CSSB 197(RLS): "An Act relating to health care services provided by, and practices of, a health maintenance organization; providing that an enrollee in a health maintenance organization has the right to select a treating chiropractor; specifying certain chiropractic health care reports, examinations, and limits on treatment; and prohibiting health maintenance organizations from limiting free speech of health care providers."
00CS FOR SENATE BILL NO. 197(RLS) 01 "An Act relating to health care services provided by, and practices of, a health 02 maintenance organization; providing that an enrollee in a health maintenance 03 organization has the right to select a treating chiropractor; specifying certain 04 chiropractic health care reports, examinations, and limits on treatment; and 05 prohibiting health maintenance organizations from limiting free speech of health 06 care providers." 07 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF ALASKA: 08 * Section 1. AS 21.36.090(d) is amended to read: 09 (d) Except to the extent necessary to comply with AS 21.42.365 and AS 21.56, 10 a person may not practice or permit unfair discrimination against a person who 11 provides a service covered under a group health insurance policy that extends coverage 12 on an expense incurred basis, or under a group service or indemnity type contract 13 issued by a health maintenance organization or a nonprofit corporation, if the 14 service is within the scope of the provider's occupational license. In this subsection,
01 "provider" means a state licensed physician, dentist, osteopath, optometrist, 02 chiropractor, nurse midwife, advanced nurse practitioner, naturopath, physical therapist, 03 occupational therapist, psychologist, psychological associate, or licensed clinical social 04 worker, or certified direct-entry midwife. 05 * Sec. 2. AS 21.86.070(c) is amended to read: 06 (c) An evidence of coverage 07 (1) may not contain a provision or statement that is unjust, unfair, 08 inequitable, misleading, deceptive, or encourages misrepresentation, or that is untrue, 09 misleading, or prohibited under AS 21.86.150; and 10 (2) must contain a clear and concise statement [,] if a contract, or a 11 reasonably complete summary [,] if a certificate, of 12 (A) the health care services and the insurance or other benefits, 13 if any, to which the enrollee is entitled; 14 (B) limitations on the services, kind of services, benefits, or 15 kind of benefits, to be provided, including a deductible or copayment feature; 16 (C) where, and in what manner, information is available as to 17 how services may be obtained; 18 (D) the total amount of payment for health care services and the 19 indemnity or service benefits, if any, that the enrollee is obligated to pay with 20 respect to individual contracts; [AND] 21 (E) the health maintenance organization's method for resolving 22 enrollee complaints ; and 23 (F) guidelines explaining when treatment may be denied . 24 * Sec. 3. AS 21.86 is amended by adding new sections to read: 25 Sec. 21.86.075. Chiropractic health care services. (a) An enrollee may use 26 the services of a licensed chiropractor of the enrollee's choosing and may not be 27 required to obtain the prior approval of the enrollee's health maintenance organization, 28 a gatekeeper, or primary care physician. Within 10 days after an enrollee's first visit, 29 a chiropractor shall transmit a report containing the enrollee's primary complaint, 30 related history, examination findings, initial diagnosis, and treatment plan to the 31 enrollee's health maintenance organization. If the enrollee and the enrollee's
01 chiropractor determine that the condition of the enrollee has not improved within 30 02 days after the initial treatment, the chiropractor shall refer the enrollee back to the 03 enrollee's health maintenance organization for examination and possible concurrent 04 care. 05 (b) If the enrollee's chiropractor recommends chiropractic treatment beyond 06 30 days, the chiropractor shall conduct a second examination and transmit the findings 07 to the enrollee's health maintenance organization. The transmitted information must 08 include the enrollee's current status regarding the primary complaint, the progress of 09 a revised treatment plan, and the objectives for continued care. 10 (c) After receiving a 30-day treatment report from a chiropractor under (b) of 11 this section, the enrollee's health maintenance organization may request a review by 12 another chiropractor. The reviewing chiropractor shall conduct a physical examination 13 of the enrollee. The findings of the reviewing chiropractor must be disclosed to the 14 enrollee and the enrollee's chiropractor. Charges for additional chiropractic care 15 recommended by the reviewing chiropractor must be included as covered health care 16 services provided by the health maintenance organization. 17 (d) If the enrollee's treating chiropractor and the reviewing chiropractor 18 determine that the enrollee's condition has stabilized, ongoing preventative or 19 maintenance care is limited to two chiropractic visits a month. If the treating 20 chiropractor and the reviewing chiropractor disagree on the enrollee's continued 21 treatment, the enrollee and the health maintenance organization shall jointly select a 22 third chiropractor to review the enrollee's chiropractic treatment. Selection of a third 23 chiropractor must occur not more than 60 days after the date of the enrollee's initial 24 treatment by the enrollee's treating chiropractor. Until the third chiropractor's opinion 25 is received in writing by the enrollee and the health maintenance organization, the 26 enrollee may receive chiropractic treatment recommended by the treating chiropractor. 27 The opinion of the third chiropractor as to continued chiropractic treatment is binding 28 on the enrollee and the health maintenance organization. This subsection does not 29 apply if a new documented injury or a substantial exacerbation of the enrollee's 30 previous primary complaint occurs. 31 Sec. 21.86.078. Choice of health care provider. (a) A health maintenance
01 organization shall offer to every enrollee a point-of-service plan option that would 02 allow a covered person to receive covered services from an out-of-network health care 03 provider without obtaining a referral or prior authorization from the health maintenance 04 organization. The point-of-service plan option may require that an enrollee pay a 05 higher deductible or copayment and higher premium for the plan. 06 (b) A health maintenance organization shall provide each enrollee with an 07 opportunity at the time of enrollment and during the annual open enrollment period to 08 enroll in the point-of-service plan option. The health maintenance organization shall 09 provide written notice of the point-of-service plan option to each enrollee and shall 10 include in that notice a detailed explanation of the financial costs to be incurred by an 11 enrollee who selects that option. 12 * Sec. 4. AS 21.86.150 is amended by adding a new subsection to read: 13 (i) A health maintenance organization, including a health maintenance 14 organization operating a managed care plan, or a representative of a health 15 maintenance organization may not cause, request, or knowingly permit 16 (1) the imposition of limits regarding 17 (A) criticism by a health care provider of health care services 18 provided by the health maintenance organization; or 19 (B) written or oral communications between a health care 20 provider and an enrollee regarding health care services; 21 (2) the employment of a health care provider to be terminated unless 22 the provider receives written notice of the cause for the termination before being 23 terminated; 24 (3) denial of health care coverage for an enrollee unless the enrollee 25 has been examined by at least two physicians; or 26 (4) financial incentives to be given or offered to a provider for denying 27 or delaying health care services.