Citations Affected: IC 27-13.
Synopsis: Dental limited service health maintenance organizations.
Requires a limited service health maintenance organization that
provides dental care services (LSHMO) to appoint a licensed dental
director. Provides that the dental director is responsible for oversight
of policies, procedures, quality assurance, credentialing, and utilization
management decisions with input from participating providers.
Requires an LSHMO to respond to requests for reconsideration of
adverse utilization review decisions. Requires the department of
insurance to classify complaints regarding an LSHMO and provide the
information to the public. Requires an LSHMO to offer a
point-of-service product, a preferred provider plan, and an accident and
sickness insurance policy that provides dental care services beginning
July 1, 2001.
Effective: July 1, 2000.
January 10, 2000, read first time and referred to Committee on Health and Provider
Services.
January 27, 2000, amended, reported favorably _ Do Pass.
January 31, 2000, read second time, amended, ordered engrossed.
February 1, 2000, engrossed.
February 7, 2000, read third time, passed. Yeas 49, nays 1.
A BILL FOR AN ACT to amend the Indiana Code concerning
insurance.
SECTION 1. IC 27-13-34-24 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2000]: Sec. 24. (a) A limited service health
maintenance organization that provides dental care services shall
appoint a dental director who has an unlimited license to practice
dentistry under IC 25-14 or an equivalent license issued by another
state.
(b) The dental director appointed under subsection (a) is
responsible for oversight of treatment policies, protocols, quality
assurance activities, credentialing of participating providers, and
utilization management decisions of the limited service health
maintenance organization.
(c) A limited service health maintenance organization that
provides dental care services shall contract with or employ at least
one (1) individual who holds an unlimited license to practice
dentistry under IC 25-14 or an equivalent license issued by another
state to do the following:
(1) Develop, in consultation with a group of appropriate
providers, the limited service health maintenance
organization's treatment policies, protocols, and quality
assurance activities.
(2) Respond when a treating provider requests in writing that
a dentist reconsider an adverse utilization review decision.
(d) A limited service health maintenance organization that
provides dental care services that receives a written request for
reconsideration of an adverse utilization review decision from a
treating provider shall:
(1) review the decision as expeditiously as possible; and
(2) provide a response to the treating provider not more than
ten (10) business days after receiving the request.
(e)
A limited service health maintenance organization that
provides dental care services shall provide participating providers
with an opportunity to comment on
the following:
(1) Treatment policies.
(2) Protocols.
(3) Quality assurance activities.
(4) Credentialing policies and procedures.
(5) Utilization management policies and procedures.
SECTION 2. IC 27-13-34-26 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2000]: Sec. 26. (a) The department shall
maintain records concerning complaints filed against a limited
service health maintenance organization that provides dental care
services.
(b) The department shall classify complaints described in
subsection (a) in categories according to the
National Association
of Insurance Commissioners standardized complaint report
procedures.
(c) The department shall classify the disposition of complaints
in each category by:
(1) number of complaints for which corrective action is
considered necessary by the department; and
(2) number of complaints classified by National Association of
Insurance Commissioners disposition codes.
(d) The department shall make information specified in this
section available to the public in a form that does not identify any
specific individual.
(e) A limited service health maintenance organization that
provides dental care services may not take any retaliatory action,
including cancellation or refusal to renew a participating provider
contract, individual contract, or group contract, solely because a
participating provider, enrollee, or individual or group contract
holder files a complaint against the limited service health
maintenance organization.
SECTION 3. IC 27-13-37-4 IS AMENDED TO READ AS
FOLLOWS [EFFECTIVE JULY 1, 2000]: Sec. 4. (a) Beginning July
1, 1999, each Each health maintenance organization shall offer to each
purchaser of a group contract or individual contract a point-of-service
product to the extent permitted by IC 27-13-13-8.
(b) Beginning July 1, 2001, a limited service health maintenance
organization that provides dental care services shall offer to each
purchaser of a group contract or individual contract:
(1) a point-of-service product to the extent permitted by
IC 27-13-34-10(a)(6);
(2) a preferred provider plan (as defined in IC 27-8-11-1); or
(3) a policy of accident and sickness insurance (as defined in
IC 27-8-5-1);
that provides dental care services.