PA 08-126—sSB 273
Insurance and Real Estate Committee
AN ACT CONCERNING REGULATION OF THE SECONDARY MARKET IN PHYSICIAN DISCOUNTS
SUMMARY: This act requires, with some exceptions, a “contracting entity” that (1) enters into or renews a contract with a health care provider on or after January 1, 2009 and (2) sells, leases, rents, assigns, or grants access to the provider's health care services, discounted rates, or fees, to include a contract provision that it can permit a third party (i. e. , a “covered entity”) to access the provider's services, discounted rates, or fees. It specifies (1) requirements for a contracting entity when it permits such access and (2) that it does not apply in cases involving workers' compensation benefits.
The act requires covered entities that access a provider's services to pay the discounted rates or fees established in the provider's contract with the contracting entity. It specifies that a covered entity's right to access a provider's services, rates, or fees ends when the contract between the contracting entity and the provider terminates, except for any applicable (1) continuity of care requirements or (2) agreements or contractual provisions with the provider.
The act requires all written and electronic remittance advices (payment notices sent to providers) to clearly identify the name of the (1) covered entity responsible for paying the provider and (2) contracting entity whose payment rates and discounts apply.
EFFECTIVE DATE: January 1, 2009
The act defines “contracting entity” as an entity that contracts directly with a health care provider for (1) the delivery of health care services or (2) selling, leasing, renting, assigning, or granting access to a contract or its terms.
It specifies that a health care provider is not a contracting entity. It also specifies that a contracting entity does not sell, lease, rent, assign or grant access to a contract or contract terms when it administers the benefit plan that pays for the health care services rendered under the plan.
It defines “covered entity” as an entity that (1) has not contracted directly with a health care provider but buys, leases, rents, is assigned, or accesses a provider's contract or contract terms and (2) is responsible for paying for or coordinating health care services or establishing or extending health care provider networks.
Health Care Provider
It defines “health care provider” as any physician, physician group, physician network, independent practice association, physician organization, or physician hospital organization.
The act requires each contracting entity to:
1. give a provider who requests it, when first contracting with him or her, a list of all known covered entities to which it may give access to his or her services, rates, or fees and
2. maintain a website or toll-free telephone number through which a provider can obtain a listing of covered entities having access to his or her services, rates, or fees.
It requires a contracting entity or covered entity that issues a member ID card to clearly mark on the card the website address or toll-free telephone number.
The act specifies that it does not apply to any contracting entity that sells, leases, rents, assigns, or grants access to a provider's services, discounted rates, or fees to (1) entities under common ownership or control; (2) independent entities (i. e. , not under common ownership or control) operating under the same licensee program and brand; or (3) entities providing or receiving administrative services or insurance to or from the contracting entities, entities under common ownership or control, or independent entities operating under the same licensee program or brand.
OLR Tracking: JLK: JR: PF: ts