Summary

Sponsor: Senator Byrum
Committee: Health Policy
Topic: Insurance Utilization Review

This bill would add section 2212b to the Insurance Code of 1956. It would define the term ‘utilization review' to mean a system of review used to determine the appropriateness of the sources allocated to an enrollee under a health maintenance organization contract (HMO). The term ‘utilization review accreditation commission' would refer to the America Accreditation Healthcare Commission / Utilization Review Accreditation Commission.

A HMO would have to establish a policy governing the termination of health care providers. This policy would have to include notice of termination in compliance with the time and manner specified in the contract and methods by which the termination policy shall be made known. Written notification would be required to be sent to each of the enrollees at least 30 business days in advance of the termination, unless the termination was necessary for the protection of the health, safety and welfare of the insured. In this instance, no notice is necessary.

Also, HMO shall not terminate a health care provider's participation with the corporation due to the effects caused by one or more high utilization enrollees.

It would only be permissible for a HMO to perform an in house utilization review if their review standards have been approved by the utilization review accreditation commission. The HMO would also have to prove that their standards provide the same, if not more, protection of the rights of the enrollees. A HMO wishing to contract with a utilization review company would have to fulfill the same guidelines.