SCS for SBs 764, 772, 902 & 696 - This substitute contains the following sections concerning health maintenance organizations:

(1) Emergency Services (similar to SB 853) - This section of the substitute regulates the actions of health maintenance organizations (HMOs) with regard to access to emergency services. HMOs must provide 24 hour access to emergency services. HMOs must provide an access line to authorize medically necessary care.

HMO plans must reimburse emergency service providers even if they do not have a contractual arrangement with those providers. HMOs assume full legal and financial responsibility for a patient if the HMO acts against the recommendations of the attending physician of an individual following emergency services. According to the provisions of this act, HMOs may not retrospectively deny the authorization for an evaluation or treatment.

(2) The Patient Fairness Act (SB 764 & 772) - This section of the substitute directs the Department of Insurance to certify managed care plans. Before plans may be certified they must comply with certain standards including: -Plans shall disclose coverage and exclusion provisions, prior authorization requirements, all financial arrangements, statements of how provisions may financially impact enrollees, medical loss ratios, enrollee satisfaction statistics, explanation of internal complaint resolution process, and an explanation that participating providers have agreed or not agreed to seek additional payments. -Plans shall demonstrate they have adequate access to health care providers so that all covered health care services will be provided in a timely fashion. -Plans shall meet financial reserve requirements. -Plans shall give physicians a voice in health care policy. -Plans shall credential all health care providers used to deliver health care services. -Plans shall pay for medical screening exams. -Plans must give enrollees 90 days notice before dropping providers. -Plans must provide all medically necessary services that are within the enrollee's benefit package. -Plans must allow enrollees to pick their primary care provider, and assign providers evenly for those who do not choose one. -Plans must provide a hearing for all decisions to terminate a provider. -Plans must give those who contract with the plan the right to unilaterally cancel their contract if there is a material change in the plan. -Plans must pass savings through to enrollees from fee discounts. -Plans must offer a POS option with certain restrictions.

(3) Direct Access to Dermatologists (SB 902) - This section of the substitute mandates that health maintenance organizations allow for direct access to dermatologists, rather than requiring enrollees to first visit their primary care provider.

(4) Notification Requirements (SB 696) - This section of the substitute directs HMOs to disclose the following: -exclusions, restrictions, and preexisting condition limitations; -choice of physicians, pharmacists, referral to specialists, dental services, mental health services, and eye services if covered; -length of stay; -deductibles, copayments, and out-of-pocket expenses; -appeals process.
JON HAGLER