Introduced by Representativesdonahue of Northfield, Connell of Warren and Sunderland Of

BILL AS INTRODUCEDH.639

2004Page 1

H.639

Introduced by RepresentativesDonahue of Northfield, Connell of Warren and Sunderland of RutlandTown

Referred to Committee on

Date:

Subject:Health; cost containment; quality assurance

Statement of purpose: This bill proposes to (1) promote greater uniformity in health insurance and provider information; (2) authorize a standard provider credentialing form; (3) establish an any willing provider law applicable to health benefit plans; (4) create a statewide healthinformation technology plan; and (5) create new quality assurance standards in managed care.

AN ACT RELATING TO HEALTH CARE OVERHEAD, EFFICIENCY, AND COMPETITIVE MARKET ACCESS

It is hereby enacted by the General Assembly of the State of Vermont:

* * * Common Claims Forms, Billing, and Procedures * * *

Sec. 1. 18 V.S.A. § 9408 is amended to read:

§ 9408. COMMON CLAIMS FORMS, BILLING, AND PROCEDURES

(a) No later than January 15, 1993July 1, 2006, the commissioner shall adopt by rule revised uniform health insurance claims forms, and revised uniform standards and procedures for the processing of claims designed to minimize unnecessary and excessive health care administrative costs, including:

(1) electronic claims forms submission;

(2) uniform standard codes for returning claims;

(3) uniform health care provider patient invoices; and

(4) uniform health insurance statements.

(b) All health care provider patient invoices and health insurance statements shall be provided to the recipients in a common format which states in clear and understandable language the specific type and date of each individual service or cost item provided and, for each service:

(1) the specific individual who provided the service in the name of the billing provider;

(2) the provider listed charge for that service;

(3) the allowed amount paid by Medicaid for that service, if applicable;

(4) the actual amount paid by the patient’s insurer or, if pending determination, the fact that such determination is pending;

(5) the actual balance due by the patient, if known and final; otherwise an indication that the balance due is pending insurance processing.

(d) The requirements of this section shall be implemented in a manner consistent with the national electronic transactions and code sets standards adopted by the Department of Health and Human Services under the administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191.

Sec. 2. 18 V.S.A. § 9410(c) and (d) are amended to read:

(c) Health insurers, health care providers, health care facilities, and governmental agencies shall file reports, data, schedules, statistics, or other information determined by the commissioner to be necessary to carry out the purposes of this section. Such information mayshall include:

(1) health insurance claims and enrollment information used by health insurers;

(2) information relating to hospitals filed under subchapter 7 of this chapter (hospital budget reviews); and

(3) any other information relating to health care costs, utilization, or resources required to be filed by the commissioner.

(d) TheNo later than July 6, 2006, thecommissioner mayshall by rule establish the types of information to be filed under this section, the manner of collecting and filing such information, and the time and place and the manner in which such information shall be filed. Consistent with the standards adopted under the administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, such rules shall require health care facilities, health care providers, and health insurers, including any state agency administering a health benefit plan, to:

(1) computerize, network, and integrate their health care information systems; and

(2) adopt uniform health care information collecting and reporting standards and procedures, including common definitions and common financial reporting standards.

* * * Common Credentialing * * *

Sec. 3. 18 V.S.A. § 9408a is added to read:

§ 9408a. COMMON CREDENTIALING FORM

No later than July 1, 2005, the commissioner shall adopt by rule a standard provider credentialing form to be used by health insurers. A health insurer shall not require a provider to submit any information not required on the standard provider credentialing form without first obtaining permission from the commissioner.

* * * Any Willing Provider * * *

Sec. 4. 18 V.S.A. § 9420 is added to read:

§ 9420. ANY WILLING PROVIDER

A health insurer shall not discriminate against any provider located within the geographic coverage area of the health benefit plan if the provider is willing to meet the terms and conditions for participation established by the health insurer. The health insurer and the provider shall have the right to negotiate the terms and conditions of participation; fees, however, may be limited to Vermont usual and customary fees and compliance under Vermont law.

* * * Health Information Technology * * *

Sec. 5. 18 V.S.A. § 9435a is added to read:

§ 9435a. HEALTH INFORMATION TECHNOLOGY

(a) No later than July 1, 2005, the commissioner shall establish by rule a statewide health information technology plan designed to promote electronic connectivity to health care data for the purpose of improving patient care, lowering costs, and protecting patient privacy. The plan shall include:

(1) data standards related to common claims, billing, and other procedures;

(2) privacy and security practices;

(3) consumer access to health information;

(4) provider access to medical best practices; and

(5) a process that would allow hospitals and health care facilities that invest in health information technology that is compatible with the health information technology plan have those costs recognized in their budgets when reviewed by the commissioner.

(b) The purchase of an information technology system falling within the financial thresholds of subsections 9434(b) and (d) of this title shall be exempt from the requirement of this subchapter if the commissioner finds that the system is consistent with the statewide health care information plan.

(c) Purchases exceeding the financial thresholds of subsections 9434(b) and (d) of this title shall be reviewed under the same criteria set forth in those subsections, as appropriate, and also with reference to the statewide health care information plan.

* * *Managed Care Standards * * *

Sec. 6. 18 V.S.A. § 9414(b) is amended to read:

(b) A managed care organization shall assure that the health care services provided to members are consistent with prevailing professionally recognized standards of medical practice. Each managed care organization shall have procedures to assure availability, accessibility, and continuity of care, and ongoing procedures for the identification, evaluation, resolution, and follow-up of potential and actual problems in its health care administration and delivery, and, by July 1, 2005, shall ensure that:

(1) utilization reviewsshall take place in a manner that does not impose any undue burdens when the services fall within the ordinary and usual course of treatment for that diagnostic category;

(2) co-payments are based on a consistent and reliable scale of primary or secondary care across diagnostic categories determined by whether the associated care is part of an ongoing or routine course of treatment or a specialty referral for that diagnostic category;

(3) anti-therapeutic provider changes are prevented through insurer policies regarding changes in provider status with the network or transfers to innetwork providers for new enrollees based on the clinical criteria specific to the diagnostic category or discipline involved; and

(4) there is consistency of access among disciplines to ongoing care and provider availability based upon clinical standards for the particular diagnosis rather than a common standard.