(1) Access to obstetricians
and gynecologists. A health benefit plan that is delivered, issued, renewed, or
reinstated in this state on or after January 1, 2014, that provides coverage for
reproductive health or gynecological care shall not be delivered, issued, renewed,
or reinstated unless the plan provides a woman covered by the plan direct access to
an obstetrician, a gynecologist, a physician assistant authorized under section 12-240-107 (6), an advanced practice registered nurse who is a certified nurse midwife
pursuant to section 12-255-111, or a certified midwife licensed pursuant to section
12-255-111.5, participating and available under the plan for her reproductive health
care or gynecological care.
(2) Eye care services. (a) A health coverage plan or managed care plan that
provides coverage for eye care services shall not be issued or renewed after
January 1, 2001, by any entity subject to part 2, 3, or 4 of this article unless the
health coverage plan or managed care plan:
(I) Provides a covered person direct access to any eye care provider
participating and available under the plan or through its eye care services
intermediary for eye care services;
(II) Ensures that all eye care providers on a health coverage plan or managed
care plan are annually included on any publicly accessible list of participating
providers for the health coverage plan or managed care plan; and
(III) Allows each eye care provider on a health coverage plan or managed
care plan panel to furnish covered eye care services to covered persons without
discrimination between classes of eye care providers and to provide the services as
permitted by their license.
(b) A carrier offering a health coverage plan or managed care plan shall not:
(I) Impose a deductible or coinsurance for eye care services that is greater
than the deductible or coinsurance imposed for other medical services under the
health coverage plan or managed care plan;
(II) Require an eye care provider to hold hospital privileges as a condition of
participation as a provider under the health coverage plan or managed care plan,
unless an eye care provider is licensed pursuant to article 240 of title 12; or
(III) Impose penalties upon primary care providers as a result of the direct
access provisions of this section.
(c) This subsection (2) does not:
(I) Create coverage for any health-care service that is not otherwise covered
under the terms of the health coverage plan or managed care plan;
(II) Require a health coverage plan or managed care plan to include as a
participating provider every willing provider or health professional who meets the
terms and conditions of the health coverage plan or managed care plan;
(III) Prevent a covered person from seeking eye care services from the
covered person's primary care provider in accordance with the terms of the covered
person's health coverage plan or managed care plan;
(IV) Increase or decrease the scope of the practice of optometry as defined
in section 12-275-103;
(V) Require eye care services to be provided in a hospital or similar medical
facility; or
(VI) Prohibit a health coverage plan or managed care plan from requiring a
covered person to receive a referral or prior authorization from a primary care
provider for any subsequent surgical procedures.
(d) As used in this subsection (2), unless the context otherwise requires:
(I) Eye care provider means a participating provider who is an optometrist
licensed to practice optometry pursuant to article 275 of title 12 or an
ophthalmologist licensed to practice medicine pursuant to article 240 of title 12.
(II) Eye care services means those health-care services related to the
examination, diagnosis, treatment, and management of conditions and diseases of
the eye and related structures that a health coverage plan or managed care plan is
obligated to pay, reimburse, arrange, or provide for covered persons or
organizations as specified by a health coverage plan or managed care plan,
excluding those health-care services rendered in conjunction with a routine vision
examination or the filling of prescriptions for corrective eyewear.
(3) Treatment of intractable pain. (a) A service or indemnity contract issued
or renewed on or after January 1, 1998, by any entity subject to part 2, 3, or 4 of this
article 16 shall disclose in the contract and in information on coverage presented to
consumers whether the health coverage plan or managed care plan provides
coverage for treatment of intractable pain. If the contract is silent on coverage of
intractable pain, the contract is presumed to offer coverage for the treatment of
intractable pain. If the contract is silent or if the plan specifically includes coverage
for the treatment of intractable pain, the plan shall provide access to the treatment
for any individual covered by the plan either:
(I) By a primary care physician or physician assistant authorized under
section 12-240-107 (6), so long as the physician or physician assistant has
demonstrated interest and documented experience in pain management and has a
practice that includes up-to-date pain treatment;
(II) By providing direct access to a pain management specialist located
within this state and participating in and available under the plan; or
(III) By having procedures in place that ensure that, if the individual requests
a timely referral for intractable pain management to a pain management specialist
participating in and available under the plan, the carrier shall not unreasonably
deny the request for referral.
(b) The commissioner may promulgate rules to implement and administer
this subsection (3) that include the following issues:
(I) What constitutes a timely referral;
(II) Circumstances, practices, policies, contract provisions, or actions that
constitute an undue or unreasonable interference with the ability of an individual to
secure a referral or reauthorization for continuing care;
(III) The process for issuing a denial of a request, including the means by
which an individual may receive notice of a denial and the reasons for the denial in
writing;
(IV) Actions that constitute improper penalties imposed upon a primary care
physician or physician assistant authorized under section 12-240-107 (6) as a result
of referrals made pursuant to this section; and
(V) Such other issues as the commissioner deems necessary.
(c) For purposes of this subsection (3), intractable pain means a pain state
in which the cause of the pain cannot be removed and for which, in the generally
accepted course of medical practice, relief or cure of the cause of the pain is
impossible or has not been found after reasonable efforts, including evaluation by
the attending physician or physician assistant authorized under section 12-240-107
(6) and one or more physicians specializing in the treatment of the area, system, or
organ of the body perceived as the source of the pain.
(4) Access to pediatric care. (a) If a carrier offering an individual or small
employer health benefit plan requires or provides for the designation of a
participating primary health-care professional, the carrier shall permit the parent or
legal guardian of each covered person who is a child to designate any participating
physician or physician assistant authorized under section 12-240-107 (6) who
specializes in pediatrics as the child's primary health-care professional if the
pediatrician or physician assistant is available to accept the child.
(b) The provisions of paragraph (a) of this subsection (4) do not waive any
exclusions of coverage under the terms and conditions of the health benefit plan
with respect to coverage of pediatric care.
(5) Annual behavioral health screenings. A health benefit plan that is issued
or renewed in this state on or after January 1, 2020, that provides coverage for an
annual physical examination as a preventive health-care service pursuant to section
10-16-104 (18) shall include coverage and reimbursement for behavioral health
screenings using a validated screening tool for behavioral health, which coverage
and reimbursement is no less extensive than the coverage and reimbursement for
the annual physical examination.