H.B.
125
127th General Assembly
(As Introduced)
Reps. Huffman, DeGeeter, Seitz, J. McGregor, Schneider, Latta, Adams, Gibbs, Setzer, Oelslager, Uecker, R. McGregor, J. Stewart, Stebelton, Fessler, Barrett, Wagoner, Celeste, Reinhard, Widener, Blessing, Book, Carmichael, Lundy
BILL SUMMARY
· Prohibits third-party payers under a health care contract from generally selling or giving their provider network information to other persons or from requiring that a provider, as a condition of contracting with the third-party payer, provide services under more than one "product" offered by the third-party payer or waive any right or benefit under state or federal law.
· Prohibits a health care contract from including certain provisions, including a "most favored nation clause" if a third-party payer controls more than 20% of a health insurance market share in a county.
· Requires each health care contract to provide that the third-party payer or the provider may terminate the contract without cause by giving a 90-day notice and requires a health care contract to state the reasons that may be used for termination for cause if the contract provides for such termination for cause by either party.
· Specifies that disputes concerning certain provisions in the bill are subject to a mutually agreed upon arbitration mechanism that is binding on the parties and authorizes an arbitrator to award to the prevailing party reasonable attorney's fees and arbitration costs.
· Requires a third-party payer, upon presentation of a proposed health care contract for a provider's consideration and upon execution of the contract, to make available to the provider specified information regarding compensation or payment terms for health care services.
· Requires a third-party payer to include with a health care contract a summary disclosure form that discloses the compensation or payment terms and other specified information and to identify any utilization management, quality improvement, or similar program to be used to review or assess the services provided under the contract.
· Replaces existing law's procedures for amending a health care contract with new procedures.
· Specifies that the standard credentialing form for credentialing providers is the credentialing form used by the Council for Affordable Quality Healthcare (CAQH) and eliminates existing law's provisions on economic profiling of providers.
· Requires a third-party payer, upon a participating provider's submission of certain information about an enrollee, to make available electronically or by an internet portal, specified personally identifiable and other information concerning the enrollee.
· Prohibits any health insuring corporation contract with a provider or health care facility from containing any provision that violates the bill's provisions.
· Generally provides that a violation of the bill's provisions is an unfair and deceptive act or practice in the business of insurance.
· Requires the Superintendent of Insurance to adopt rules necessary to implement the bill's provisions.
· Applies its provisions only to contracts that are delivered, issued for delivery, or renewed or modified in Ohio on or after the act's effective date.
TABLE OF CONTENTS
Prohibitions applicable to third-party payers
Prohibitions regarding health care contracts
Termination of health care contract
Information on compensation or payment terms
Disclosure of program used to review services
Amendment of health care contract
Unfair and deceptive act or practice in the business of insurance
Prohibited contents of health insuring corporation contract with
provider
or health care facility
CONTENT AND OPERATION
R.C. Chapter 1751. (Health Insuring Corporation Law) governs the operations of corporations to which the Superintendent of Insurance has issued a certificate of authority to establish and operate a "health insuring corporation" (see COMMENT 1). R.C. Chapter 3923. (Sickness and Accident Insurance Law) governs the issuance of sickness and accident insurance policies by insurers licensed and regulated by the Superintendent of Insurance (see COMMENT 2). R.C. 1753.01 to 1753.30 (Physician-Health Plan Partnership Law) contains provisions dealing with health insuring corporations and addressing provider contractual issues and issues relating to patient access to covered health care services, quality assurance programs, and utilization review (see COMMENT 3). R.C. 3901.38 and 3901.381 to 3901.3814 contain provisions for the prompt payment by third-party payers of claims submitted by providers.
R.C.
1751.08 and 1753.30 govern the relations among the laws described in the
preceding paragraph. R.C. 1751.08(A)
provides that, except as otherwise specifically provided in the Health Insuring
Corporation Law (R.C. Chapter 1751.) or the Insurance Law (R.C. Title XXXIX),
the provisions of the Insurance Law (including the Sickness and Accident
Insurance Law and new R.C. Chapter 3963. enacted by the bill) are not
applicable to any health insuring corporation holding a certificate of
authority under the Health Insuring Corporation Law. However, this nonapplicability provision does not apply to an
insurer licensed and regulated pursuant to the Insurance Law except with
respect to its health insuring corporation activities authorized and regulated
pursuant to the Health Insuring Corporation Law. In other words, except as otherwise specifically provided in the
Health Insuring Corporation Law or the Insurance Law, a licensed insurer is
regulated under the Insurance Law with respect to its activities other than
its health insuring corporation activities that are authorized and regulated
under the Health Insuring Corporation.
R.C.
1753.30 provides that nothing in R.C. Chapter 1753. (Physician-Health Plan
Partnership Law) prevents or otherwise affects the application to any health
care plan of those provisions of R.C. Title XVII (Corporations and
Partnerships) or XXXIX (Insurance) that would otherwise apply.
The bill enacts a new chapter in the Insurance Law (R.C. Chapter 3963.) that primarily regulates health care contracts entered into by certain health care providers and third-party payers. It includes specific prohibitions applicable to third-party payers and health care contracts. The bill requires specified disclosures regarding compensation or payment terms to be made by third-party payers upon presentation of a proposed health care contract to providers and additional disclosures upon execution of the contract. It specifies that disputes concerning the enforcement of certain provisions are subject to a mutually agreed upon and binding arbitration mechanism. The bill requires third-party payers, upon a provider's submission of certain information regarding an enrollee, to make available electronically or through the internet personally identifiable and other information concerning the enrollee. The bill's standardized provider credentialing procedures replace the credentialing procedures in existing law.
The bill prohibits any "third-party payer" from doing either of the following (R.C. 3963.02(A)) (see "Definitions," below, for definitions of any terms that appear above or below in quotation marks):
(1) Selling, renting, or giving its "provider" network information to any other person, except for the purpose of providing claims processing for the third-party payer;
(2) Requiring, as a condition of contracting with the third-party payer, that a "provider" provide services under more than one "product" offered by the third-party payer or waive or forego any right or benefit to which the provider may be entitled under state or federal law.
The bill further prohibits any third-party payer, other than the third-party payer that executes a "health care contract," from enforcing against the provider the payment or compensation terms of the health care contract unless the other third-party payer is contractually bound to all terms and conditions of the health care contract executed by the provider, and either (1) the other third-party payer is clearly identified in the health care contract executed by the provider, or (2) before health care services are provided, the health care contract is amended by a writing in which the provider agrees to provide health care services for the payment or compensation described in the health care contract to be paid by the other third-party payer. (R.C. 3963.02(B).)
The bill prohibits any health care contract from doing any of the following (R.C. 3963.02(C)):
(1) Interfering with a provider's right to set the provider's payer-mix ratio in the provider's practice;
(2) Precluding its use or disclosure for the purpose of enforcing the bill's provisions or other state or federal law, except that a health care contract may require that appropriate measures be taken to preserve the confidentiality of any proprietary or trade-secret information;
(3) Including a "most favored nation clause" (defined in the following sentence) if a third-party payer controls more than 20% of a health insurance market share in a particular county. "Most favored nation clause" means a contract provision that: (a) prohibits, or grants a third-party payer an option to prohibit, the provider from contracting with another third-party payer to provide services at a lower price than the payment specified in the contract, (b) requires, or grants a third-party payer an option to require, the provider to accept a lower payment in the event the provider agrees to provide services to any other third-party payer at a lower price, (c) requires, or grants the third-party payer an option to require, termination or renegotiation of the existing health care contract in the event the provider agrees to provide services to any other third-party payer at a lower price, or (d) requires the provider to disclose the provider's contractual reimbursement rates with other third-party payers. Any health care contract provision that violates the prohibition against including a most favored nation clause if a third-party payer controls more than 20% of a health insurance market share in a particular county is null and void.
The bill requires each health care contract to provide that the third-party payer or the provider may terminate the health care contract without cause by giving not less than 90 days written notice to the other party. If the health care contract provides for termination for cause by either party, the health care contract must state the reasons that may be used for termination for cause and those terms must be reasonable. The health care contract is required to state the time by which the parties must provide notice of termination for cause and to whom the parties must give the notice. The bill provides that no term for compensation or payment in a health care contract survives the termination of the contract, except with the agreement of the provider or for a continuation of coverage arrangement otherwise required by law. (R.C. 3963.02(D), (E), and (F).) (See COMMENT 4.)
The bill specifies that disputes among parties concerning the enforcement of the provisions described in "Prohibitions applicable to third-party payers," "Prohibitions regarding health care contracts," and "Termination of health care contract," above, and in "Disclosure requirements" and "Amendment of health care contract," below, are subject to a mutually agreed upon arbitration mechanism that is binding on all parties. The arbitrator may award to the prevailing party reasonable attorney's fees and costs for arbitration relating to the enforcement of the arbitration provision. The limitation to reasonable attorney's fees and costs do not apply to disputes regarding breach of contract. (R.C. 3963.02(G).)
The bill requires a third-party payer to make specific disclosures to a provider upon presentation of a proposed health care contract for the provider's consideration and upon execution of the contract.
When a third-party payer presents a proposed health care contract for consideration by a provider, the bill requires the third-party payer to provide in writing or make reasonably available the information sufficient for the provider to determine the compensation or payment terms for health care services, including all of the following (R.C. 3963.03(A)(1) and (B)):
(1) The manner of payment, such as fee-for-service, capitation, or risk;
(2) The fee schedule of codes reasonably expected to be billed by a provider's specialty for services provided pursuant to the health care contract, including, if applicable, current procedural terminology codes and the Centers for Medicare and Medicaid Services health care common procedure coding system and the associated payment or compensation for each "procedure code." A fee schedule may be provided electronically. Upon request, a third-party payer must provide a provider with the fee schedule for any other codes requested and a written fee schedule, which cannot be required more frequently than twice per year excluding when it is provided in connection with any change to the schedule. The third-party payer also must state the effect, if any, on payment or compensation if more than one procedure code applies to the service. A third-party payer may satisfy this requirement by providing a clearly understandable, readily available mechanism, such as a web site, that allows a provider to determine the effect of service codes on payment or compensation before a service is provided or a claim is submitted.
(3) The methodology used to calculate any fee schedule, such as relative value unit system and conversion factor, percentage of Medicare payment system, or percentage of billed charges. If applicable, the methodology disclosure must include the name of any relative value system, its version, edition, or publication date, any applicable conversion or geographic factor, and any date by which compensation or fee schedules may be changed by the methodology as anticipated at the time of contract.
(4) The
identity of any internal processing "edits" used by the third-party
payer, including the publisher, product name, version, and version update of
any editing software used by the third-party payer.
If the above information is not disclosed in writing, it must be disclosed in a manner that allows the provider to evaluate the provider's payment or compensation for services under the health care contract. After the health care contract is executed, a third-party payer must disclose the above described information upon request by the provider. The third-party payer need not provide such information in written format more than twice a year. (R.C. 3963.03(B).)
The bill requires each third-party payer to include a summary disclosure form with a health care contract that discloses in plain language all of the following information: (1) the information described in paragraphs (1) to (4), above, in "Information on compensation or payment terms," (2) any "product" for which the provider is to provide services, (3) the term of the health care contract and how it may be terminated, (4) the identity of the third-party payer responsible for the processing of the provider's compensation or payment, (5) any internal mechanism provided by the third-party payer to resolve disputes concerning the interpretation or application of the terms or conditions of the contract, (6) any provisions for the amendment of the contract, and (7) a list of addenda, if any, to the contract. (R.C. 3963.03(A).)
The bill requires a third-party payer to identify any utilization management, quality improvement, or a similar program the third-party payer uses to review, monitor, evaluate, or assess the services provided pursuant to a health care contract. The third-party payer must disclose the policies, procedures, or guidelines of such a program applicable to a provider upon request by the provider within 14 days after the date of the request. (R.C. 3962.03(C).)
The Physician-Health Plan Partnership Law requires a health insuring corporation (see COMMENT 1) that amends a participation contract to notify the participating provider of the amendment prior to the effective date of the amendment. A health insuring corporation must also notify a participating provider prior to the effective date of an amendment to any document incorporated by reference into such a contract if the amendment directly and materially affects the participating provider. These amendments are not to be effective with regard to the participating provider until the participating provider has had reasonable time, as defined in the contract, to exercise the participating provider's right to terminate the provider's participation status in accordance with the terms and conditions of the contract. These provisions pertaining to the amendment of a participating provider's contract do not apply to amendments that are required by state or federal law, rule, or regulation, and they do not apply if a delay caused by compliance with the provisions could result in imminent harm to an enrollee.[1] (R.C. 1753.08.)
The bill outright repeals the above provisions in the Physician-Health Plan Partnership Law and replaces them with the following provisions. It requires a third-party payer to notify a provider 120 days prior to the effective date of an amendment to the provider's contract with the third-party payer, and 120 days prior to the effective date of an amendment to any document incorporated by reference into the contract if the amendment of the document directly and materially affects the provider. The amendments are not effective with regard to a provider until the provider has agreed in writing to the change. These provisions do not apply if the delay caused by compliance with them could result in imminent harm to an "enrollee" or if the amendment is required by state or federal law, rule, or regulation.
The provisions described in the preceding paragraph do not apply if the provider's payment or compensation is based on the current Medicare physician fee schedule final rule as published by the Centers for Medicaid and Medicare Services annually in the Federal Register, and the change in payment or compensation results solely from a change in the physician fee schedule.
Notwithstanding the provisions described in the two preceding paragraphs, a health care contract may be modified without the need for amendment by operation of law as required by any applicable state or federal law or rule or regulation. All of the above provisions regarding the amendment of a health care contract are not to be construed to require the renegotiation of a contract in existence before the bill's effective date until such time as the contract is renewed or modified. (R.C. 3963.04.)
Existing law
The
Physician-Health Plan Partnership Law requires the Superintendent of Insurance
to prescribe a standard credentialing form to be used by all health insuring
corporations when initially credentialing or recredentialing providers in
connection with policies, contracts, and agreements providing basic health care
services. The Director of Health may
make recommendations to the Superintendent for such a standard credentialing
form, and the Superintendent must consider those recommendations in prescribing
a standard credentialing form. If the Director
makes such recommendations, the Director is required to take into consideration
the standard credentialing forms developed by the National Association of
Insurance Commissioners, the American Medical Association, the American
Association of Health Plans, and any other national organization that has
developed such a form. The
Superintendent may amend or revise the prescribed standard credentialing form
as necessary, and a health insuring corporation must use the amended or revised
form to credential or recredential providers.
A health insuring corporation may request information from a provider,
in addition to that information provided from the standard credentialing form,
as necessitated by the health insuring corporation's credentialing
standards. (R.C. 1753.03 and 1753.04.)
Existing law permits a health insuring corporation to use "economic profiling" as a factor in credentialing a provider, if the economic profiling takes into consideration the case mix, severity of illness, and age of patients. "Economic profiling" means a health insuring corporation's use of economic performance data and economic information in determining whether to contract with a provider for the provision of health care services to enrollees as a participating provider.
A health insuring corporation may request the information necessary to perform an economic profile with regard to an initial applicant. If the health insuring corporation requests information on case mix, severity of illness, and age of patients, but the information is not produced by the applicant, the health insuring corporation is not required to take these factors into consideration in its economic profile of the provider. The Law states that it does not prohibit a health insuring corporation from taking into consideration the quality and appropriateness of care given by a provider when deciding whether to employ, contract with, or terminate the provider. (R.C. 1753.01(A) and 1753.05.)
The bill outright repeals the above credentialing provisions in existing law and replaces them with the following provisions regarding "credentialing." It eliminates the existing provisions (R.C. 1753.05) on economic profiling as a factor in credentialing providers. The bill specifies that the standard credentialing form is the credentialing form used by the Council for Affordable Quality Healthcare (CAQH), in electronic or paper format. It prohibits any third-party payer from doing either of the following (R.C. 3963.05):
(1) Failing to use that standard credentialing form when initially credentialing or recredentialing providers in connection with policies, health care contracts, and agreements providing basic or supplemental health care services;
(2) Requiring a provider to provide any information in addition to the information required by the standard credentialing form in connection with policies, health care contracts, and agreements providing basic or supplemental health care services.
If a provider submits to a third-party payer a credentialing form that is not complete, the third-party payer that receives the form must notify the provider of the deficiency not later than 14 days after the third-party payer receives the form. A third-party payer must reimburse a provider who has submitted a complete credentialing form for entrance into a health care contract with the third-party payer when the period of review of the provider's credentialing form exceeds 45 days and until the third-party payer rejects or approves the provider for a health care contract.
If the third-party payer and the provider enter into a health care contract, the third-party payer must retroactively reimburse the provider according to the terms of the contract for any basic or supplemental health care services the provider provided to enrollees after the provider submitted to the third-party payer a complete credentialing form and until the third-party payer and the provider enter into a health care contract. A provider may keep record of in-network claims incurred while the provider's credentialing is pending and submit the claims to be paid by the third-party payer once the third-party payer and the provider enter into a health care contract. (R.C. 3963.06.)
The bill requires each third-party payer, upon a "participating provider's" submission of an "enrollee's" name, the enrollee's relationship to the primary enrollee, and the enrollee's birth date, make available information maintained in the ordinary course of business that is sufficient for the provider to determine at the time of the enrollee's visit all of the following: (1) the enrollee's identification number assigned by the third-party payer, (2) the birth date and gender of the primary enrollee, (3) the names, birth dates, and gender of all covered dependents, (4) the current enrollment and eligibility status of the enrollee, (5) whether a specific type or category of service is a covered benefit for the enrollee, (6) the enrollee's excluded benefits or limitations, whether group or individual, (7) the enrollee's copayment requirements, and (8) the unmet amount of the enrollee's deductible or the enrollee's financial responsibility. A third-party payer must make available the information described in this paragraph electronically or by an internet portal. The bill prohibits any third-party payer from directly or indirectly charging a provider any fee for the above information the third-party payer makes available.
Notwithstanding the above requirement for a third-party payer to make available the described information regarding an enrollee, a third-party payer is not required to make that information available to any person except to a participating provider who is authorized under state and federal law to receive personally identifiable information concerning an enrollee or an enrollee's dependent. (R.C. 3963.07.)
The bill requires the Superintendent of Insurance to adopt any rules necessary for the implementation of its provisions (R.C. 3963.08).
The bill specifies that, unless otherwise stated, a violation of its provisions is an unfair and deceptive act or practice in the business of insurance under R.C. 3901.19 to 3901.26 (R.C. 3963.09).
The bill defines the following terms for purposes of its provisions (R.C. 3963.01):
"Edit" means adjusting one or more procedure codes billed by a provider on a claim for payment or a third-party payer's practice that results in: (1) payment for some, but not all of the procedure codes originally billed by a provider, (2) payment for a different procedure code than the procedure code originally billed by a provider, or (3) a reduced payment as a result of services provided to an enrollee that are claimed under more than one procedure code on the same service date.
"Health care contract" means a contract entered into or renewed between a third-party payer and a provider for the delivery of basic or supplemental health care services to enrollees.
"Procedure codes" includes the American Medical Association's current procedural terminology code, and the Centers for Medicare and Medicaid Services health care common procedure coding system.
"Product" means a product line for health services, including, but not limited to a health insuring corporation product or a Medicare or Medicaid product as established by a third-party payer and for which the provider may be obligated to provide services pursuant to a contract.
"Provider" means a physician, podiatrist, dentist, pharmacist, chiropractor, optometrist, psychologist, or other health care provider entitled to reimbursement by a third-party payer for services rendered to an enrollee under a heath care contract. "Provider" does not mean a hospital or nursing home.
"Third-party payer" means any person that has a primary business purpose of contracting with health care providers for the delivery of basic health care services.
"Credentialing" means the process of assessing and validating the qualifications of a provider applying to be approved by a third-party payer to provide basic health care services to the third-party payer's enrollees.
"Enrollee" means any person eligible for health care benefits under a health benefit plan and includes all of the following terms: (1) enrollee and subscriber as defined by R.C. 1751.01, (2) member as defined by R.C. 1739.01, (3) insured and plan member pursuant to R.C. Chapter 3923., (4) beneficiary as defined by R.C. 3901.38, and (5) claimant pursuant to R.C. Chapter 4121., 4123., 4127., or 4131. (See COMMENT 5.)
"Participating provider" means a provider that has a health care contract with the third-party payer.
The current Health
Insuring Corporation Law precludes any health insuring corporation contract
with a provider or health care facility from containing provisions that do any
of the following: (1) directly or indirectly offer an
inducement to the provider or health care facility to reduce or limit medically
necessary health care services to a covered enrollee, (2) penalize a provider
or health care facility that assists an enrollee in seeking reconsideration of
a health insuring corporation's decision to deny or limit benefits, (3) limit
or otherwise restrict the provider's or health care facility's ethical and
legal responsibility to fully advise enrollees about their medical condition
and about medically appropriate treatment options, (4) penalize a provider or
health care facility for principally advocating for medically necessary health
care services, or (5) penalize a provider or health care facility for providing
information or testimony to a legislative or regulatory body or agency if the
information or testimony is not libelous or slanderous or does not disclose
trade secrets that the provider or health care facility has no privilege or
permission to disclose. (R.C.
1751.13(D)(1)(a) to (e).)
The bill additionally precludes any
health insuring corporation contract with a provider or health care facility
from containing any provision that violates the bill's provisions (R.C.
1751.13(D)(1)(f)).
The bill states that its provisions apply only to contracts that are delivered, issued for delivery, or renewed or modified in Ohio on or after the effective date of the act. A health insuring corporation having fewer than 15,000 enrollees must comply with the "provisions of this section" within 12 months after the act's effective date. (Section 3.)
COMMENT
1. R.C. 1751.01(O), not in the bill,
defines "health insuring corporation" as a corporation that, pursuant
to a policy, contract, certificate, or agreement, pays for, reimburses, or
provides, delivers, arranges for, or otherwise makes available, basic health
care services, supplemental health care services, or specialty health care services,
or a combination of basic health care services and either supplemental health
care services or specialty health care services, through either an "open
panel plan" or a "closed panel plan" (see below).
"Health
insuring corporation" does not include a limited liability company
formed pursuant to R.C. Chapter 1705., an insurer licensed under R.C. Title
XXXIX (Insurance Law) if that insurer offers only open panel plans under which
all providers and health care facilities participating receive their compensation
directly from the insurer, a corporation formed by or on behalf of a
political subdivision or a department, office, or institution of the state, or
a public entity formed by or on behalf of a board of county commissioners, a
county board of mental retardation and developmental disabilities, an alcohol
and drug addiction services board, a board of alcohol, drug addiction, and
mental health services, or a community mental health board, as those terms are
used in R.C. Chapters 340. and 5126.
"Closed
panel plan" means a health care plan that requires enrollees to use
participating providers. "Open
panel plan" means a health care plan that provides incentives for
enrollees to use participating providers and that also allows enrollees to use
providers that are not participating providers. (R.C. 1751.01(E) and (S)(1), not in the bill.) No health insuring
corporation may offer an open panel plan, unless the health insuring
corporation is also licensed as an insurer under the Insurance Law, the health
insuring corporation, on June 4, 1997, holds a certificate of authority or
license to operate under R.C. Chapter 1736. or 1740. (both chapters have been
repealed), or an insurer licensed under the Insurance Law is responsible for
the out-of-network risk as evidenced by both an evidence of coverage filing
under R.C. 1751.11 (evidence of subscriber's coverage for health care plan
under which health care benefits are provided) and a policy and certificate
filing under R.C. 3923.02 (sickness and accident insurance policy or
certificate). (R.C. 1751.01(S)(2), not
in the bill.)
2. "Policy
of sickness and accident insurance" includes any policy, contract, or
certificate of insurance against loss or expense resulting from the sickness of
the insured or from bodily injury or death of the insured by accident, or both
(R.C. 3923.01, not in the bill).
3. The provisions of the Physician-Health Plan Partnership Law addressing contractual issues generally: (1) require the Superintendent of Insurance to prescribe a standard credentialing form to be used by health insuring corporations in credentialing providers, (2) require a health insuring corporation to give participating providers an opportunity to take corrective action prior to terminating the provider's participation in the health insuring corporation, (3) prohibit the inclusion of certain provisions in a health insuring corporation's contract with a provider or health care facility, including "gag" clauses, and (4) require a health insuring corporation to make certain disclosures to participating providers and provider applicants.
4. The
Physician-Health Plan Partnership Law contains distinct provisions regarding
the termination of a provider's participation and a provider's option to take
corrective action. Under R.C. 1753.30
(see the last paragraph in "Background," above),
nothing in these termination provisions (described below) in the
Physician-Health Plan Partnership Law (R.C. Chapter 1753.) prevents or affects
the application to a health care plan of provisions in Title XVII (17) or XXXIX
(39) that would otherwise apply. Thus,
it appears that the bill's provision (R.C. 3963.02(E)) requiring a
health care contract to provide that a third-party payer or the provider may
terminate the contract without cause by giving the other party a 90-day
written notice preempts the following provisions in R.C. 1753.09 in the
Physician-Health Plan Partnership Law.
Under
R.C. 1753.09, except as described in the following paragraph, prior to
terminating the participation of a provider on the basis of the participating
provider's failure to meet the health insuring corporation's standards for
quality or utilization in the delivery of health care services, a health
insuring corporation must give the participating provider notice of the reason
or reasons for its decision to terminate the provider's participation and an
opportunity to take corrective action.
The health insuring corporation must develop a performance improvement
plan in conjunction with the participating provider. If after being afforded the opportunity to comply with the
performance improvement plan, the participating provider fails to do so, the
health insuring corporation may terminate the participation of the
provider. A participating provider
whose participation has so terminated may appeal the termination to the
appropriate medical director of the health insuring corporation. The medical
director must give the participating provider an opportunity to discuss with
the medical director the reason or reasons for the termination. If a satisfactory resolution of the appeal
cannot be reached, the participating provider may appeal the termination to a
panel composed of participating providers who have comparable or higher levels
of education and training than the participating provider making the
appeal. A representative of the
participating provider's specialty must be a member of the panel, if
possible. This panel must hold a
hearing and render its recommendation in the appeal within 30 days after
holding the hearing. The recommendation must be presented to the medical
director and to the participating provider.
The medical director must review and consider the panel's recommendation
before making a decision. The decision rendered by the medical director is
final. A provider's status as a participating provider remains in effect during
the appeal process unless the termination was based on any of the reasons
listed in the following paragraph.
(R.C. 1753.09(A), (B), and (C).)
Notwithstanding
the above provisions regarding the termination of the participation of a
provider on the basis of the participating provider's failure to meet the
health insuring corporation's standards for quality or utilization in the
delivery of health care services, a provider's participation may be immediately
terminated if the participating provider's conduct presents an imminent risk of
harm to an enrollee or enrollees; if there has occurred unacceptable quality of
care, fraud, patient abuse, loss of clinical privileges, loss of professional liability
coverage, incompetence, or loss of authority to practice in the participating
provider's field; or if a governmental action has impaired the participating
provider's ability to practice. The
termination provisions described in this and the preceding paragraph apply only
to providers who are natural persons.
Nothing in these provisions prohibits a health insuring corporation from
rejecting a provider's application for participation, or from terminating a participating
provider's contract, if the health insuring corporation determines that the
health care needs of its enrollees are being met and no need exists for the
provider's or participating provider's services. These provisions are not to be construed as prohibiting a health
insuring corporation from terminating a participating provider who does not
meet the terms and conditions of the participating provider's contract. (R.C. 1753.09(D), (E), and (F).)
5. The definition of "enrollee" in the bill includes all of the following: (a) "enrollee" and "subscriber" as defined in R.C. 1751.01(J) and (AA) ("enrollee" means any natural person who is entitled to receive health care benefits provided by a health insuring corporation; "subscriber" means a person who is responsible for making payments to a health insuring corporation for participation in a health care plan, or an enrollee whose employment or other status is the basis of eligibility for enrollment in a health insuring corporation), (b) "member" as defined by R.C. 1739.01(E) ("member" means an individual or an employer that is a member of an organization sponsoring a "multiple employer welfare arrangement," defined as an employee welfare benefit plan, trust, or any other arrangement, whether such plan, trust, or arrangement is subject to the "Employee Retirement Income Security Act of 1974," 29 U.S.C.A. 1001, that is established or maintained for the purpose of offering or providing, through group insurance or group self-insurance programs, medical, surgical, or hospital care or benefits, or benefits in the event of sickness, accident, disability, or death, to the employees, and their dependents, of two or more employers, or to two or more self-employed individuals and their dependents (R.C. 1739.01(F))), (c) insured and plan member pursuant to R.C. Chapter 3923. (Sickness and Accident Insurance), (d) "beneficiary" as defined by R.C. 3901.38(A) ("beneficiary" means any policyholder, subscriber, member, employee, or other person who is eligible for benefits under a "benefits contract," which means a sickness and accident insurance policy providing hospital, surgical, or medical expense coverage, or a health insuring corporation contract or other policy or agreement under which a third-party payer agrees to reimburse for covered health care or dental services rendered to beneficiaries, up to the limits and exclusions contained in the benefits contract), and (e) claimant pursuant to R.C. Chapter 4121. (Industrial Commission; Bureau of Workers' Compensation), 4123. (Workers' Compensation), 4127. (Public Works Relief Compensation), or 4131. (Separate Compensation Funds).
HISTORY
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ACTION |
DATE |
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|
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Introduced |
03-22-07 |
H0125-I-127.doc/ejs
[1] R.C. 1753.01(B) (not in
the bill), by reference to R.C. 1751.01(J), defines "enrollee" as any natural
person who is entitled to receive health care benefits provided by a health
insuring corporation.