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1998 SESSION

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HB 1075 Health maintenance organizations; point-of-service plans.

Introduced by: Kenneth R. Melvin | all patrons    ...    notes | add to my profiles

SUMMARY:

Health maintenance organizations; point-of-service plans. Requires health maintenance organizations (HMOs) to include a point of service (POS) benefit to be offered in conjunction with the HMO's health care plan as an additional benefit for the enrollee, at the enrollee's option, individually to accept or reject. HMOs may contract with another health insurance carrier to provide the POS benefit required by the legislation. Premiums charged to enrollees who choose the POS benefit may be different from those charged to enrollees who do not choose the POS benefit. The premiums charged for the POS benefit must be actuarially sound and supported by a sworn certification of an officer of each carrier offering the POS benefit.

Unless otherwise directed or authorized by the group contract holder, (i) any enrollee who selects the POS benefit is responsible for the additional premium cost, and (ii) no portion of the additional cost for the POS benefit may be reflected in the premium charged by the carrier to the group contract holder for a health benefit plan without the POS benefit. Generally, different co-insurance, co-payments, deductibles and other cost-sharing arrangements for the POS benefit can be imposed so long as these requirements are consistent with similar provisions in other POS benefit plans actively marketed by the carrier. The co-insurance required of the POS enrollees cannot exceed the greater of 30 percent of the carrier's allowable charge or the co-insurance amount that would have been required had the covered items or services been received through the provider panel. Reimbursement to providers for services received through the POS benefit must be at least as favorable as (i) reimbursement made to similar providers in another POS benefit plan which is regulated under Title 38.2 and is offered and actively marketed in the Commonwealth, or (ii) reimbursement made to similar providers on the HMO's provider panel. Additionally, the scope of POS benefits must be as great as the corresponding benefits provided through the health care plan for a particular group, and marketing materials must reflect that scope.

HMOs are not required to offer the POS benefit if the HMO determines in good faith that the group contract holder will be concurrently offering another POS benefit plan to its enrollees. The POS requirement applies only to group health benefit plans issued in the commercial group market, and does not apply to (i) the individual market, (ii) Medicare, (iii) Medicaid, (iv) federal employees, (v) CHAMPUS, (vi) state employee health benefits program, (vii) self-insured or self-funded health benefit plans which allow enrollees to access care from their provider of choice whether or not the provider is a member of the health maintenance organization's panel, and (viii) other limited types of policies. The State Corporation Commission is authorized to issue regulations consistent with the provisions of the legislation.


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