BULLETIN 1997-8

Issued by the Kansas Insurance Department, Kathleen Sebelius, Commissioner

June 27, 1997

TO:All Insurance Companies, Nonprofit Medical and Hospital Service Corporations, Municipal Group-funded Pools, Fraternal Benefit Societies, Health Maintenance Organizations or any other entity which is Authorized to Transact Accident & Health Insurance Business in Kansas

SUBJECT: Patient Protection Act, Section 16 through 23 of 1997 Kansas Senate Bill No. 204

The Patient Protection Act shall apply to a Health Benefit plan which includes any hospital or medical expense policy, health, hospital or medical service corporation contract, a plan provided by a municipal group-funded pool, a policy or agreement entered into by a health insurer or a health maintenance organization contract offered by an employer or any certificate issued under such policies contracts or plans. The Act shall become effective on July 1, 1997.

This act establishes standards for payment of "Emergency Services" which includes ambulance services and health care items and services furnished or required to evaluate and treat an emergency medical condition, as directed or ordered by a physician. Pursuant to Section 18(a), of the Act, a health plan shall not deny coverage for emergency services if the symptoms presented by an insured and recorded by the attending provider indicate that an emergency medical condition exists, or for emergency services necessary to provide an insured with a medical examination and stabilizing treatment, regardless of whether prior authorization was obtained to provide those services. It is important to note that these services shall be provided both in and out-of-network.

The Patient Protection Act also stipulates the following important requisites:

• if a participating provider or other authorized representative of a health insurer authorizes emergency services, then the health insurer shall not subsequently rescind or modify that authorization, except as stated in the Act;
• once an insured is stabilized, a health benefit plan may require as a condition of further coverage that a hospital emergency facility promptly contact the health insurer for prior authorization for continuing treatment, specialty consultations, transfer arrangements or other medically necessary and appropriate care for an insured; and,
• coverage of emergency services shall be subject to applicable copayments, coinsurance and deductibles. However, an insurer shall not impose any other penalty provisions which pertain specifically to emergency services.

Other provisions of the Act that are noteworthy include the following:

• No health insurer shall prohibit or restrict any participating provider from discussing with or disclosing to any insured medically appropriate health care information in regard to options for treatment, the risk or alternatives thereto, the availability of alternative therapies or tests or from advocating on behalf of the insured within a grievance review process;
• No health insurer shall have a compensation arrangement with providers which would reduce or limit the delivery of medically necessary services;
• Every health insurer shall, upon the request of a prospective insured, provide in writing information which includes a complete description of health services provided under the plan, a description of limitations, exceptions or exclusions of coverage, a listing of the health benefit plan's participating providers; notification in advance of any changes in the health benefit plan which either reduces the coverage or benefits, or increases the cost to such person; and a description of the grievance and appeal procedures under the plan and an insured's rights regarding termination, disenrollment, nonrenewal or cancellation of coverage.
• A health insurer providing a health benefit plan shall maintain a provider network that is sufficient in numbers and types of providers to assure that all covered are accessible without unreasonable delay; and,
• The insurer shall have a plan by which referrals are made to specialized medical care for insureds with chronic or disabling condition or disease.

If you have any questions and would like to speak with someone, please contact the Accident & Health Division of this department at (785) 296-7850.

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