COMMITTEE ON COMMERCE
HOUSE OF REPRESENTATIVES AMENDMENTS TO H.B. 2599
(Reference to printed bill)
Page 1, line 8, after the second "service" strike remainder of line
Line 9, strike "PART,"; after "SERVICE" insert ", in whole or in part,"
Line 10, strike "or" insert "or"
Line 14, strike "OF COVERAGE"
Line 33, after "provided" strike remainder of line
Line 34, strike "which no minimum dollar amount may be imposed"
Page 2, line 5, strike "OF COVERAGE"
Line 15, after "FINAL" insert "internal"
Line 16, strike "BY THE HEALTH CARE INSURER" insert ", in whole or in part,"; after the second "THE" insert "HEALTH CARE INSURER’S"
Line 17, strike "APPEALS PROCESS" insert "LEVELS OF REVIEW"; strike "THAT HAS" insert "AN ADVERSE DETERMINATION WITH RESPECT TO WHICH THE INTERNAL LEVELS OF REVIEW have"
Between lines 17 and 18, insert:
"7. "Grandfathered individual plan" means coverage provided by an individual health care insurer which was purchased before March 23, 2010 and which has not lost such status due to changes in benefits."
Renumber to conform
Between lines 23 and 24, insert:
Renumber to conform
Page 2, line 26, strike "ten business days" insert "the prescribed time frames pursuant to 20-3404"
Line 28, strike "LEVEL" insert "levels"
Line 31, after "INITIAL" insert "internal"
Page 3, strike lines 22 through 43
Renumber to conform
Page 4, line 7, strike "adverse"
Page 6, line 5, after "A." insert "No minimum dollar amount may be imposed on any claim that is the subject of an adverse determination for a member to, and"
Line 6, after "may" insert a comma
Line 20, after the comma insert "and for grandfathered individual plans,"
Line 26, strike "FOR AN"
Line 27, strike "ADVERSE DETERMINATION, PROVIDE" insert "that has already been provided, send"; strike "WITH"
Line 30, strike ", PROVIDE" insert "that has already been provided, send"; strike "WITH"
Line 34, strike "INSURERS" insert "insurer’s"
Line 35, after "SERVICE" strike remainder of line
Line 36, strike "ADVERSE DETERMINATION, PROVIDE" insert "that has already been provided, send"; strike "WITH"
Line 37, after "AFTER" insert "the health care insurer receives"
Line 40, strike ", PROVIDE" insert "that has already been provided, send"; strike "WITH"
Page 7, line 33, after "each" insert "applicable"
Page 8, line 44, strike "is" insert "involves"
Line 45, after the first "OR" insert "appropriateness, including health care setting, level of care or effectiveness of a covered benefit, or"
Page 9, line 2, strike "INTERNAL" insert "initial"
Page 9, line 4, strike "is" insert "involves"; after "necessity" insert "or appropriateness, including health care setting, level of care or effectiveness of a covered benefit,"
Line 11, after "FINAL" insert "internal"
Line 16, after "RESPOND" insert "within the applicable time frames for the health care insurer to provide the member with a written determination prescribed in subsections c and d of this section"
Line 43, strike "one business day" insert "seventy-two hours"
Page 10, line 2, strike "is" insert "involves"
Line 3, after "necessity" insert "or appropriateness, including health care setting, level of care or effectiveness of a covered benefit,"
Line 7, after "14," insert "16,"; after "19" insert ", 19.1"
Line 29, strike "is" insert "involves" ; after "necessity" insert "or appropriateness, including health care setting, level of care or effectiveness of a covered benefit,"
Line 31, after "covered," strike remainder of line
Strike lines 32 through 43
Line 44, strike "to the requirements of this subsection,"
Line 45, strike "the" insert "a"; strike ", physician or other health care professional"
Page 11, line 1, after "DETERMINATION" insert "based on the utilization review plan adopted by the utilization review agent"
Line 2, strike the first comma insert "OR"; strike ", physician or other health care"
Line 3, strike "professional"
Line 7, after the period insert: "for the purposes of this subsection, "provider" means either of the following:
1. A physician or other health care professional who is licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29, who is qualified in a similar scope of practice as a physician or other health care professional licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 and who is employed or under contract with the utilization review agent.
2. An out-of-state physician or other health care professional who is licensed in another state and who is not licensed in this state, who is employed or under contract with the utilization review agent and who either is qualified in a similar scope of practice as a physician or other health care professional licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or who typically manages the medical condition under appeal."
Page 11, line 15 and 16, strike "is denied a service OR WHOSE CLAIM FOR A SERVICE THAT HAS ALREADY BEEN PROVIDED IS DENIED" insert "receives an adverse determination"
Strike lines 28 through 31
Reletter to conform
Line 35, strike "IS" insert "involves"
Line 44, after "PHYSICIAN" insert "or other health care professional licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29"
Line 45, after "EMPLOYED" insert "OR"
Page 12, line 3, after "WHO" insert "either is qualified in a similar scope of practice as a physician or other health care professional licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or who"
Line 22, strike "E F" insert "E"
Line 31, after "PLAN" insert "or grandfathered individual plan"
Line 34, strike "MEMBER" insert "health care insurer"
Line 42, after the comma insert "or a grandfathered individual plan,"
Line 43, after "VOLUNTARY" insert "internal"
Page 13, line 2, after "VOLUNTARY" insert "internal"
Strike lines 9 through 11
Reletter to conform
Line 16, strike "is" insert "involves"
Line 20, after "covered," strike remainder of line
Page 13, strike lines 21 through 32
Line 33, strike "this subsection,"; strike the second "the" insert "a"; strike the second comma
Line 34, strike "physician or other health care professional who shall" insert "to"
Line 35, strike "the" insert "a"; after "DETERMINATION" insert "based on the utilization review plan adopted by the utilization review agent. For the purposes of this subsection, "provider" means either of the following:
1. A physician or other health care professional who is licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29, who is qualified in a similar scope of practice as a physician or other health care professional licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 and who is employed under contract with the utilization review agent.
2. An out-of-state physician or other health care professional who is licensed in another state and who is not licensed in this state, who is employed or under contract with the utilization review agent and who either is qualified in a similar scope of practice as a physician or other health care professional Licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or who typically manages the medical condition under appeal"
Page 14, line 9, strike "E" insert "D"
Page 15, line 12, strike "decision" insert "determination"
Line 18, strike "J" insert "L"
Lines 22 and 34, after "necessity" insert "or appropriateness, including health care setting, level of care or effectiveness of a covered benefit, or is experimental or investigational"
Line 40, after "necessary" insert "or appropriate, including health care setting, level of care or effectiveness of a covered benefit, or is experimental or investigational"
Page 16, line 7, after "g." strike remainder of line
Page 16, strike lines 8 through 11
Line 12, strike "A DETERMINATION THAT IS" insert "The independent review organization’s determination pursuant to subsection f of this section shall be"
Line 13, strike "SEND A COPY OF THE DETERMINATION TO THE DIRECTOR"
Between lines 21 and 22, insert:
"(e) For claims or requests for services denied for reasons other than as experimental or investigational, the independent review organization shall also consider:
"(i) The most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by the federal government, national or professional medical societies, boards and associations.
(ii) Any applicable clinical review criteria developed and used by the health carrier or its designee utilization review organization.
(iii) The opinion of the independent review organization’s clinical reviewer or reviewers after considering subdivisions (a) through (d) and subdivision (e), items (i) and (ii) of this paragraph to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate."
Reletter to conform
Page 16, line 22, after "(e)" insert "For claims or requests for services denied as experimental or investigational, the independent review organization shall also consider"
Page 17, line 2, strike "(d)" insert "(e), items (i) and (ii)"
Page 18, line 5, strike "PROVIDERS" insert "provider"; after the second "OR" insert "if"
Page 18, line 17, strike "A MATTER" insert "an adverse determination"
Line 18, strike DETERMINATION" insert "service"
Line 20, strike "THAT"
Line 36, strike "RATIONAL" insert "rationale"
Page 19, line 18, strike "decision" insert "determination"
Amend title to conform