Senate Bill No. 144

Introduced By Keating, Bookout, Eck, bartlett, wyatt, holden

A Bill for an Act entitled: An Act providing for the inclusion of participating obstetricians and gynecologists as primary care physicians; providing that a health benefit plan may not require a referral from a primary care physician as a condition for the coverage of the services of an obstetrician or gynecologist; PROVIDING COVERAGE FOR SERVICES PROVIDED BY AN ADVANCED PRACTICE REGISTERED NURSE IN COLLABORATION WITH THE PARTICIPATING OBSTETRICIAN OR GYNECOLOGIST; requiring notice to covered persons; AMENDING sections 33-22-101 and 33-31-111, MCA; and providing an immediate effective date and an applicability date.

WHEREAS, the specialty of obstetrics and gynecology is devoted to primary and preventative health care of women throughout their lifetime; and

WHEREAS, significant numbers of women view their obstetrician and gynecologist as their primary or only physician; and

WHEREAS, for many women, an obstetrician or gynecologist is often the only physician they see regularly during their reproductive years; and

WHEREAS, a general medical examination was the second most frequently cited purpose for patient visits to obstetricians and gynecologists in 1989 and 1990; and

WHEREAS, obstetricians and gynecologists refer their patients less frequently than other primary care physicians, thus avoiding costly and time-consuming referrals to specialists.

Be it enacted by the Legislature of the State of Montana:

Section 1.  Scope -- purpose. The provisions of [sections 1 through 8] apply to all health benefit plans offered to persons who receive health care services in this state. The purpose of [sections 1 through 8] is to ensure that obstetricians and gynecologists may be participating primary care physicians under health benefit plans offered to patients who receive health care services in this state and that persons covered by health benefit plans have direct access to the services of a participating obstetrician or gynecologist of their choice.

Section 2.  Definitions. As used in [sections 1 through 8], the following definitions apply:

(1) "Covered person" means a policyholder, subscriber, certificate holder, enrollee, or other individual who is participating in a health benefit plan.

(2) "Health benefit plan" means any individual or group plan, policy, certificate, subscriber contract, contract of insurance provided by a managed care plan, preferred provider agreement, or health maintenance organization subscriber contract that is issued, delivered, issued for delivery, or renewed in this state by a health carrier that pays for, purchases, or furnishes health care services to covered persons who receive health care services in this state. For the purposes of [sections 1 through 8], a health benefit plan located or domiciled outside of the state of Montana is subject to the provisions of [sections 1 through 8] if it receives, processes, adjudicates, pays, or denies claims for health care services submitted by or on behalf of covered persons who reside or who receive health care services in the state of Montana.

(3) "Health carrier" means a disability insurer, health care insurer, health maintenance organization, accident and sickness insurer, fraternal benefit society, nonprofit hospital service corporation, health service corporation, health care service plan, preferred provider organization or arrangement, multiple employer welfare arrangement, or any other person, firm, corporation, joint venture, or similar business entity.

(4) "Obstetrician or gynecologist" means a physician who is board-eligible or board-certified by the American board of obstetrics and gynecology.

(5) "Participating obstetrician or gynecologist" means an obstetrician or gynecologist who is employed by or under contract with a health benefit plan.

(6) "Primary care physician" means a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referrals for specialist care.

Section 3.  Obstetricians or gynecologists as primary care physicians. (1) Each health benefit plan that provides coverage for primary care or obstetrical or gynecological care must allow obstetricians and gynecologists to participate as primary care physicians. The health carrier that provides the health benefit plan shall contract with a sufficient number of obstetricians and gynecologists to ensure that covered persons have access to the options under this section without unreasonable delay if there are obstetricians or gynecologists practicing in the geographic service areas in which the plan operates who are willing to participate in the plan. An obstetrician or gynecologist may not be required to accept primary care physician status if the obstetrician or gynecologist does not wish to be designated as a primary care physician. A health benefit plan must use the same criteria with regard to credentials and other selection criteria for a participating obstetrician or gynecologist as are applied by the health benefit plan with respect to other physicians who are participating in the health benefit plan. An obstetrician or gynecologist wishing to accept designation as a primary care physician must meet the same criteria with regard to credentials and other selection criteria for a participating primary care physician as other physicians who are participating as primary care physicians in the health benefit plan.

(2) Each health benefit plan must allow a covered person to select any participating obstetrician or gynecologist of the covered person's choice as the covered person's primary care physician.

Section 4.  Self-referral for obstetrical or gynecological care permitted. (1) A health benefit plan must permit self-referral to any participating obstetrician or gynecologist by a covered person who has not selected a participating obstetrician or gynecologist as the covered person's primary care physician for services covered under the health benefit plan. This self-referral is for the purpose of receiving any obstetrical or gynecological examination or care and primary and preventative obstetrical and gynecological services required as a result of any obstetrical or gynecological examination or condition. This self-referral must be allowed without prior authorization or precertification from the health benefit plan or covered person's primary care physician, but the health benefit plan may require the covered person to notify the plan prior to self-referral.

(2) The services covered by this section may be limited to those services defined by the most recent published recommendations of the American college of obstetricians and gynecologists. The self-referral permitted by this section may be limited to one participating obstetrician or gynecologist for obstetrical care and one participating obstetrician or gynecologist for gynecological care of the covered person's choice annually.

(3) The participating obstetrician or gynecologist and the covered person shall comply with the health benefit plan's coordination and referral policies. The health benefit plan may require the participating obstetrician or gynecologist to whom the covered person self-refers to discuss with the covered person's primary care physician any services or treatment the participating obstetrician or gynecologist recommends for the covered person.

(4) Self-referral under this section may not affect the covered person's coverage under the health benefit plan. It is the intent of this section that a covered person must at all times have direct access to the covered services of the participating obstetrician or gynecologist of the covered person's choice under any health benefit plan.

Section 5.  Surcharges not allowed. A health benefit plan may not impose a surcharge or additional copayments or deductibles upon a covered person who seeks or receives health care services under [section 3 or 4] unless similar surcharges or additional copayments or deductibles are imposed for other types of health care services not described in [sections 3 and 4].

Section 6. Payment of covered services provided by certified advanced practice registered nurses.  A health benefit plan may not deny payment for covered services provided to a covered person under [sections 3 and 4] by a certified advanced practice registered nurse practicing in collaboration with the participating obstetrician or gynecologist. This section may not be construed to expand the definitions of participating obstetrician or gynecologist or primary care physician in [section 2] to include certified advanced practice registered nurses.

Section 7.  Disclosure. Each health benefit plan shall disclose in all of its plan literature, in clear, accurate language, the covered person's option to seek the care described in [sections 1 through 8] without preapproval, preauthorization, or referral.

Section 8.  Enforcement. If the commissioner determines that a health benefit plan does not comply with [sections 1 through 8] or that a health carrier has not complied with a provision of [sections 1 through 8], the commissioner may:

(1) recommend a correction plan that must be followed by the health carrier;

(2) institute corrective action that must be followed by the health carrier;

(3) suspend or revoke the certificate of authority or deny the health carrier's application for a certificate of authority; or

(4) use any of the commissioner's enforcement powers to obtain the health carrier's compliance with [sections 1 through 8].

Section 9.  Section 33-22-101, MCA, is amended to read:

"33-22-101.   Exceptions to scope. Parts 1 through 4 of this chapter, except 33-22-107, 33-22-110, 33-22-111, 33-22-114, 33-22-125, 33-22-130 through 33-22-132, 33-22-243, and 33-22-304, and [sections 1 through 8] do not apply to or affect:

(1)  any policy of liability or workers' compensation insurance with or without supplementary expense coverage;

(2)  any group or blanket policy;

(3)  life insurance, endowment, or annuity contracts or supplemental contracts that contain only those provisions relating to disability insurance as:

(a)  provide additional benefits in case of death or dismemberment or loss of sight by accident or accidental means; or

(b)  operate to safeguard contracts against lapse or to give a special surrender value or special benefit or an annuity in the event that the insured or annuitant becomes totally and permanently disabled, as defined by the contract or supplemental contract;

(4)  reinsurance."

Section 10.  Section 33-31-111, MCA, is amended to read:

"33-31-111.   Statutory construction and relationship to other laws. (1) Except as otherwise provided in this chapter, the insurance or health service corporation laws do not apply to any health maintenance organization authorized to transact business under this chapter. This provision does not apply to an insurer or health service corporation licensed and regulated pursuant to the insurance or health service corporation laws of this state except with respect to its health maintenance organization activities authorized and regulated pursuant to this chapter.

(2)  Solicitation of enrollees by a health maintenance organization granted a certificate of authority or its representatives may not be construed as a violation of any law relating to solicitation or advertising by health professionals.

(3)  A health maintenance organization authorized under this chapter may not be considered to be practicing medicine and is exempt from Title 37, chapter 3, relating to the practice of medicine.

(4)  The provisions of this chapter do not exempt a health maintenance organization from the applicable certificate of need requirements under Title 50, chapter 5, parts 1 and 3.

(5)  The provisions of this section do not exempt a health maintenance organization from material transaction disclosure requirements under 33-3-701 through 33-3-704. A health maintenance organization must be considered an insurer for the purposes of 33-3-701 through 33-3-704.

(6) The provisions of this section do not exempt a health maintenance organization from the provisions of [sections 1 through 8]."

Section 11.  Codification instruction. [Sections 1 through 8] are intended to be codified as an integral part of Title 33, chapter 22, and the provisions of Title 33, chapter 22, apply to [sections 1 through 8].

Section 12.  Severability. If a part of [this act] is invalid, all valid parts that are severable from the invalid part remain in effect. If a part of [this act] is invalid in one or more of its applications, the part remains in effect in all valid applications that are severable from the invalid applications.

Section 13.  Applicability. [This act] applies to each health benefit plan that is issued, delivered, issued for delivery, or renewed in Montana on or after January 1, 1998.

Section 14.  Effective date. [This act] is effective on passage and approval.

-END-