6392-S.E AMH HC AMH-Y
ESSB 6392 - H COMM AMD
By Committee on Health Care
ADOPTED AS AMENDED 3/2/96
Strike everything after the enacting clause and insert the following:
"NEW SECTION. Sec. 1. LEGISLATIVE FINDINGS. It is the intent of the legislature to ensure that all enrollees in managed care settings have access to adequate information regarding health care services covered by health carriers' health plans, and provided by health care providers and health care facilities. It is only through such disclosure that Washington state citizens can be fully informed as to the extent of health insurance coverage, availability of health care service options, and necessary treatment. With such information, citizens are able to make knowledgeable decisions regarding their health care.
NEW SECTION. Sec. 2. CENSORING PROVIDER INFORMATION TO PATIENTS BY CARRIERS. (1) No health carrier subject to the jurisdiction of the state of Washington may in any way preclude or discourage their providers from informing patients of the care they require, including various treatment options, and whether in their view such care is consistent with medical necessity, medical appropriateness, or otherwise covered by the patient's service agreement with the health carrier. No health carrier may prohibit, discourage, or penalize a provider otherwise practicing in compliance with the law from advocating on behalf of a patient with a health carrier. Nothing in this section shall be construed to authorize providers to bind health carriers to pay for any service.
(2) No health carrier may preclude or discourage patients or those paying for their coverage from discussing the comparative merits of different health carriers with their providers. This prohibition specifically includes prohibiting or limiting providers participating in those discussions even if critical of a carrier.
(3) The insurance commissioner is prohibited from adopting rules regarding this section.
NEW SECTION. Sec. 3. PATIENT AND PROVIDER MANAGED CARE OPT-OUT PROVISION. Notwithstanding any other provision of law, no health carrier subject to the jurisdiction of the state of Washington may prohibit directly or indirectly its enrollees from freely contracting at any time to obtain any health care services outside the health care plan on any terms or conditions the enrollees choose. Nothing in this section shall be construed to bind a carrier for any services delivered outside the health plan. The provisions of this section shall be disclosed pursuant to section 4(2) of this act. The insurance commissioner is prohibited from adopting rules regarding this section.
NEW SECTION. Sec. 4. CARRIER DISCLOSURE TO PATIENTS REGARDING CARRIER POLICIES. (1) Upon the request of an enrollee or a prospective enrollee, a health carrier, as defined in RCW 48.43.005, and the Washington state health care authority, established by chapter 41.05 RCW, shall provide the following information:
(a) The availability of a point-of-service plan and how the plan operates within the coverage;
(b) Any documents, instruments, or other information referred to in the enrollment agreement;
(c) A full description of the procedures to be followed by an enrollee for consulting a provider other than the primary care provider and whether the enrollee's primary care provider, the carrier's medical director, or another entity must authorize the referral;
(d) Whether a plan provider is restricted to prescribing drugs from a plan list or plan formulary, what drugs are on the plan list or formulary, and the extent to which enrollees will be reimbursed for drugs that are not on the plan's list or formulary;
(e) Procedures, if any, that an enrollee must first follow for obtaining prior authorization for health care services;
(f) A written description of any reimbursement or payment arrangements, including, but not limited to, capitation provisions, fee-for-service provisions, and health care delivery efficiency provisions, between a carrier and a provider;
(g) Circumstances under which the plan may retrospectively deny coverage for emergency and nonemergency care that had prior authorization under the plan's written policies;
(h) A copy of all grievance procedures for claim or service denial and for dissatisfaction with care; and
(i) Descriptions and justifications for provider compensation programs, including any incentives or penalties that are intended to encourage providers to withhold services or minimize or avoid referrals to specialists.
(2) Each health carrier, as defined in RCW 48.43.005, and the Washington state health care authority, established by chapter 41.05 RCW, shall provide to all enrollees and prospective enrollees a list of available disclosure items.
(3) Nothing in this section shall be construed to require a carrier to divulge proprietary information to an enrollee.
(4) The insurance commissioner is prohibited from adopting rules regarding this section.
NEW SECTION. Sec. 5. LIABILITY IMMUNITY FOR PLAN COMPARISON ACTIVITIES. (1) A public or private entity who exercises due diligence in preparing a document of any kind that compares health carriers of any kind is immune from civil liability from claims based on the document and the contents of the document.
(2)(a) There is absolute immunity to civil liability from claims based on such a comparison document and its contents if the information was provided by the carrier, was substantially accurately presented, and contained the effective date of the information that the carrier supplied, if any.
(b) Where due diligence efforts to obtain accurate information have been taken, there is immunity from claims based on such a comparison document and its contents if the publisher of the comparison document asked for such information from the carrier, was refused, and relied on any usually reliable source for the information including, but not limited to, carrier enrollees, customers, agents, brokers, or providers. The carrier enrollees, customers, agents, brokers, or providers are likewise immune from civil liability on claims based on information they provided if they believed the information to be accurate and had exercised due diligence in their efforts to confirm the accuracy of the information provided.
(3) The immunity from liability contained in this section applies only if the comparison document contains the following in a conspicuous place and in easy to read typeface:
This comparison is based on information believed to be reliable by its publisher, but the accuracy of the information cannot be guaranteed. Caution is suggested to all readers who are encouraged to confirm data of importance to the reader before any purchasing or other decisions are made.
(4) The insurance commissioner is prohibited from adopting rules regarding this section.
NEW SECTION. Sec. 6. CAPTIONS. Captions used in this act do not constitute part of the law.
NEW SECTION. Sec. 7. CODIFICATION. Sections 1 through 5 of this act are each added to chapter 48.43 RCW.
NEW SECTION. Sec. 8. EFFECTIVE DATE. This act shall take effect July 1, 1996."
ESSB 6392 - H COMM AMD
By Committee on Health Care
On page 1, line 1 of the title, after "entities;" strike the remainder of the title and insert "adding new sections to chapter 48.43 RCW; creating a new section; and providing an effective date."
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