Health benefit plans; process further specified for making coverage determinations with enforcement and oversight given to the Department of Insurance.
Impact
This legislation introduces specific time frames for coverage determinations: nonurgent care requests must be decided within 72 hours, while urgent care requests are to be addressed within 24 hours. Furthermore, it mandates that these determinations are reviewed by licensed healthcare professionals. These measures aim to expedite the decision-making process, thus recognizing the rights of enrollees to timely access medically necessary services.
Summary
House Bill 557, also known as the Health Care Service Utilization Review, Accountability, and Transparency Act, aims to amend existing regulations surrounding the utilization review process managed by health insurers in Alabama. The bill proposes transferring oversight of utilization review functions from the Department of Public Health to the Department of Insurance. Additionally, health insurers will be required to submit annual reports detailing the number of coverage requests denied, alongside making their coverage criteria accessible to both enrollees and healthcare providers.
Contention
Notably, the bill also establishes an ombudsman program tasked with receiving and investigating complaints from enrollees and healthcare providers about coverage decisions, providing an additional layer of accountability. To ensure compliance, the Department of Insurance is granted enforcement powers, including the ability to impose civil fines on insurers who violate these regulations. A significant point of contention could arise from the potential for increased costs associated with compliance for insurers, as well as discussions on the adequacy of the measures to protect consumers against arbitrary coverage denials.
Office of Occupational and Professional Licensing, created within the Department of Labor; oversight provided to professional or occupational licensing boards.
Agricultural organization, nonprofit, health benefits, authorized to offer to members and families, conditions, specified not to be engaged in health insurance business.
Insurance Department insurers required to be licensed, unauthorized insurers, exceptions for surplus line brokers, further provided for, authority for membership in the Surplus Line Insurance Multi-State Compliance Compact Act repealed.