Bill Text: MS HB1329 | 2011 | Regular Session | Introduced
Bill Title: Managed care plans; regulate contracts with participating providers.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Failed) 2011-02-01 - Died In Committee [HB1329 Detail]
Download: Mississippi-2011-HB1329-Introduced.html
MISSISSIPPI LEGISLATURE
2011 Regular Session
To: Public Health and Human Services
By: Representative DeLano
House Bill 1329
AN ACT TO CREATE THE MANAGED CARE PLAN AND PARTICIPATING PROVIDER CONTRACTING ACT; TO PROVIDE DEFINITIONS FOR THE ACT; TO REQUIRE GOOD FAITH NEGOTIATIONS BETWEEN MANAGED CARE PLANS AND PARTICIPATING PROVIDERS; TO PROVIDE MINIMUM STANDARDS FOR MANAGED CARE PLAN CONTRACTS WITH PROVIDERS; TO PRESCRIBE REQUIREMENTS FOR MANAGED CARE PLAN'S DETERMINATION OF ENROLLEE ELIGIBILITY AND COVERED SERVICES; TO PROVIDE REQUIREMENTS FOR HEALTH CARE PROVIDER CREDENTIALING; TO PROVIDE REQUIREMENTS FOR HEALTH CARE PROVIDER CLAIM SUBMISSIONS; TO PROVIDE CERTAIN ADMINISTRATIVE POLICIES AND PROCEDURES; TO PROVIDE REQUIREMENTS FOR DISPUTE RESOLUTION; TO PROHIBIT A MANAGED CARE PLAN FROM COMPELLING A HEALTH CARE PROVIDER TO PARTICIPATE IN ALL OF THE MANAGED CARE PLAN'S BUSINESS LINES; TO REQUIRE COMPLIANCE WITH THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996; TO AUTHORIZE THE MISSISSIPPI INSURANCE DEPARTMENT TO ASSESS AN ADMINISTRATIVE PENALTY FOR A VIOLATION OF THIS ACT; TO AUTHORIZE THE MISSISSIPPI INSURANCE DEPARTMENT TO PROMULGATE RULES AND REGULATIONS TO ADMINISTER AND ENFORCE THIS ACT; AND FOR RELATED PURPOSES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:
SECTION 1. This act shall be known and may be cited as the Managed Care Plan and Participating Provider Contracting Act.
SECTION 2. The following words and phrases when used in this act shall have the meanings given to them in this section unless the context clearly indicates otherwise:
(a) "Commissioner" means the Commissioner of Insurance.
(b) "CPT codes" means Current Procedural Terminology codes established by the American Medical Association or the Centers for Medicare and Medicaid Services.
(c) "Department" means the Mississippi Insurance Department.
(d) "Enrollee" means a policyholder, subscriber, covered person, covered dependent or spouse or other person who is entitled to receive health care benefits from a managed care plan subject to this act.
(e) "Health care provider" means a physician or other health care professional who is licensed or certified and regulated by the state to provide health care services to health care consumers and who enters into contracts with managed care plans. The term includes a physician, podiatrist, optometrist, psychologist, physical therapist, certified nurse practitioner, registered nurse, nurse midwife, physician assistant, chiropractor, dentist, pharmacist and professional who provides behavioral health services. The term also includes an integrated delivery system in the context of its contractual relations with managed care plans.
(f) "Health care service" means a covered diagnostic or therapeutic service, surgical procedure, medical supplies, equipment, drugs or biologics, admission to a health care facility or other service, including behavioral health service, that is prescribed, proposed or provided by a health care provider to the enrollee of a managed care plan.
(g) "HIPAA" means the Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191, 110 Stat. 1936).
(h) "Integrated delivery system" or "IDS" means a partnership, association, corporation or other legal entity that:
(i) Enters into a contractual arrangement with a managed care plan;
(ii) Employs or has contracts with its participating providers;
(iii) Agrees under its arrangements with the managed care plan to provide or arrange for the provision of a defined set of health care services to the plan's enrollees principally through its participating providers; and
(iv) Assumes some responsibility for disease management programs, quality assurance, utilization review, credentialing, provider relations or related functions.
(i) "Managed care entity" means a managed care entity as defined in Section 83-41-403.
(j) "Managed care plan" means a managed care plan as defined in Section 83-41-403.
(k) "Managed care plan contract." A written agreement between a health care provider and a managed care plan or managed care contractor for a managed care plan that establishes the responsibilities and obligations of the parties to each other and to the enrollees of the plan. The term includes all attachments and appendices to the contract and other documents that are referred to in the agreement that may affect the health care provider's ability to make an informed decision and may prompt the provider to seek additional information or clarification from the health plan before entering into the contract. The term does not include an employment contract between a managed care organization or a managed care plan and health care provider.
(l) "Managed care contractor" means a managed care contract as defined in Section 83-41-403.
(m) "Participating provider" means a participating provider as defined in Section 83-41-403.
SECTION 3. (1) A managed care plan shall negotiate the terms of any contract in good faith with any health care provider.
(2) A health care provider shall have the right of at least sixty (60) days from receipt to review any managed care plan contract and amendments thereto before execution of the contract or amendments is required and before revisions to an existing contract become effective.
(3) A managed care plan shall:
(a) Supply copies of every appendix, attachment or other document referred to in the contract to allow the health care provider to make an informed decision whether to enter into
the contract.
(b) Send these materials with proposed contracts to health care providers.
(c) In the event any materials are missing or a health
care provider requests supplementary information, supply the materials within seven (7) business days of the request.
(4) No managed care plan may be required to give a health care provider any proprietary materials the disclosure of which would harm the plan's competitive or financial position in the marketplace.
(5) No managed care plan may include in any contract terms or conditions to which a reasonable and prudent health care provider would not agree.
(6) Each managed care plan contract shall include appendices that define:
(a) Key terms and phrases in the contract.
(b) The diagnostic and therapeutic services that the plan commonly authorizes.
(c) The prescription drug formularies commonly used by
the managed care plan or its pharmacy benefit manager.
SECTION 4. A managed care plan contract shall adhere to the following minimum standards to facilitate review by and negotiation with health care providers:
(a) The managed care plan contract shall be in plain English and readily understandable to the average reasonable physician or other health care provider.
(b) The managed care plan contract shall explicitly define the managed care plan's responsibilities to the health care provider, the provider's responsibilities to the plan and their joint responsibilities to managed care plan enrollees.
(c) The managed care plan contract or its cover materials shall clearly and conspicuously disclose to the health care provider the names, telephone numbers, facsimile numbers and e-mail addresses of managed care plan officials who can supply the materials necessary to answer any questions in order to make an informed decision about whether to enter into the contract.
(d) The managed care plan contract shall include an indemnification clause that commits a participating provider to indemnify the plan in the event of any liability claim and shall clearly state that each party is fully responsible and liable for its own actions.
(e) The managed care plan contract shall state that the managed care plan may not use a health care provider's agreement to the contract to represent that provider as a member of any network other than the one committed to in the agreement.
(f) The managed care plan contract shall state that the managed care plan may not compel a health care provider to enter into an exclusive contract that precludes the provider from entering into an agreement with other entities.
(g) The managed care plan contract shall not exceed one (1) year in duration and may be renewed automatically only if the managed care plan notifies the participating provider of the pending renewal sixty (60) days prior to the renewal date. The managed care plan contract may renew automatically under the same terms and conditions if the health care provider does not respond to the managed care plan's reminder notice within the sixty-day period.
(h) The managed care plan contract shall include an appeal process for health care providers to seek reconsideration of any decision by the managed care plan to terminate the contract for cause. To ensure appropriate continuity of care for enrollees, the managed care plan contract shall define the obligations of the managed care plan and the health care providers to enrollees after the termination date of the contract. The managed care plan contract shall notify enrollees of the termination of any contract with a health care provider.
SECTION 5. (1) A managed care plan shall quickly and efficiently determine an enrollee's eligibility for coverage and reimbursement of health care services by the plan.
(2) A managed care plan shall provide information systems that allow participating providers to determine an enrollee's eligibility for services that include either a toll-free hotline or a secure Internet website.
(3) (a) If a managed care plan erroneously informs a participating provider that a person is enrolled and eligible for services when in fact the person is not, the managed care plan shall reimburse the provider for all covered services rendered up to the time that the plan notifies the provider and nonenrolled person of the error.
(b) The managed care plan may not bear any financial responsibility for services that the participating provider renders to the nonenrolled person after the date of notification.
(c) The health care provider may bill the former nonenrolled person for these services.
(4) A managed care plan shall adopt and maintain a definition of "medical necessity" as health care services or products that a prudent physician would provide to a patient for the purposes of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is in accordance with generally accepted standards of medical practice and clinically appropriate in terms of type, frequency, extent, site and duration.
SECTION 6. (1) (a) A managed care plan shall complete the credentialing of a health care provider or health care facility within forty-five (45) days or less of receipt of a completed application.
(b) The managed care plan shall notify applicants of any discrepancies and omissions in their application and supporting documentation within five (5) business days of receipt of such application and shall expedite consideration of the corrected application upon receipt.
(c) The managed care plan may not recredential health care providers more frequently than is consistent with the standards for health plan credentialing of participating physicians established by the National Committee for Quality Assurance.
(d) The managed care plan shall complete any recredentialing of a health care provider under contract within forty-five (45) days.
(2) (a) A managed care plan shall agree to make retroactive reimbursement for any claims that a participating provider incurs during the credentialing process when the provider is successfully credentialed by the plan.
(b) During the credentialing process, health care providers may not submit their claims for health care services provided to enrollees until credentialing is completed.
(c) If the health care provider or health care facility
does not successfully complete the credentialing process, neither the managed care plan nor its enrollee bear financial responsibility for any pending claims.
SECTION 7. (1) (a) A managed care plan contract shall require health care providers to submit claims on the Health Care Financing Administration Form 1500 or its successor, as defined by the Centers for Medicare and Medicaid Services.
(b) No managed care plan may require health care providers to submit claims electronically unless the plan offers the appropriate tools and infrastructure to facilitate electronic claims submission.
(2) (a) No managed care plan may withhold future reimbursement as a means to recoup payments believed to have been made in error.
(b) A managed care plan shall establish, disclose in contracts and include in provider procedure or policy manuals the administrative process by which the plan may challenge and seek to recover potentially erroneous payments to health care providers.
(c) A managed care plan shall disclose its intent to challenge a potentially erroneous payment within one hundred eighty (180) days of the date of the payment.
(d) A managed care plan that seeks to recoup overpayments made to a health care provider shall complete its administrative procedures and allow the provider to complete available appeal procedures within ninety (90) days of the date it notifies the provider of its intent to seek remuneration.
(e) For any amount in excess of Ten Thousand Dollars ($10,000.00), a managed care plan shall allow the provider to reimburse the plan in installments over not more than three (3) years.
(3) Subsections (1) and (2) of this section shall not apply where the managed care plan suspects fraud, illegality or other malfeasance regarding claims submitted and payments made.
(4) (a) A managed care plan may compel health care providers to submit claims or encounter data to the plan within not less than one hundred eighty (180) days nor more than three hundred sixty (360) days from the date of service.
(b) The managed care plan and the enrollee shall not be financially responsible for claims that a health care provider does not submit within the claim period.
SECTION 8. (1) A managed care plan contract shall disclose the following information about potential reimbursements:
(a) (i) The actuarial assumptions upon which capitated payments to primary health care providers and, if applicable, specialists are calculated and a mechanism for health care providers to challenge or question the assumptions.
(ii) For each capitated health care provider, the health plan shall calculate and make its per-member-per-month reimbursement to the provider for any enrollee who selects that provider.
(iii) The reimbursement shall be based on the day that the enrollee enrolls in the plan, selects that provider and the member or employer pays premiums to the health plan.
(iv) At no time may a health plan, as part of any capitated agreement with the health care provider, delay per-member-per-month payments to the provider for any enrollee until the enrollee actually begins to utilize health care services.
(b) For health care providers who commonly participate with and are paid by Medicare:
(i) A statement of how the managed care plan's reimbursement compares to Medicare reimbursement for the health care providers.
(ii) A table that contains the ten (10) most commonly submitted evaluation and management current procedural terminology codes, if applicable, and the ten (10) most commonly submitted nonevaluation and management CPT codes, showing Medicare's average reimbursement for that year and the managed care plan's actual reimbursement for those codes, to facilitate a direct comparison.
(c) Upon request, the managed care plan shall disclose to a health care provider its range of payments for the one hundred (100) CPT codes most commonly submitted in the health care provider's field of practice.
(2) (a) A managed care plan shall abide by the CPT codes, modifiers and definitions as established by the American Medical Association or the Centers for Medicare and Medicaid Services.
(b) No managed care plan may arbitrarily alter the CPT code on a submitted claim or bundle multiple CPT codes into one (1) code to reduce reimbursement.
SECTION 9. (1) Within ten (10) days of execution of a contract with a health care provider, a managed care plan shall make available all of its administrative policy and procedure manuals, including, but not limited to:
(a) Coverage policies and technology assessments of specific diagnostic or therapeutic services, drugs or biologics, devices or medical supplies or equipment.
(b) Mechanisms for resolving administrative or clinical disputes and opportunities for participating in plan governance by participating providers.
(c) Health care provider peer review, quality assurance and credentialing programs.
(2) A managed care plan contract shall describe the plan's policies and procedures as they relate to the plan's relationship with its health care providers. The managed care plan shall make available to any health care provider considering a contract copies of procedure or policy manuals typically made available to participating providers.
SECTION 10. (1) No managed care plan may compel a health care provider to accept arbitration as the sole or primary means of dispute resolution between the parties. A contract may provide for arbitration as an option for dispute resolution available to the parties only when there is joint consent and the contract describes all of the following:
(a) The circumstances in which arbitration is an option.
(b) The procedures to seek an arbitration.
(c) The process for selecting a certified arbitrator.
(d) How the parties would share the costs of the arbitration.
(2) (a) A managed care plan and a health care provider may agree to an informal dispute resolution system for the review and resolution of disputes between the managed care plan and health care provider.
(b) Disputes that may be handled informally include denials based on procedural errors and administrative denials involving the level or types of health care service provided.
(c) The informal dispute resolution system shall be set forth in the managed care plan contract and shall be impartial, include specific and reasonable time frames in which to initiate appeals, receive written information, conduct hearings, render decisions and provide for final review and determination of disputes.
(d) An alternative dispute resolution system may not be used for any external grievance filed by an enrollee.
SECTION 11. No managed care plan may compel a health care provider to participate in all of the managed care plan's business lines. A managed care plan shall differentiate between its business lines in each contract and give health care providers the opportunity to affirmatively choose or defer participation in any particular business line without penalty.
SECTION 12. A managed care plan contract shall delineate the obligations of each party to comply with the terms of HIPAA and shall state that the managed care plan and the health care provider are covered entities under the terms of HIPAA and shall comply with HIPAA or any more restrictive law of this state.
SECTION 13. In addition to any other remedy available at law or in equity, the department may assess an administrative penalty for a violation of this act. The penalty shall not exceed Five Thousand Dollars ($5,000.00) per violation.
SECTION 14. The department may promulgate rules and regulations to administer and enforce this act.
SECTION 15. This act shall take effect and be in force from and after July 1, 2011.
