H*3928(Rat #0170, Act #0098 of 1999)  General Bill, By Cato
 A BILL TO AMEND SECTION 38-33-50, AS AMENDED, CODE OF LAWS OF SOUTH CAROLINA,
 1976, RELATING TO THE POWERS OF HEALTH MAINTENANCE ORGANIZATIONS, SO AS TO
 PROVIDE THAT THOSE POWERS INCLUDE THE OFFERING OF AN OUT-OF NETWORK COVERAGE
 UNDER A POINT OF SERVICE OPTION, TO BE IMPLEMENTED BY REGULATIONS AND POLICY
 BULLETIN BY THE DIRECTOR OF THE DEPARTMENT OF INSURANCE; TO AMEND SECTION
 38-33-80, AS AMENDED, RELATING TO THE PROVISION THAT EVERY ENROLLEE IN A
 HEALTH MAINTENANCE ORGANIZATION IS ENTITLED TO EVIDENCE OF COVERAGE, SO AS TO
 PROVIDE THAT FOR A POINT OF SERVICE OPTION OFFERED JOINTLY BY A HEALTH
 MAINTENANCE ORGANIZATION AND AN INSURER, ONLY ONE EVIDENCE OF COVERAGE IS
 REQUIRED AS LONG AS THE BENEFITS PROVIDED BY EACH PARTY ARE CLEARLY
 IDENTIFIED; TO AMEND SECTION 38-33-20, AS AMENDED, RELATING TO DEFINITIONS
 UNDER THE PROVISIONS REGULATING HEALTH MAINTENANCE ORGANIZATIONS, SO AS TO
 PROVIDE A DEFINITION FOR "EMPLOYING ENTITY"; TO AMEND SECTION 38-33-130, AS
 AMENDED, RELATING TO HEALTH MAINTENANCE ORGANIZATIONS, SECURITY DEPOSIT,
 INDIVIDUAL STOP-LOSS COVERAGE, UNPAID CLAIM LIABILITY, AND INDIVIDUAL
 CONVERSION POLICY, SO AS TO PROVIDE THAT AN EMPLOYING ENTITY MAY EXECUTE ONE
 AGREEMENT ON BEHALF OF THE EMPLOYING ENTITY AND ALL OF ITS PROVIDERS, AND
 PROVIDE THAT AN EMPLOYING ENTITY MAY ALSO EXECUTE ONE PARTICIPATION AGREEMENT
 AND ONE OF OTHER SIMILAR REQUIRED FORMS ON BEHALF OF THE EMPLOYING ENTITY AND
 ALL OF ITS PROVIDERS; TO AMEND THE 1976 CODE BY ADDING SECTION 38-71-46 SO AS
 TO PROVIDE THAT ON OR AFTER JANUARY 1, 2000, EVERY HEALTH MAINTENANCE
 ORGANIZATION, INDIVIDUAL, AND GROUP HEALTH INSURANCE POLICY OR CONTRACT SHALL
 PROVIDE COVERAGE FOR THE EQUIPMENT, SUPPLIES, AND OUTPATIENT SELF-MANAGEMENT
 TRAINING AND EDUCATION FOR THE TREATMENT OF PEOPLE WITH DIABETES MELLITUS, IF
 MEDICALLY NECESSARY, AND PRESCRIBED BY A HEALTH CARE PROFESSIONAL LEGALLY
 AUTHORIZED TO PRESCRIBE SUCH ITEMS WHO DEMONSTRATES ADHERENCE TO MINIMAL
 STANDARDS OF CARE FOR DIABETES MELLITUS AS ADOPTED AND PUBLISHED BY THE
 DIABETES INITIATIVE OF SOUTH CAROLINA; AND PROVIDE FOR RELATED MATTERS; AND TO
 PROVIDE THAT SECTION 38-71-46 APPLIES TO ALL INDIVIDUAL AND GROUP HEALTH
 INSURANCE AND HEALTH MAINTENANCE ORGANIZATION POLICIES ISSUED, DELIVERED,
 ISSUED FOR DELIVERY, OR RENEWED ON OR AFTER JANUARY 1, 2000.-AMENDED TITLE

   04/15/99  House  Introduced and read first time HJ-4
   04/15/99  House  Referred to Committee on Labor, Commerce and
                     Industry HJ-5
   05/05/99  House  Committee report: Favorable with amendment Labor,
                     Commerce and Industry HJ-3
   05/06/99  House  Amended HJ-8
   05/06/99  House  Read second time HJ-8
   05/06/99  House  Unanimous consent for third reading on next
                     legislative day HJ-9
   05/07/99  House  Read third time and sent to Senate HJ-1
   05/11/99  Senate Introduced and read first time SJ-34
   05/11/99  Senate Referred to Committee on Banking and Insurance SJ-34
   05/13/99  Senate Recalled from Committee on Banking and Insurance SJ-11
   05/18/99  Senate Amended SJ-15
   05/18/99  Senate Read second time SJ-15
   05/18/99  Senate Ordered to third reading with notice of
                     amendments SJ-15
   05/20/99  Senate Read third time and returned to House with
                     amendments SJ-24
   05/27/99  House  Concurred in Senate amendment and enrolled HJ-129
   06/09/99         Ratified R 170
   06/11/99         Signed By Governor
   06/11/99         Effective date 06/11/99; Sec. 38-71-46 applies to
                     all individual & group health insurance
                     policies, as the case may be, issued, etc. or
                     renewed in this State on or after 01/01/00
   07/01/99         Copies available
   07/06/99         Act No. 98

AN ACT TO AMEND SECTION 38-33-50, AS AMENDED, CODE OF LAWS OF SOUTH CAROLINA, 1976, RELATING TO THE POWERS OF HEALTH MAINTENANCE ORGANIZATIONS, SO AS TO PROVIDE THAT THOSE POWERS INCLUDE THE OFFERING OF AN OUT-OF-NETWORK COVERAGE UNDER A POINT OF SERVICE OPTION, TO BE IMPLEMENTED BY REGULATIONS AND POLICY BULLETIN BY THE DIRECTOR OF THE DEPARTMENT OF INSURANCE; TO AMEND SECTION 38-33-80, AS AMENDED, RELATING TO THE PROVISION THAT EVERY ENROLLEE IN A HEALTH MAINTENANCE ORGANIZATION IS ENTITLED TO EVIDENCE OF COVERAGE, SO AS TO PROVIDE THAT FOR A POINT OF SERVICE OPTION OFFERED JOINTLY BY A HEALTH MAINTENANCE ORGANIZATION AND AN INSURER, ONLY ONE EVIDENCE OF COVERAGE IS REQUIRED AS LONG AS THE BENEFITS PROVIDED BY EACH PARTY ARE CLEARLY IDENTIFIED; TO AMEND SECTION 38-33-20, AS AMENDED, RELATING TO DEFINITIONS UNDER THE PROVISIONS REGULATING HEALTH MAINTENANCE ORGANIZATIONS, SO AS TO PROVIDE A DEFINITION FOR "EMPLOYING ENTITY"; TO AMEND SECTION 38-33-130, AS AMENDED, RELATING TO HEALTH MAINTENANCE ORGANIZATIONS, SECURITY DEPOSIT, INDIVIDUAL STOP-LOSS COVERAGE, UNPAID CLAIM LIABILITY, AND INDIVIDUAL CONVERSION POLICY, SO AS TO PROVIDE THAT AN EMPLOYING ENTITY MAY EXECUTE ONE AGREEMENT ON BEHALF OF THE EMPLOYING ENTITY AND ALL OF ITS PROVIDERS, AND PROVIDE THAT AN EMPLOYING ENTITY MAY ALSO EXECUTE ONE PARTICIPATION AGREEMENT AND ONE OF OTHER SIMILAR REQUIRED FORMS ON BEHALF OF THE EMPLOYING ENTITY AND ALL OF ITS PROVIDERS; TO AMEND THE 1976 CODE BY ADDING SECTION 38-71-46 SO AS TO PROVIDE THAT ON OR AFTER JANUARY 1, 2000, EVERY HEALTH MAINTENANCE ORGANIZATION, INDIVIDUAL, AND GROUP HEALTH INSURANCE POLICY OR CONTRACT SHALL PROVIDE COVERAGE FOR THE EQUIPMENT, SUPPLIES, AND OUTPATIENT SELF-MANAGEMENT TRAINING AND EDUCATION FOR THE TREATMENT OF PEOPLE WITH DIABETES MELLITUS, IF MEDICALLY NECESSARY, AND PRESCRIBED BY A HEALTH CARE PROFESSIONAL LEGALLY AUTHORIZED TO PRESCRIBE SUCH ITEMS WHO DEMONSTRATES ADHERENCE TO MINIMAL STANDARDS OF CARE FOR DIABETES MELLITUS AS ADOPTED AND PUBLISHED BY THE DIABETES INITIATIVE OF SOUTH CAROLINA; AND PROVIDE FOR RELATED MATTERS; AND TO PROVIDE THAT SECTION 38-71-46 APPLIES TO ALL INDIVIDUAL AND GROUP HEALTH INSURANCE AND HEALTH MAINTENANCE ORGANIZATION POLICIES ISSUED, DELIVERED, ISSUED FOR DELIVERY, OR RENEWED ON OR AFTER JANUARY 1, 2000.

Be it enacted by the General Assembly of the State of South Carolina:

Out-of-network coverage; point of service option; etc.

SECTION 1. Section 38-33-50(A) of the 1976 Code is amended by adding:

"(8) the offering of an out-of-network coverage under a point of service option; the Director of the Department of Insurance shall, by regulations and/or policy bulletin, implement the provisions of this item."

One evidence of coverage required

SECTION 2. Section 38-33-80(A)(1) of the 1976 Code is amended to read:

"(1) Every enrollee is entitled to an evidence of coverage issued by the health maintenance organization. If any of the enrollee's benefits are provided through an insurance policy, the insurer shall issue a separate evidence of coverage for those benefits provided. However, for a point of service option offered jointly by a health maintenance organization and an insurer, only one evidence of coverage is required, as long as the benefits provided by each party are clearly identified therein."

"Employing entity" defined

SECTION 3. Section 38-33-20 of the 1976 Code is amended by adding an appropriately numbered subsection to read:

"( ) 'Employing entity' means a person employing one or more providers and agreeing to perform or provide a duty or function of the provider pursuant to this chapter, where the provider is prevented by contract with the employing entity or the employing entity's governing documents from performing such statutory duty or function individually. With respect to a statutory duty or function for which the employing entity acts for providers, an employing entity shall possess all corresponding rights and duties of its providers and shall be allowed to collectively satisfy such duty or function under this chapter as to all its providers (for example, by furnishing one hold harmless agreement and one participation agreement to a health maintenance organization on behalf of all the employing entity's providers)."

Agreements which may be executed

SECTION 4. Section 38-33-130(B) of the 1976 Code is amended to read:

"(B) Each health maintenance organization shall require every provider who participates in the health maintenance organization and furnishes health care services to the health maintenance organization's enrollees to execute an agreement not to bill the enrollees or otherwise hold the enrollees financially responsible for services rendered. Provided, an employing entity may execute one agreement on behalf of the employing entity and all of its providers. An employing entity may also execute one participation agreement and one of other similar required forms on behalf of the employing entity and all of its providers. The provider's agreement must be given on forms prescribed or approved by the director or his designee, shall extend to all services furnished to the enrollee during the time he was enrolled in the health maintenance organization, and shall apply even where the provider or employing entity had not been paid by the health maintenance organization."

Coverage for diabetes mellitus; etc.

SECTION 5. Chapter 71 of Title 38 of the 1976 Code is amended by adding:

"Section 38-71-46. (A) On or after January 1, 2000, every health maintenance organization, individual and group health insurance policy, or contract issued or renewed in this State shall provide coverage for the equipment, supplies, and outpatient self-management training and education for the treatment of people with diabetes mellitus, if medically necessary, and prescribed by a health care professional legally authorized to prescribe such items by law who demonstrates adherence to minimal standards of care for diabetes mellitus as adopted and published by the Diabetes Initiative of South Carolina.

(B) Services and payment for diabetes education programs shall conform to regulations of the Health Care Financing Administration, US Department of Health and Human Services, pursuant to Section 4105 of the Balanced Budget Act of 1997. Diabetes outpatient self-management training and education shall be provided by a registered or licensed health care professional with certification in diabetes by the National Certification Board of Diabetes Educators, or other accredited program approved by the Diabetes Initiative of South Carolina, or by the Diabetes Control Program of the SC Department of Health and Environmental Control in order to meet the needs of rural communities wherein certified health care professionals providing this service are not available.

(C) Nothing contained in this section may be construed to affect in any way the ability of a managed care plan to credential or re-credential a provider.

(D) For purposes of this section: 'Health insurance policy' means a health benefit plan, contract, or evidence of coverage providing health insurance coverage as defined in Section 38-71-670(6) and Section 38-71-840(14)."

Applicability of Section 38-71-46; time effective

SECTION 6. This act takes effect upon approval by the Governor. Section 38-71-46 applies to all individual and group health insurance and health maintenance organization policies, as the case may be, issued, delivered, issued for delivery, or renewed in this State on or after January 1, 2000.

Ratified the 9th day of June, 1999.

Approved the 11th day of June, 1999.