Managed care organizations may provide for enrollees to receive services or reimbursement in accordance with this section.
Terms Used In Utah Code 31A-45-303
Administrator: means the same as that term is defined in Subsection (182). See Utah Code 31A-1-301
benefit: means the health care services to which a covered person is entitled under the terms of a health care insurance plan offered by a managed care organization. See Utah Code 31A-45-102
Contract: A legal written agreement that becomes binding when signed.
Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
Exclusion: means for the purposes of accident and health insurance that an insurer does not provide insurance coverage, for whatever reason, for one of the following:
(a)
a specific physical condition;
(b)
a specific medical procedure;
(c)
a specific disease or disorder; or
(d)
a specific prescription drug or class of prescription drugs. See Utah Code 31A-1-301
Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care, including major medical expense coverage. See Utah Code 31A-1-301
Health care: means any of the following intended for use in the diagnosis, treatment, mitigation, or prevention of a human ailment or impairment:
a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;
(ii)
a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and
(iii)
a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301
Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
Network provider: means a health care provider who has an agreement with a managed care organization to provide health care services to an enrollee with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly from the managed care organization. See Utah Code 31A-1-301
Proceeding: includes an action or special statutory proceeding. See Utah Code 31A-1-301
State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
(2)
(a)
Subject to restrictions under this section, a managed care organization may enter into contracts with health care providers under which the health care providers agree to be a network provider and supply services, at prices specified in the contracts, to enrollees.
(b)
A network provider contract shall require the network provider to accept the specified payment in this Subsection (2) as payment in full, relinquishing the right to collect amounts other than copayments, coinsurance, and deductibles from the enrollee.
(c)
The insurance contract may reward the enrollee for selection of network providers by:
(i)
reducing premium rates;
(ii)
reducing deductibles;
(iii)
coinsurance;
(iv)
other copayments; or
(v)
any other reasonable manner.
(3)
(a)
When reimbursing for services of health care providers that are not network providers, the managed care organization may:
(i)
make direct payment to the enrollee; and
(ii)
impose a deductible on coverage of health care providers not under contract.
(b)
(i)
Subsections (3)(b)(iii) and (c) apply to a managed care organization licensed under:
When selecting health care providers with whom to contract under Subsection (2), a managed care organization described in Subsection (3)(b)(i) may not unfairly discriminate between classes of health care providers, but may discriminate within a class of health care providers, subject to Subsection (6).
(c)
For purposes of this section, unfair discrimination between classes of health care providers includes:
(i)
refusal to contract with class members in reasonable proportion to the number of insureds covered by the insurer and the expected demand for services from class members; and
(ii)
refusal to cover procedures for one class of providers that are:
(A)
commonly used by members of the class of health care providers for the treatment of illnesses, injuries, or conditions;
(B)
otherwise covered by the managed care organization; and
(C)
within the scope of practice of the class of health care providers.
(4)
Before the enrollee consents to the insurance contract, the managed care organization shall fully disclose to the enrollee that the managed care organization has entered into network provider contracts. The managed care organization shall provide sufficient detail on the network provider contracts to permit the enrollee to agree to the terms of the insurance contract. The managed care organization shall provide at least the following information:
(a)
a list of the health care providers under contract, and if requested their business locations and specialties;
(b)
a description of the insured benefits, including deductibles, coinsurance, or other copayments;
(c)
a description of the quality assurance program required under Subsection (5); and
(d)
a description of the adverse benefit determination procedures required under Section 31A-22-629.
(5)
(a)
A managed care organization using network provider contracts shall maintain a quality assurance program for assuring that the care provided by the network providers meets prevailing standards in the state.
(b)
The commissioner in consultation with the executive director of the Department of Health may designate qualified persons to perform an audit of the quality assurance program. The auditors shall have full access to all records of the managed care organization and the managed care organization’s health care providers, including medical records of individual patients.
(c)
The information contained in the medical records of individual patients shall remain confidential. All information, interviews, reports, statements, memoranda, or other data furnished for purposes of the audit and any findings or conclusions of the auditors are privileged. The information is not subject to discovery, use, or receipt in evidence in any legal proceeding except hearings before the commissioner concerning alleged violations of this section.
(6)
(a)
A health care provider or managed care organization may not discriminate against a network provider for agreeing to a contract under Subsection (2).
(b)
(i)
Subsections (6)(b) and (c) apply to a managed care organization that is described in Subsection (3)(b)(i) and do not apply to a managed care organization described in Subsection (3)(b)(ii).
(ii)
A health care provider licensed to treat an illness or injury within the scope of the health care provider’s practice, that is willing and able to meet the terms and conditions established by the managed care organization for designation as a network provider, shall be able to apply for and receive the designation as a network provider. Contract terms and conditions may include reasonable limitations on the number of designated network providers based upon substantial objective and economic grounds, or expected use of particular services based upon prior provider-patient profiles.
(c)
Upon the written request of a provider excluded from a network provider contract, the commissioner may hold a hearing to determine if the managed care organization’s exclusion of the provider is based on the criteria set forth in Subsection (6)(b).
(7)
Nothing in this section is to be construed as to require a managed care organization to offer a certain benefit or service as part of a health benefit plan.
(8)
Notwithstanding Subsection (2) or (6)(b), a managed care organization described in Subsection (3)(b)(i) or third party administrator is not required to, but may, enter into a contract with a licensed athletic trainer, licensed under Title 58, Chapter 40a, Athletic Trainer Licensing Act.
