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1999 SESSION

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SB 1235 Health care for state employees, managed care ombudsman created.

Introduced by: Martin E. Williams | all patrons    ...    notes | add to my profiles

SUMMARY AS PASSED: (all summaries)

State employees’ health insurance plan and managed care health insurance plans generally. Implements comprehensive reforms in health insurance plans (including group or individual insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis, individual or group subscription contracts provided by nonstock corporations, and health care plans for health care services provided by health maintenance organizations) and the state employees' health plan by providing for increased benefits and protections for covered persons.

The bill establishes, within the State Corporation Commission's Bureau of Insurance, a process of independent external review for individuals denied a course of treatment by their health insurance plan. If the person seeking review is determined by the Bureau of Insurance to (i) have coverage by the health plan, (ii) be seeking a treatment that appears to be covered by the plan and costs more than $500, (iii) have exhausted all available utilization review complaint and appeals procedures and (iv) have provided all information necessary to begin review, an impartial health entity shall review the final adverse decision to determine whether the decision is objective, clinically valid, compatible with established principles of health care, and contractually appropriate. Each individual seeking such review will pay a filing fee of $50, which is nonrefundable. Insurers writing accident and sickness insurance in Virginia will pay an assessment not to exceed 0.015 percent of the direct gross premium income during the preceding year to fund such appeals process. The impartial health entity will issue a written recommendation within 30 days of the acceptance of the appeal by the Bureau of Insurance, and the State Corporation Commission will issue a binding order carrying out the recommendation of the impartial health entity. These appeals provisions become effective either (i) 90 days following the promulgation of regulations by the State Corporation Commission or (ii) July 1, 2000. A similar appeals process is available, within the Department of Personnel and Training, for state employees who receive health care coverage through the state health insurance plan.

The Office of the Managed Care Ombudsman within the Bureau of Insurance is established. The Managed Care Ombudsman is charged with promoting and protecting the interests of covered persons under health insurance plans in Virginia. The duties of the Managed Care Ombudsman include assisting persons in understanding their rights and processes available to them under their managed care plan, developing information on the types of managed health insurance plans available in Virginia, and monitoring and providing information to the General Assembly on managed care issues. The Department of Personnel and Training is also required to appoint an Ombudsman to similarly assist state health insurance plan participants.

Contracts between health insurance plans and health care providers are prohibited from containing provisions which require a provider or provider group to deny medical services that are medically necessary and appropriate. Health insurance plans, as well as the state employees’ health plan, are also required to have personnel available to provide authorization at all times that preauthorization prior to receiving medical treatment is required.

Health insurance plans are required to provide written notice to covered persons at least 60 days in advance prior to increasing premiums more than 35 percent. Additionally, notice of any benefit reductions must be provided to covered persons at least 60 days prior to such benefit reductions becoming effective.

Health insurance plans and the state employees’ health plan may develop closed prescription drug formularies only after consultation with a pharmacy and therapeutics committee. This pharmacy and therapeutics committee will have a majority of its members who are physicians, pharmacists, and other health care providers. Additionally, these health plans must allow a covered person to obtain, without additional cost-sharing beyond that provided for formulary prescription drugs within the covered benefits, a specific, medically necessary, nonformulary prescription drug if, after reasonable investigation and consultation with the prescribing physician, the formulary drug is determined to be an inappropriate therapy for the medical condition of the enrollee. The insurer, corporation, or health maintenance organization must act on such requests within one business day of receipt of the request.

Health insurance plans and the state employees’ health plan must provide access to specialists for those individuals with ongoing special conditions. Once such covered individual is referred to the specialist, the specialist may begin treating the individual in the same manner as the individual's primary care provider would otherwise be permitted, including the ability to authorize tests, procedures, referrals, and other medical services. Additionally, procedures must be developed whereby a covered person with an ongoing special condition may receive a standing referral to a specialist. These health plans may require a specialist to provide written notification to the individual's primary care physician, including a description of the services rendered.

Health insurance plans and the state employees’ health plan must provide 90 days notice to enrollees prior to terminating providers, and must allow enrollees to continue using a terminated provider for 90 days unless the provider is terminated for cause. Pregnant women may continue receiving treatment from a terminated provider through delivery, and the terminally ill may continue receiving treatment from such a provider until death.

Health insurance plans and the state employees’ health plan are required to provide coverage for patient costs associated with clinical trials for treatment studies on cancer, including ovarian cancer. Patient costs covered include the costs of medically necessary health care services required in conjunction with the clinical trials. Costs not covered include the costs of research management or the cost of an investigational drug or device. The clinical trials must be approved by the National Cancer Institute, the Department of Veterans Affairs, the Food and Drug Administration or the other specified organizations. Phases II, III and IV cancer trials would be covered. Coverage of Phase I trials would be on a case-by-case basis.

Women covered under a health insurance plan or the state health plan will receive a minimum hospital stay of 23 hours when undergoing a laparoscopy-assisted vaginal hysterectomy, and a minimum stay of 48 hours for a vaginal hysterectomy, unless the attending physician, in consultation with the patient, decides that a shorter hospital stay is appropriate.

Health insurance plans and the state employees’ health plan may not refuse to accept or make reimbursement pursuant to an assignment of benefits made to a dentist or oral surgeon by a covered person. An "assignment of benefits" means the transfer of dental care coverage reimbursement benefits or other rights under an insurance policy, subscription contract or dental services plan by a covered person. Such covered person must notify the insured, subscriber or enrollee in writing of the assignment.

Finally, the bill prohibits health care coverage plan providers from refusing to accept assignments of benefits executed by covered individuals in favor of health care providers and hospitals. This specific provision must be reenacted by the 2000 General Assembly prior to becoming effective.


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