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ARIZONA HOUSE OF REPRESENTATIVESFifty-fourth Legislature Second Regular Session |
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HB 2628: health care insurance; amendments
Sponsor: Representative Bolick, LD 20
Committee on Commerce
Overview
Makes various changes to statute governing Health Care Insurers.
History
Hospital, medical, dental and optometric service corporations is defined as corporations organized under the laws of this state for the purpose of establishing, maintaining and operating nonprofit hospital service or medical or dental or optometric service plans, or a combination of such plans, whereby hospital, medical or dental or optometric service may be provided by hospitals, physicians, podiatrists, dentists or optometrists with which the corporations have contracted for such purpose (A.R.S. § 20-822).
Health care services organization means any person that undertakes to conduct one or more health care plans. Unless the context otherwise requires, health care services organization includes a provider sponsored health care services organization (A.R.S. § 20-1051).
Utilization review means a system for reviewing the appropriate and efficient allocation of inpatient hospital resources, inpatient medical services and outpatient surgery services that are being given or are proposed to be given to a patient, and of any medical, surgical and health care services or claims for services that may be covered by a health care insurer depending on determinable contingencies, including without limitation outpatient services, in-office consultations with medical specialists, specialized diagnostic testing, mental health services, emergency care and inpatient and outpatient hospital services (A.R.S. § 20-2501).
Provisions
Hospital, Medical, Dental, and Optometric Service Organizations
1. Specifies laws governing insurance company holding systems applies to all service corporations. (Sec. 5)
2. Allows a corporation to pay any officer or employee any salary, compensation or emolument without authorization from the board of directors of the corporation. (Sec. 6)
3. Removes language prohibiting a corporation from influencing the subscriber in their choice of hospital, physician, registered nurse, dentist or optometrist. (Sec. 7)
4. Removes language requiring a hospital and medical service corporation to pay AHCCCS for paid covered items or services. (Sec. 8)
Health Care Services Organizations
5. Removes language outlining prohibited practices by a person. (Sec. 9)
6. Removes language requiring a health care services organization to pay AHCCCS for paid covered items or services. (Sec. 10)
7. Requires a health care services organization to semiannually, rather than monthly, submit a report to the Department of Insurance (DOI) a list of all major provider contracts that have been terminated during the previous six months.
a) Defines major provider. (Sec. 11)
Disability and Group and Blanket Disability Insurers
8. Removes language requiring an insurer to pay AHCCCS for paid covered items or services. (Sec. 12, 13)
Group Health Plan
9. Removes language requiring a health care services organization to pay AHCCCS for paid covered items or services. (Sec. 14)
Accountable Health Plans
10. Makes a conforming change. (Sec. 15)
11. Modifies the definition of creditable coverage. (Sec. 15)
12. Specifies statute governing premium rates does not apply if a small employer obtains a health benefits plan that is complies with federal law. (Sec. 16)
13. Repeals laws relating to prohibited mandatory coverage of a basic health benefit plan and an accountable health plan submission of claims by electronic means. (Sec. 17)
Utilization Review
14. Exempts a person from specified laws relating to certification requirements provided certain criteria are met. (Sec. 18)
15. Allows a provider or enrollee to appeal a denial of a formulary exception for a plan covered by federal law through the process prescribed in the federal rule. (Sec. 19)
16. Requires a utilization review agent to file a specified notice regardless if the agent is exempt from certification requirements. (Sec. 20)
17. Requires a health care insurer to provide access to a copy of the information packet, which explains the appeal process, on the health care insurer's website rather than to the member. (Sec. 21)
18. Instructs a utilization review agent to telephonically provide and mail the member a notice of an adverse decision as well as providing the member a notice of a decision, including criteria used and clinical reasons for such decision. (Sec. 22)
19. Requires the DOI to adopt rules establishing criteria and factors to evaluate when determining whether an independent review organization has demonstrated bias toward a health care insurer or provider.
a) Instructs DOI to terminate the services of any biased organization. (Sec. 23)
Miscellaneous
20. Repeals laws relating to contracts and forms in effect prior to January 1, 1955. (Sec. 1)
21. Specifies the term person includes a service corporation and a health care services organization. (Sec. 2)
22. Clarifies the timely payment of a clean claim. (Sec. 3)
23. Specifies statute relating to assignment of benefits applies to a hospital and medical service corporation. (Sec. 4)
24. Instructs DOI to:
a) Adopt rules that substantially conform to the current version of the National Association of Insurance Commissioners Unfair Claim Settlement Practices Model Act; and
b) Amend the rules governing coordination of benefits. (Sec. 24)
25. Exempts DOI from rulemaking for one year. (Sec. 24)
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29. Initials PRB Commerce
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