§ 23-17.13-3 - Certification of health plans.
SECTION 23-17.13-3
§ 23-17.13-3 Certification of healthplans. – (i) The director shall establish a process for certification of health plansmeeting the requirements of certification in subsection (b).
(ii) The director shall act upon the health plan's completedapplication for certification within ninety (90) days of receipt of suchapplication for certification.
(2) Review and recertification. To ensure compliancewith subsection (b), the director shall establish procedures for the periodicreview and recertification of qualified health plans not less than every five(5) years; provided, however, that the director may review the certification ofa qualified health plan at any time if there exists evidence that a qualifiedhealth plan may be in violation of subsection (b).
(3) Cost of certification. The total cost of obtainingand maintaining certification under this title and compliance with therequirements of the applicable rules and regulations are borne by the entitiesso certified and shall be one hundred and fifty percent (150%) of the totalsalaries paid to the certifying personnel of the department engaged in thosecertifications less any salary reimbursements and shall be paid to the directorto and for the use of the department. That assessment shall be in addition toany taxes and fees otherwise payable to the state.
(4) Standard definitions. To help ensure a patient'sability to make informed decisions regarding their health care, the directorshall promulgate regulation(s) to provide for standardized definitions (unlessdefined in existing statute) of the following terms in this subdivision,provided, however, that no definition shall be construed to require a healthcare entity to add any benefit, to increase the scope of any benefit, or toincrease any benefit under any contract:
(i) Allowable charge;
(ii) Capitation;
(iii) Co-payments;
(iv) Co-insurance;
(v) Credentialing;
(vi) Formulary;
(vii) Grace period;
(viii) Indemnity insurance;
(ix) In-patient care;
(x) Maximum lifetime cap;
(xi) Medical necessity;
(xii) Out-of-network;
(xiii) Out-patient;
(xiv) Pre-existing conditions;
(xv) Point of service;
(xvi) Risk sharing;
(xvii) Second opinion;
(xviii) Provider network;
(xix) Urgent care.
(b) Requirements for certification. The director shallestablish standards and procedures for the certification of qualified healthplans that conduct business in this state and who have demonstrated the abilityto ensure that health care services will be provided in a manner to assureavailability and accessibility, adequate personnel and facilities, andcontinuity of service, and has demonstrated arrangements for ongoing qualityassurance programs regarding care processes and outcomes; other standards shallconsist of, but are not limited to, the following:
(1) Prospective and current enrollees in health plans must beprovided information as to the terms and conditions of the plan consistent withthe rules and regulations promulgated under chapter 12.3 of title 42 so thatthey can make informed decisions about accepting and utilizing the health careservices of the health plan. This must be standardized so that customers cancompare the attributes of the plans, and all information required by thisparagraph shall be updated at intervals determined by the director. Of thoseitems required under this section, the director shall also determine whichitems shall be routinely distributed to prospective and current enrollees aslisted in this subsection and which items may be made available upon request.The items to be disclosed are:
(i) Coverage provisions, benefits, and any restriction orlimitations on health care services, including but not limited to, anyexclusions as follows: by category of service, and if applicable, by specificservice, by technology, procedure, medication, provider or treatment modality,diagnosis and condition, the latter three (3) of which shall be listed by name.
(ii) Experimental treatment modalities that are subject tochange with the advent of new technology may be listed solely by the broadcategory "Experimental Treatments". The information provided to consumers shallinclude the plan's telephone number and address where enrollees may call orwrite for more information or to register a complaint regarding the plan orcoverage provision.
(2) Written statement of the enrollee's right to seek asecond opinion, and reimbursement if applicable.
(3) Written disclosure regarding the appeals processdescribed in § 23-17.12-1 et seq. and in the rules and regulations for theutilization review of care services, promulgated by the department of health,the telephone numbers and addresses for the plan's office which handlescomplaints as well as for the office which handles the appeals process under§ 23-17.12-1 et seq. and the rules and regulations for the utilization ofhealth.
(4) Written statement of prospective and current enrollees'right to confidentiality of all health care record and information in thepossession and/or control of the plan, its employees, its agents and partieswith whom a contractual agreement exists to provide utilization review or whoin any way have access to care information. A summary statement of the measurestaken by the plan to ensure confidentiality of an individual's health carerecords shall be disclosed.
(5) Written disclosure of the enrollee's right to be freefrom discrimination by the health plan and the right to refuse treatmentwithout jeopardizing future treatment.
(6) Written disclosure of a plan's policy to direct enrolleesto particular providers. Any limitations on reimbursement should the enrolleerefuse the referral must be disclosed.
(7) A summary of prior authorization or other reviewrequirements including preauthorization review, concurrent review, post-servicereview, post-payment review and any procedure that may lead the patient to bedenied coverage for or not be provided a particular service.
(8) Any health plan that operates a provider incentive planshall not enter into any compensation agreement with any provider of coveredservices or pharmaceutical manufacturer pursuant to which specific payment ismade directly or indirectly to the provider as an inducement or incentive toreduce or limit services, to reduce the length of stay or the use ofalternative treatment settings or the use of a particular medication withrespect to an individual patient, provided however, that capitation agreementsand similar risk sharing arrangements are not prohibited.
(9) Health plans must disclose to prospective and currentenrollees the existence of financial arrangements for capitated or other risksharing arrangements that exist with providers in a manner described inparagraphs (i), (ii), and (iii):
(i) "This health plan utilizes capitated arrangements, withits participating providers, or contains other similar risk sharingarrangements;
(ii) This health plan may include a capitated reimbursementarrangement or other similar risk sharing arrangement, and other financialarrangements with your provider;
(iii) This health plan is not capitated and does not containother risk sharing arrangements."
(10) Written disclosure of criteria for accessing emergencyhealth care services as well as a statement of the plan's policies regardingpayment for examinations to determine if emergency health care services arenecessary, the emergency care itself, and the necessary services followingemergency treatment or stabilization. The health plan must respond to therequest of the treating provider for post-stabilization treatment by approvingor denying it as soon as possible.
(11) Explanation of how health plan limitations impactenrollees, including information on enrollee financial responsibility forpayment for co-insurance, co-payment, or other non-covered, out-of-pocket, orout-of-plan services. This shall include information on deductibles andbenefits limitations including, but not limited to, annual limits and maximumlifetime benefits.
(12) The terms under which the health plan may be renewed bythe plan enrollee, including any reservation by the plan of any right toincrease premiums.
(13) Summary of criteria used to authorize treatment.
(14) A schedule of revenues and expenses, including directservice ratios and other statistical information which meets the requirementsset forth below on a form prescribed by the director.
(15) Plan costs of health care services, including but notlimited to all of the following:
(i) Physician services;
(ii) Hospital services, including both inpatients andoutpatient services;
(iii) Other professional services;
(iv) Pharmacy services, excluding pharmaceutical productsdispensed in a physician's office;
(v) Health education;
(vi) Substance abuse services and mental health services.
(16) Plan complaint, adverse decision, and priorauthorization statistics. This statistical data shall be updated annually:
(i) The ratio of the number of complaints received to thetotal number of covered persons, reported by category, listed in paragraphs(b)(15)(i) – (vi);
(ii) The ratio of the number of adverse decisions issued tothe number of complaints received, reported by category;
(iii) The ratio of the number of prior authorizations deniedto the number of prior authorizations requested, reported by category;
(iv) The ratio of the number of successful enrollee appealsto the total number of appeals filed.
(17) Plans must demonstrate that:
(i) They have reasonable access to providers, so that allcovered health care services will be provided. This requirement cannot bewaived and must be met in all areas where the health plan has enrollees;
(ii) Urgent health care services, if covered, shall beavailable within a time frame that meets standards set by the director.
(18) A comprehensive list of participating providers listedby office location, specialty if applicable, and other information asdetermined by the director, updated annually.
(19) Plans must provide to the director, at intervalsdetermined by the director, enrollee satisfaction measures. The director isauthorized to specify reasonable requirements for these measures consistentwith industry standards to assure an acceptable degree of statistical validityand comparability of satisfaction measures over time and among plans. Thedirector shall publish periodic reports for the public providing information onhealth plan enrollee satisfaction.
(1) Upon receipt of an application for certification, thedirector shall notify and afford the public an opportunity to comment upon theapplication.
(2) A health care plan will meet the requirements ofcertification, subsection (b) by providing information required in subsection(b) to any state or federal agency in conformance with any other applicablestate or federal law, or in conformity with standards adopted by an accreditingorganization provided that the director determines that the information issubstantially similar to the previously mentioned requirements and is presentedin a format that provides a meaningful comparison between health plans.
(3) All health plans shall be required to establish amechanism, under which providers, including local providers participating inthe plan, provide input into the plan's health care policy, includingtechnology, medications and procedures, utilization review criteria andprocedures, quality and credentialing criteria, and medical managementprocedures.
(4) All health plans shall be required to establish amechanism under which local individual subscribers to the plan provide inputinto the plan's procedures and processes regarding the delivery of health careservices.
(5) A health plan shall not refuse to contract with orcompensate for covered services an otherwise eligible provider ornon-participating provider solely because that provider has in good faithcommunicated with one or more of his or her patients regarding the provisions,terms or requirements of the insurer's products as they relate to the needs ofthat provider's patients.
(6) All health plans shall be required to publicly notifyproviders within the health plans' geographic service area of the opportunityto apply for credentials. This notification process shall be required only whenthe plan contemplates adding additional providers and may be specific as togeographic area and provider specialty. Any provider not selected by the healthplan may be placed on a waiting list.
(ii) This credentialing process shall begin upon acceptanceof an application from a provider to the plan for inclusion.
(iii) Each application shall be reviewed by the plan'scredentialing body.
(iv) All health plans shall develop and maintaincredentialing criteria to be utilized in adding providers from the plans'network. Credentialing criteria shall be based on input from providerscredentialed in the plan and these standards shall be available to applicants.When economic considerations are part of the decisions, the criteria must beavailable to applicants. Any economic profiling must factor the specialtyutilization and practice patterns and general information comparing theapplicant to his or her peers in the same specialty will be made available. Anyeconomic profiling of providers must be adjusted to recognize case mix,severity of illness, age of patients and other features of a provider'spractice that may account for higher than or lower than expected costs.Profiles must be made available to those so profiled.
(7) A health plan shall not exclude a provider of coveredservices from participation in its provider network based solely on:
(i) The provider's degree or license as applicable understate law; or
(ii) The provider of covered services lack of affiliationwith, or admitting privileges at a hospital, if that lack of affiliation is duesolely to the provider's type of license.
(8) Health plans shall not discriminate against providerssolely because the provider treats a substantial number of patients who requireexpensive or uncompensated medical care.
(9) The applicant shall be provided with all reasons used ifthe application is denied.
(10) Plans shall not be allowed to include clauses inphysician or other provider contracts that allow for the plan to terminate thecontract "without cause"; provided, however, cause shall include lack of needdue to economic considerations.
(11) There shall be due process for non-institutionalproviders for all adverse decisions resulting in a change of privileges of acredentialed non-institutional provider. The details of the health plan's dueprocess shall be included in the plan's provider contracts.
(ii) A health plan is deemed to have met the adequate noticeand hearing requirement of this section with respect to a non-institutionalprovider if the following conditions are met (or are waived voluntarily by thenon-institutional provider):
(A) The provider shall be notified of the proposed actionsand the reasons for the proposed action.
(B) The provider shall be given the opportunity to contestthe proposed action.
(C) The health plan has developed an internal appeals processthat has reasonable time limits for the resolution of an internal appeal.
(12) If the plan places a provider or provider group atfinancial risk for services not provided by the provider or provider group, theplan must require that a provider or group has met all appropriate standards ofthe department of business regulation.
(13) A health plan shall not include a most favored rateclause in a provider contract.