTH BENEFIT PLAN AND ANY IN-NETWORK AND
22 OUT-OF-NETWORK FEATURES OF EACH SUCH HEALTH BENEFIT PLAN;
23 (b) A DESCRIPTION OF ANY COST-SHARING, INCLUDING PREMIUMS,
24 DEDUCTIBLES, COINSURANCE, AND COPAYMENT AMOUNTS, FOR WHICH THE
25 COVERED PERSON OR ENROLLEE WILL BE RESPONSIBLE, INCLUDING ANY
26 ANNUAL OR LIFETIME LIMITS ON BENEFITS, FOR EACH SUCH HEALTH
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1 BENEFIT PLAN;
2 (c) A DESCRIPTION OF ANY OPTIONAL SUPPLEMENTAL BENEFITS
3 OFFERED BY EACH SUCH HEALTH BENEFIT PLAN AND THE TERMS AND
4 CONDITIONS, INCLUDING PREMIUMS OR COST-SHARING, FOR SUCH
5 SUPPLEMENTAL BENEFITS;
6 (d) A DESCRIPTION OF ANY RESTRICTIONS ON PAYMENTS FOR
7 HEALTH CARE SERVICES FURNISHED TO A COVERED PERSON OR ENROLLEE
8 BY A PROVIDER THAT IS NOT A PARTICIPATING PROVIDER AND THE
9 LIABILITY OF THE COVERED PERSON OR ENROLLEE FOR ADDITIONAL
10 PAYMENTS FOR THESE HEALTH CARE SERVICES;
11 (e) A DESCRIPTION OF THE ESTABLISHED GEOGRAPHICAL SERVICE
12 AREA OF EACH SUCH HEALTH BENEFIT PLAN, INCLUDING THE PROVISION OF
13 ANY OUT-OF-AREA HEALTH CARE SERVICES;
14 (f) A DESCRIPTION OF THE EXTENT TO WHICH COVERED PERSONS
15 OR ENROLLEES MAY SELECT THE PRIMARY CARE PROVIDER OF THEIR
16 CHOICE, INCLUDING PROVIDERS BOTH IN-NETWORK AND OUT-OF-NETWORK
17 OF EACH SUCH HEALTH BENEFIT PLAN, IF THE HEALTH BENEFIT PLAN
18 PERMITS OUT-OF-NETWORK SERVICES;
19 (g) A DESCRIPTION OF THE PROCEDURES FOR ADVANCE DIRECTIVES
20 AND ORGAN DONATION DECISIONS IF THE HEALTH BENEFIT PLAN
21 MAINTAINS SUCH PROCEDURES;
22 (h) A DESCRIPTION OF THE REQUIREMENTS AND PROCEDURES,
23 INCLUDING TELEPHONE NUMBERS AND BUSINESS ADDRESSES, TO BE USED
24 TO OBTAIN PREAUTHORIZATION FOR HEALTH CARE SERVICES, INCLUDING
25 REFERRALS FOR SPECIALTY CARE;
26 (i) A SUMMARY OF THE RULES AND METHODS FOR APPEALING
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1 COVERAGE DECISIONS AND FILING GRIEVANCES, INCLUDING THE
2 TELEPHONE NUMBERS AND MAILING ADDRESSES NEEDED TO FILE AN
3 APPEAL OR GRIEVANCE, AS WELL AS OTHER AVAILABLE REMEDIES;
4 (j) A SUMMARY OF THE RULES FOR ACCESS TO EMERGENCY ROOM
5 CARE AND ANY AVAILABLE EDUCATIONAL MATERIAL REGARDING PROPER
6 USE OF EMERGENCY SERVICES;
7 (k) A DESCRIPTION OF WHETHER BENEFITS ARE PROVIDED FOR
8 EXPERIMENTAL TREATMENTS, INVESTIGATIONAL TREATMENTS, OR
9 CLINICAL TRIALS, AND THE CIRCUMSTANCES UNDER WHICH ACCESS TO
10 SUCH TREATMENTS OR TRIALS IS MADE AVAILABLE;
11 (l) A DESCRIPTION OF THE SPECIFIC PREVENTIVE SERVICES
12 COVERED UNDER THE HEALTH BENEFIT PLAN IF ANY SUCH HEALTH CARE
13 SERVICES ARE COVERED;
14 (m) A STATEMENT THAT THE FOLLOWING INFORMATION OR
15 INSTRUCTIONS ON OBTAINING SUCH INFORMATION, INCLUDING TELEPHONE
16 NUMBERS AND, IF AVAILABLE, INTERNET WEBSITES, SHALL BE MADE
17 AVAILABLE UPON REQUEST:
18 (I) THE NAMES, ADDRESSES, TELEPHONE NUMBERS, AND STATE
19 LICENSURE STATUS OF THE HEALTH BENEFIT PLAN'S PARTICIPATING
20 PROVIDERS AND PARTICIPATING HEALTH CARE FACILITIES, AND, IF
21 AVAILABLE, THE EDUCATION, TRAINING, SPECIALITY QUALIFICATIONS, OR
22 CERTIFICATIONS OF SUCH PROVIDERS;
23 (II) A SUMMARY DESCRIPTION OF THE METHODS USED FOR
24 COMPENSATING PARTICIPATING PROVIDERS, SUCH AS CAPITATION,
25 FEE-FOR-SERVICE, SALARY, OR A COMBINATION THEREOF. THE
26 REQUIREMENT OF THIS SUBPARAGRAPH (II) SHALL NOT BE CONSTRUED AS
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1 REQUIRING PLANS TO PROVIDE INFORMATION CONCERNING PROPRIETARY
2 PAYMENT METHODOLOGY.
3 10-16-130. Ombudsman program - creation. (1) THERE IS
4 HEREBY ESTABLISHED IN THE DEPARTMENT OF PUBLIC HEALTH AND
5 ENVIRONMENT A STATE HEALTH INSURANCE CARE OMBUDSMAN PROGRAM,
6 REFERRED TO IN THIS SECTION AS THE "PROGRAM". THE PROGRAM SHALL
7 BE OPERATED BY THE DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
8 DIRECTLY OR BY CONTRACT WITH OR GRANT TO ANY PUBLIC AGENCY OR
9 OTHER APPROPRIATE PRIVATE NONPROFIT ORGANIZATION; EXCEPT THAT
10 SUCH PROGRAM SHALL NOT BE OPERATED BY ANY AGENCY OR
11 ORGANIZATION RESPONSIBLE FOR LICENSING OR CERTIFYING HEALTH
12 INSURANCE COMPANIES IN THE STATE. THE PROGRAM SHALL BE
13 ADMINISTERED BY A FULL-TIME QUALIFIED STATE HEALTH INSURANCE
14 OMBUDSMAN WHO SHALL BE DESIGNATED IN ACCORDANCE WITH RULES
15 PROMULGATED BY THE STATE BOARD OF HEALTH CREATED IN SECTION
16 25-1-103, C.R.S.
17 (2) IN ADDITION TO ANY OTHER DUTIES ASSIGNED TO THE PROGRAM
18 BY RULE OF THE STATE BOARD OF HEALTH, THE PROGRAM SHALL HAVE THE
19 FOLLOWING DUTIES:
20 (a) TO ASSIST CONSUMERS IN THE STATE IN CHOOSING AMONG
21 HEALTH BENEFIT PLANS OR AMONG HEALTH BENEFIT PLAN OPTIONS
22 OFFERED BY THE SAME CARRIER; AND
23 (b) TO PROVIDE COUNSELING AND ASSISTANCE TO COVERED
24 PERSONS AND ENROLLEES DISSATISFIED WITH THEIR HEALTH CARE
25 SERVICES BY PROVIDERS IN REGARD TO SUCH HEALTH BENEFIT PLANS AND
26 WITH RESPECT TO GRIEVANCES AND APPEALS REGARDING
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1 DETERMINATIONS UNDER SUCH HEALTH BENEFIT PLANS.
2 (3) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO PREVENT
3 THE USE OF OTHER FORMS OF ASSISTANCE TO COVERED PERSONS OR
4 ENROLLEES.
5 10-16-131. Quality standards. (1) A CARRIER THAT OFFERS A
6 HEALTH BENEFIT PLAN SHALL ESTABLISH AND MAINTAIN AN ONGOING,
7 INTERNAL QUALITY ASSURANCE PROGRAM THAT MEETS THE FOLLOWING
8 REQUIREMENTS:
9 (a) THE CARRIER HAS A SEPARATE IDENTIFIABLE UNIT WITH
10 RESPONSIBILITY FOR ADMINISTRATION OF THE QUALITY ASSURANCE
11 PROGRAM;
12 (b) THE CARRIER HAS A WRITTEN PLAN FOR THE QUALITY
13 ASSURANCE PROGRAM THAT IS UPDATED ANNUALLY AND THAT SPECIFIES,
14 AT A MINIMUM, THE FOLLOWING:
15 (I) THE QUALITY ASSURANCE ACTIVITIES TO BE CONDUCTED;
16 (II) THE QUALITY ASSURANCE PROGRAM'S ORGANIZATIONAL
17 STRUCTURE;
18 (III) THE DUTIES OF THE DIRECTOR OF THE QUALITY ASSURANCE
19 PROGRAM; AND
20 (IV) THE CRITERIA AND PROCEDURES FOR THE ASSESSMENT OF
21 QUALITY;
22 (c) THE QUALITY ASSURANCE PROGRAM PROVIDES FOR
23 SYSTEMATIC REVIEW OF THE TYPE OF HEALTH CARE SERVICES PROVIDED,
24 CONSISTENCY OF HEALTH CARE SERVICES PROVIDED WITH GOOD MEDICAL
25 PRACTICE, AND PATIENT OUTCOMES;
26 (d) THE QUALITY ASSURANCE PROGRAM:
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1 (I) USES CRITERIA BASED ON MEASURED PROVIDER PERFORMANCE
2 AND PATIENT OUTCOMES WHERE FEASIBLE AND APPROPRIATE;
3 (II) INCLUDES CRITERIA THAT ARE DIRECTED SPECIFICALLY AT
4 MEETING THE NEEDS OF AT-RISK POPULATIONS AND COVERED PERSONS
5 AND ENROLLEES WITH CHRONIC CONDITIONS OR SEVERE ILLNESSES,
6 INCLUDING GENDER-SPECIFIC CRITERIA AND PEDIATRIC-SPECIFIC CRITERIA
7 WHERE AVAILABLE AND APPROPRIATE;
8 (III) INCLUDES METHODS FOR INFORMING COVERED PERSONS AND
9 ENROLLEES OF THE BENEFIT OF PREVENTIVE CARE AND WHAT SPECIFIC
10 BENEFITS WITH RESPECT TO PREVENTIVE CARE ARE COVERED UNDER THE
11 HEALTH BENEFIT PLAN; AND
12 (IV) MAKES AVAILABLE TO THE PUBLIC A DESCRIPTION OF THE
13 CRITERIA USED UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH (d);
14 (e) THE QUALITY ASSURANCE PROGRAM HAS PROCEDURES FOR THE
15 REPORTING OF POSSIBLE QUALITY CONCERNS BY PROVIDERS, COVERED
16 PERSONS, AND ENROLLEES AND FOR REMEDIAL ACTIONS TO CORRECT
17 QUALITY PROBLEMS, INCLUDING WRITTEN PROCEDURES FOR RESPONDING
18 TO CONCERNS AND TAKING APPROPRIATE CORRECTIVE ACTION;
19 (f) THE QUALITY ASSURANCE PROGRAM PROVIDES FOR AN
20 ANALYSIS OF THE CARRIER'S PERFORMANCE ON QUALITY MEASURES USING
21 DATA THAT INCLUDE MEASURED PROVIDER PERFORMANCE AND PATIENT
22 OUTCOME DATA COLLECTED UNDER SECTION 10-16-131.
23 10-16-132. Internal and external appeals process. (1) A
24 CARRIER, IN CONNECTION WITH THE PROVISION OF A HEALTH BENEFIT
25 PLAN, SHALL ESTABLISH AND MAINTAIN A GRIEVANCE SYSTEM, REFERRED
26 TO IN THIS SECTION AS THE "SYSTEM", TO PROVIDE FOR THE PRESENTATION
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1 AND RESOLUTION OF ORAL AND WRITTEN GRIEVANCES BROUGHT BY A
2 COVERED PERSON OR ENROLLEE, AN INDIVIDUAL ACTING ON BEHALF OF A
3 COVERED PERSON OR ENROLLEE WITH THE COVERED PERSON'S OR
4 ENROLLEE'S CONSENT, OR A PROVIDER REGARDING ANY ASPECT OF THE
5 CARRIER'S SERVICES.
6 (2) THE SYSTEM SHALL ADDRESS, BUT NOT BE LIMITED TO,
7 GRIEVANCES REGARDING ACCESS TO AND AVAILABILITY OF HEALTH CARE
8 SERVICES, QUALITY OF CARE, CHOICE AND ACCESSIBILITY OF PROVIDERS,
9 NETWORK ADEQUACY, AND COMPLIANCE WITH THE REQUIREMENTS OF THIS
10 ARTICLE.
11 (3) THE SYSTEM SHALL INCLUDE THE FOLLOWING COMPONENTS
12 WITH RESPECT TO COVERED PERSONS AND ENROLLEES:
13 (a) WRITTEN NOTIFICATION TO ALL SUCH COVERED PERSONS,
14 ENROLLEES, AND PROVIDERS OF THE TELEPHONE NUMBERS AND BUSINESS
15 ADDRESSES OF THE CARRIER PERSONNEL RESPONSIBLE FOR RESOLUTION OF
16 GRIEVANCES AND APPEALS;
17 (b) A SYSTEM TO RECORD AND DOCUMENT, OVER A PERIOD OF AT
18 LEAST THREE PREVIOUS YEARS, ALL GRIEVANCES AND APPEALS BROUGHT
19 AND THEIR STATUS;
20 (c) A PROCESS PROVIDING FOR TIMELY PROCESSING AND
21 RESOLUTION OF GRIEVANCES;
22 (d) PROCEDURES FOR FOLLOW-UP ACTION, INCLUDING THE
23 METHODS TO INFORM THE COVERED PERSON OR ENROLLEE BRINGING THE
24 GRIEVANCE OF THE RESOLUTION OF THE GRIEVANCE;
25 (e) NOTIFICATION TO THE QUALITY ASSURANCE PROGRAM
26 ESTABLISHED IN SECTION 10-16-131 OF ALL GRIEVANCES AND APPEALS
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1 RELATING TO QUALITY OF CARE.
2 (4) A COVERED PERSON OR ENROLLEE, AN INDIVIDUAL ACTING ON
3 BEHALF OF A COVERED PERSON OR ENROLLEE WITH THE COVERED
4 PERSON'S OR ENROLLEE'S CONSENT, OR ANY PROVIDER MAY APPEAL ANY
5 APPEALABLE DECISION UNDER THE PROCEDURES DESCRIBED IN THIS
6 SECTION. SUCH COVERED PERSONS, ENROLLEES, INDIVIDUALS, AND
7 PROVIDERS SHALL BE PROVIDED WITH A WRITTEN EXPLANATION OF THE
8 APPEALS PROCESS AND THE OUTCOME OF THE APPEAL UPON THE
9 CONCLUSION OF THE APPEALS PROCESS.
10 (5) (a) EACH CARRIER SHALL ESTABLISH AND MAINTAIN AN
11 INTERNAL APPEALS PROCESS UNDER WHICH ANY COVERED PERSON OR
12 ENROLLEE, INDIVIDUAL ACTING ON BEHALF OF A COVERED PERSON OR
13 ENROLLEE WITH THE COVERED PERSON'S OR ENROLLEE'S CONSENT, OR
14 PROVIDER WHO IS DISSATISFIED WITH ANY APPEALABLE DECISION HAS THE
15 OPPORTUNITY TO APPEAL THE APPEALABLE DECISION. THE NOTICE OF
16 INTERNAL APPEAL MAY BE COMMUNICATED ORALLY TO THE CARRIER.
17 (b) THE INTERNAL APPEALS PROCESS SHALL INCLUDE A REVIEW OF
18 THE APPEALABLE DECISION BY AT LEAST ONE PHYSICIAN OR OTHER
19 PROVIDER WHO HAS BEEN SELECTED BY THE CARRIER AND WHO HAS NOT
20 BEEN INVOLVED IN THE APPEALABLE DECISION AT ISSUE IN THE INTERNAL
21 APPEAL.
22 (c) THE CARRIER SHALL CONCLUDE EACH INTERNAL APPEAL AS
23 SOON AS POSSIBLE AFTER RECEIPT OF THE INTERNAL APPEAL IN
24 ACCORDANCE WITH MEDICAL EXIGENCIES OF THE CASE INVOLVED, BUT IN
25 NO EVENT LATER THAN:
26 (I) SEVENTY-TWO HOURS AFTER RECEIPT OF AN EMERGENCY
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1 APPEAL; OR
2 (II) FIFTEEN BUSINESS DAYS AFTER RECEIPT OF AN INTERNAL
3 APPEAL IN THE CASE OF ALL OTHER APPEALS.
4 (6) (a) A CARRIER OFFERING A HEALTH BENEFIT PLAN SHALL
5 PROVIDE FOR AN EXTERNAL APPEALS PROCESS THAT MEETS THE
6 REQUIREMENTS OF THIS SUBSECTION (6) IN THE CASE OF AN EXTERNALLY
7 APPEALABLE DECISION.
8 (b) A CARRIER MAY CONDITION THE USE OF AN EXTERNAL APPEALS
9 PROCESS IN THE CASE OF AN EXTERNALLY APPEALABLE DECISION UPON
10 COMPLETION OF THE INTERNAL APPEALS PROCESS PROVIDED UNDER
11 SUBSECTION (5) OF THIS SECTION, BUT ONLY IF THE INTERNAL APPEALS
12 DECISION IS MADE ON A TIMELY BASIS CONSISTENT WITH THE DEADLINES
13 PROVIDED UNDER PARAGRAPH (c) OF SUBSECTION (5) OF THIS SECTION.
14 (c) (I) THE EXTERNAL APPEALS PROCESS OF A CARRIER SHALL BE
15 CONDUCTED UNDER A CONTRACT BETWEEN THE CARRIER AND ONE OR
16 MORE QUALIFIED EXTERNAL APPEAL ENTITIES, AS SET FORTH IN
17 SUBPARAGRAPH (II) OF THIS PARAGRAPH (c).
18 (II) THE DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT MAY
19 PROVIDE FOR THE EXTERNAL APPEALS PROCESS TO BE CONDUCTED BY A
20 QUALIFIED EXTERNAL APPEAL ENTITY THAT IS DESIGNATED BY THE
21 COMMISSIONER OR THAT IS SELECTED BY THE COMMISSIONER IN SUCH A
22 MANNER AS TO ASSURE AN UNBIASED DETERMINATION.
23 10-16-133. Communications between provider and patient.
24 (1) THE PROVISIONS OF ANY CONTRACT OR AGREEMENT, OR THE
25 OPERATION OF ANY CONTRACT OR AGREEMENT, BETWEEN A CARRIER IN
26 RELATION TO A HEALTH BENEFIT PLAN, INCLUDING ANY PARTNERSHIP,
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1 ASSOCIATION, OR OTHER ORGANIZATION THAT ENTERS INTO OR
2 ADMINISTERS SUCH A CONTRACT OR AGREEMENT, AND A PROVIDER OR
3 GROUP OF PROVIDERS SHALL NOT PROHIBIT OR RESTRICT THE PROVIDER
4 FROM ENGAGING IN MEDICAL COMMUNICATIONS WITH THE PROVIDER'S
5 PATIENT.
6 (2) ANY CONTRACT PROVISION OR AGREEMENT PROHIBITING OR
7 RESTRICTING THE PROVIDER FROM ENGAGING IN MEDICAL
8 COMMUNICATIONS WITH THE PROVIDER'S PATIENT AS DESCRIBED IN
9 SUBSECTION (1) OF THIS SECTION SHALL BE NULL AND VOID.
10 (3) NOTHING IN THIS SECTION SHALL BE CONSTRUED:
11 (a) TO PROHIBIT THE ENFORCEMENT, AS PART OF A CONTRACT OR
12 AGREEMENT TO WHICH A PROVIDER IS A PARTY, OF ANY MUTUALLY
13 AGREED UPON TERMS AND CONDITIONS, INCLUDING TERMS AND
14 CONDITIONS REQUIRING A PROVIDER TO PARTICIPATE IN AND COOPERATE
15 WITH ALL PROGRAMS, POLICIES, AND PROCEDURES DEVELOPED OR
16 OPERATED BY A CARRIER TO ASSURE, REVIEW, OR IMPROVE THE QUALITY
17 AND EFFECTIVE UTILIZATION OF HEALTH CARE SERVICES, IF SUCH
18 UTILIZATION IS ACCORDING TO GUIDELINES OR PROTOCOLS THAT ARE
19 BASED ON CLINICAL OR SCIENTIFIC EVIDENCE AND THE PROFESSIONAL
20 JUDGMENT OF THE PROVIDER, BUT ONLY IF THE GUIDELINES OR PROTOCOLS
21 UNDER SUCH UTILIZATION DO NOT PROHIBIT OR RESTRICT MEDICAL
22 COMMUNICATIONS BETWEEN PROVIDERS AND THEIR PATIENTS; OR
23 (b) TO PERMIT A PROVIDER TO MISREPRESENT THE SCOPE OF
24 BENEFITS COVERED UNDER THE HEALTH BENEFIT PLAN OR TO OTHERWISE
25 REQUIRE A CARRIER TO REIMBURSE PROVIDERS FOR HEALTH CARE
26 SERVICES NOT COVERED UNDER THE HEALTH BENEFIT PLAN.
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1 10-16-134. Liability of carrier. (1) NO CONTRACT OR
2 AGREEMENT BETWEEN A CARRIER OR ANY AGENT ACTING ON BEHALF OF A
3 CARRIER AND A PROVIDER SHALL CONTAIN ANY PROVISION PURPORTING TO
4 TRANSFER TO THE PROVIDER BY INDEMNIFICATION OR OTHERWISE ANY
5 LIABILITY RELATING TO ACTIVITIES, ACTIONS, OR OMISSIONS OF THE
6 CARRIER OR AGENT AS OPPOSED TO THE PROVIDER.
7 (2) ANY CONTRACT PROVISION OR AGREEMENT PURPORTING TO
8 TRANSFER TO THE PROVIDER ANY LIABILITY AS DESCRIBED IN SUBSECTION
9 (1) OF THIS SECTION SHALL BE NULL AND VOID.
10 10-16-135. Agreements between carriers and providers. (1) IF
11 A CARRIER OFFERS A HEALTH BENEFIT PLAN THAT PROVIDES BENEFITS
12 THROUGH PARTICIPATING PROVIDERS, THE CARRIER SHALL ESTABLISH
13 REASONABLE PROCEDURES RELATING TO THE PARTICIPATION UNDER
14 AGREEMENTS BETWEEN PROVIDERS AND THE CARRIER. SUCH PROCEDURES
15 SHALL INCLUDE:
16 (a) PROVIDING NOTICE OF THE RULES REGARDING PARTICIPATION;
17 (b) PROVIDING WRITTEN NOTICE OF PARTICIPATION DECISIONS
18 THAT ARE ADVERSE TO PROVIDERS; AND
19 (c) A PROCESS BY WHICH PROVIDERS MAY APPEAL SUCH ADVERSE
20 DECISIONS, INCLUDING THE PRESENTATION OF INFORMATION AND VIEWS
21 OF THE PROVIDER REGARDING SUCH DECISION.
22 (2) A CARRIER THAT OFFERS A HEALTH BENEFIT PLAN SHALL
23 CONSULT WITH PARTICIPATING PHYSICIANS, IF ANY, REGARDING THE
24 CARRIER'S MEDICAL POLICY, QUALITY, AND MEDICAL MANAGEMENT
25 PROCEDURES.
26 SECTION 2. Effective date - applicability. This act shall take
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1 effect July 1, 1999, and shall apply to health benefit plan policies and
2 contracts entered into or renewed on or after said date.
3 SECTION 3. Safety clause. The general assembly hereby finds,
4 determines, and declares that this act is necessary for the|~ immediate
|~ 5 preservation of the public peace, health, and safety.