AN ACT
Relating to disclosure by managed care entities; adding new sections to chapter
48.43 RCW; creating a new section; and providing an effective date.
BE IT ENACTED BY THE LEGISLATURE
OF THE STATE OF WASHINGTON:
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.
