Recognizing that we have just passed the “mid-point” of 2011, I thought it might be beneficial to highlight some of this year’s health insurance legislative and regulatory updates, alphabetically by state of course, along with specific references to bill numbers, regulations and bulletins.
Alabama’s HB 75, effective June 9, 2011, provides for the adoption of the Interstate Insurance Product Regulation Compact which allows for the uniform approval of individual and group disability income and long-term care insurance policies, as well as other lines of business.
Alaska’s Bulletin B-11-01 addresses the annual survey requiring the reporting of the number of individual and group policies sold or terminated and the annual percentage of health claims paid that meet the statutory requirements. Insurers were required to complete the survey, or submit a statement that the insurer reported no direct premiums or paid claims on their annual statement, by May 1, 2011.
Arkansas’ HB 1915, effective July 26, 2011, mandates coverage for gastric pacemakers for all health benefit plans. Eligible charges and limits of, or exclusions from, coverage must be based on medical necessity or the plan’s coverage criteria for other medical services. Prior authorization for a gastric pacemaker may be required in the same manner that prior authorization is required for any other covered benefit and the health benefit plan may impose copayments, deductibles, or coinsurance amounts for a gastric pacemaker if the amounts are no greater than the copayments, deductibles, or coinsurance amounts that apply to other benefits under the health benefit plan.
Arizona’s HB 2213, effective August 7, 2011, updates terminology throughout the Arizonastatutes relating to individuals who are developmentally disabled. Some specific revisions in health insurance law sections include the deletion of the terms “mental retardation” and “mentally retarded” and replacement with “intellectual disabilities.”
California’s Department of Managed Health Care (DMHC) issued Director’s Letter No. 5-K, reminding health carriers of their obligations to cover emergency services and care under the Knox-Keene Act. DMHC Director’s Letter No. 7-K outlines health insurers’ obligations to expedite authorization requests for health services for patients involved in clinical cancer trials. State law requires provider authorization requests to be made in a timely fashion, not to exceed five business days from the plan’s receipt of the information necessary to make a determination. Additionally, if the enrollee’s condition poses an imminent and serious threat to his or her health, decisions regarding provider authorization requests must be made in a timely fashion, not to exceed 72 hours after the health plan receives the requested information.
Colorado’s SB 187 requires that for policies and plans issued or renewed on or after January 1, 2012, licensed acupuncturists are added to the list of health care providers that cannot be denied reimbursement by a health insurance carrier when the services are performed. Yet another noteworthy regulatory document was the Colorado Division of Insurance Bulletin B-4.39 which provides the health insurance industry guidance regarding the required notification to the Colorado Division for Developmental Disabilities when the individual or group coverage of an eligible child has been terminated or canceled. Notice must be provided within 90 days of knowledge that child is no longer covered.
Connecticut’s HB 5032, with an operative date of January 1, 2012, requires that each individual health insurance policy and group health plan providing coverages including basic hospital expense coverage, basic medical-surgical expense coverage, major medical expense, hospital or medical service plan contract and hospital and medical coverage provided to subscribers of a health care center must provide coverage for expenses arising from human leukocyte antigen testing, also referred to as histocompatibility locus antigen testing, for A, B and DR antigens for utilization in bone marrow transplantation. Specific policy requirements are set forth in this legislative mandate.
Delaware’s Domestic/Foreign Insurers Bulletin 43, titled “Prohibition of post-claim rescission” was issued on June 9, 2011. While this Bulletin refers to a 2010 enactment, it addresses the ongoing requirement that insurers seeking to rescind a health insurance policy are required to complete and submit the on-line application, along with all supporting information, to the Department. Rescissions of health insurance policies, issued and delivered after September 23, 2010 based on post-claim underwriting, must receive prior approval from the Insurance Department.
District of Columbia’s Notice dated March 18, 2011, provides information on its permanently adopted temporary regulations regarding open enrollment and enrollment following a qualifying event for child-only individual policies. A child-only policy is individual health insurance coverage with an effective date on or after September 23, 2010, providing coverage to a person under the age of 19. It does not include individual health insurance coverage that covers children under age 19 as dependents. Annual open enrollment periods are specified and if a court has ordered health benefits for a child, an insurance company must accept these applications outside of the open enrollment periods.
Florida’s HB 1193, effective June 2, 2011, provides that a person may not be compelled to purchase health insurance, except as a condition of the following: public employment, voluntary participation in a state or local benefit, operating a dangerous instrumentality, undertaking an occupation having a risk of occupational injury or illness, an order of child support, or activity between private persons.
Georgia’s HB 47, effective July 1, 2011, allows insurance companies authorized to transact insurance in that state to issue individual accident and sickness policies that are currently approved for issuance in other states.
Hawaii’s SB 1273, effective April 25, 2011, states that accident and health or sickness insurers, mutual benefit societies, and health maintenance organizations are required to comply with applicable federal law and that the insurance commissioner will enforce PPACA’s market reforms and consumer protections.
Idaho’s HB 131, effective July 1, 2011, amends several statutory sections concerning external reviews, exhaustion of internal grievances and expedited external reviews. Included in these revisions are the expansion of the definition of adverse benefit determination to include not only medical necessity and investigational procedures, but also appropriateness, health care setting, level of care and effectiveness. The bill has also changed the mandatory notification language for adverse determinations.
Illinois’ Bulletin 2011-06 provides insurers with information on “The Religious Freedom Protection and Civil Union Act” which became effective on June 1, 2011. The Bulletin notes that insurers are not required to file amended policy forms with the Department prior to complying with the Act. However, companies need to administer policies in accordance with the Act, as parties to a civil union and a marriage are to be provided identical benefits, protections, and financial security.
Indiana HB 1467, effective July 1, 2011, mandates that a policy of accident and sickness insurance that provides coverage for physical medicine and rehabilitative services must provide the coverage for physical medicine and rehabilitative services that are: (1) rendered by an athletic trainer who is licensed under IC 25-5.1 and (2) within the athletic trainer’s scope of practice. However, the bill also states that it does not require a policy of accident and sickness insurance to provide coverage for physical medicine or rehabilitative services.
Iowa’s HF 597, effective July 1, 2011, sets forth uniform standards for establishing and maintaining external review procedures to assure that covered persons have the opportunity for an independent review of an adverse determination or final adverse determination made by a health carrier as required by the Patient Protection and Affordable Care Act.
Kansas’ HB 2075, effective July 1, 2011, revises a number of insurance law sections including ones addressing creditable coverage, the definition of emergency medical condition, rights to external review, and judicial review of an external review.
Kentucky’s SB 112, effective June 8, 2011, requires that a copayment or coinsurance amount charged for services rendered by a licensed occupational therapist or licensed physical therapist cannot be more than those charged for services rendered by a physician or a licensed osteopath. An insurer must clearly state the availability of occupational and physical therapy coverage under its plan and all related limitations, conditions, and exclusions.
Louisiana’s HB 345, applicable only to a health benefit plan, group health plan, or individual health insurance policy delivered, issued for delivery, or renewed on or after January 1, 2012, enacts new insurance law provisions concerning coverage by a health benefit plan of prescription drugs through the use of a drug formulary.
Maine’s Bulletin 377 addresses compliance with the “any-willing pharmacy” requirements for plans subject to the Maine Health Plan Improvement Act. This Act requires insurers, and preferred provider arrangements offering such plans, to contract with any pharmacy willing to meet the requirements for participating in the plan’s network.
Maryland’s HB 83 and SB 154 set forth a mandate for health insurers regarding the reimbursement of ambulance service providers. Effective January 1, 2012, insurers, non-profit health plans, and health maintenance organizations are required to reimburse ambulance service providers directly for certain covered services under specified circumstances.
Massachusetts’ adoption of 105 CMR 129 effective March 4, 2011, establishes requirements for consumer requests to enroll in a nongroup health plans outside of the open enrollment period. Definitions and provisions for individuals applying to the Office of Patient Protection, the state agency which assists consumers who are enrolled in aMassachusettsmanaged care plan and have questions or problems obtaining covered services for enrollment waivers. This situation occurs when an insurer has advised an individual of ineligibility to enroll in a health benefit plan outside of open enrollment. Reporting requirements are also addressed.
Michigan’s Bulletin 2010-07-INS announces the current minimum required annual individual coverage for the substance abuse benefit. Insurers must provide $3969 for this coverage effective April 1, 2011 through March 31, 2012.
Minnesota’s SF 302, effective August 1, 2011, revises two health insurance law sections concerning dental service including a new provision requiring a dental organization proposing an amendment or change in a dental provider contract to disclose such change to the dentist at least 90 days before the change goes into effect. Another change requires a dental organization conducting audits of dental providers to provide a written explanation of the reason for the audit, the processes used to audit patient charts, and the processes available to the provider once the dental organization completes its review of audited patient records.
Mississippi’s Bulletin 2011-6 reminds dental insurance carriers that any covered person has the right to select a dentist of his or her choice to furnish dental care services, provided that the selected dentist is licensed. Additionally, any dentist has the right to participate as a contracting provider, as long as the dentist is willing to abide by the terms of the policy.
Missouri addresses coverage of prosthetic devices with its adoption of 20 CSR 400-2.180 effective April 30, 2011. This rule permits insurer to offer more generous coverage than that otherwise described in legislative or regulatory provisions. Additionally, if the purchaser of a health insurance plan does not accept the offer of coverage in this rule, the health carrier is not prohibited from offering alternative coverage for prosthetic devices and services or from using alternative definitions of the terms “prosthetic devices” and “services” related to prosthetic devices provided in the rule.
Montana’s HB 547, effective July 1, 2011, requires health benefit plans to reimburse for services performed by advanced practice registered nurses and registered nurse first assistants.
Nebraska’s Notice dated March 18, 2011, reminds insurance companies that, effective 90 days after the conclusion of the current legislative session, all sickness and accident policies must contain the following provision: “CONFORMITY WITH STATE AND FEDERAL LAW: Any provision of this policy which, on its effective date, is in conflict with the law of federal government or the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such law.”
Nevada’s Second Notice dated June 7, 2011, addresses the new HIPAA Basic and Standard plan designs which were established effective July 1, 2011.
New Hampshire’s HB 31 provides that each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance or any policy of group or blanket accident or health insurance that constitutes health coverage under RSA 420-G:2, IX, and that provides benefits for medically necessary ambulance services must reimburse the ambulance service provider directly or by a check payable to the insured and the ambulance service provider subject to the terms and conditions of the policy, plan, or contract. Provision is made for an insurer to negotiate with and entering into a contract with a non-participating ambulance provider that establishes rates of reimbursement for emergency medical services.
New Jersey’s NJAC 11:25-2.3, effective June 6, 2011, mandates that systems which record and document the status of all internal appeals must include information on whether the appeal is pending or resolved, the type of coverage, type of claim, the specific disposition of the appeal, and the amount of additional benefits paid on resolved internal appeals. The data must be available to the Department of Banking and Insurance upon request.
New Mexico’s SB 89, effective June 17, 2011, revises the definition of group health insurance to include coverage under a policy issued to a cooperative. A definition of a “cooperative” was also added
New York’s Regulation 62 has a new subsection titled “Internal Appeal” effective March 30, 2011. This sets forth minimum standards for internal appeal benefits found in long term care insurance, nursing home and home care insurance, nursing home insurance only, and home care insurance only policies and certificates.
North Carolinaadopted a new regulation establishing long-term care partnership standards effective February 1, 2011. Specific requirements in 11 NCAC 12 .1030 include inflation protections and disclosures.
North Dakota’s HB 1127, effective July 1, 2011, provides that the delivery, issue, execution, or renewal of any health insurance policy, health service contract, or evidence of coverage on an individual, group, blanket, franchise, or association basis is prohibited unless it meets the minimum requirements concerning external appeals and internal claims and appeals under specified federal laws.
Ohio’s Bulletin 2011-06 provides information on annual dollar limit restrictions for essential benefits in individual non-grandfathered health insurance policies. Insurers, under the specified conditions, must offer PPACA-compliant basic and standard policies with the annual limit restriction of a minimum of $750,000 for essential benefits for non-grandfathered policy years from the date of this Bulletin (March 7, 2011) through September 22, 2011.
Oklahoma’s SB 778, effective August 25, 2011, creates the Uniform Health Carrier External Review Act which requires all health carriers to notify the insured parties of external review rights. It also provides for external review procedures and guidelines.
Oregon’s SB 787 provides that effective January 1, 2012 health benefit plans must provide coverage of diabetic telemedical health services if the plan provides the same coverage in person, the care is medically necessary to a specific patient and the telemedical services are provided by a representative of an academic health center. These services may be subject to deductible, copayment or coinsurance requirements that are applicable to comparable health services provided in person.
Pennsylvania’s two 2011 Market Data Calls for Medicare Supplement data outline insurer requirements and include links to the Excel worksheets for insurers to submit the required annual refund calculation data to the Department for each individual or group standardized Medicare Supplement benefit plan. The refund calculation data was due by May 31, 2011.
Rhode Island’s SB 107 created a new Chapter 20.11 which provides for mandatory coverage for autism spectrum disorders. Applicable to specific policies on or after January 1, 2012, this mandated benefit includes coverage for applied behavior analysis, physical therapy, speech therapy and occupational therapy services for the treatment of autism spectrum disorders. Applied behavior analysis is limited to $32,000 per person per year, with benefits continuing until the covered individual reaches age fifteen.
South Carolina’s Bulletin 2011-03 addresses the recent federal “Health Insurance Issuer Rate Increases: Disclosure and Review Requirements Rule” and includes some additional reporting requirements for health insurers offering health insurance coverage in the individual market and small group market. In addition to the current filing requirements, all health insurance issuers shall submit the following information for the specifed rate increase filings: (1) Rate Increase Summary (Part 1), with the rate increase summary should be submitted in the standard excel format as provided by HHS; (2) written Explanation of the Rate Increase (Part II); and (3) Rate Filing Documentation (Part III.) These additional reporting requirements apply to any rate increase filed inSouth Carolinaon or after September 1, 2011.
South Dakota, in revising Rule 20:06:55:25 effective May 31, 2011, mandates that any substantially completed individual plan application received within 15 days of the signature date during an open enrollment must be treated as an application received during open enrollment. Also provided for is a requirement that an individual health insurance carrier may not deny coverage to an applicant under 19 years old during the open enrollment solely because the applicant is a current insured on an individual health plan or was previously insured with that same individual health carrier.
Tennessee’s SB 1119 provides that, effective April 25, 2011, health insurance plans may offer a voluntary wellness or health improvement program that offers incentives or rewards for participation. SB 1461, effective May 23, 2011, mandates that dental plans cannot require a participating dentist to provide services to an enrollee at a set fee. A dental plan may not provide nominal or de minimis coverage to avoid this requirement.
Texas’ 28 TAC s 3.3708, effective May 19, 2012, addresses the payment of certain basic benefit claims and related disclosures and specifies insurer requirements when a preferred provider is not reasonably available to an insured and services are instead rendered by a nonpreferred provider.
Utah’s HB 19, effective May 10, 2011, revises several insurance laws sections regarding grace periods, conversion rights and eligible groups.
Vermont’s HB 201, effective June 1, 2011, states that health plans can offer coverage for a terminal care management program and an enhanced hospice access benefit. The new law specifies what should be included in a terminal care management program. The enhanced hospice access benefit allows members to access hospice benefits without first being required to discontinue curative therapy.
Virginia’s HB 1928, effective July 1, 2011, addresses and provides for health carriers’ internal appeal process and external review in order to comply with PPACA. Generally conforming to the NAIC’s Uniform Health Carrier External Review Model Act, the bill revises the process for independent external reviews of a health carrier’s adverse decision regarding covered health care benefits including expanding situations for which an independent external review may be requested to include covered persons of all licensed health carriers.
Washington’s HB 1709, effective July 22, 2011, expands the definition of an eligible group for disability insurance to include discretionary groups. Conditions for the offering of a group disability insurance depends on the commissioner’s determination that: (1) the issuance of the group policy is not contrary to the best interest of the public; (2) the issuance of the group policy would result in economies of acquisition or administration; and (3) the benefits are reasonable in relation to the premium charged.
Wisconsin’s Bulletin issued July 18, 2011, provides rate change filing information for health insurers authorized to write individual and small employer group health insurance. Effective September 1, 2011 these health insurers must make all initial and subsequent rate change filings at least 30 days prior to the effective date of the rates contained in the filing. Required data elements and the actuarial memorandum are attached to the Bulletin.
West Virginia’s HB 2693, effective July 1, 2011, addresses the autism spectrum disorders mandated benefit. Coverage must be provided to individuals aged 18 months through 18 years, with the individual’s autism spectrum disorder diagnosis required to have been made at age 8 or younger and must also include applied behavioral analysis with an annual maximum benefit not to exceed $30,000 per individual for 3 consecutive years from the date that treatment commences. Other specific benefits are also included in this bill.
Wyoming’s HB 73 provides that no person or entity contracting with dentists to provide coverage or reimbursement for dental services shall require a dentist to provide services at a fee set by the contract, a policy or a certificate unless the services are covered services by the terms of the contract, policy or certificate. This requirement applies to contracts, policies or certificates issued, renewed, delivered or issued for delivery in this state on or after July 1, 2011.
