BP BHEAD INT S

AN ACT Relating to consumer health information; adding new sections to chapter 48.43 RCW; and creating a new section.

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

NEW SECTION. Sec. 1. LEGISLATIVE FINDINGS. The legislature finds that:

(1) The pace of health care reforms initiated by both the public and private sectors can result in unforeseen consequences in the delivery system unless safeguards are put in place. These undesired consequences can include negative effects on the quality of patient care, reducing the options open to patients to receive the kind of care they desire, depriving the patients of information that is necessary for an informed choice, regulation that decreases the competition in the delivery system, and concentration in the marketplace, the effect of which is to achieve market power in relation to consumers and to disrupt established and historically useful relationships in the delivery system.

(2) Preserving the best of what already exists in the delivery system, while providing for sufficient flexibility so the system can evolve into a more cost-effective one, requires careful balancing among competing objectives.

NEW SECTION. Sec. 2. INSURER DISCLAIMING LIABILITY TO PATIENTS. (1) No public or private health care payor subject to the jurisdiction of the state of Washington may propose, issue, sign, or renew an agreement of any kind, including an enrollee service agreement, that contains a clause or language whose effect, in any way, is to disclaim liability for the care delivered or not delivered to an enrollee because of a decision of the health care payor as to whether the care was a covered service, medically necessary, economically provided, medically appropriate, or similar consideration.

(2) No public or private health care payor subject to the jurisdiction of the state of Washington may propose, issue, sign, or renew an agreement of any kind, including an enrollee service agreement, that contains a clause or language whose effect, in any way, is to shift liability to the provider or the patient, or both, for the care delivered or not delivered in material part because of a payment or other related decision of the payor. A clause is a violation of this subsection if, by way of illustration and not limitation, it says that the decision to obtain care is between the provider and the patient, failing to acknowledge the role of payment in such decisions.

(3) Nothing in this section shall be construed to create new liability on anyone for the payor's payment or related decisions. The intent of this section is only to prevent payors from disclaiming or shifting any existing liability to either providers or patients, or both.

NEW SECTION. Sec. 3. CENSORING PROVIDER INFORMATION TO PATIENTS BY INSURERS. (1) No health care payor 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 care payor. No health care payor may prohibit, discourage, or penalize a provider otherwise practicing in compliance with the law from advocating on behalf of a patient with a health care payor. Nothing in this section shall be construed to authorize providers to bind health care payors to pay for any service.

(2) No health care payor may preclude or discourage patients or those paying for their coverage from discussing the comparative merits of different health care payors with their providers. This prohibition specifically includes prohibiting or limiting providers participating in those discussions even if critical of a payor.

NEW SECTION. Sec. 4. PATIENT AND PROVIDER MANAGED CARE OPT-OUT PROVISION. Notwithstanding any other provision of law, no health care payor 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.

NEW SECTION. Sec. 5. PLAIN PLAN LANGUAGE. All health care payors subject to the jurisdiction of the state of Washington shall, to the maximum extent consistent with precision of expression necessary in legal documents, adopt a style of prose in their enrollee service agreements that is understandable to a person with an average comprehension of the relevant language. Nothing in this section shall be construed to create an obligation on health care payors to have their service agreements in languages other than English.

NEW SECTION. Sec. 6. INSURER DISCLOSURE TO PATIENTS REGARDING INSURER POLICIES. (1) Upon request by an enrollee or prospective enrollee, all health care payors subject to the jurisdiction of the state of Washington shall provide the following:

(a) Whether a point-of-service plan is available and how it is structured;

(b) Any documents, instruments, or other information referred to in the enrollee's service agreement;

(c) A full description of the procedures to be followed by an enrollee for consulting a practitioner other than the primary care practitioner, and whether the enrollee's practitioner, the plan's medical director, or someone else must first authorize the referral;

(d) Whether a plan practitioner 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 that list or formulary.

(2)(a) A public or private entity who in good faith prepares a document of any kind that compares health care payors of any kind is immune from civil liability from claims based on the document and the contents of the document.

(b)(i) 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 payor, was substantially accurately presented, and contained the effective date of the information that the payor supplied, if any.

(ii) In the absence of reckless disregard for the truth proven by clear and convincing evidence, 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 payor, was refused, and relied on any usually reliable source for the information including, but not limited to, payor enrollees, customers, agents, brokers, or providers. The payor 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 reasonable grounds for doing so.

(c) 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.

NEW SECTION. Sec. 7. ENROLLEE RIGHT TO JOIN APPEAL OF TERMINATION OF PRACTITIONER BY INSURER. An enrollee may join in the appeal of a practitioner regarding the denial, nonrenewal, limitation, or termination of his or her participating agreement, or substantial equivalent, by a health care payor subject to the jurisdiction of the state of Washington in accordance with a procedure created by rules adopted by the insurance commissioner pursuant to RCW 48.43.055 and this section. The rules must apply uniformly to all health care payors subject to the jurisdiction of the state of Washington, including the state health care authority, and must state on what grounds a payor decision can be overturned by the process created.

NEW SECTION. Sec. 8. UTILIZATION REVIEW BY INSURERS. All health care payors subject to the jurisdiction of the state of Washington shall perform their utilization reviews in compliance with the following:

(1) A doctor of medicine or osteopathy licensed pursuant to chapter 18.57 or 18.71 RCW shall be responsible for all final recommendations regarding the medical necessity or appropriateness of services or the site at which the services are to be provided and shall consult with medical and mental health specialists in making such recommendations.

(2) Any enrollee, or provider at the request of an enrollee, who has had a request for treatment or payment for services denied as not medically necessary, or its equivalent, or as experimental, must be provided an opportunity for a timely appeal before an appropriate medical consultant or peer review committee.

(3) An enrollee request or one by a provider at the request of an enrollee for prior authorization of nonemergency service must be answered within two business days, and qualified health care personnel must be available for same-day telephone responses to inquiries concerning certification of continued length of stay.

(4) When prior approval for a service or other covered item is required and obtained, unless there is a material misrepresentation or omission of relevant facts, the approval shall be final and may not be rescinded after the service or other covered item has been approved.

For purposes of this section, "utilization review" includes all programs of health care payors subject to the jurisdiction of the state of Washington customarily included or identified as programs of utilization review, quality assurance, quality improvement, or management and similar programs if they involve or affect any payment or related decision or other function specified in this section.

NEW SECTION. Sec. 9. CAPTIONS. Captions used in this act do not constitute part of the law.

NEW SECTION. Sec. 10. CODIFICATION. Sections 1 through 8 of this act are each added to chapter 48.43 RCW.