Consumer Access To Health Care
Concerning changes in the requirements for the coverage of health care benefits to allow for increased consumer access to health care services.
2017 Regular Session
Health Care & Health Insurance
The bill requires a health insurance carrier or an intermediary that conducts credentialing, utilization management, or utilization review to:
- Base health care coverage authorizations and medical necessity determinations on generally accepted and evidence-based standards and criteria of clinical practice;
- Disclose to a carrier's policyholders and providers the evidence-based standards and criteria of clinical practice and processes that the carrier uses for coverage authorizations and medical necessity determinations of health care services;
- Ensure that coverage authorizations and medical necessity determinations are performed by a health care provider;
- Categorize a condition as a new episode of care if the same provider has not treated the policyholder for the condition within the previous 30 days; and
- Ensure that tiered prior authorization criteria are based on generally accepted and evidence-based standards and criteria of clinical practice.
The bill prohibits:
- An intermediary from requiring coverage authorization or a medical necessity determination prior to the evaluation and management services provided by a health care provider to a policyholder during an initial health care visit; and
- A carrier from creating incentives to reduce or deny coverage authorizations or medical necessity determinations.
(Note: This summary applies to this bill as introduced.)