MISSISSIPPI LEGISLATURE

1998 Regular Session

To: Insurance; Judiciary A

By: Representatives Howell, Read, Smith (35th)

AN ACT TO CREATE A NEW SECTION TO BE CODIFIED AS SECTION 83-41-419, MISSISSIPPI CODE OF 1972, TO PROVIDE THAT A MANAGED CARE ENTITY SHALL BE LIABLE TO A PATIENT FOR ACTUAL DAMAGES IF THE PATIENT'S HEALTH CARE PROVIDER RECOMMENDS A TREATMENT OR TEST FOR THE PATIENT, THE MANAGED CARE ENTITY DOES NOT ALLOW THE TREATMENT OR TEST, AND THE PATIENT LATER DEVELOPS AN ILLNESS THAT WOULD NOT HAVE LIKELY HAVE OCCURRED IF THE TREATMENT OR TEST HAD BEEN ALLOWED; TO AMEND SECTIONS 83-41-409 AND 83-41-415, MISSISSIPPI CODE OF 1972, IN CONFORMITY TO THE PRECEDING PROVISION; AND FOR RELATED PURPOSES. 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:

SECTION 1. The following shall be codified as Section 83-41-419, Mississippi Code of 1972:

83-41-419. (1) A managed care entity shall be liable to a patient for actual damages if all of the following is proven by a preponderance of the evidence:

(a) A licensed health care provider who has a contract or agreement with the managed care entity to provide services to patients enrolled in a managed care plan operated by the managed care entity is providing care or treatment to a patient who is enrolled in the managed care plan; and

(b) The provider, based on his professional judgment, recommends that the patient should be provided a certain treatment, or follow a certain treatment procedure, or have a certain test performed, and the provider documents his recommendation in writing in the patient's medical records; and

(c) The managed care entity does not allow the treatment to be provided, the treatment procedure to be followed, or the test to be performed, as recommended by the provider; and

(d) The patient later develops an illness, or the patient's existing physical or mental condition becomes worse; and

(e) The patient would not likely have developed that illness, or the patient's existing condition would not likely have become worse, if the treatment had been provided, the treatment procedure had been followed, or the test had been performed, as recommended by the provider.

(2) If a managed care entity is determined to be liable to a patient for actual damages under subsection (1) of this section, and the health care provider who is providing care or treatment to the patient is also determined to be liable to the patient for actual damages because the patient developed an illness or the patient's existing condition became worse, the provider and the managed care entity shall be jointly liable to the patient for the actual damages.

SECTION 2. Section 83-41-409, Mississippi Code of 1972, is amended as follows:

83-41-409. 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) Not contain any provision that limits the liability of the managed care entity in cases described in Section 83-41-419.

SECTION 3. Section 83-41-415, Mississippi Code of 1972, is amended as follows:

83-41-415. Article 7 and 9 do not apply to the Division of Medicaid in the Office of the Governor, with the exception of Section 83-41-419, relating to the liability of a managed care entity to a patient under certain conditions.

SECTION 4. This act shall take effect and be in force from and after July 1, 1998.