House Bill 820

AN ACT TO CREATE AN INDEPENDENT DISPUTE RESOLUTION PROCESS FOR SITUATIONS WHEN A LARGE HEALTH INSURER AND A LARGE HEALTH SYSTEM ENTER INTO CONTRACT NEGOTIATIONS, AND THOSE NEGOTIATIONS RESULT IN THE LARGE HEALTH SYSTEM NO LONGER BEING WITHIN THE LARGE HEALTH INSURER'S NETWORK, AND THE COMMISSIONER OF INSURANCE FINDS THAT SUCH EXCLUSION WILL RESULT IN A LARGE NUMBER OF COVERED PERSONS NOT HAVING ACCESSIBLE HEALTH CARE SERVICES WITHIN A GEOGRAPHIC AREA, OR A LARGE NUMBER OF COVERED PERSONS NOT HAVING REASONABLE ACCESS TO COVERED BENEFITS RESULTING IN THE COVERED PERSONS HAVING TO RECEIVE THOSE SERVICES OUT OF THEIR GEOGRAPHIC AREA, OR THE LARGE HEALTH SYSTEM IS CONSIDERED AN ESSENTIAL COMMUNITY PROVIDER AND THE EXCLUSION OF THE LARGE HEALTH SYSTEM WILL RESULT IN SIGNIFICANT HARM TO MISSISSIPPI CITIZENS; TO PROVIDE DEFINITION; TO AUTHORIZE THE COMMISSIONER OF INSURANCE TO ORDER THE PARTIES TO ATTEMPT TO RESOLVE THE DISPUTE THROUGH MEDIATION; TO PROVIDE THE PROCEDURE FOR THE MEDIATION; TO PROVIDE THAT IF THE MEDIATION IS UNSUCCESSFUL, THE GOVERNOR MAY ORDER THAT THE DISPUTE BE DETERMINED BY BINDING ARBITRATION; TO PROVIDE THE PROCEDURE FOR THE ARBITRATION; AND FOR RELATED PURPOSES.

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

SECTION 1. For purposes of this act, the following words and phrases shall have the meanings as defined in this section unless the context clearly indicates otherwise:

(a) "Arbitration" means the hearing and determination of a disputed case by an arbitrator.

(b) "Arbitrator" means a person with power to decide a dispute in an independent dispute resolution process.

(d) "Covered benefits" or "benefits" means those health care services to which a covered person is entitled under the terms of a health benefit plan.

(e) "Covered person" means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan.

(f) "Essential community provider" means a provider that serves predominantly low-income, medically underserved individuals.

(g) "Facility" means an institution providing health care services or a health care setting including, but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.

(h) "Governor" means the Governor of the State of Mississippi.

(i) "Health benefit plan" means a policy, contract, certificate or agreement entered into, offered or issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.

(j) "Health care provider" means a health care professional or a facility.

(k) "Health care services" means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.

(l) "Health insurance coverage" or "health benefits" means a policy, contract, certificate or agreements entered into, offered or issued by a health insurer to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.

(m) "Health insurer" means an insurance company, nonprofit health care services plan, fraternal benefit society, health maintenance organization, to the extent consistent with federal law any self-insurance arrangement covered by the Employee Retirement Income Security Act of 1974, as amended, that provides health care benefits in this state, or any other entity providing a plan of health insurance coverage or health benefits subject to state insurance regulation.

(n) "Independent dispute resolution" means a forum, either arbitration or mediation, for resolving a dispute that exists outside the judicial system.

(o) "Large health insurer" means a health insurer who holds fifty percent (50%) or more of the market share of covered persons in this state.

(p) "Large health system" means an organization that owns and operates a network of at least five (5) or more healthcare facilities, one (1) of which is a hospital, and includes at least one (1) group of physicians who provide comprehensive care that are connected with each other and the healthcare facility either through common ownership or joint management, which provides health care services to a large number of covered persons within a geographic area, and is a participating provider.

(q) "Market share" means the portion of a market controlled by a particular health insurer.

(r) "Mediation" means the act or process of intervening between conflicting parties to promote settlement.

(s) "Mediator" means one that mediates between parties in an independent dispute resolution process.

(t) "Network" means the group of participating providers providing services to covered persons through a network plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use, participating providers, managed, owned, under contract with or employed by the health insurer.

(u) "Participating provider" means a facility or health care professional who, under a contract with the health insurer or with its contractor of subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payments, other than coinsurance, copayments or deductibles, directly or indirectly from the health insurer.

(v) "Person" means an individual, corporation, partnership association, joint venture, joint stock company, a trust, an unincorporated organization, any similar entity or any combination of the foregoing.

SECTION 2. When a large health insurer and a large health system enter into contract negotiations, and those negotiations result in the large health system no longer being within the large health insurer's network, the parties may be directed to enter into an independent dispute resolution process, as provided in Section 4 of this act, if the Commissioner finds that such exclusion will result in the following:

(a) A large number of covered persons not having accessible health care services within a geographic area;

(b) A large number of covered persons not having reasonable access to covered benefits resulting in the covered persons having to receive those services out of their geographic area; or

(c) The large health system is considered an essential community provider, and the exclusion of the large health system will result in significant harm to Mississippi citizens.

SECTION 3. (1) Upon a finding by the Commissioner that the criteria has been met to call an independent dispute resolution, the Commissioner shall first order the parties to attempt to resolve the dispute through mediation in the following manner:

(a) Within fifteen (15) calendar days of the order to mediate, the parties shall select a mutually acceptable mediation provider mediator who is a licensed attorney with knowledge of health insurance and health insurance networks, and who certifies in writing that he or she has no ongoing business relationship with either party;

(b) The mediator shall conduct the mediation in accordance with the Court Annexed Mediation Rules for Civil Litigation;

(d) The mediation shall be treated as a settlement discussion and shall be confidential and may not be used against either party in any later proceeding relating to the dispute;

(e) The mediator may not testify for either party in any later proceeding relating to the dispute;

(f) Each party shall treat information received from the other party pursuant to the mediation that is appropriately marked as confidential as confidential information; and

(g) Each party shall share equally in the fees and expenses of the mediator.

(2) If, within thirty (30) days after the beginning of the mediation and any extension of such periods as mutually agreed to by the parties and the Commissioner, the matter has not been resolved, the mediator shall report to the Commissioner and the Governor that the mediation has been unsuccessful.

(3) If mediation has been unsuccessful, the Governor may order that the dispute shall be determined by binding arbitration as provided in the following manner:

(a) The matter will be heard and decided by three (3) arbitrators. The Governor shall select one (1) arbitrator, the large health insurer shall select one (1) arbitrator, and the large health system shall select one (1) arbitrator. The arbitrators shall be licensed attorneys with knowledge of health insurance and health insurance networks. No arbitrator chosen shall have a conflict of interest regarding the dispute;

(b) The arbitration shall be conducted pursuant to the provisions of Sections 11-15-1 through 11-15-37;

(d) The arbitrators shall enter a decision within thirty (30) days of the hearing;

(e) The decision of the arbitrators shall be binding upon the parties involved; and

(f) The decision shall not be subject to judicial review.

SECTION 4. This act shall take effect and be in force from and after its passage.