HB557 Alabama 2025 Session

Summary

Primary Sponsor

Kelvin Datcher Representative

Democrat

Session

2025 Regular Session

Title

Health benefit plans; process further specified for making coverage determinations with enforcement and oversight given to the Department of Insurance.

Description

Under existing law, "utilization review," the process by which health insurers determine whether or not to pay or reimburse for health care services, is regulated under the Alabama Department of Public Health.

This bill would place regulation of utilization review functions under the Department of Insurance.

This bill would require health insurers to annually report the number of coverage requests denied to the Department of Insurance and make their coverage criteria accessible to enrollees and health care providers.

This bill would require coverage determinations to be made and communicated to a health care provider within 72 hours for nonurgent care requests and 24 hours for urgent care requests.

This bill would require that coverage determinations be reviewed by a licensed health care professional.

This bill would also require the Department of Insurance to establish an ombudsman to receive and investigate complaints from enrollees and health care providers concerning coverage decisions.

This bill would further provide enforcement HB557 INTRODUCED powers to the Department of Insurance, including the authority to impose civil fines on an insurer who violates this act, and would recognize that an enrollee aggrieved by a utilization review determination may pursue civil damages.

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Subjects

Insurance