Legislative Session number- 81

Bill Name: SF1219

E Relating to health; establishing a uniform complaint resolution process for
health plan companies, excluding companies licensed to sell accident and
sickness insurance and nonprofit health service plan corporations providing only
dental or vision coverage; defining complaint and complainant; requiring health
plan companies to establish and maintain an internal complaint resolution
process meeting certain requirements; specifying the procedures for filing a
complaint and certain notice requirements of health plan companies relating to
decisions; requiring health plan companies to establish an internal appeal
process for reviewing decisions relating to filed complaints and specifying the
procedures for filing an appeal; requiring health plan companies to inform
enrollees of the complaint resolution procedure and the procedure for
utilization review in member handbooks, subscriber contracts or certificates of
coverage, specifying certain notice requirements; requiring health plan
companies to maintain records of enrollee complaints and resolutions, specifying
a minimum retention period requirement, requiring reports of unresolved
complaints to the commissioners of commerce or health; granting enrollees
receiving adverse determinations the right to external review, defining adverse
determination and imposing a request filing fee, cost of the external review in
excess of the filing fee to be borne by the health plan company, authorizing
human services program recipient requests for expert medical opinions under the
external review process during the course of appeal of medical determinations to
the commissioner of human services, costs to be paid by the commissioner;
requiring the commissioner of administration in consultation with the
commissioners of health and commerce to contract with an organization or
business entity to provide independent external reviews of adverse
determinations, specifying certain request for proposal criteria and prescribing
the external review process and certain standards of review, decision to be
nonbinding on the enrollee and binding on the health plan company, authorizing
the health plan company to seek judicial review on certain grounds; granting
immunity from civil liability to persons participating in good faith in external
reviews; requiring the commissioners to make available to the public upon
request summary data on rendered decisions; including health maintenance
organizations under the requirements; specifying certain geographic
accessibility requirements for certain HMO services, providing for certain
exceptions; modifying certain provisions under the utilization review act,
conforming certain provisions to the complaint resolution and appeal processes;
expanding jurisdiction to community integrated service networks (CISN) and
accountable provider networks and modifying the scope; modifying certain
definitions and defining health plan company; requiring communication of initial
determination on requests for utilization review to the provider and enrollee
within a certain number of days of the request and modifying the procedure for
notice of determination not to certify; requiring use of an expedited initial
determination under certain conditions; modifying the appeal process and notice
requirements and certain requirements relating to prior authorization of
services; repealing the HMO complaint system and the health plan company
complaint procedure and dispute resolution processes and certain rules ( ja)