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963Type of Legislation: General Bill GBIntroducing Body: SenateIntroduced Date: 20000111Primary Sponsor: FairAll Sponsors: Fair, MescherDrafted Document Number: l:\council\bills\gjk\20844djc00.docResiding Body: SenateCurrent Committee: Banking and Insurance Committee 02 SBISubject: Health maintenance organization provider plan, referrals to specialists, provisions; Insurance, MedicalHistory Body Date Action Description Com Leg Involved ______ ________ ______________________________________ _______ ____________ Senate 20000601 Co-Sponsor added by Senator Mescher Senate 20000111 Introduced, read first time, 02 SBI referred to Committee Senate 19991207 Prefiled, referred to Committee 02 SBI Versions of This Bill
TO AMEND CHAPTER 33, TITLE 38, CODE OF LAWS OF SOUTH CAROLINA, 1976, RELATING TO HEALTH MAINTENANCE ORGANIZATIONS, BY ADDING SECTION 38-33-330 SO AS TO PROVIDE THAT ONCE AN ENROLLEE HAS BEEN REFERRED TO A SPECIALIST OR OTHER HEALTH CARE PROVIDER IN A HEALTH CARE PLAN BY THEIR PRIMARY CARE PROVIDER, THE HEALTH MAINTENANCE ORGANIZATION AND THE HEALTH BENEFIT PLAN MUST ALLOW THAT SPECIALIST OR OTHER HEALTH CARE PROVIDER TO MAKE ADDITIONAL REFERRALS TO OTHER SPECIALISTS AND HEALTH CARE SERVICES AS NECESSARY AND PROPER FOR THE CARE AND TREATMENT OF THE ENROLLEE WITHOUT FURTHER REQUIREMENTS, AND TO PROVIDE FOR MEMBER NOTIFICATION OF PLAN PROVISIONS RELATING TO REFERRALS AS PROVIDED BY THIS SECTION.
Be it enacted by the General Assembly of the State of South Carolina:
SECTION 1. Chapter 33, Title 38 of the 1976 Code is amended by adding:
"Section 38-33-330. (A) For purposes of this section:
(1) 'Health benefit plan' or 'plan' means a health maintenance organization, a preferred provider plan, an exclusive provider plan, or any other managed care arrangement plan.
(2) 'Health care services' means the full scope of diagnostic testing and medical services that are necessary and proper for the prevention, treatment, and cure of diseases or conditions adversely affecting or threatening the life or health of a plan enrollee.
(B) Once a plan enrollee has been referred to a specialist or other health care provider by the enrollee's primary care provider, the health maintenance organization and the health benefit plan must allow that specialist or other health care provider to make additional referrals to other specialists and health care providers for health care services as necessary and proper for the care and treatment of the enrollee without requiring the enrollee to return to the primary care provider for approval of the subsequent referrals, or requiring the subsequent referrals be processed or receive prior approval for payment by either the primary care provider or the health maintenance organization.
(C) Except as provided in subsection (B), a specialist or other health care provider to whom a plan enrollee has been referred must follow the procedures established by the health care plan for referrals to other specialists and health care providers. Written communication should be sent to the patient's primary care physician by the specialist or health care provider to whom the enrollee was referred regarding the condition being treated within a reasonable time after each visit. However, for subsequent referrals and for continuing treatment provided by a specialist or other health care provider, authorization for medical necessity must be made directly by the health care plan.
(D) All health benefit plans must notify its members of the provisions of this section. Information relating to referrals and continuing treatment provided by specialists must be included in a health benefit plan's summary plan description and enrollment materials."
SECTION 2. This act takes effect upon approval by the Governor.
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