Bill Text: MS HB737 | 2019 | Regular Session | Introduced
Bill Title: Patient Protection Act of 1995; revise to make additional prohibitions and requirements of managed care plans.
Sponsorship: Partisan Bill (Republican 1)
Status: (Failed) 2019-02-05 - Died In Committee [HB737 Detail]
Download: Mississippi-2019-HB737-Introduced.html
MISSISSIPPI LEGISLATURE
2019 Regular Session
To: Insurance
By: Representative Powell
House Bill 737
AN ACT TO AMEND SECTION 83-41-409, MISSISSIPPI CODE OF 1972, TO AMEND THE PATIENT PROTECTION ACT OF 1995 TO PROVIDE CERTAIN PROHIBITIONS AND REQUIREMENTS FOR MANAGED CARE PLANS, INCLUDING PROVIDING A CERTAIN FEE SCHEDULE TO PROVIDERS, ESTABLISHING A PHYSICIAN ADVISORY COMMITTEE, AND ESTABLISHING A BILLING DISPUTE EXTERNAL REVIEW PROCESS; TO MAKE CERTAIN ADDITIONAL REQUIREMENTS OF A MANAGED CARE PLAN FOR CERTIFICATION OR RECERTIFICATION; TO ALLOW THE COMMISSIONER TO ISSUE CERTAIN WAIVERS; AND FOR RELATED PURPOSES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:
SECTION 1. Section 83-41-409, Mississippi Code of 1972, is amended as follows:
83-41-409. (1) Except as provided under subsection (4) of this section, in order to be certified and recertified under this article, beginning with any certification and recertification occurring sixty (60) days or later after the effective date of this act, a managed care plan shall:
(a) Provide enrollees or other applicants with written information on the terms and conditions of coverage in easily understandable language including, but not limited to, information on the following:
(i) Coverage provisions, benefits, limitations, exclusions and restrictions on the use of any providers of care;
(ii) Summary of utilization review and quality assurance policies; and
(iii) Enrollee financial responsibility for copayments, deductibles and payments for out-of-plan services or supplies;
(b) Demonstrate that its provider network has providers of sufficient number throughout the service area to assure reasonable access to care with minimum inconvenience by plan enrollees;
(c) File a summary of the plan credentialing criteria and process and policies with the State Department of Insurance to be available upon request;
(d) Provide a participating provider with a copy of his/her individual profile if economic or practice profiles, or both, are used in the credentialing process upon request;
(e) When any provider application for participation is denied or contract is terminated, the reasons for denial or termination shall be reviewed by the managed care plan upon the request of the provider; and
(f)
Establish procedures to ensure that all applicable state and federal laws
designed to protect the confidentiality of medical records are followed * * *;
(g) Establish procedures that allow participating providers to view on CD-ROM or electronically, at the participating provider's option, on a confidential basis, complete fee information showing all fee schedule amounts by the fee for service dollar amount allowable for each Current Procedural Terminology (CPT) code or Healthcare Common Procedure Coding System (HCPCS) Code for those CPT or HCPCS codes that the managed care plan uses in providing covered services, for each participating provider covered by the managed care plan; however, participating providers may elect to receive a hard copy of the complete fee schedule in lieu of the foregoing;
(h) Establish a physician advisory committee which shall include twelve (12) members, one of whom shall be the managed care plan's chief medical officer or his/her designee, who shall serve as chairperson of the Physician Advisory Committee, with the remaining members of the Physician Advisory Committee to be participating providers and the managed care plan shall consider whether the implementation of any recommendation of the Physician Advisory Committee is: (i) reasonable considering the opportunities and constraints of the current health care financing/administration marketplace; (ii) consistent with the best interests of managed care plan's participating providers, plan members, customers, shareholders and other constituents; and (iii) in furtherance of scientifically and clinically sound medical care; provided further that if the managed care plan decides not to accept a recommendation of the Physician Advisory Committee, the managed care plan shall communicate that decision in writing to the committee with an explanation of the reasons, and shall also disclose the recommendation and response on its provider website; provided further that the managed care plan shall post on its provider website a listing of all Physician Advisory Committee recommendations made to the managed care plan and its responses to such recommendations; and
(i) Establish a Billing Dispute External Review Process, posted on the managed care plan's website, which shall provide for a Billing Dispute Reviewer, to resolve disputes with participating providers arising from covered services provided to managed care plan members concerning (i) application of coding and payment rules and methodologies for fee for service claims (including without limitation any bundling, downcoding, application of a CPT modifier, and/or other reassignment of a code by the major managed care plan) to patient specific factual situations, including without limitation the appropriate payment when two (2) or more CPT codes are billed together, or whether a payment enhancing modifier is appropriate, or (ii) any retained claims, so long as such retained claims are submitted by the participating provider to the Billing Dispute Reviewer prior to thirty (30) days after exhaustion of the managed care plan's internal appeals process and when the amount in dispute exceeds Five Hundred Dollars ($500.00).
(2) Except as provided under subsection (4) of this section, in order to be certified and recertified under this article, beginning with any certification and recertification occurring sixty (60) days or later after the effective date of this act, a managed care plan shall not:
(a) Amend any material provision of, or a manual, policy, procedure, or other document referenced in, a provider network contract with a participating provider, including, but not limited to, amendments that effect a change in the amount to be paid a participating provider for services provided under the contract, without mutual written consent of duly authorized representatives of the participating provider and the managed care entity, and the plan must require that any amendment proposed by the managed care entity shall be made known to the participating provider by written notice sent by United States certified mail or, if the managed care entity offers it, electronically at the option of the participating provider, at least sixty (60) days before the proposed material change(s) are to become effective, and said material amendment must be mutually agreed upon prior to implementation unless the amendment is required by federal or state law;
(b) Provide that any participating provider employed by a hospital is required to execute a separate participating provider agreement if the hospital offers to execute one or more master participating provider agreements to cover the participating provider;
(c) Require any participating provider to comply with any requirements for reimbursement of telemedicine services other than those provided for in Chapter 9, Title 83 of the Mississippi Code of 1972;
(d) Require any participating provider to execute a provider network contract that exceeds a term of five (5) years or contains an automatic renewal or evergreen clause; or
(e) Terminate a provider network contract with a participating provider, sanction a participating provider, or otherwise affect a participating provider's network participation or status, in relation to the prohibitions set forth in this subsection (2).
(3) Except as provided under subsection (4) of this section, beginning with any certification and recertification occurring sixty (60) days or later after the effective date of this act, a managed care plan shall not be certified or recertified under this article unless the commissioner has certified that the managed care entity that operates the managed care plan has not maintained an excessive surplus for the reporting year immediately prior to the submission of the managed care plan. After the commissioner has determined the surplus of a managed care entity to be excessive, the commissioner:
(a) Shall order the managed care entity to submit a plan for distribution of the excess surplus in a fair and equitable manner; or
(b) If the managed care entity fails to submit a plan for distribution of the excess surplus within sixty (60) days, shall compile a plan and order the managed care entity to implement it.
If a managed care entity fails to comply with any order of the commissioner under this subsection (3), the managed care plan shall not be certified or recertified under this article.
The commissioner shall publish regulations to implement this subsection (3) within ninety (90) days of the effective date of this act, pursuant to the Administrative Procedures Law, including, but not limited to, factors to determine whether: (i) a managed care entity's surplus is excessive in relation to the managed care entity's outstanding liabilities and adequate in relation to its reasonable financial needs; and (ii) a plan for distribution of excess surplus is fair and equitable to persons enrolled in the managed care plan and participating providers.
(4) Any requirement of subsection (1), (2) or (3) of this section may be waived by the commissioner, in his discretion, upon written application of a managed care entity that is determined by the commissioner to have a statewide market share of accident and health insurance business in Mississippi of less than ten percent (10%) or upon application of a managed care contractor whose provider network is not utilized by a managed care entity with a statewide market share of accident and health insurance business in Mississippi of greater than ten percent (10%).
SECTION 2. This act shall take effect and be in force from and after its passage.
