BP BHEAD INT S

AN ACT Relating to the protection of patient choice in health care insurance and in the choice of health care providers; amending RCW 48.43.045; adding a new section to chapter 43.70 RCW; and creating a new section.

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

NEW SECTION. Sec. 1. The legislature finds that patient choice of health care providers is the most effective form of health care cost containment and quality assurance. The legislature further finds that insurance carriers and other payers are limiting access to needed health services by refusing to contract with some providers, by eliminating some providers from health plans, and by discriminating between providers in reimbursement.

It is the intent of the legislature to protect patients' choice of health care providers by preventing insurance carriers' arbitrary interference with these personal choices which should be patients' rights in our free enterprise system.

Sec. 2. RCW 48.43.045 and 1995 c 265 s 8 are each amended to read as follows:

(1) Every carrier, with respect to every health plan delivered, issued for delivery, or renewed ((~~by a health carrier~~)) on and after January 1, ((~~1996~~)) 1997, shall:

((~~(1)~~)) (a) Permit every ((~~category of health care provider~~)) individual health care provider regulated under chapter 18.130 RCW to provide health services or care for conditions ((~~included in the basic health plan services~~)) to the extent that:

((~~(a)~~)) (i) The plan covers the condition or provides the service;

(ii) The provision of such health services or care is within the health care ((~~providers'~~)) provider's permitted scope of practice; and

((~~(b)~~)) (iii) The ((~~providers agree~~)) provider agrees to abide by the carrier's reasonable terms and conditions which shall not arbitrarily discriminate between providers and which may include standards related to:

((~~(i)~~)) (A) Provision, utilization review, and cost containment of health services;

((~~(ii)~~)) (B) Management and administrative procedures; and

((~~(iii)~~)) (C) Provision of cost-effective and clinically efficacious health services((.)); and

((~~(2)~~)) (b) Annually report the names and addresses of all officers, directors, or trustees of the health carrier during the preceding year, and the amount of wages, expense reimbursements, or other payments to such individuals.

(2) Subsection (1)(a) of this section does not apply to:

(a) Any provider whose license, certification, or registration has been suspended or revoked within five years prior to the provider's application to contract with a carrier to provide health care services; or

(b) Any provider who violates the terms and conditions of the provider's contract with the carrier, but only after the grievance and dispute resolution procedures of the contract and of the insurance commissioner adopted pursuant to subsection (4) of this section have been complied with and only for a maximum period of five years.

(3) A health maintenance organization, to the extent that it directly employs providers, is in compliance with subsection (1)(a) of this section so long as the health maintenance organization:

(a) Permits every category of health care provider regulated under chapter 18.130 RCW to provide health services or care for conditions to the extent that:

(i) The plan covers the conditions or provides the service or care;

(ii) The provision of such health services or care is within the health care provider's permitted scope of practice; and

(iii) The provider agrees to abide by standards related to:

(A) Provision, utilization review, and cost containment of health services;

(B) Management and administrative procedures; and

(b) Complies with section 3 of this act.

(4) The insurance commissioner shall adopt such rules as are appropriate and necessary to give full effect to the provisions and intent of this act, including but not limited to rules defining unfair practices, grievance and dispute resolution procedures, reasonable contracting terms and conditions, and fair and reasonable cost-sharing requirements.

(5) No provider or facility may enter into an agreement or contract in violation of this act.

NEW SECTION. Sec. 3. A new section is added to chapter 43.70 RCW to read as follows:

(1) Any quality assurance commission, professional regulatory board, committee, or professional association for professions subject to the secretary's authority under chapter 18.130 RCW may recommend to the secretary the adoption of rules providing for standards of patient care with respect to the terms and conditions of a contract or agreement between a licensee and a health maintenance organization to the extent that the health maintenance organization directly employs providers. Recommendations shall be considered by the secretary only if the proposed rule would foster strict compliance with standards of patient care, professional conduct, and scopes of practice; would promote quality medical and health practice to improve the public's health status; would prevent unreasonable interference with patient access to needed health services; and would protect the public health and safety.

(2) The secretary is authorized to adopt rules based upon recommendations made in accordance with subsection (1) of this section. When practical and appropriate, and with the approval of the appropriate commission, board, or committee, the secretary shall apply the rules to all licensees to promote consistent standards for contracting between licensees and all health maintenance organizations to the extent that the health maintenance organizations directly employ providers.

(3) Beginning one year after the promulgation of standards of patient care under this section, the secretary may impose such standards of patient care as a condition of licensure, certification, or registration. It is a violation of practice requirements to enter into a contract that does not meet such standards with a health maintenance organization to the extent that the health maintenance organization directly employs providers.