BILL REQ. #:  S-3755.1 

Read first time 01/20/14.   Referred to Committee on Health Care .

     AN ACT Relating to preserving patient and practitioner freedom to obtain and provide health care by prohibiting unfair and deceptive practices in contracting for and managing health care delivery under health plans; and adding a new section to chapter 48.43 RCW.

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

NEW SECTION.  Sec. 1   A new section is added to chapter 48.43 RCW to read as follows:
     (1) A health plan may not impose a per visit cost sharing amount that requires the covered person to pay more than fifty percent of the amount the plan allows for coverage for the visit.
     (2) A health carrier may not directly, indirectly through contracted networks, or otherwise:
     (a) Require a covered person to obtain prior authorization for routine health care services for which a person may self refer;
     (b) Require a health care provider to participate in one plan, program, or health care arrangement as a condition for participating in any of the carrier's other plans, programs, or arrangements. Violations of this subsection include, but are not limited to, requiring a provider who has agreed to furnish care to enrollees of a health plan to also participate in a discount program for uninsured health care services or to participate in a workers' compensation program;
     (c) Require a provider to provide a discount from usual and customary rates for health care services not covered under a health plan, policy, or other agreement, to which the provider is a party; or
     (d) Terminate the network participation agreement or provider agreement or impose penalties upon a provider based solely upon the provider's efforts to enforce his or her rights or the rights of his or her patient under this section.
     (3) A carrier, whether directly or indirectly through subcontracted networks, shall disclose:
     (a) Its criteria and methods for establishing limits on access to network providers, including, but not limited to, the carrier's method used to determine that a network provider may provide care to a covered person without prior authorization while imposing prior authorization requirements on other network providers; and
     (b) Its methods and clinical protocols for authorizing coverage of health care services, including, but not limited to, the carrier's method for determining initial visit limits for a particular health care service.
     (4)(a) A health care provider with whom a carrier consults regarding a decision to deny, limit, or terminate a person's covered health care services must hold a license, certification, or registration, in good standing in Washington and must be actively practicing in the same health field or specialty as the health care provider being reviewed.
     (b) If a covered person is being treated by more than one provider, the review shall be completed by a provider who holds a license, certification, or registration, in good standing in Washington and who is actively practicing in the same health field or specialty as the principal prescribing or diagnosing provider, unless otherwise agreed to by the covered person and the carrier. This subsection (4)(b) does not prohibit the carrier from providing additional reviews of other categories of providers.