managed care accountability
act
HB 2600 makes numerous changes to statutes governing managed health care plans relating to health care services oversight, the medical decision making process, medical directors, standing referrals, the expedited review process, prescription formularies, anti-retaliation, financial incentives, liability, timely payment of claims, chiropractic care, continuity of care, off-label use of prescription drugs for cancer treatment, third party intermediaries and advertisements.
· Any denial by a health care service organization of a doctor prescribed treatment decision shall be made by a medical director who holds a license to practice medicine in Arizona. All denials made on the basis of a medical necessity determination shall be made in writing and contain an explanation of why the treatment was denied. Copies of all written denials shall be maintained by the health care service organization and be made available for review by the Department of Insurance.
· Health care plans shall develop procedures for which an enrollee with a chronic condition needing ongoing care from a specialist shall receive a standing referral to such a specialist.
·
An expedited review must occur when the treating
physician certifies that a delay is likely to cause harm to the patient. Under current law, the expedited review
process saves the enrollee from going through the informal review step, but
still subjects the enrollee to formal appeal which can take up to 30 days. The 30 day formal review process has been
replaced by a three day formal review process.
If the service is still denied, the appeal goes immediately to external
review at the Department of Insurance.
·
Establishes a three day expedited external independent
review.
PRESCRIPTION FORMULARIES
· Health care plans shall maintain a process by which providers may obtain authorization for a medically necessary non-formulary drug.
· A health care plan shall approve a health care provider’s request for a non-formulary drug if either one of the following conditions is met: (1) the formulary’s equivalent has been ineffective in treatment of the enrollee’s condition or (2) the formulary drug has caused an adverse or harmful reactions in the enrollee.
· Copies of all written denials shall be maintained by the health care service organization and be made available for review by the Department of Insurance.
· Until an enrollee has been notified by the health care plan or pharmacy that there has been a change in the plan formulary, a health care plan shall not limit or exclude coverage for a prescription refill for at least 60 days if the drug previously had been approved and the provider continues to prescribe the drug.
ANTI RETALIATION RULE
· Health care plans are prohibited from terminating a provider contract or refusing to renew a contract on the basis that a provider advocates on behalf of a patient.
· Contracts shall not contain financial incentive plans that are an inducement to deny, reduce, limit or delay medically necessary care.
· Health care service organizations shall provide benefits covering care by network chiropractic providers for at least twelve chiropractic visits in a contract period.
· Chiropractic services includes nonsurgical and noninvasive treatment of neck and back pain through physiotherapy, musculoskeletal manipulation and other physical corrections of musculoskeletal conditions within the scope of the chiropractic practice.
· Health care plans shall allow an enrollee to continue an active course of treatment with his/her health care provider for a transitional period if the enrollee has either: (1) a life threatening disease or condition in which case the transitional period is not more than 30 days, or (2) the enrollee has entered into the third trimester of pregnancy in which case the transitional period includes the delivery and care up to six weeks after delivery.
· In the event that a drug is on a plan formulary for the treatment of one form of cancer, that drug may be used to treat another form of cancer if the medical literature recognizes that drug as a safe and effective treatment for that cancer.
· Health care plans shall not contract with a risk bearing third party intermediary without the third party intermediary posting a dynamic bond in the amount of two months annualized revenue.
· Third party intermediaries shall maintain a deposit to be held in trust for the protection of insureds, health care providers and health care insurers whose monies the intermediary handles.
· The amount of the surety bond is payable on the failure of the intermediary to pay benefits it is legally obligated to pay.
· Prohibits the Director from releasing a cash deposit or bond unless the surety files a written notice of termination with the Director at least 30 days before terminating the bond.
· Establishes time frames for the payment of claims to health care providers.
· Health care plans shall pay interest at the legal rate (10 per cent) for late payment on approved claims.
·
The Department of Insurance may track late payments to
providers for the purpose of determining whether or not the health care plan
may be having financial problems.
· Health care plans are required to maintain an internal system for resolving disputes.
ADVERTISEMENTS
· HB 2600 removes the requirement that the Department of Insurance pre-authorize all advertising and sales material before a health care plan can distribute the material.
· Health care plans shall not issue or deliver advertising or sales material until the material has been filed with the Department of Insurance.
· In the event that the Director of the Department of Insurance finds that the advertising or sales material is false, misleading or deceptive, the Director may order that the health care service organization stop distribution of the misleading information and/or assess penalties pursuant to Title 20.
· Specifies that a health care insurer shall have a five day period to cure any deficiency in the advertising matter or sales material.
·
HB
2600 establishes the right to sue a health care insurer for damages caused to
an enrollee by the insurer’s delay in authorizing or failure to authorize a
request for a covered service that is medically necessary or by the insurer’s
denial of payment of benefits covered under the health care plan if the health
care insurer acted in bad faith.
·
Requires
that the enrollee either complete the health care appeals process or provide
written notice setting forth the basis for the suit to the health care insurer
at least 30 days prior to filing an action.
·
Excludes
an employer or employer organization from liability.
·
States
that a health care insurer is not liable for harm attributable to a health care
provider.
· Adds specific language to be included in any information sent to an enrollee regarding the status of a bill. The specific language clarifies that the information is not a bill and shall be prominently displayed at the top of the page. Violation of this section shall lead to a fine no less than three times the amount of the provider or hospital charges at issue.
· Requires DOI to investigate and enforce complaints of billing for covered health care services.