HB 1610

Bill Subjects

Health, Health Care Costs; Health Insurance Health, Health Care Professionals Insurance, State Department And Agencies Welfare, Medicaid

Abstract

Amends the law concerning the prior authorization of health care services by a health plan (which includes a policy of accident and sickness insurance, a health maintenance organization contract, and the Medicaid risk based managed care program). Provides that: (1) if a health plan, during a six month evaluation period, approves at least 90% of a health care provider's requests for prior authorization for a particular type of health care service, the health plan may not require the health care provider to obtain prior authorization for that type of health care service for the entire duration of an exemption period of six calendar months immediately following the evaluation period; and (2) at the conclusion of the initial exemption period, the health plan shall continue granting consecutive exemption periods of six months to the health care provider unless the health plan rescinds the exemption. Provides that a health plan may rescind a health care provider's exemption only on the basis of a determination by a physician that, in at least five and not more than 20 cases randomly selected for review, less than 90% of the health care services provided by the health care provider met the health plan's medical necessity criteria. Authorizes a health care provider that is notified of the rescission of its exemption to initiate a review of the rescission by an independent review panel. Requires the independent review panel to determine whether at least 90% of the health care services provided by the health care provider met the health plan's medical necessity criteria. Requires a health plan to restore the health care provider's exemption if the independent review panel's determination is in favor of the health care provider. Requires the insurance commissioner to adopt rules.