31A-8-501 - Access to health care providers.
31A-8-501. Access to health care providers.
(1) As used in this section:
(a) "Class of health care provider" means a health care provider or a health care facilityregulated by the state within the same professional, trade, occupational, or certification categoryestablished under Title 58, Occupations and Professions, or within the same facility licensurecategory established under Title 26, Chapter 21, Health Care Facility Licensing and InspectionAct.
(b) "Covered health care services" or "covered services" means health care services forwhich an enrollee is entitled to receive under the terms of a health maintenance organizationcontract.
(c) "Credentialed staff member" means a health care provider with active staff privilegesat an independent hospital or federally qualified health center.
(d) "Federally qualified health center" means as defined in the Social Security Act, 42U.S.C. Sec. 1395x.
(e) "Independent hospital" means a general acute hospital or a critical access hospitalthat:
(i) is either:
(A) located 20 miles or more from any other general acute hospital or critical accesshospital; or
(B) licensed as of January 1, 2004;
(ii) is licensed pursuant to Title 26, Chapter 21, Health Care Facility Licensing andInspection Act; and
(iii) is controlled by a board of directors of which 51% or more reside in the countywhere the hospital is located and:
(A) the board of directors is ultimately responsible for the policy and financial decisionsof the hospital; or
(B) the hospital is licensed for 60 or fewer beds and is not owned, in whole or in part, byan entity that owns or controls a health maintenance organization if the hospital is a contractingfacility of the organization.
(f) "Noncontracting provider" means an independent hospital, federally qualified healthcenter, or credentialed staff member who has not contracted with a health maintenanceorganization to provide health care services to enrollees of the organization.
(2) Except for a health maintenance organization which is under the common ownershipor control of an entity with a hospital located within 10 paved road miles of an independenthospital, a health maintenance organization shall pay for covered health care services rendered toan enrollee by an independent hospital, a credentialed staff member at an independent hospital, ora credentialed staff member at his local practice location if:
(a) the enrollee:
(i) lives or resides within 30 paved road miles of the independent hospital; or
(ii) if Subsection (2)(a)(i) does not apply, lives or resides in closer proximity to theindependent hospital than a contracting hospital;
(b) the independent hospital is located prior to December 31, 2000 in a county with apopulation density of less than 100 people per square mile, or the independent hospital is locatedin a county with a population density of less than 30 people per square mile; and
(c) the enrollee has complied with the prior authorization and utilization review
requirements otherwise required by the health maintenance organization contract.
(3) A health maintenance organization shall pay for covered health care services renderedto an enrollee at a federally qualified health center if:
(a) the enrollee:
(i) lives or resides within 30 paved road miles of the federally qualified health center; or
(ii) if Subsection (3)(a)(i) does not apply, lives or resides in closer proximity to thefederally qualified health center than a contracting provider;
(b) the federally qualified health center is located in a county with a population density ofless than 30 people per square mile; and
(c) the enrollee has complied with the prior authorization and utilization reviewrequirements otherwise required by the health maintenance organization contract.
(4) (a) A health maintenance organization shall reimburse a noncontracting provider orthe enrollee for covered services rendered pursuant to Subsection (2) a like dollar amount as itpays to contracting providers under a noncapitated arrangement for comparable services.
(b) A health maintenance organization shall reimburse a federally qualified health centeror the enrollee for covered services rendered pursuant to Subsection (3) a like amount as paid bythe health maintenance organization under a noncapitated arrangement for comparable servicesto a contracting provider in the same class of health care providers as the provider who renderedthe service.
(5) (a) A noncontracting independent hospital may not balance bill a patient when thehealth maintenance organization reimburses a noncontracting independent hospital or an enrolleein accordance with Subsection (4)(a).
(b) A noncontracting federally qualified health center may not balance bill a patient whenthe federally qualified health center or the enrollee receives reimbursement in accordance withSubsection (4)(b).
(6) A noncontracting provider may only refer an enrollee to another noncontractingprovider so as to obligate the enrollee's health maintenance organization to pay for the resultingservices if:
(a) the noncontracting provider making the referral or the enrollee has received priorauthorization from the organization for the referral; or
(b) the practice location of the noncontracting provider to whom the referral is made:
(i) is located in a county with a population density of less than 25 people per square mile;and
(ii) is within 30 paved road miles of:
(A) the place where the enrollee lives or resides; or
(B) the independent hospital or federally qualified health center at which the enrolleemay receive covered services pursuant to Subsection (2) or (3).
(7) Notwithstanding this section, a health maintenance organization may contract directlywith an independent hospital, federally qualified health center, or credentialed staff member.
(8) (a) A health maintenance organization that violates any provision of this section issubject to sanctions as determined by the commissioner in accordance with Section 31A-2-308.
(b) Violations of this section include:
(i) failing to provide the notice required by Subsection (8)(d) by placing the notice in anyhealth maintenance organization's provider list that is supplied to enrollees, including anywebsite maintained by the health maintenance organization;
(ii) failing to provide notice of an enrolles's rights under this section when:
(A) an enrollee makes personal contact with the health maintenance organization bytelephone, electronic transaction, or in person; and
(B) the enrollee inquires about his rights to access an independent hospital or federallyqualified health center; and
(iii) refusing to reprocess or reconsider a claim, initially denied by the healthmaintenance organization, when the provisions of this section apply to the claim.
(c) The commissioner shall, pursuant to Chapter 2, Part 2, Duties and Powers ofCommissioner:
(i) adopt rules as necessary to implement this section;
(ii) identify in rule:
(A) the counties with a population density of less than 100 people per square mile;
(B) independent hospitals as defined in Subsection (1)(e); and
(C) federally qualified health centers as defined in Subsection (1)(d).
(d) (i) A health maintenance organization shall:
(A) use the information developed by the commissioner under Subsection (8)(c) toidentify the rural counties, independent hospitals, and federally qualified health centers that arelocated in the health maintenance organization's service area; and
(B) include the providers identified under Subsection (8)(d)(i)(A) in the notice requiredin Subsection (8)(d)(ii).
(ii) The health maintenance organization shall provide the following notice, in bold type,to enrollees as specified under Subsection (8)(b)(i), and shall keep the notice current:
"You may be entitled to coverage for health care services from the following non-HMOcontracted providers if you live or reside within 30 paved road miles of the listed providers, or ifyou live or reside in closer proximity to the listed providers than to your HMO contractedproviders:
This list may change periodically, please check on our website or call for verification. Please be advised that if you choose a noncontracted provider you will be responsible for anycharges not covered by your health insurance plan.
If you have questions concerning your rights to see a provider on this list you may contactyour health maintenance organization at ________. If the HMO does not resolve your problem,you may contact the Office of Consumer Health Assistance in the Insurance Department, tollfree."
(e) A person whose interests are affected by an alleged violation of this section maycontact the Office of Consumer Health Assistance and request assistance, or file a complaint asprovided in Section 31A-2-216.
Amended by Chapter 12, 2009 General Session