Consumer Access To Health Care

The bill requires a health insurance carrier or an intermediary that conducts credentialing, utilization management, or utilization review to:

• Base health care coverage authorizations and medical necessity determinations on generally accepted and evidence-based standards and criteria of clinical practice;
• Disclose to a carrier's policyholders and providers the evidence-based standards and criteria of clinical practice and processes that the carrier uses for coverage authorizations and medical necessity determinations of health care services;
• Ensure that coverage authorizations and medical necessity determinations are performed by a health care provider;
• Categorize a condition as a new episode of care if the same provider has not treated the policyholder for the condition within the previous 30 days; and
• Ensure that tiered prior authorization criteria are based on generally accepted and evidence-based standards and criteria of clinical practice.

The bill prohibits:

• An intermediary from requiring coverage authorization or a medical necessity determination prior to the evaluation and management services provided by a health care provider to a policyholder during an initial health care visit; and
• A carrier from creating incentives to reduce or deny coverage authorizations or medical necessity determinations.
  (Note: This summary applies to this bill as introduced.)