(A) The Governor shall appoint an advisory committee to the director which shall recommend the form and level of coverages to be made available by small employer insurers pursuant to Section 38-71-1360. At least one member of the committee shall be a licensed independent insurance agent who represents multiple health and accident insurance carriers. In preparing its initial recommendations, the advisory committee shall build on the work of the Governor's Committee on Basic Health Services.
(B) The committee shall recommend benefit levels, cost-sharing levels, exclusions and limitations for the basic health insurance plan and the standard health insurance plan. The committee shall specifically recommend which, if any, mandated coverages of health care services or health care providers should be included in the basic and standard health insurance plans and shall recommend as well whether the plans should be exempt from any other statutory provisions otherwise applicable to group health insurance policies. Section 38-71-200 is applicable to the basic and standard health insurance plans and is not subject to exemption. The committee also shall design a basic health insurance plan and a standard health insurance plan which contain benefit and cost-sharing levels that are consistent with the basic method of operation and the benefit plans of health maintenance organizations, including any restrictions imposed by federal law.
(1) The plans recommended by the committee may include cost containment features such as:
(a) utilization review of health care services, including review of medical necessity of hospital and physician services;
(b) case management;
(c) selective contracting with hospitals, physicians, and other health care providers;
(d) reasonable benefit differentials applicable to providers that participate or do not participate in arrangements using restricted network provisions; and
(e) other managed care provisions.
(2) The committee shall submit the health insurance plans described in paragraphs (A) and (B) to the director for approval by January 1, 1995. If, for any reason, the committee does not provide the director with a recommendation as to the form and level of coverages to be made available pursuant to this article, the board shall make such recommendation to the director. If, subsequent to the approval of the benefit levels of the basic and standard health insurance plans, amendments to the plans become necessary, the board shall make such recommendations to the director for his approval.
HISTORY: 1994 Act No. 339, Section 12.