1997 Regular Session
By: Representative Ford
House Bill 1122
AN ACT TO AMEND SECTION 83-41-409, MISSISSIPPI CODE OF 1972, TO REQUIRE MANAGED HEALTH CARE PLANS TO PROVIDE FOR A DUE PROCESS HEARING AND REVIEW PROCESS FOR A PROVIDER WHO IS INVOLUNTARILY DELETED FROM A PROVIDER NETWORK OR DENIED PARTICIPATION IN THE NETWORK; TO REQUIRE MANAGED HEALTH CARE PLANS TO COVER EMERGENCY ROOM VISITS BASED UPON THE "PRUDENT LAY PERSON" STANDARD; TO REPEAL SECTION 83-41-415, MISSISSIPPI CODE OF 1972, WHICH PROVIDES THAT THE PROVISIONS OF THE PATIENT PROTECTION ACT OF 1995 AND THE HEALTH MAINTENANCE ORGANIZATION-PREFERRED PROVIDER ORGANIZATION-PREPAID HEALTH BENEFIT PLAN PROTECTION ACT DO NOT APPLY TO THE MISSISSIPPI MEDICAID PROGRAM; 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) In order to be certified and recertified under this article, 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; * * *
(f) Establish procedures to ensure that all applicable state and federal laws designed to protect the confidentiality of medical records are followed; and
(g) Establish mechanisms to assure basic fairness in processing applications for initial provider participation and for making decisions that adversely affect participation status.
These mechanisms shall include: (i) provisions for giving reasonably prompt consideration to each applicant for initial participation and for biennial renewal of participation; (ii) provisions for a physician to receive a written statement of reasons, and to have an opportunity to respond, either in writing or at a formal meeting, before a final decision is made to deny an application for initial participation or renewal, terminate or permanently restrict participation. If the action that is under consideration is of a type that must be reported to the national Practitioner Data Bank or to a state medical board under federal or state law, the physician's procedural rights, at a minimum, must meet the standards of fairness contemplated by the federal Health Care Quality Improvement Act of 1986, 42 USCS Sections 11101-11152; (iii) provisions to ensure that before initiation of termination, denial or restriction of participation in the plan based on utilization of services or economic criteria, the physician shall receive a written statement of reasons, which must take into consideration and recognize the physician's practice that may account for higher or lower than expected costs. The physician shall have the opportunity to respond either in writing or at a meeting, and the opportunity to enter into and complete a corrective action plan, except in cases where there is imminent harm to patient health or an action by the State Board of Medical Licensure or other government agency that effectively impairs the physician's ability to practice medicine within the jurisdiction.
(2) Managed care plans shall cover emergency room services based upon the prudent lay person standard and shall sufficiently educate enrollees regarding appropriate times to utilize emergency facilities. For purposes of this subsection, "emergency room services based upon the prudent lay person standard" means those health care services that are provided in a hospital emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent lay person, who possesses an average knowledge of health and medicine, to result in: (a) placing the patient's health in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part.
SECTION 2. Section 83-41-415, Mississippi Code of 1972, which provides that the provisions of the Patient Protection Act of 1995 and the Health Maintenance Organization-Preferred Provider Organization-Prepaid Health Benefit Plan Protection Act do not apply to the Mississippi Medicaid Program, is repealed.
SECTION 3. This act shall take effect and be in force from and after July 1, 1997.