MISSISSIPPI LEGISLATURE

1997 Regular Session

To: Public Health and Welfare

By: Senator(s) Kirby

AN ACT TO AMEND SECTION 83-41-409, MISSISSIPPI CODE OF 1972, TO REQUIRE MANAGED CARE PLANS TO COVER EMERGENCY SERVICES BASED UPON THE PRUDENT LAYPERSON STANDARD AND TO PROVIDE MECHANISMS TO ASSURE BASIC FAIRNESS IN PROCESSING PROVIDER APPLICATIONS FOR INITIAL PARTICIPATION AND FOR MAKING DECISIONS THAT ADVERSELY AFFECT PROVIDER PARTICIPATION STATUS; 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. In order to be certified and recertified under this act, 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) Establish mechanisms to assure basic fairness in processing provider applications for initial participation and for making decisions that adversely affect provider 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, or 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, shall meet the standards of fairness contemplated by the federal Health Care Quality Improvement Act of 1986, 42 U.S.C. 11101-11152; (iii) provisions to ensure that prior to 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 shall 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. * * *

(f) Establish procedures to ensure that all applicable state and federal laws designed to protect the confidentiality of medical records are followed; and

(g) Cover emergency services based upon the prudent layperson standard and shall sufficiently educate enrollees regarding appropriate times to utilize emergency facilities. For purposes of this paragraph (g), the term "emergency services" 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 layperson, who possesses an average knowledge of health and medicine, to result in: (i) placing the patient's health in serious jeopardy, (ii) serious impairment of bodily functions, or (iii) serious dysfunction of any bodily organ or part.

SECTION 3. This act shall take effect and be in force from and after July 1, 1997.