HB0367 Barnes, James

P R E F I L E D

HB 367 -- Managed Care

The bill requires the Department of Insurance to establish standards for managed care plans by August 28, 1996. Certain managed care plans that meet federal standards or are nationally accredited are not required to meet the standards. The department is required to establish an appeal process for entities aggrieved by department decisions.

Standards required of managed care plans include providing information to prospective enrollees concerning: plan benefits and exclusions; review procedures for denial of coverage; financial arrangements with providers that limit services; responsibility of the enrollee for payment of coinsurance, noncovered services or out-of-plan services; loss ratios; and enrollee satisfaction.

Other standards include requiring plans to:

(1) Show adequate access to health care providers;

(2) Meet certain reserve requirements;

(3) Have physician participation in deciding plan policy; and

(4) Issue credentials to physicians and allow physicians in the plan service area to apply for credentials.