5927-S AMS KEIS NEED 941
SSB 5927 - S AMD 417
By Senators Keiser, Becker
ADOPTED 05/03/2011
On page 6, beginning on line
13, strike all of subsections (7) and (8) and insert the following:
"(7) A managed health care system shall negotiate in accordance with
community standards for industry with health care providers to assure an
adequate network of health care providers within its service areas and within
each facility that has a written contract with the managed health care system.
To facilitate negotiations with health care providers, a managed health care
system shall provide the department documentation indicating that the managed
health care system attempted to contract with the nonparticipating provider or
provider group on similar terms to other participating providers delivering the
same care in the same service area.
(8) If the requirement of subsection (7) of this section is satisfied,
for services provided by nonparticipating providers, the managed health care
system shall only be obligated to pay an amount determined by establishing the
mode reimbursement rate for the same services in the same service area
contracted for under this section by the managed health care system.
(9) In any case where a managed health care system must send an enrollee
to a nonparticipating provider for contracted services under the circumstances
and conditions set forth in subsection (8) of this section, it must notify the
department and the provider as to the basis for utilizing the nonparticipating
provider's services. Any disagreement between the managed health care system
and a provider or provider group regarding whether the managed health care system
satisfied the requirements set forth in subsection (7) of this section shall be
decided by the department.
(10)Pursuant to federal managed care access standards, 42 CFR 438,
managed health care systems must maintain a network of appropriate providers that
is supported by written agreements sufficient to provide adequate access to all
services covered under the contract with the department, including
hospital-based physician services."
(11)Subsections (7) through (10) of this section expire January 1, 2014."
On page 10, beginning on line 7, after "(2)" strike
all material through "program." on line 10 and insert "(a)
A managed health care system shall negotiate in accordance with community
standards for industry with health care providers to assure an adequate network
of health care providers within its service areas and within each facility that
has a written contract with the managed health care system. To facilitate
negotiations with health care providers, a managed health care system shall provide
the administrator documentation indicating that the managed health care system
attempted to contract with the nonparticipating provider or provider group on
similar terms to other participating providers delivering the same care in the
same service area.
(b) This subsection (2) expires January 1, 2014."
Beginning on page 11, line 29, strike all of section 5 and insert the following:
"NEW SECTION. Sec. 5. A new section is added to chapter 70.47 RCW to read as follows:
(1) If the requirements of RCW 70.47.100 are satisfied, for services provided by nonparticipating providers, the managed health care system shall only be obligated to pay an amount determined by establishing the mode reimbursement rate for the same services in the same service area contracted for under this section by the managed health care system.
(2) In any case where a managed health care system must send an enrollee to a nonparticipating provider for contracted services under the circumstances and conditions set forth in subsection (1) of this section, it must notify the administrator and the provider as to the basis for utilizing the nonparticipating provider's services. Any disagreement between the managed health care system and a provider or provider group regarding whether the managed health care system satisfied the requirements set forth in RCW 70.47.100 shall be decided by the administrator pursuant to the requirements set forth in RCW 70.47.100.
(3) This section expires January 1, 2014."
SSB 5927 - S AMD
By Senators Keiser, Becker
ADOPTED 05/03/2011
On page 1, beginning on line 4 of the title, after "70.47 RCW;" strike the remainder of the title and insert "creating a new section; and providing expiration dates."
|
|
EFFECT: · Removes provisions requiring Medicaid and Basic Health managed care plans to pay nonparticipating providers the Medicaid fee for service reimbursement rate · The managed health care system must provide documentation to the department indicating that an attempt was made to contract with the nonparticipating providers on similar terms to other providers in the services area. · If the requirements are met, the managed health care system is obligated to pay the mode reimbursement rate for the same service in the same service area (for Medicaid or Basic Health contracted services). · The managed health care system must notify the department as to the basis for utilizing the nonpreferred provider's services. Any disagreement as to whether requirements were met will be decided by the department. · Inserts an expiration date of 1/1/14 for the substantive sections of the bill. |
--- END ---