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Consumer Access To Physical Rehabilitation Services

Concerning changes in the requirements for the coverage of health care benefits for physical rehabilitation services to allow for increased consumer access to services.
2016 Regular Session
Health Care & Health Insurance
Bill Summary

The bill requires a health insurance carrier that is providing benefits for physical rehabilitation services and an intermediary who has contracted with the carrier to:
  • Base coverage authorization and medical necessity determinations on generally accepted and evidence-based criteria and disclose the criteria to health care providers and policyholders;
  • Disclose the process that must be followed to obtain coverage authorizations and medical necessity determinations to providers and policyholders;
  • Ensure that the authorizations and determinations are made by a licensed provider in good standing in the same field or specialty as the requesting provider; and
  • Categorize care for a recurring condition as a new episode if the same provider has not treated the policyholder within the last 30 days.

The contract between the health care provider and intermediary must not:

  • Allow for utilization management or utilization review as direct medical care or quality improvement;
  • Impose different or tiered authorization standards and criteria for participating providers of the same licensed profession in the same network;
  • Require prior authorization for coverage for the evaluation and management in the initial visit; or
  • Require a provider to discount billed charges for physical rehabilitation services or products not covered under a health coverage plan unless the carrier or intermediary has disclosed to the provider and the carrier's policyholders in writing that providers are required to give the discount.

The bill prohibits a carrier from providing incentives to an intermediary who has a contract for its coverage authorizations and medical necessity determinations for services provided to a policyholder.

The bill makes a violation of these terms an unfair or deceptive trade practice in the business of insurance.

(Note: This summary applies to this bill as introduced and does not reflect any amendments that were subsequently adopted.)




Bill Text

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The effective date for bills enacted without a safety clause is August 7, 2024, if the General Assembly adjourns sine die on May 8, 2024, unless otherwise specified. Details