Rep. Norm Thurston — Voting Record

Bill

Number

H.B. 315 Second Substitute (2018GS)

Sponsor

Rep. Greene, B.

Final action

House/ filed 3/8/2018

Outcome

Failed / filed without passage

Summary

What it does

• This bill:
• makes technical changes; and
• repeals an exclusion from preferred provider nondiscrimination provisions for athletic trainer services.

Every vote on this bill

Bill text

HEALTH INSURANCE ATHLETIC TRAINER SERVICES
AMENDMENTS
GENERAL SESSION
STATE OF UTAH
Chief Sponsor: Brian M. Greene
Senate Sponsor: 
____________
LONG TITLE
General Description:
This bill repeals an exclusion from preferred provider nondiscrimination provisions for
athletic trainer services.
Highlighted Provisions:
This bill:
▸ makes technical changes; and
▸ repeals an exclusion from preferred provider nondiscrimination provisions for
athletic trainer services.
Money Appropriated in this Bill:
None
Other Special Clauses:
None
Utah Code Sections Affected:
AMENDS:
31A-22-618.5
, as last amended by Laws of Utah 2017, Chapter 292
31A-27a-403
, as enacted by Laws of Utah 2007, Chapter 309
31A-45-303
, as last amended by Laws of Utah 2017, Chapter 168 and renumbered and
amended by Laws of Utah 2017, Chapter 292
Be it enacted by the Legislature of the state of Utah:
Section 1. Section 
31A-22-618.5
 is amended to read:
31A-22-618.5.
Coverage of insurance mandates imposed after January 1, 2009.
(1) The purpose of this section is to increase the range of health benefit plans available
in the small group, small employer group, large group, and individual insurance markets.
(2) A health maintenance organization that is subject to Chapter 8, Health Maintenance
Organizations and Limited Health Plans:
(a) shall offer to potential purchasers at least one health benefit plan that is subject to
the requirements of Chapter 8, Health Maintenance Organizations and Limited Health Plans;
and
(b) may offer to a potential purchaser one or more health benefit plans that:
(i) are not subject to one or more of the following:
(A) the limitations on insured indemnity benefits in Subsection 
31A-8-105
(4);
(B) except as provided in Subsection (2)(b)(ii), basic health care services as defined in
Section 
31A-8-101
; or
(C) coverage mandates enacted after January 1, 2009 that are not required by federal
law, provided that the insurer offers one plan under Subsection (2)(a) that covers the mandate
enacted after January 1, 2009; and
(ii) when offering a health plan under this section, provide coverage for an emergency
medical condition as required by Section 
31A-22-627
.
(3) An insurer that offers a health benefit plan that is not subject to Chapter 8, Health
Maintenance Organizations and Limited Health Plans:
(a) may offer a health benefit plan that is not subject to Section 
31A-22-618
 and
Subsection [
31A-45-303
(3)(b)(iii)
] 
31A-45-303
(4)
;
(b) when offering a health plan under this Subsection (3), shall provide coverage of
emergency care services as required by Section 
31A-22-627
; and
(c) is not subject to coverage mandates enacted after January 1, 2009 that are not
required by federal law, provided that an insurer offers one plan that covers a mandate enacted
after January 1, 2009.
(4) Section 
31A-8-106
 does not prohibit the offer of a health benefit plan under
Subsection (2)(b).
(5) (a) Any difference in price between a health benefit plan offered under Subsections
(2)(a) and (b) shall be based on actuarially sound data.
(b) Any difference in price between a health benefit plan offered under Subsection
(3)(a) shall be based on actuarially sound data.
(6) Nothing in this section limits the number of health benefit plans that an insurer may
offer.
Section 2. Section 
31A-27a-403
 is amended to read:
31A-27a-403.
Continuance of coverage -- Health maintenance organizations.
(1) As used in this section:
(a) "Basic health care services" [
is as
] 
means the same at that term is
 defined in Section
31A-8-101
.
[
(b) "Enrollee" is as defined in Section 
31A-8-101
.
]
[
(c)
] 
(b)
 "Health care" [
is as
] 
means the same at that term is
 defined in Section
31A-1-301
.
[
(d)
] 
(c)
 "Health maintenance organization" [
is as
] 
means the same at that term is
defined in Section 
31A-8-101
.
[
(e)
] 
(d)
 "Limited health plan" [
is as
] 
means the same at that term is
 defined in Section
31A-8-101
.
[
(f)
] 
(e)
 (i) "Managed care organization" means an entity licensed by, or holding a
certificate of authority from, the department to furnish health care services or health insurance.
(ii) "Managed care organization" includes:
(A) a limited health plan;
(B) a health maintenance organization;
(C) a preferred provider organization;
(D) a fraternal benefit society; or
(E) an entity similar to an entity described in Subsections (1)[
(f)
]
(e)
(ii)(A) through (D).
(iii) "Managed care organization" does not include:
(A) an insurer or other person that is eligible for membership in a guaranty association
under Chapter 28, Guaranty Associations;
(B) a mandatory state pooling plan;
(C) a mutual assessment company or an entity that operates on an assessment basis; or
(D) an entity similar to an entity described in Subsections (1)[
(f)
]
(e)
(iii)(A) through
(C).
[
(g)
] 
(f)
 "Participating provider" means a provider who, under a contract with a
managed care organization authorized under Section 
31A-8-407
, agrees to provide health care
services to enrollees with an expectation of receiving payment:
(i) directly or indirectly, from the managed care organization; and
(ii) other than a copayment.
[
(h)
] 
(g)
 "Participating provider contract" means the agreement between a participating
provider and a managed care organization authorized under Section 
31A-8-407
.
[
(i)
] 
(h)
 "Preferred provider" means a provider who agrees to provide health care
services under an agreement authorized under [
Subsection 
31A-22-617
(1)
] 
Section
31A-45-303
.
[
(j)
] 
(i)
 "Preferred provider contract" means the written agreement between a preferred
provider and a managed care organization authorized under [
Subsection 
31A-22-617
(1)
]
Section 
31A-45-303
.
[
(k)
] 
(j)
 (i) Except as provided in Subsection (1)[
(k)
]
(j)
(ii), "preferred provider
organization" means a person that:
(A) furnishes at a minimum, through a preferred provider, basic health care services to
an enrollee in return for prepaid periodic payments in an amount agreed to before the time
during which the health care may be furnished;
(B) is obligated to the enrollee to arrange for the services described in Subsection
(1)[
(k)
]
(j)
(i)(A); and
(C) permits the enrollee to obtain health care services from a provider who is not a
preferred provider.
(ii) "Preferred provider organization" does not include:
(A) an insurer licensed under Chapter 7, Nonprofit Health Service Insurance
Corporations; or
(B) an individual who contracts to render professional or personal services that the
individual performs.
[
(l)
] 
(k)
 "Provider" [
is as defined in Section 
31A-8-101
.
] 
means any person who:
(i) furnishes health care directly to the enrollee; and
(ii) is licensed or otherwise authorized to furnish the health care in this state.
[
(m)
] 
(l)
 "Uncovered expenditure" means a cost of health care services that is covered
by an organization for which an enrollee is liable in the event of the managed care
organization's insolvency.
(2) The rehabilitator or liquidator may take one or more of the actions described in
Subsections (2)(a) through (g) to assure continuation of health care coverage for enrollees of an
insolvent managed care organization.
(a) (i) Subject to Subsection (2)(a)(ii), a rehabilitator or liquidator may require a
participating provider or preferred provider to continue to provide the health care services the
provider is required to provide under the provider's participating provider contract or preferred
provider contract until the earlier of:
(A) 90 days after the day on which the following is filed:
(I) a petition for rehabilitation; or
(II) a petition for liquidation; or
(B) the day on which the term of the contract ends.
(ii) A requirement by the rehabilitator or liquidator under Subsection (2)(a)(i) that a
participating provider or preferred provider continue to provide health care services under the
provider's participating provider contract or preferred provider contract expires when health
care coverage for all enrollees of the insolvent managed care organization is obtained from
another managed care organization or insurer.
(b) (i) Subject to Subsection (2)(b)(ii), a rehabilitator or liquidator may reduce the fees
a participating provider or preferred provider is otherwise entitled to receive from the managed
care organization under the provider's participating provider contract or preferred provider
contract during the time period in Subsection (2)(a)(i).
(ii) Notwithstanding Subsection (2)(b)(i), a rehabilitator or liquidator may not reduce a
fee to less than 75% of the regular fee set forth in the provider's participating provider contract
or preferred provider contract.
(iii) An enrollee shall continue to pay the same copayments, deductibles, and other
payments for services received from a participating provider or preferred provider that the
enrollee is required to pay before the day on which the following is filed:
(A) the petition for rehabilitation; or
(B) the petition for liquidation.
(c) A participating provider or preferred provider shall:
(i) accept the amounts specified in Subsection (2)(b) as payment in full; and
(ii) relinquish the right to collect additional amounts from the insolvent managed care
organization's enrollee.
(d) Subsections (2)(b) and (c) apply to the fees paid to a provider who agrees to
provide health care services to an enrollee but is not a preferred or participating provider.
(e) If the managed care organization is a health maintenance organization, Subsections
(2)(e)(i) through (vi) apply.
(i) A solvent health maintenance organization licensed under Chapter 8, Health
Maintenance Organizations and Limited Health Plans, shall extend to the enrollees of an
insolvent health maintenance organization all rights, privileges, and obligations of being an
enrollee in the accepting health maintenance organization:
(A) subject to Subsections (2)(e)(ii), (iii), and (v);
(B) upon notification from and subject to the direction of the rehabilitator or liquidator
of an insolvent health maintenance organization licensed under Chapter 8, Health Maintenance
Organizations and Limited Health Plans; and
(C) if the solvent health maintenance organization operates within a portion of the
insolvent health maintenance organization's service area.
(ii) Notwithstanding Subsection (2)(e)(i), the accepting health maintenance
organization shall give credit to an enrollee for any waiting period already satisfied under the
enrollee's contract with the insolvent health maintenance organization.
(iii) A health maintenance organization accepting an enrollee of an insolvent health
maintenance organization under Subsection (2)(e)(i) shall charge the enrollee the premiums
applicable to the existing business of the accepting health maintenance organization.
(iv) A health maintenance organization's obligation to accept an enrollee under
Subsection (2)(e)(i) is limited in number to the accepting health maintenance organization's pro
rata share of all health maintenance organization enrollees in this state, as determined after
excluding the enrollees of the insolvent insurer.
(v) (A) The rehabilitator or liquidator of an insolvent health maintenance organization
shall take those measures that are possible to ensure that no health maintenance organization is
required to accept more than its pro rata share of the adverse risk represented by the enrollees
of the insolvent health maintenance organization.
(B) If the methodology used by the rehabilitator or liquidator to assign an enrollee is
one that can be expected to produce a reasonably equitable distribution of adverse risk, that
methodology and its results are acceptable under this Subsection (2)(e)(v).
(vi) (A) Notwithstanding Section 
31A-27a-402
, the rehabilitator or liquidator may
require all solvent health maintenance organizations to pay for the covered claims incurred by
the enrollees of the insolvent health maintenance organization.
(B) As determined by the rehabilitator or liquidator, payments required under this
Subsection (2)(e)(vi) may:
(I) begin as of the day on which the following is filed:
(Aa) the petition for rehabilitation; or
(Bb) the petition for liquidation; and
(II) continue for a maximum period through the time all enrollees are assigned pursuant
to this section.
(C) If the rehabilitator or liquidator makes an assessment under this Subsection
(2)(e)(vi), the rehabilitator or liquidator shall assess each solvent health maintenance
organization its pro rata share of the total assessment based upon its premiums from the
previous calendar year.
(D) (I) A solvent health maintenance organization required to pay for covered claims
under this Subsection (2)(e)(vi) may file a claim against the estate of the insolvent health
maintenance organization.
(II) Any claim described in Subsection (2)(e)(vi)(D)(I), if allowed by the rehabilitator
or liquidator, shall share in any distributions from the estate of the insolvent health
maintenance organization as a Class 3 claim.
(f) (i) A rehabilitator or liquidator may transfer, through sale or otherwise, the group
and individual health care obligations of the insolvent managed care organization to one or
more other managed care organizations or other insurers, if those other managed care
organizations and other insurers:
(A) are licensed to provide the same health care services in this state that are held by
the insolvent managed care organization; or
(B) have a certificate of authority to provide the same health care services in this state
that is held by the insolvent managed care organization.
(ii) The rehabilitator or liquidator may combine group and individual health care
obligations of the insolvent managed care organization in any manner the rehabilitator or
liquidator considers best to provide for continuous health care coverage for the maximum
number of enrollees of the insolvent managed care organization.
(iii) If the terms of a proposed transfer of the same combination of group and
individual policy obligations to more than one other managed care organization or insurer are
otherwise equal, the rehabilitator or liquidator shall give preference to the transfer of the group
and individual policy obligations of an insolvent managed care organization as follows:
(A) from one category of managed care organization to another managed care
organization of the same category, as follows:
(I) from a limited health plan to a limited health plan;
(II) from a health maintenance organization to a health maintenance organization;
(III) from a preferred provider organization to a preferred provider organization;
(IV) from a fraternal benefit society to a fraternal benefit society; and
(V) from an entity similar to an entity described in this Subsection (2)(f)(iii)(A) to a
category that is similar;
(B) from one category of managed care organization to another managed care
organization, regardless of the category of the transferee managed care organization; and
(C) from a managed care organization to a nonmanaged care provider of health care
coverage, including insurers.
(g) If an insolvent managed care organization has required surplus, a rehabilitator or
liquidator may use the insolvent managed care organization's required surplus to continue to
provide coverage for the insolvent managed care organization's enrollees, including paying
uncovered expenditures.
Section 3. Section 
31A-45-303
 is amended to read:
31A-45-303.
Network provider contract provisions.
(1) Managed care organizations may provide for enrollees to receive services or
reimbursement under the health benefit plans in accordance with this section.
(2) (a) Subject to restrictions under this section, a managed care organization may enter
into contracts with health care providers under which the health care providers agree to be a
network provider and supply services, at prices specified in the contracts, to enrollees.
(b) A network provider contract shall require the network provider to accept the
specified payment in [
this
] Subsection (2)
(a)
 as payment in full, relinquishing the right to
collect amounts other than copayments, coinsurance, and deductibles from the enrollee.
(c) The insurance contract may reward the enrollee for selection of network providers
by:
(i) reducing premium rates;
(ii) reducing deductibles;
(iii) coinsurance;
(iv) other copayments; or
(v) any other reasonable manner.
(3) [
(a)
] When reimbursing for services of health care providers that are not network
providers, the managed care organization may:
[
(i)
] 
(a)
 make direct payment to the enrollee; and
[
(ii)
] 
(b)
 impose a deductible on coverage of health care providers not under contract.
[
(b) (i) Subsections (3)(b)(iii) and (c) apply to a managed care organization licensed
under:
]
[
(A) Chapter 5, Domestic Stock and Mutual Insurance Corporations;
]
[
(B) Chapter 7, Nonprofit Health Service Insurance Corporations; or
]
[
(C) Chapter 14, Foreign Insurers; and
]
[
(ii) Subsections (3)(b)(iii) and (c) and Subsection (6)(b) do not apply to a managed
care organization licensed under Chapter 8, Health Maintenance Organizations and Limited
Health Plans.
]
[
(iii)
] 
(4) (a)
 When selecting health care providers with whom to contract under
Subsection (2), a managed care organization [
described in Subsection (3)(b)(i)
] may not
unfairly discriminate between classes of health care providers, but may discriminate within a
class of health care providers, subject to [
Subsection (6)
] 
Subsections (7) and (8)
.
[
(c)
] 
(b)
 For purposes of this section, unfair discrimination between classes of health
care providers includes:
(i) refusal to contract with class members in reasonable proportion to the number of
insureds covered by the insurer and the expected demand for services from class members; and
(ii) refusal to cover procedures for one class of providers that are:
(A) commonly used by members of the class of health care providers for the treatment
of illnesses, injuries, or conditions;
(B) otherwise covered by the managed care organization; and
(C) within the scope of practice of the class of health care providers.
[
(4)
] 
(5) (a)
 Before the enrollee consents to the insurance contract, the managed care
organization shall fully disclose to the enrollee that the managed care organization has entered
into network provider contracts.
(b)
 The managed care organization shall provide sufficient detail on the network
provider contracts to permit the enrollee to agree to the terms of the insurance contract.
(c)
 The managed care organization shall provide at least the following information:
[
(a)
] 
(i)
 a list of the health care providers under contract, and if requested their business
locations and specialties;
[
(b)
] 
(ii)
 a description of the insured benefits, including deductibles, coinsurance, or
other copayments;
[
(c)
] 
(iii)
 a description of the quality assurance program required under Subsection (5);
and
[
(d)
] 
(iv)
 a description of the adverse benefit determination procedures required under
Section 
31A-22-629
.
[
(5)
] 
(6)
 (a) A managed care organization using network provider contracts shall
maintain a quality assurance program for [
assuring
] 
ensuring
 that the care provided by the
network providers meets prevailing standards in the state.
(b) 
(i)
 The commissioner in consultation with the executive director of the Department
of Health may designate qualified persons to perform an audit of the quality assurance
program.
(ii)
 The auditors shall have full access to all records of the managed care organization
and the managed care organization's health care providers, including medical records of
individual patients.
(c) 
(i)
 The information contained in the medical records of individual patients shall
remain confidential.
(ii)
 All information, interviews, reports, statements, memoranda, or other data
furnished for purposes of the audit and any findings or conclusions of the auditors are
privileged.
(iii)
 The information is not subject to discovery, use, or receipt in evidence in any legal
proceeding except hearings before the commissioner concerning alleged violations of this
section.
[
(6) (a)
] 
(7)
 A health care provider or managed care organization may not discriminate
against a network provider for agreeing to a contract under Subsection (2).
[
(b) (i) Subsections (6)(b) and (c) apply to a managed care organization that is
described in Subsection (3)(b)(i) and do not apply to a managed care organization described in
Subsection (3)(b)(ii).
]
[
(ii)
] 
(8) (a)
 A health care provider licensed to treat an illness or injury within the scope
of the health care provider's practice, that is willing and able to meet the terms and conditions
established by the managed care organization for designation as a network provider, shall be
able to apply for and receive the designation as a network provider.
(b)
 Contract terms and conditions may include reasonable [
limitations
] 
limits
 on the
number of designated network providers based upon substantial objective and economic
grounds, or expected use of particular services based upon prior provider-patient profiles.
(c) Upon the written request of a provider excluded from a network provider contract,
the commissioner may hold a hearing to determine if the managed care organization's exclusion
of the provider is based on the criteria [
set forth in
] 
described in this
 Subsection [
(6)(b)
] 
(8)
.
(9) Subsections (4) and (8):
(a) apply to a managed care organization licensed under:
(i) Chapter 5, Domestic Stock and Mutual Insurance Corporations;
(ii) Chapter 7, Nonprofit Health Service Insurance Corporations; or
(iii) Chapter 14, Foreign Insurers; and
(b) do not apply to a managed care organization licensed under Chapter 8, Health
Maintenance Organizations and Limited Health Plans.
[
(7)
] 
(10)
 Nothing in this section [
is to
] 
may
 be construed as [
to require
] 
requiring
 a
managed care organization to offer a certain benefit or service as part of a health benefit plan.
[
(8) Notwithstanding Subsection (2) or Subsection (6)(b), a managed care organization
described in Subsection (3)(b)(i) or third party administrator is not required to, but may, enter
into a contract with a licensed athletic trainer, licensed under Title 58, Chapter 40a, Athletic
Trainer Licensing Act.
]
Legislative Review Note
Office of Legislative Research and General Counsel