514C.13 - GROUP MANAGED CARE HEALTH PLANS -- REQUIREMENTS ATTACHED TO LIMITED PROVIDER NETWORK PLAN OFFERS.
514C.13 GROUP MANAGED CARE HEALTH PLANS -- REQUIREMENTS ATTACHED TO LIMITED PROVIDER NETWORK PLAN OFFERS. 1. As used in this section, unless the context otherwise requires: a. "Carrier" means an entity that provides health benefit plans in this state. "Carrier" includes an insurance company, group hospital or medical service corporation, health maintenance organization, multiple employer welfare arrangement, and any other person providing health benefit plans in this state subject to regulation by the commissioner of insurance. b. "Health benefit plan" means a policy, certificate, or contract providing hospital or medical coverage, benefits, or services rendered by a health care provider. "Health benefit plan" does not include a group conversion plan, accident-only, specific-disease, short-term hospital or medical hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, or disability income insurance, coverage issued as a supplement to liability insurance, workers' compensation or similar insurance, or automobile medical payment insurance. c. "Health care provider" means a hospital licensed pursuant to chapter 135B, a person licensed under chapter 148, 148C, 149, 151, or 154, or a person licensed as an advanced registered nurse practitioner under chapter 152. d. "Indemnity plan" means a hospital or medical expense-incurred policy, certificate, or contract, major medical expense insurance, or hospital or medical service plan contract. e. "Large employer" means a person actively engaged in business who, during at least fifty percent of the employer's working days during the preceding calendar year, employed more than fifty full-time equivalent employees. f. "Limited provider network plan" means a managed care health plan which limits access to or coverage for services to selected health care providers who are under contract with the managed care health plan. g. "Managed care health plan" means a health benefit plan that selects and contracts with health care providers; manages and coordinates health care delivery; monitors necessity, appropriateness, and quality of health care delivered by health care providers; and performs utilization review and cost control. h. "Organized delivery system" means an organized delivery system as defined in section 513C.3. i. "Point of service plan option" means a provision in a managed care health plan that permits insureds, enrollees, or subscribers access to health care from health care providers who have not contracted with the managed care health plan. j. "Small employer" means a person actively engaged in business who, during at least fifty percent of the employer's working days during the preceding calendar year, employed not less than two and not more than fifty full-time equivalent employees. 2. A carrier or organized delivery system which offers to a small employer a limited provider network plan to provide health care services or benefits to the small employer's employees shall also offer to the small employer a point of service option to the limited provider network plan. 3. A carrier or organized delivery system which offers to a large employer a limited provider network plan to provide health care services or benefits to the large employer's employees shall also offer to the large employer one or more of the following: a. A point of service plan option to the limited provider network plan. The price of the point of service plan option shall be actuarially determined. b. A managed care health plan that is not a limited provider network plan. c. An indemnity plan. 4. A large employer that offers a limited provider network plan to its employees shall also offer to its employees one or more of the following: a. A point of service plan option to the limited provider network plan. b. A managed care health plan that is not a limited provider network plan. c. An indemnity plan.
Section History: Recent Fo/b> 97 Acts, ch 88, §1; 2008 Acts, ch 1088, §131 Referred to in § 505.25