To repeal sections 354.400, 354.430, 354.440 and 354.535, RSMo 1994, relating to health maintenance organizations, and to enact in lieu thereof twelve new sections relating to the same subject.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF MISSOURI,

AS FOLLOWS:

Section A. Sections 354.400, 354.430, 354.440 and 354.535, RSMo 1994, are repealed and twelve new sections enacted in lieu thereof, to be known as sections 354.400, 354.430, 354.440 354.535, 376.1270, 376.1275, 376.1279, 376.1280, 376.1281, 376.1282, 376.1283, and 376.1335, to read as follows:

354.400. As used in sections 354.400 to 354.550, the following terms [shall] mean:

(1) "Basic health care services", health care services which an enrolled population might reasonably require in order to be maintained in good health, including, as a minimum, emergency care, inpatient hospital and physician care, and outpatient medical services;

(2) "Director", the director of the department of insurance;

(3) "Emergency services", those health care services provided in a licensed hospital emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that urgent or unscheduled medical care is required;

(4) "Enrollee", an individual who [has been] is enrolled in a health maintenance organization;

[(4)] (5) "Evidence of coverage", any certificate, agreement, or contract issued to an enrollee setting out the coverage to which [he] the enrollee is entitled;

[(5)] (6) "Health care services", any services included in the furnishing to any individual of medical or dental care or hospitalization, or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability;

[(6)] (7) "Health maintenance organization", any person which undertakes to provide or arrange for basic and supplemental health care services to enrollees on a prepaid basis, or which meets the requirements of section 1301 of the United States Public Health Service Act;

[(7)] (8) "Health maintenance organization plan", any arrangement whereby any person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services and at least part of such arrangement consists of providing and assuring the availability of basic health care services to enrollees, as distinguished from mere indemnification against the cost of such services, on a prepaid basis through insurance or otherwise, and as distinguished from the mere provision of service benefits under health service corporation programs;

[(8)] (9) "Individual practice association", a partnership, corporation, association, or other legal entity which delivers or arranges for the delivery of health care services and which has entered into a services arrangement with persons who are licensed to practice medicine, osteopathy, dentistry, chiropractic, pharmacy, podiatry, optometry, or any other health profession and a majority of whom are licensed to practice medicine or osteopathy. Such an arrangement shall provide:

(a) That such persons shall provide their professional services in accordance with a compensation arrangement established by the entity; and

(b) To the extent feasible for the sharing by such persons of medical and other records, equipment, and professional, technical, and administrative staff;

[(9)] (10) "Medical group/staff model", a partnership, association, or other group:

(a) Which is composed of health professionals licensed to practice medicine or osteopathy and of such other licensed health professionals (including dentists, chiropractors, pharmacists, optometrists, and podiatrists) as are necessary for the provisions of health services for which the group is responsible;

(b) A majority of the members of which are licensed to practice medicine or osteopathy; and

(c) The members of which (i) as their principal professional activity over fifty percent individually and as a group responsibility engaged in the coordinated practice of their profession for a health maintenance organization; (ii) pool their income from practice as members of the group and distribute it among themselves according to a prearranged salary or drawing account or other plan, or are salaried employees of the health maintenance organization; (iii) share medical and other records and substantial portions of major equipment and of professional, technical, and administrative staff; (iv) establish an arrangement whereby an enrollee's enrollment status is not known to the member of the group who provides health services to the enrollee;

[(10)] (11) "Person", any partnership, association, or corporation;

[(11)] (12) "Provider", any physician, hospital, or other person which is licensed or otherwise authorized in this state to furnish health care services;

[(12)] (13) "Uncovered expenditures", the costs of health care services that are covered by a health maintenance organization, but that are not guaranteed, insured, or assumed by a person or organization other than the health maintenance organization, or those costs which a provider has not agreed to forgive enrollees if the provider is not paid by the health maintenance organization.

(14) "Medically necessary services" and "medical necessity", those services which the treating physician believes, in accordance with prevailing professional medical standards of care, are reasonable and necessary to establish a diagnosis and provide palliative, curative or restorative treatment for physical and mental health conditions.

354.430. 1. Every enrollee residing in this state is entitled to evidence of coverage. If the enrollee obtains coverage through an insurance policy or a contract issued by a health services corporation, whether by option or otherwise, the insurer or the health services corporation shall issue the evidence of coverage. Otherwise the health maintenance organization shall issue the evidence of coverage.

2. No evidence of coverage, or amendment thereto, shall be issued or delivered to any person in this state until a copy of the form of the evidence of coverage, or amendment thereto, has been filed with the director.

3. An evidence of coverage shall contain:

(1) No provisions or statements which are unjust, unfair, inequitable, misleading, or deceptive, or which encourage misrepresentation, or which are untrue, misleading, or deceptive as defined in subsection 1 of section 354.460; and

(2) A clear and complete statement, if a contract, or a reasonably complete summary, if a certificate, of:

(a) The health care services and the insurance or other benefits, if any, to which the enrollee is entitled;

(b) Any exclusions, restrictions or limitations on the services, kind of services, benefits or kinds of benefits to be provided, including any deductible or copayment feature or any other potential out-of-pocket expense;

(c) Where and in what manner information is available as to how services may be obtained;

(d) The total amount of payment for health care services and the indemnity or service benefits, if any, which the enrollee is obligated to pay with respect to individual contracts; [and]

(e) A clear and understandable description of the health maintenance organization's method for resolving enrollee complaints[.]; and

(f) Whether and how coverage decisions can be fairly and simply appealed within the corporation or organization.

4. Any subsequent change in an evidence of coverage may be made in a separate document issued to the enrollee.

5. A copy of the form of the evidence of coverage to be used in this state, and any amendment thereto, shall be subject to the filing of subsection 2 of this section unless it is subject to the jurisdiction of the director under the laws governing health insurance or health services corporations, in which event the filing provisions of those laws shall apply.

6. The evidence of coverage must be objective, truthful, and written in consumer tested terms.

354.440. 1. Every health maintenance organization shall make available to its enrollees:

(1) The most recent annual statement of financial condition, including a balance sheet and summary of receipts and disbursements;

(2) A description of the organizational structure and operation of the health care plan and a summary of any material changes since the issuance of the last report;

(3) A description of services and information as to where and how to secure them; and

(4) A clear and understandable description of the health maintenance organization's method for resolving enrollee complaints.

2. Every health maintenance organization shall make available to its potential enrollees a concise, written statement of the following:

(1) The health care services and the insurance or other benefits available;

(2) Any exclusions, restrictions or limitations on the services, or types of services to be provided, including but not limited to:

(a) Choice of physicians and pharmacists;

(b) Referral to specialty physicians and other providers;

(c) Clinical laboratory tests;

(d) Diagnostic tests including mammography exams and screening tests for osteoporosis and prostate cancer;

(e) Dental services;

(f) Coverage of specific prescription drugs including the use of formularies and prior approval procedures;

(g) Coverage of eye care services and providers;

(h) Mental health services and providers including psychiatrists and psychologists; and

(i) Length of stay.

(3) The types and amounts of any deductibles, copayments and other potential out-of-pocket expenses;

(4) How and whether coverage decisions can be fairly and simply appealed; and

(5) Whether coverage may be denied because of a preexisting condition.

3. All descriptions and explanations for potential enrollees under this section must be objective, truthful, and in consumer tested terms.

354.535. [In the event that] 1. If a pharmacy, operated by or contracted with by a health maintenance organization, is closed or is unable to provide health care services to an enrollee in an emergency, a pharmacist may take an assignment of such enrollee's right to reimbursement, if the policy or contract provides for such reimbursement, for those goods or services provided to a [member] enrollee of a health maintenance organization. No health maintenance organization shall refuse to pay the pharmacists any payment due the enrollee under the terms of the policy or contract.

2. A health maintenance organization plan shall include twenty-four hour access to emergency services. A plan may not require prior authorization for emergency services, which include a medical screening exam and stabilizing treatment as defined in Section 1867 of the Social Security Act, 42 U.S.C. Section 1395(dd), 1986.

3. A health maintenance organization plan may require prior authorization for medically necessary services arising from a medical screening exam. A health maintenance organization plan or its contracting medical providers shall provide a twenty-four hour access line for enrollees and providers to request timely authorization for medically necessary care. Prior authorization shall be deemed to be approved unless the request for authorization is denied within thirty minutes. A physician shall be available to the personnel staffing the access line whenever necessary to make a determination regarding preauthorization.

4. A health maintenance organization plan shall reimburse providers for emergency services, federally mandated screening examinations as required by Section 1867 of the Social Security Act, and care of its enrollees, until such care results in the stabilization of the enrollee and the health maintenance organization plan assumes care of the enrollee, whether or not such providers have a contractual relationship with the health maintenance organization plan.

5. If a person staffing the access line for a health maintenance organization and the attending physician disagree concerning the proper treatment for an enrollee who, following emergency services, is unstable as defined by section 1867, 42 U.S.C. Section 1395(dd), 1986 of the Social Security Act, the health maintenance organization shall assume all responsibility for actions which are taken against the recommendations of the attending physician.

6. If a primary care physician or health maintenance organization has authorized the evaluation or treatment of an enrollee, the health maintenance organization may not retrospectively deny the authorization for such evaluation and treatment.

376.1270. 1. Sections 376.1270 through 376.1283 of this act shall be known and may be cited as the "Patient Fairness Act".

2. As used in this act, the following terms mean:

(1) "Director", the director of the department of insurance;

(2) "Emergency services", those health care services provided in a licensed hospital emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that urgent or unscheduled medical care is required;

(3) "Health care provider" or "provider", any physician, hospital, or other person which is licensed or otherwise authorized in this state to furnish health care services, except the provisions of this act shall not apply to persons who engage in the sale of pharmaceutical products or the processing of prescription drug claims in interstate commerce, provided that the revenue from such activities in interstate commerce exceeds fifty percent of total revenue of such person;

(4) "Managed care contractor", a person who:

(a) Establishes, operates or maintains a network of participating providers; and

(b) Contracts with an insurance company, a hospital or medical service plan, an employer, an employee organization, or any other entity providing coverage for health care services to operate a managed care plan;

(5) "Managed care entity", a licensed insurance company, hospital or medical service plan, health maintenance organization, an employer or employee organization, provider groups or a managed care contractor that operates a managed care plan;

(6) "Managed care plan", a plan operated by a managed care entity that provides for the financing and delivery of health care services to persons enrolled in such plan through:

(a) Arrangements with selected providers to furnish health care services;

(b) Explicit standards for the selection of participating providers; and

(c) Financial incentives for persons enrolled in the plan to use the participating providers and procedures provided for by the plan;

(7) "Medical loss ratios", the percentage of total premium revenues spent on medical care in relation to the percentage of total premium revenues spent on administrative costs, including but not limited to, a financial itemization of the premium revenues spent on marketing, executive salaries, non- medical personnel compensation and managed care plan profits;

(8) "Medically necessary services" and "medical necessity", those services which the treating physician believes, in accordance with prevailing professional medical standards of care, are reasonable and necessary to establish a diagnosis and provide palliative, curative or restorative treatment for physical and mental health conditions;

(9) "Participating provider", any health care provider that has entered into an agreement with a managed care entity to provide such services or supplies to a patient enrolled in a managed care plan;

(10) "Provider network", those providers who have entered into a contract or agreement with the managed care plan under which such providers are obligated to provide services to eligible individuals enrolled in the managed care plan, or have an agreement to provide services on a fee-for-service basis;

(11) "Qualified managed care plan", a managed care plan that the director certifies, upon application by the program, as meeting the requirements of this act.

376.1275 Nothing in this act shall be construed as prohibiting the following:

(1) An individual from purchasing any health care services with that individual's own funds, whether such services are covered within the individual's benefit package or from another health care provider or plan;

(2) Employers from providing coverage for benefits in addition to the managed care plan's benefit package.

376.1279 1. The director shall establish a process for certification of managed care plans meeting the requirements of this section. The director shall establish procedures for the periodic review and recertification of qualified managed care plans. The director shall terminate or suspend the certification of a previously qualified managed care plan if the director determines that such plan no longer meets the applicable requirements for certification. Before effecting a termination or suspension, the director shall provide the managed care plan notice and opportunity for a hearing on the proposed termination.

2. An eligible organization, as defined in section 1876(b) of the Social Security Act, shall be deemed to meet the requirements of subsection 4 of this section for certification as a qualified managed care plan.

3. If the director finds that a national accreditation body establishes requirements for accreditation of a managed care plan that are at least equivalent to requirements established under subsection 4 of this section, the director may, to the extent appropriate, treat a managed care plan thus accredited as meeting the requirements of subsection 4 of this section.

4. The director shall establish standards for the certification of qualified managed care plans that conduct business in this state, including standards whereby:

(1) Prospective enrollees in managed care plans must be provided information as to the terms and conditions of the plan so that they can make informed decisions about accepting a certain system of health care delivery. Where the plan is described orally to enrollees, easily understood, truthful, and objective terms shall be used. All written plan descriptions shall be in a readable and understandable format, consistent with standards developed for supplemental insurance coverage under Title XVIII of the Social Security Act. This format shall be standardized so that customers can compare the attributes of the plans. Specific items that shall be included are:

(a) Coverage provisions, including amount, duration, and scope of coverage, benefits, and any exclusions of health care services by category of service, health care provider, and if applicable, by specific service;

(b) Any and all prior authorization or other review requirements including but not limited to preauthorization review, concurrent review, post-service review, post-payment review and any procedures that may lead the patient to be denied coverage for or restricts or limits access to and delivery of a particular service;

(c) Financial arrangements or contractual provisions with review companies or any other health care provider that would limit the type or amount, duration and scope of services offered, restrict or limit referral or treatment options, or negatively affect the health care provider's fiduciary responsibility to patients, including but not limited to financial incentives to limit, restrict or deny access to or delivery of medical or other services;

(d) An explanation of how plan limitations or restrictions impact enrollees, including information on enrollee financial responsibility for payment for coinsurance or other non-covered or out-of-plan services;

(e) Medical loss ratios;

(f) Enrollee satisfaction statistics, including re-enrollment statistics, reasons for leaving the plan, and the number of complaints filed against the plan;

(g) An explanation of the internal complaint resolution process maintained by the plan as required by section 354.445, RSMo, and information on accessing and utilizing the customer quality assurance process maintained by the state;

(h) A list of the names, locations and specialties of the participating providers and the financial arrangements between the managed care plan and the providers; and

(i) An explanation that participating providers have agreed, or have not agreed, to seek additional payments from patients for performing covered services if that is the agreement;

(2) Plans shall demonstrate that they have adequate access to health care providers so that all covered health care services will be provided in a timely fashion. Plans shall permit enrollees to select a participating provider to serve as the enrollee's primary care provider. This requirement cannot be waived and shall be met in all areas where the plan has enrollees, including rural areas;

(3) Plans shall meet financial reserve requirements that are established to assure proper payment for covered services provided;

(4) All plans shall be required to establish a mechanism, with defined rights, under which participating providers provide input into the plan's health care policy, including coverage of new technology and procedures, utilization review criteria and procedures, quality and credentialing criteria, and health care management procedures;

(5) All plans shall be required to credential all health care providers used to deliver those health services offered by the plan, and the plan shall not discriminate against any class of health care provider on the basis of licensure. All plans shall allow all providers within the plan's geographical service area, whose scope of licensure authorizes the delivery of such covered services, to apply for such credentials. For the purposes of credentialing its participating providers, every plan shall have a credentialing committee with appropriate representation of the applicant's specialty. Credentialing shall be based on objective standards of quality established with input from health care providers credentialed in the plan, and such standards shall be made available to applicants and enrollees. When economic considerations are part of the decision, objective criteria shall be used and shall be made available to applicants, participating providers and enrollees. Any economic profiling of health care providers shall be adjusted to recognize case mix, severity of illness, age of patients and other features of a health care provider's practice that may account for higher than or lower than expected costs. Profiles shall be made available to those so profiled. When graduate medical education is a consideration in credentialing, equal recognition shall be given to training programs accredited by the Accrediting Council of Graduate Medical Education and by the American Osteopathic Association. Plans shall not discriminate against enrollees because of an enrollee's health or medical condition. Plans shall also be prohibited from discriminating against health care providers whose practices contain a substantial number of such patients. All decisions shall be made on the record, and the health care provider shall be provided with all reasons used, if an application is denied or the contract not renewed. A plan's decision to deny an application shall not be subject to the appeals process set out in subsection 5 of this section. Plans shall not be allowed to include clauses in provider contracts that allow for the plan to terminate the contract without cause;

(6) All plans shall pay for any screening to determine if an enrollee has a medical emergency for any necessary emergency services, including treatment and stabilization, whether or not the emergency care is provided by a participating provider. In the services of a preferred provider plan, reimbursement must be at the preferred provider level if the patient cannot reasonably reach a preferred provider and until he or she can reasonably be expected to transfer to a preferred provider;

(7) All plans must give at least ninety days of notice to enrollees before dropping any participating provider from its provider network. If such notice is not provided, the managed care plan must continue to pay the provider at no less than the contract or preferred provider rate for ninety days after the termination if the provider is willing to continue treating the patient;

(8) Managed care plans shall provide all medically necessary services that are within the enrollee's benefit package. No plan may use any financial incentive to induce participating providers to limit medically necessary services, and no plan may require providers to pay for damages caused by the managed care plan;

(9) All plans requiring primary care physicians must have application forms which allow an applicant to choose a primary care physician. If an enrollee does not select a primary care physician upon joining, the plan may assign him or her to a primary care physician in the ZIP code nearest to the residence or place of employment of the enrollee. Assignment must result as far as possible in fair and equal distribution of patients among providers on the network. Patients shall have the right to change primary care physicians, although the plan may limit such changes to four in a one-year period;

(10) All plans must make application information available upon request to any provider who seeks admission to the managed care plan. Any plan refusing or terminating a provider must give a written explanation to the provider. A participating provider terminated for cause has the right to a review by an advisory panel, including at least one person from his or her specialty if one is available;

(11) Any plan may refuse admission without further cause upon the basis that it already has enough providers;

(12) All plans shall allow referrals for the use of providers not in the managed care plan when covered services are not available from providers contracted with the managed care plan. If a plan opposes such a referral, there must be a review by a provider of the same or similar specialty as the one to which the referral is requested;

(13) All plans must give employers and others who contract with the plan the right to unilaterally cancel their managed care contract if the plan makes a material change affecting the benefits or services provided;

(14) All plans must pass savings through to patients from fee discounts negotiated between physicians and insurance companies;

(15) Plans may not retaliate against enrollees, employers or health care providers because of complaints or appeals on behalf of a patient.

5. The director shall establish a due process appeal mechanism for providers for all decisions to terminate for cause or for a failure to renew a contract for cause in lieu of termination. Appeals for all decisions to terminate for cause or for a failure to renew a contract for cause in lieu of termination may be made to the department in the same manner as provided for in sections 536.060 to 536.100, RSMo.

6. The same standards and procedures used for an application for credentials shall also be used in the cases where the plan seeks to reduce or withdraw such credentials. Prior to initiation of a proceeding leading to a termination of a contract for cause, the health care provider shall be provided notice, an opportunity for discussion, and an opportunity to enter into and complete a corrective action plan, except in cases where there is imminent harm to patient health or an action by a state licensing board or other government agency that effectively impairs the health care provider's ability to practice his or her profession within the jurisdiction.

7. An enrollee or participating provider who has been aggrieved by any decision of a managed care entity shall, upon request, be provided a written statement of the reasons for the decision.

8. (1) The director shall establish a consumer quality assurance process to resolve complaints filed by enrollees and participating providers. The department may contract with an independent review entity for the purpose of complying with this section. The consumer quality assurance process shall, at a minimum, provide for the timely review of complaints relating to:

(a) A managed care entity decision regarding the medical necessity or therapeutic value of any procedure, treatment or service;

(b) A managed care entity decision to deny or discontinue enrollment of an enrollee;

(c) A claim of inadequate access to health care services or providers;

(d) A claim of failure to provide covered services in the amount, duration or scope appropriate for the enrollee's condition.

The review and decision related to all complaints shall be completed within fifteen days from the date the complaint is received.

(2) The director may impose an administrative penalty against the managed care entity of not more than one thousand dollars per day per violation of the decision rendered by the consumer quality assurance process, in addition to any other discipline or sanction which may be imposable by law, with the revenue generated through administrative penalties to be placed in the "Consumer Quality Assurance Process Fund" which is hereby created in the central treasury and to be disbursed for the costs of administering this complaint process.

(3) The enrollee and participating provider shall be provided written notice of their right to utilize the consumer quality assurance process at the time of enrollment, annually thereafter and at the time of notification of any denial, limitation, reduction or termination of coverage for a service.

(4) Managed care entities are prohibited from retaliating against enrollees, health care providers or employers on the basis of complaints filed pursuant to this section.

(5) The director shall set the amount of all fees authorized and required by this act and the provisions of sections 354.400 to 354.550, RSMo, by rule and regulation. The director may assess a fee upon all qualified managed care entities at the time of certification and annually thereafter. All such fees shall be set at a level designed to produce revenue which shall not substantially exceed the cost and expense of administering the provisions of this act and sections 354.400 to 354.550, RSMo and shall be placed in the consumer quality assurance process fund.

9. Procedures shall be established to ensure that all federal and state laws designed to protect the confidentiality of provider and individual medical records are followed.

10. Standards shall first be established under this section not later than twelve months after the effective date of this section. In developing standards under this section, the director shall:

(1) Review standards in use by national private accreditation organizations and the National Association of Insurance Commissioners;

(2) Recognize, to the extent appropriate, differences in the organizational structure and operation of managed care plans; and

(3) Establish procedures for the timely consideration of applications for certification by managed care plans.

11. The director shall periodically review the standards established under this section, and may revise the standards from time to time to assure that such standards continue to reflect appropriate policies and practices for the cost-effective and medically appropriate use of services within managed care plans.

12. Nothing in sections 376.1270 through 376.1283 of this act shall be deemed to create a cause of action by any party, nor shall this act restrict any cause of action or defense to any cause of action pursuant to any other provision of law.

13. No rule or portion of a rule promulgated under the authority of sections 376.1270 through 376.1283 shall become effective unless it has been promulgated pursuant to the provisions of section 536.024, RSMo.

376.1280 1. Any managed care entity that offers a plan that restricts access to providers or controls utilization shall offer to all eligible enrollees the opportunity to obtain from the plan coverage for out-of-network services through a point of service option, as defined by subsection 2 of this section, at the time of enrollment and at least for a continuous one-month period annually thereafter.

2. For the purposes of sections 376.1270 through 376.1283, a point of service option means a plan that provides additional coverage and/or access to providers not contracted with the managed care plan to an eligible enrollee when the plan restricts access to items and services provided by a health care provider who is not a member of the plan's provider network, or that may cover any other services the enrollee seeks, whether such covered services are provided in or outside of the enrollee's plan.

3. A plan may charge an enrollee who opts to obtain point of service coverage an alternative premium that reflects no more than the actuarial value of such coverage.

4. A point of service option may require payment of coinsurance for an out-of-network item or service with the applicable coinsurance percentage to be based on the plan's actual payment for items or services. No copayment shall exceed the rate established by the Missouri Consolidated Health Care Plan.

5. The point of service plan shall include coverage for all health services provided for in the standardized plan.

376.1281. All managed care entities shall be in compliance with the provisions of sections 376.1270 through 376.1283 by January 1, 1997.

376.1282. Nothing in sections 376.1270 through 376.1283 shall be construed as an "any willing provider provision", that requires any managed care plan to accept the application of any provider willing to abide by the terms and conditions of that plan's contract.

376.1283. The provisions of section 376.1280 shall not apply to those managed care plans that provide health care coverage to medicaid recipients. Nothing in section 376.1280 of this act shall obligate the state of Missouri to pay the additional cost for the opportunity to obtain from a health care plan additional services beyond those provided for by section 208.152, RSMo, or access to non-network providers or both for needy persons who are eligible to receive medical assistance to the extent and in the manner provided in section 208.151, RSMo. The additional services or access to non-network providers or both shall not be provided by a health care plan if the state does not pay the additional cost.

376.1335. 1. As used in this section, the following terms mean:

(1) "Dermatological services", services ordinarily and customarily rendered by a physician specializing in the practice of dermatology;

(2) "Health benefit policy", any individual or group plan, policy, or contract for health care services issued, delivered, issued for delivery, or renewed in this state by a health care corporation, health maintenance organization, accident and sickness insurer, fraternal benefit society, nonprofit hospital service corporation, nonprofit medical service corporation, or similar entity regulated by the department of insurance;

(3) "Primary care physician", a physician who is board certified or board eligible and practices in general internal medicine, pediatrics, obstetrics, gynecology, or family practice.

2. No health benefit policy which is issued, delivered, issued for delivery, or renewed in this state on or after August 28, 1996, shall require as a condition to the coverage of dermatological services that an enrollee, subscriber, or insured first obtain a referral from a primary care physician and no such health benefit policy shall discriminate against or impose any extraordinary copayments, deductibles, or other financial penalties upon an enrollee for seeking dermatological services without first obtaining a referral from a primary care physician.

3. This section shall not apply to supplemental insurance policies, including accident-only policies, specified disease policies, hospital policies providing a fixed daily benefit only, Medicare supplement policies, and long-term care policies.