CSSB 197(RLS) AM: "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) am 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 21.86.060(a) is amended to read: 09 (a) A health maintenance organization may provide provider [PHYSICIAN] 10 services directly, through provider [PHYSICIAN] employees, or may provide the 11 services under arrangements with individual providers [PHYSICIANS] or one or more 12 groups of providers [PHYSICIANS]. 13 * Sec. 2. AS 21.86.070(c) is amended to read: 14 (c) An evidence of coverage
01 (1) may not contain a provision or statement that is unjust, unfair, 02 inequitable, misleading, deceptive, or encourages misrepresentation, or that is untrue, 03 misleading, or prohibited under AS 21.86.150; and 04 (2) must contain a clear and concise statement [,] if a contract, or a 05 reasonably complete summary [,] if a certificate, of 06 (A) the health care services and the insurance or other benefits, 07 if any, to which the enrollee is entitled; 08 (B) limitations on the services, kind of services, benefits, or 09 kind of benefits, to be provided, including a deductible or copayment feature; 10 (C) where, and in what manner, information is available as to 11 how services may be obtained; 12 (D) the total amount of payment for health care services and the 13 indemnity or service benefits, if any, that the enrollee is obligated to pay with 14 respect to individual contracts; [AND] 15 (E) the health maintenance organization's method for resolving 16 enrollee complaints ; and 17 (F) guidelines explaining when treatment may be denied . 18 * Sec. 3. AS 21.86 is amended by adding new sections to read: 19 Sec. 21.86.075. Chiropractic health care services. (a) An enrollee may use 20 the services of a licensed chiropractor of the enrollee's choosing and may not be 21 required to obtain the prior approval of the enrollee's health maintenance organization, 22 a gatekeeper, or primary care physician. Within 10 days after an enrollee's first visit, 23 a chiropractor shall transmit a report containing the enrollee's primary complaint, 24 related history, examination findings, initial diagnosis, and treatment plan to the 25 enrollee's health maintenance organization. If the enrollee and the enrollee's 26 chiropractor determine that the condition of the enrollee has not improved within 30 27 days after the initial treatment, the chiropractor shall refer the enrollee back to the 28 enrollee's health maintenance organization for examination and possible concurrent 29 care. 30 (b) If the enrollee's chiropractor recommends chiropractic treatment beyond 31 30 days, the chiropractor shall conduct a second examination and transmit the findings
01 to the enrollee's health maintenance organization. The transmitted information must 02 include the enrollee's current status regarding the primary complaint, the progress of 03 a revised treatment plan, and the objectives for continued care. 04 (c) After receiving a 30-day treatment report from a chiropractor under (b) of 05 this section, the enrollee's health maintenance organization may request a review by 06 another chiropractor. The reviewing chiropractor shall conduct a physical examination 07 of the enrollee. The findings of the reviewing chiropractor must be disclosed to the 08 enrollee and the enrollee's chiropractor. Charges for additional chiropractic care 09 recommended by the reviewing chiropractor must be included as covered health care 10 services provided by the health maintenance organization. 11 (d) If the enrollee's treating chiropractor and the reviewing chiropractor 12 determine that the enrollee's condition has stabilized, ongoing preventative or 13 maintenance care is limited to two chiropractic visits a month. If the treating 14 chiropractor and the reviewing chiropractor disagree on the enrollee's continued 15 treatment, the enrollee and the health maintenance organization shall jointly select a 16 third chiropractor to review the enrollee's chiropractic treatment. Selection of a third 17 chiropractor must occur not more than 60 days after the date of the enrollee's initial 18 treatment by the enrollee's treating chiropractor. Until the third chiropractor's opinion 19 is received in writing by the enrollee and the health maintenance organization, the 20 enrollee may receive chiropractic treatment recommended by the treating chiropractor. 21 The opinion of the third chiropractor as to continued chiropractic treatment is binding 22 on the enrollee and the health maintenance organization. This subsection does not 23 apply if a new documented injury or a substantial exacerbation of the enrollee's 24 previous primary complaint occurs. 25 Sec. 21.86.078. Choice of health care provider. (a) A health maintenance 26 organization shall offer to every enrollee a point-of-service plan option that would 27 allow a covered person to receive covered services from an out-of-network health care 28 provider without obtaining a referral or prior authorization from the health maintenance 29 organization. The point-of-service plan option may require that an enrollee pay a 30 higher deductible or copayment and higher premium for the plan. 31 (b) A health maintenance organization shall provide each enrollee with an
01 opportunity at the time of enrollment and during the annual open enrollment period to 02 enroll in the point-of-service plan option. The health maintenance organization shall 03 provide written notice of the point-of-service plan option to each enrollee and shall 04 include in that notice a detailed explanation of the financial costs to be incurred by an 05 enrollee who selects that option. 06 * Sec. 4. AS 21.86.150 is amended by adding a new subsection to read: 07 (i) A health maintenance organization, including a health maintenance 08 organization operating a managed care plan, or a representative of a health 09 maintenance organization may not cause, request, or knowingly permit 10 (1) the imposition of limits regarding 11 (A) criticism by a health care provider of health care services 12 provided by the health maintenance organization; or 13 (B) written or oral communications between a health care 14 provider and an enrollee regarding health care services; 15 (2) the employment of a health care provider to be terminated unless 16 the provider receives written notice of the cause for the termination before being 17 terminated; 18 (3) denial of health care coverage for an enrollee unless the enrollee 19 has been examined by at least two physicians; or 20 (4) financial incentives to be given or offered to a provider for denying 21 or delaying health care services.