Participating Provider Network Selection Criteria

The bill requires a health insurer (carrier) to develop and use standards for:

• Selecting participating health care providers (providers) for its network of providers; and
• Tiering providers within a tiered network if the carrier offers a tiered network.

A carrier cannot establish selection and tiering criteria in a manner that would allow a carrier to discriminate against high-risk populations or exclude providers that treat high-risk populations.

A carrier must make its standards for selecting and tiering available to the commissioner of insurance for review, communicate the standards to providers participating in one or more of the carrier's networks, and make the standards available, in plain language, to the public. Additionally, upon request but not more often than quarterly, a carrier is required to provide a provider who is participating in one or more of its networks with a complete list of all network plans and products the carrier offers to consumers.

At least 60 days before implementing a decision to terminate or place a participating provider in a tiered network, a carrier must notify the affected provider in writing of the pending action, including an explanation of the reasons for the proposed action, and inform the provider of the right to request that the carrier reconsider its decision. The bill requires the carrier to develop procedures for providers to request reconsideration and sets forth minimum requirements for, components of, and deadlines for the procedures.

When a carrier does not select a provider to participate in the carrier's provider network, the carrier shall provide written notice to the provider.

If the commissioner determines that a carrier has failed to comply with a requirement of the bill, the commissioner shall require the carrier to follow a corrective plan and may use enforcement powers available under the insurance laws to obtain compliance.

The bill appropriates $42,006 to the department of regulatory agencies for use by the division of insurance to implement the bill, with $36,828 allocated for personal services and $5,178 allocated for operating expenses and capital outlay costs.

(Note: This summary applies to the reengrossed version of this bill as introduced in the second house.)