CSHB 211(L&C): "An Act relating to liability for providing managed care services, to regulation of managed care insurance plans, and to patient rights and prohibited practices under health insurance; amending Rule 602(b), Alaska Rules of Appellate Procedure; and providing for an effective date."
00CS FOR HOUSE BILL NO. 211(L&C) 01 "An Act relating to liability for providing managed care services, to regulation 02 of managed care insurance plans, and to patient rights and prohibited practices 03 under health insurance; amending Rule 602(b), Alaska Rules of Appellate 04 Procedure; and providing for an effective date." 05 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF ALASKA: 06 * Section 1. The uncodified law of the State of Alaska is amended by adding a new 07 section to read: 08 SHORT TITLE. Section 3 of this Act may be known as the Alaska Patients Bill of 09 Rights. 10 * Sec. 2. AS 09.65 is amended by adding a new section to read: 11 Sec. 09.65.175. Civil liability of managed care entity. (a) A managed care 12 entity has the duty to exercise ordinary care when making a health care treatment 13 decision. 14 (b) A managed care entity is civilly liable for damages for harm to a covered
01 person 02 (1) proximately caused by 03 (A) its failure to exercise ordinary care; or 04 (B) a health care treatment decision that constitutes a failure to 05 exercise ordinary care made by an employee, agent, ostensible agent, or 06 representative who is acting on behalf of a managed care entity; or 07 (2) resulting from the failure to provide care or treatment covered by 08 the health care plan. 09 (c) This section does not create 10 (1) an obligation on the part of a managed care entity to provide to a 11 covered person care or treatment that is not covered by the health care plan; or 12 (2) civil liability for an employer, an association of employers, a labor 13 organization, or other employer group if the employer, association, labor organization, 14 or group does not make health care treatment decisions. 15 (d) It is a defense to a civil action asserted against a managed care entity if 16 the managed care entity proves by a preponderance of the evidence that it did not 17 control, influence, or participate in the health care treatment decision and did not deny 18 or delay payment for any treatment prescribed or recommended to a covered person 19 by a treating provider. 20 (e) In a civil action against a managed care entity, a finding that a physician 21 or other health care provider is an employee, agent, ostensible agent, or representative 22 of that managed care entity may not be based solely on proof that the physician's or 23 health care provider's name appears in a list of approved physicians or health care 24 providers made available to a covered person under the health care plan of the 25 managed care entity. 26 (f) In this section, 27 (1) "covered person" means a person enrolled in or insured by a health 28 care plan; 29 (2) "health care treatment decision" means 30 (A) a determination made when medical services are actually 31 provided by a health care plan;
01 (B) a decision that affects the quality of the diagnosis, care, or 02 treatment provided to a health care plan's insureds or enrollees; and 03 (C) a decision based on prospective and current review of 04 proposed medical treatment; 05 (3) "managed care entity" has the meaning given in AS 21.07.250; 06 (4) "ordinary care" means care that satisfies reasonable medical 07 standards that prevail in the area in which the person being treated is located. 08 * Sec. 3. AS 21 is amended by adding a new chapter to read: 09 Chapter 07. Regulation of Managed Care Insurance Plans. 10 Sec. 21.07.010. Patient and health care provider protection. (a) A contract 11 between a participating health care provider and a managed care entity that offers a 12 group managed care plan must contain a provision that 13 (1) clearly identifies all health care services to be provided; 14 (2) clearly identifies which health care services are to be provided by 15 a contracting health care provider; 16 (3) clearly identifies and describes each insurance policy used by the 17 group managed care plan to provide identified health care services to a covered person; 18 (4) clearly states the health care provider's rate of compensation; 19 (5) clearly states all ways in which the contract between the health care 20 provider and managed care entity may be terminated; a provision that provides for 21 discretionary termination by either party must apply equitably to both parties; 22 (6) provides that, in the event of a dispute between the parties to the 23 contract, the following procedure must be used before either party may pursue other 24 remedies: 25 (A) an initial meeting at which all parties are present or 26 represented by individuals with full decision-making authority regarding the 27 matters in dispute shall be held within seven working days after the plan 28 receives notice of the dispute or gives notice to the provider, unless the parties 29 otherwise agree in writing to a different schedule; 30 (B) if, within 30 days following the initial meeting, the parties 31 have not resolved the dispute, the dispute shall be submitted to mediation
01 directed by a mediator who is mutually agreeable to the parties and who is not 02 regularly under contract to or employed by either of the parties; each party 03 shall bear its proportionate share of the cost of mediation, including the 04 mediator fees; 05 (C) if, after a period of 60 days following commencement of 06 mediation, the parties are unable to resolve the dispute, either party may submit 07 the dispute to binding arbitration in accordance with (E) of this paragraph; 08 (D) the parties shall agree to negotiate in good faith in the 09 initial meeting and in mediation; 10 (E) after 10 days' written notice to the other party, either party 11 may submit the dispute to final and binding arbitration; binding arbitration shall 12 be held in the judicial district in this state where the services at issue in the 13 dispute were or are to be performed; at the request of either party, an 14 arbitration proceeding may be conducted electronically, including by telephone 15 or video conferencing; and 16 (F) binding arbitration shall be conducted under the rules of the 17 National Health Lawyers Association Alternative Dispute Resolution Project; 18 each party shall be responsible for its own costs and expenses related to the 19 arbitration, including attorney fees, and shall bear a proportionate share of the 20 arbitrator fees; the arbitrator shall be selected by mutual agreement between the 21 parties; the arbitrator shall be a person who is knowledgeable of state law and 22 business practices, an attorney, and a member of the National Academy of 23 Arbitrators or the National Health Lawyers Association; 24 (7) states that a health care provider may not be penalized or the health 25 care provider's contract terminated by the managed care entity because the health care 26 provider acts as an advocate for a covered person in seeking appropriate, medically 27 necessary health care services; 28 (8) protects the ability of a health care provider to communicate openly 29 with a covered person about all appropriate diagnostic testing and treatment options; 30 and 31 (9) defines words in a clear and concise manner.
01 (b) A contract between a participating health care provider and a managed care 02 entity that offers a group managed care plan may not contain a provision that 03 (1) provides financial incentives to the health care provider for 04 withholding covered health care services that are medically necessary; 05 (2) describes the products used by the plan as including all products 06 that are currently offered or that may be offered in the future by the managed care 07 entity; and 08 (3) requires the health care provider to be compensated for health care 09 services performed at the same rate as the health care provider has contracted with 10 another managed care entity. 11 (c) A managed care entity may not enter into a contract with a health care 12 provider that includes an indemnification or hold harmless clause for the acts or 13 conduct of the managed care entity. An indemnification or hold harmless clause 14 entered into in violation of this subsection is void. 15 Sec. 21.07.020. Required contract provisions for group managed care 16 plans. A group managed care plan must contain 17 (1) a provision that payment for a covered medical procedure that has 18 been preapproved by a managed care entity may not be denied after it has been 19 preapproved; 20 (2) a provision for emergency room services if any coverage is 21 provided for treatment of a medical emergency; 22 (3) a provision that covered health care services be reasonably available 23 in the community in which a covered person resides or that adequate referrals outside 24 the community be available if the health care service is not available in the 25 community; this paragraph is intended to require that a managed care entity contract 26 with a sufficient number of health care providers in each community in which it 27 operates or intends to operate to allow persons covered by the plan to have access to 28 health care services that fall within the standard of care for that community; 29 (4) a provision that any utilization review decision 30 (A) must be made within 72 hours after receiving the necessary 31 claim for payment or request for preapproval for nonemergency situations; for
01 emergency situations, utilization review decisions for care following emergency 02 services must be made as soon as is practicable but in any event no later than 03 24 hours after receiving the request for preapproval or for coverage 04 determination; and 05 (B) to deny, reduce, or terminate a health care benefit or to 06 deny payment for a health care service because that service is not medically 07 necessary shall be made by an employee or agent of the managed care entity 08 who is a licensed health care provider trained in the specialty or subspecialty 09 pertaining to the health care service involved and only after consultation with 10 the covered person's treating health care provider; 11 (5) a provision that provides for an internal appeal mechanism for a 12 covered person who disagrees with a utilization review decision made by a managed 13 care entity; this appeal mechanism must provide for a written decision from the 14 managed care entity within 15 working days from the date an appeal is received; 15 (6) a provision that discloses the existence of the right to an external 16 appeal of a utilization review decision made by a managed care entity; the external 17 appeal shall be as conducted in accordance with AS 21.07.050; 18 (7) a provision that discloses covered items and services, optional 19 supplemental benefits, and benefits relating to and restrictions on nonparticipating 20 provider services; 21 (8) a provision that describes the covered service area, preapproval 22 requirements, and the coverage for clinical trial, experimental, or investigational 23 treatment; 24 (9) a provision describing compensation methods, including assignment 25 of benefits, for health care providers and health care facilities; 26 (10) a provision describing availability of prescription medications or 27 a formulary guide, including specific exclusions; if a formulary guide is made 28 available, the guide must be updated annually; and 29 (11) a provision describing available translation or interpreter services, 30 including audiotape or braille information. 31 Sec. 21.07.030. Choice of health care provider. (a) If a managed care entity
01 offers a group health plan that provides for coverage of health care services only if the 02 services are furnished through a network of health care providers that have entered into 03 a contract with the managed care entity, the managed care entity shall also offer a non- 04 network option to enrollees at initial enrollment, as provided under (c) of this section. The 05 non-network option may require that a covered person pay a higher deductible or copayment 06 and a higher premium for the plan if the higher deductible, copayment, or premium results 07 from increased costs caused by the use of a non-network provider. The managed care entity 08 shall provide an actuarial demonstration of the increased costs to the director at the director's 09 request. If the increased costs are not justified, the director shall determine the appropriate 10 costs allowed and determine the appropriate amount of higher deductible, copayment, or 11 premium. This subsection does not apply to an enrollee who is offered non-network coverage 12 through another group health plan or through another managed care entity in the group market. 13 (b) The amount of any additional premium charged by the managed care entity 14 for the additional cost of the creation and maintenance of the option described in (a) 15 of this section and the amount of any additional cost sharing imposed under this option 16 shall be paid by the enrollee unless it is paid by the employer through agreement with 17 the managed care entity. 18 (c) An enrollee may make a change to the health care coverage option 19 provided under this section only during a time period determined by the managed care 20 entity. The time period described in this subsection must occur at least annually. 21 (d) If a managed care entity that offers a group managed care plan requires or 22 provides for a designation by an enrollee of a participating primary care provider, the 23 managed care entity shall permit the enrollee to designate any participating primary 24 care provider that is available to accept the enrollee. 25 (e) Except as provided in this subsection, a managed care entity that offers a 26 group managed care plan shall permit an enrollee to receive medically necessary or 27 appropriate specialty care, subject to appropriate referral procedures, from any qualified 28 participating health care provider that is available to accept the individual for medical 29 care. This subsection does not apply to specialty care if the managed care entity 30 clearly informs enrollees of the limitations on choice of participating health care 31 providers with respect to medical care. In this subsection,
01 (1) "appropriate referral procedures" means procedures for referring 02 patients to other health care providers that comply with ethical guidelines established 03 by the American Medical Association; 04 (2) "specialty care" means care provided by a health care provider with 05 training and experience in treating a particular injury, illness, or condition. 06 (f) A managed care entity shall notify a covered person when a contract 07 between a health care provider and the managed care entity is terminated for cause. 08 (g) If a contract between a health care provider and a managed care entity is 09 terminated, a covered person may continue to be treated by that health care provider 10 as provided in this subsection. If a covered person was treated by a provider within 11 the six-month period immediately preceding the date of the termination of the contract 12 between that provider and the managed care entity, the covered person may continue 13 to receive health care services from that provider, and the managed care entity shall 14 continue to treat the provider in all respects as if the contract were still in force. The 15 covered person shall be treated for the purposes of benefit determination or claim 16 payment as if the provider were still under contract with the managed care entity. 17 However, treatment is required to continue only while the group managed care plan 18 remains in effect and 19 (1) for the period that is the longest of 20 (A) the end of the current plan year; 21 (B) the end of the medically necessary treatment for the 22 condition, disease, illness, or injury that the covered person was treated for 23 during that most recent six-month period before the termination of the contract 24 between the provider and the managed care entity; or 25 (C) six months from the initial treatment by a provider; or 26 (2) until the end of the medically necessary treatment for the condition, 27 disease, illness, or injury if the person has a terminal condition, disease, illness, or 28 injury; in this paragraph "terminal" means a life expectancy of less than one year. 29 (h) The requirements of this section do not apply to health care services 30 covered by Medicaid. 31 Sec. 21.07.040. Confidentiality of managed care information. (a) Medical
01 and financial information in the possession of a managed care entity regarding an 02 applicant or a current or former person covered by a managed care plan is confidential 03 and is not subject to public disclosure. 04 (b) This section does not apply to medical information that is disclosed for 05 research purposes if 06 (1) the individual whose identity is disclosed gives written consent to 07 the disclosure; or 08 (2) the information is released in a form that does not reveal the 09 identity of an individual. 10 Sec. 21.07.050. External health care appeals. (a) A managed care entity 11 offering group health insurance coverage shall provide for an external appeal process 12 that meets the requirements of this section in the case of an externally appealable 13 decision for which a timely appeal is made either by the managed care entity or by the 14 enrollee. 15 (b) A managed care entity may condition the use of an external appeal process 16 in the case of an externally appealable decision upon a final decision in an internal 17 review under AS 21.07.020, but only if the decision is made in a timely basis 18 consistent with the deadlines provided under this chapter. 19 (c) A managed care entity 20 (1) may condition the use of an external appeal process upon payment 21 to the managed care entity of a filing fee that does not exceed $25; 22 (2) may not require payment of a filing fee in the case of an enrollee 23 who certifies that the enrollee is indigent; 24 (3) shall refund payment of the filing fee under (1) of this subsection 25 if the recommendation of the external appeal agency is to reverse or modify the denial 26 of a claim for benefits that is the subject of the appeal. 27 (d) Except as provided in this subsection, the external appeal process shall be 28 conducted under a contract between the managed care entity and one or more external 29 appeal agencies that have qualified under AS 21.07.060. The managed care entity 30 shall provide 31 (1) that the selection process among external appeal agencies qualifying
01 under AS 21.07.060 does not create any incentives for external appeal agencies to 02 make a decision in a biased manner; 03 (2) for auditing a sample of decisions by external appeal agencies to 04 assure that decisions are not made in a biased manner; and 05 (3) that all costs of the process, except those incurred by the enrollee 06 or treating professional in support of the appeal, shall be paid by the managed care 07 entity and not by the enrollee; this paragraph does not apply to the imposition of a 08 filing fee under (c) of this section. 09 (e) An external appeal process must include at least the following: 10 (1) a fair, de novo determination based on coverage provided by the 11 plan and by applying terms as defined by the plan; however, nothing in this paragraph 12 may be construed as providing for coverage of items and services for which benefits 13 are specifically excluded under the plan or coverage; 14 (2) an external appeal agency shall determine whether the managed care 15 entity's decision, is in accordance with the medical needs of the patient involved, as 16 determined by the managed care entity, taking into account, as of the time of the 17 managed care entity's decision, the patient's medical needs and any relevant and 18 reliable evidence the agency obtains under (4) of this subsection; if the agency 19 determines the decision is in accordance with the patient's needs, the agency shall 20 affirm the decision and to the extent that the agency determines the decision is not in 21 accordance with the patient's needs, the agency shall reverse or modify the decision; 22 (3) in making a determination, the external appeal agency shall 23 consider, but is not bound by, any language in the plan or coverage document relating 24 to the definitions of the terms "medical necessity," "medically necessary or 25 appropriate," "experimental," "investigational," or similar terms; 26 (4) the external appeal agency shall include among the evidence taken 27 into consideration 28 (A) the decision made by the managed care entity upon internal 29 review under AS 21.07.020 and any guidelines or standards used by the 30 managed care entity in reaching a decision; 31 (B) any personal health and medical information supplied with
01 respect to the individual whose denial of claim for benefits has been appealed; 02 and 03 (C) the opinion of the individual's treating physician or health 04 care provider; 05 (5) the external appeal agency may also take into consideration, but is 06 not limited to considering, the following evidence: 07 (A) the results of studies that meet professionally recognized 08 standards of validity and replicability or that have been published in peer- 09 reviewed journals; 10 (B) the results of professional consensus conferences conducted 11 or financed in whole or in part by one or more government agencies; 12 (C) practice and treatment guidelines prepared or financed in 13 whole or in part by government agencies; 14 (D) government-issued coverage and treatment policies; 15 (E) community standard of care and generally accepted 16 principles of professional medical practice; 17 (F) to the extent that the agency determines it to be free of any 18 conflict of interest, the opinions of individuals who are qualified as experts in 19 one or more fields of health care that are directly related to the matters under 20 appeal; and 21 (G) to the extent that the agency determines it to be free of any 22 conflict of interest, the results of peer reviews conducted by the managed care 23 entity involved; 24 (6) an external appeal agency shall determine 25 (A) whether a denial of a claim for benefits is an externally 26 appealable decision; 27 (B) whether an externally appealable decision involves an 28 expedited appeal; and 29 (C) for purposes of initiating an external review, whether the 30 internal review process has been completed; 31 (7) a party to an externally appealable decision may submit evidence
01 related to the issues in dispute; 02 (8) the managed care entity involved shall provide the external appeal 03 agency with access to information and to provisions of the plan or health insurance 04 coverage relating to the matter of the externally appealable decision, as determined by 05 the external appeal agency; and 06 (9) a determination by the external appeal agency on the decision must 07 (A) be made orally or in writing and, if it is made orally, shall 08 be supplied to the parties in writing as soon as possible; 09 (B) be made in accordance with the medical exigencies of the 10 case involved, but in no event later than 21 working days after the appeal is 11 filed, or, in the case of an expedited appeal, 72 hours after the time of 12 requesting an external appeal of the managed care entity's decision; 13 (C) state, in layperson's language, the basis for the 14 determination, including, if relevant, any basis in the terms or conditions of the 15 plan or coverage; and 16 (D) inform the enrollee of the individual's rights, including any 17 limitation on those rights, to seek further review by the courts of the external 18 appeal determination. 19 (f) If the external appeal agency reverses or modifies the denial of a claim for 20 benefits, the managed care entity shall 21 (1) upon receipt of the determination, authorize benefits in accordance 22 with that determination; 23 (2) take action as may be necessary to provide benefits, including items 24 or services, in a timely manner consistent with the determination; and 25 (3) submit information to the external appeal agency documenting 26 compliance with the agency's determination. 27 (g) A decision of an external appeal agency is binding unless a person who is 28 aggrieved by a final decision of an external appeal agency appeals the decision to the 29 superior court. 30 (h) An appeal of a final decision of an external appeal agency must be filed 31 within six months after the date of the decision of the external appeal agency.
01 (i) In this section, "externally appealable decision" 02 (1) means 03 (A) a denial of a claim for benefits that is based in whole or in 04 part on a decision that the item or service is not medically necessary or 05 appropriate or is investigational or experimental, or in which the decision as to 06 whether a benefit is covered involves a medical judgment; or 07 (B) a failure to meet an applicable deadline for internal review 08 under AS 21.07.020; 09 (2) does not include specific exclusions or express limitations on the 10 amount, duration, or scope of coverage that do not involve medical judgment, or a 11 decision regarding whether an individual is a participant, beneficiary, or enrollee under 12 the plan or coverage. 13 Sec. 21.07.060. Qualifications of external appeal agencies. (a) An external 14 appeal agency qualifies to consider external appeals if, with respect to a group health 15 plan, the agency is certified by a qualified private standard-setting organization 16 approved by the director or by a health insurer operating in this state as meeting the 17 requirements imposed under (b) of this section. 18 (b) An external appeal agency is qualified to consider appeals of group health 19 plan health care decisions if the agency meets the following requirements: 20 (1) the agency meets the independence requirements of this section; 21 (2) the agency conducts external appeal activities through a panel of 22 not fewer than three clinical peers; and 23 (3) the agency has sufficient medical, legal, and other expertise and 24 sufficient staffing to conduct external appeal activities for the managed care entity on 25 a timely basis consistent with this chapter. 26 (c) A clinical peer or other entity meets the independence requirements of this 27 section if 28 (1) the peer or entity does not have a familial, financial, or professional 29 relationship with a related party; 30 (2) compensation received by a peer or entity in connection with the 31 external review is reasonable and not contingent on any decision rendered by the peer
01 or entity; 02 (3) the plan and the issuer have no recourse against the peer or entity 03 in connection with the external review; and 04 (4) the peer or entity does not otherwise have a conflict of interest with 05 a related party. 06 (d) In this section, "related party" means 07 (1) with respect to 08 (A) a group health plan or health insurance coverage offered in 09 connection with a plan, the plan or the insurer offering the coverage; or 10 (B) individual health insurance coverage, the insurer offering 11 the coverage, or any plan sponsor, fiduciary, officer, director, or management 12 employee of the plan or issuer; 13 (2) the health care professional that provided the health care involved 14 in the coverage decision; 15 (3) the institution at which the health care involved in the coverage 16 decision is provided; 17 (4) the manufacturer of any drug or other item that was included in the 18 health care involved in the coverage decision; or 19 (5) any other party that, under the regulations that the director may 20 prescribe, is determined by the director to have a substantial interest in the coverage 21 decision. 22 Sec. 21.07.070. Limitation on liability of reviewers. An external appeal 23 agency qualifying under AS 21.07.060 and having a contract with a managed care 24 entity, and a person who is employed by the agency or who furnishes professional 25 services to the agency, may not be held by reason of the performance of any duty, 26 function, or activity required or authorized under this chapter to have violated any 27 criminal law, or to be civilly liable if due care was exercised in the performance of the 28 duty, function or activity and there was no actual malice or gross misconduct in the 29 performance of the duty, function, or activity. 30 Sec. 21.07.080. Religious nonmedical providers. This chapter may not be 31 construed to
01 (1) restrict or limit the right of a managed care entity to include health 02 care services provided by a religious nonmedical provider as health care services 03 covered by the managed care plan; 04 (2) require a managed care entity, when determining coverage for 05 health care services provided by a religious nonmedical provider, to 06 (A) apply medically based eligibility standards; 07 (B) use health care providers to determine access by a covered 08 person; 09 (C) use health care providers in making a decision on an 10 internal or external appeal; or 11 (D) require a covered person to be examined by a health care 12 provider as a condition of coverage; or 13 (3) require a managed care plan to exclude coverage for health care 14 services provided by a religious nonmedical provider because the religious nonmedical 15 provider is not providing medical or other data required from a health care provider 16 if the medical or other data is inconsistent with the religious nonmedical treatment or 17 nursing care being provided. 18 Sec. 21.07.250. Definitions. In this chapter, 19 (1) "clinical peer" means a health care provider who is licensed to 20 provide the same or similar health care services and who is trained in the specialty or 21 subspecialty applicable to the health care services that are provided; 22 (2) "clinical trial" means treatment, research, study, or investigation 23 over a period of time of an injury, illness, or medical condition; 24 (3) "emergency room services" means health care services provided by 25 a hospital or other emergency facility after the sudden onset of a medical condition 26 that manifests itself by symptoms of sufficient severity, including severe pain, that the 27 absence of immediate medical attention would reasonably be expected by a prudent 28 person who possesses an average knowledge of health and medicine to result in 29 (A) the placing of the person's health in serious jeopardy; 30 (B) a serious impairment to bodily functions; or 31 (C) a serious dysfunction of a bodily organ or part;
01 (4) "group managed care plan" or "plan" means a group health 02 insurance plan operated by a managed care entity; 03 (5) "health care provider" means a person licensed in this state or 04 another state of the United States to provide health care services; 05 (6) "health care services" means treatment of an individual for an 06 injury, illness, or disability and includes preventative treatment of an injury or illness; 07 (7) "health insurance" has the meaning given in AS 21.12.050(a); 08 (8) "managed care" means a contract given to an individual, family, or 09 group of individuals under which a member is entitled to receive a defined set of 10 health care benefits in exchange for defined consideration and that requires the member 11 to comply with utilization review guide lines; "managed care" does not include 12 Medicaid coverage under 42 U.S.C. 1396 - 1396p (Social Security Act); 13 (9) "managed care contractor" means a contractor who establishes, 14 operates, or maintains a network of participating health care providers, conducts or 15 arranges for utilization review activities, and contracts with a managed care entity; 16 (10) "managed care entity" means an insurer, a hospital or medical 17 service corporation, a health maintenance organization, an employer or employee 18 health care organization, a managed care contractor that operates a group managed care 19 plan, or a person who has a financial interest in health care services provided to an 20 individual; 21 (11) "medical emergency" means the sudden onset of a medical 22 condition that manifests itself by symptoms of sufficient severity, including severe pain 23 that in the absence of immediate medical attention would reasonably be expected by 24 a prudent person who possesses an average knowledge of health and medicine to result 25 in 26 (A) the placing of the person's health in serious jeopardy; 27 (B) a serious impairment to bodily functions; or 28 (C) a serious dysfunction of any bodily organ or part; 29 (12) "medical necessity" means those health care services or products 30 that a prudent physician would provide to a patient for the purpose of preventing, 31 diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is
01 (A) consistent with generally accepted standards of medical 02 practice; 03 (B) clinically appropriate in terms of type, frequency, extent, 04 site, and duration; and 05 (C) not primarily for the convenience of the patient, physician, 06 or other health care provider; 07 (13) "participating health care provider" means a health care provider 08 who has entered into an agreement with a managed care entity to provide services or 09 supplies to a patient covered by a group managed care plan; 10 (14) "primary care provider" means a health care provider who provides 11 general health care services and does not specialize in treating a single injury, illness, 12 or condition or who provides obstetrical, gynecological, or pediatric health care 13 services; 14 (15) "provider" means a health care provider; 15 (16) "religious nonmedical provider" means a person who does not 16 provide medical care, but who provides only religious nonmedical treatment or nursing 17 care for an illness or injury; 18 (17) "utilization review" means a system of reviewing the medical 19 necessity, appropriateness, or quality of health care services and supplies provided 20 under a group managed care plan using specified guidelines, including preadmission 21 certification, the application of practice guidelines, continued stay review, discharge 22 planning, preauthorization of ambulatory procedures, and retrospective review; 23 (18) "working day" means a day of the week that is not a Saturday, 24 Sunday, or a holiday. 25 * Sec. 4. AS 21.36.125 is amended by adding a new paragraph to read: 26 (16) violate a provision contained in AS 21.07. 27 * Sec. 5. AS 21.42 is amended by adding a new section to read: 28 Sec 21.42.390. Required health insurance coverage provisions. (a) A 29 health care insurer may not include in a health care insurance plan or contract a 30 provision that restricts a covered person's right to receive full information from the 31 person's health care provider regarding the care or treatment options that the health
01 care provider believes are in the best interests of the person. 02 (b) A health care insurer may not deny, reduce, or terminate health care 03 payments or deny payment for a health care service because that service is not 04 medically necessary unless that decision is made by an employee or agent of the 05 insurer who is a licensed health care provider trained in that specialty or subspecialty 06 pertaining to that health care service involved and only after consultation with the 07 covered person's treating health care provider. 08 (c) An insurer may not deny coverage, cancel a health insurance policy or 09 subscriber contract, or otherwise take action against an insured person or a health care 10 provider because that person has asserted a right described in this section. 11 (d) A covered person may bring a civil action against a health care insurer to 12 enforce the person's rights under this section. 13 (e) In this section, "health care provider" means a person licensed in this state 14 or another state of the United States to provide health care services. 15 * Sec. 6. AS 21.86.150(j) is repealed. 16 * Sec. 7. The uncodified law of the State of Alaska is amended by adding a new section 17 to read: 18 INDIRECT COURT RULE AMENDMENT. AS 21.07.050(h), as enacted by sec. 3 19 of this Act, has the effect of amending Rule 602(b), Alaska Rules of Appellate Procedure, by 20 providing that an appeal from a decision of an external appeal agency must be filed within 21 six months of the decision of the external appeal agency. 22 * Sec. 8. The uncodified law of the State of Alaska is amended by adding a new section 23 to read: 24 CONDITIONAL EFFECT. AS 21.07.050(h), as enacted by sec. 3 of this Act, takes 25 effect only if sec. 7 of this Act receives the two-thirds majority vote of each house required 26 by art. IV, sec. 15, Constitution of the State of Alaska. 27 * Sec. 9. This Act takes effect July 1, 2000.