CAUSE NO. ________
IN THE DISTRICT COURT OF
TRAVIS COUNTY, TEXAS
Defendants. : __________ DISTRICT COURT
ASSURANCE
OF VOLUNTARY COMPLIANCE
TO THE
HONORABLE JUDGE OF SAID COURT:
COME
NOW, the State of Texas, by and through the Attorney General of Texas John
Cornyn
("Attorney General"), Aetna U.S. Healthcare, Inc. (a Texas corporation),
Aetna U.S.
THE
TEXAS ATTORNEY GENERAL AND AETNA’S AGREEMENT
AFFECTING
AETNA’S TEXAS HMOS
Recognizing
the importance of maintaining and improving the quality and integrity of
benefits
provided by health maintenance organizations (HMOs), the Texas Attorney General
and
The
principles that the Attorney General and Aetna have agreed upon provide important
new
First,
this agreement seeks to improve the quality and integrity of determinations
of medical
necessity
and covered benefits by HMOs by assuring that determinations of medical necessity
are:(1) based solely on state of the art medical standards after reviewing
all relevant medical
Second,
this agreement seeks to improve the quality and integrity of member choices
and
access
to health care services by: (1) prohibiting physicians from discriminating
against any Aetna
Aetna’s
external review process.
Third,
this agreement seeks to improve the quality and integrity of the physician-patient
relationship
by ensuring that Aetna’s contractual and financial arrangements with physicians
and
Fourth,
Aetna agrees to create an Office of Ombudsman within Aetna. The Office of
Ombudsman
will educate Aetna members, will act as an independent advocate on behalf of
members,
and will report to the Attorney General on Aetna’s ability and efforts to
comply with the
In
addition to these four areas of protection, the Attorney General and Aetna
have established
ASSURANCES
I.
IMPROVING
THE QUALITY AND INTEGRITY OF DETERMINATIONS
OF
MEDICAL NECESSITY AND COVERED BENEFITS
1.
Aetna agrees that it will pay for all contractually covered medically necessary
care to Aetna
2.
Aetna agrees that covered benefits are health care services paid for under
the applicable certificate of coverage that are not otherwise excluded or
limited. Aetna agrees that any exclusions
3.
Aetna agrees that medically necessary care shall be defined as health care
services and
supplies
that under the applicable standard of care are appropriate:
(a)
to improve or preserve health, life, or function; or
(b)
to slow the deterioration of health, life, or function; or
(c)
for the early screening, prevention, evaluation, diagnosis or treatment of a
disease,
condition, illness, or injury.
Determinations
by Aetna of whether care is medically necessary under this definition shall
also
potential
harmful effects.
4.
Aetna agrees that, if it does not have enough information for a determination
of whether
proposed
care is medically necessary, Aetna will, within the time appropriate to the
circumstances
sufficient
information.
5.
Aetna agrees that the definition of medically necessary care in Section I.
of this AVC in no
6.
Recognizing that medical necessity determinations should be made according to
the
appropriate
medical standard of care, Aetna agrees that any non-case specific materials
used by
7.
Aetna agrees that Aetna’s Coverage Policy Bulletins and any other similar
non-case specific
8.
Aetna agrees that any determination that a proposed course of treatment, health
care service,
9.
Aetna agrees to conduct audits or reviews every 180 days of utilization review
personnel to
10.
Aetna agrees that any Adverse Determination it makes will be ultimately decided
only by
11.
Aetna agrees that it will require all entities to which it delegates or assigns
utilization review
12.
Except to the extent otherwise required by law, plan or certificate of coverage,
Aetna agrees
13.
Aetna agrees to maintain or apply for National Committee for Quality Assurance
accreditation
for Aetna’s commercial HMO operations in Texas. Aetna agrees to make the
results
of
these applications public.
14.
Aetna agrees that any Member, or Network Provider upon written consent of a
Member, may
appeal
any of the following denials or reductions through Aetna’s internal appeal
process and if any
part
of that denial or reduction is upheld on appeal then Aetna shall permit the
Member or Network
Provider,
upon written consent of a Member, to seek a timely external review of that
denial or
reduction
provided at least $500.00 is at issue. Aetna agrees that in complying with this
Section I.14
of
this AVC, it will meet all requirements and standards imposed by Texas law on
the operation of,
and
provision of access to, an internal appeals process. The denials or reductions
which are subject
to
this Section I.14 of this AVC are: (a) any denial or reduction of payment for
emergency care
based
on failure to meet the prudent lay person standard; (b) any denial or reduction
of payment
because
the health care services furnished or proposed are deemed to be experimental or
investigational;
(c) any denial of payment for drugs for covered health care services sought by
a
Member
whose plan includes a prescription drug rider for any reason not subject to
independent
review
pursuant to Art. 21.52J, TEX. INS. CODE ANN.; and, (d) any denial of a written request
for
a
standing referral to a Specialist for reasons other than medical necessity. For
purposes of this
Section
I.14 of this AVC, a “reduction of payment” shall include a requirement of a
higher copayment.
For
the purposes of this AVC, “external review” is review arranged for and provided
by
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 9
Aetna
to Aetna’s Members by a neutral and independent licensed Physician with
appropriate
expertise
to consider the matter under review. Aetna shall not use any Independent Review
Organization
currently certified at the time of executing this AVC by the Texas Commissioner
of
Insurance
under the authority of Art. 21.58C, TEX. INS. CODE ANN. to conduct external reviews,
unless
specifically authorized by the Texas Department of Insurance.
15.
Aetna agrees that it will inform Members of their right to external review in
Aetna’s Member
handbook
and disclosure form. Aetna agrees that when it makes determinations subject to
external
review
it will clearly explain, to the Member and Network Provider, all steps
necessary for the
Member
to appeal the determination and seek external review, including instructions
for seeking
help
from Aetna’s Ombudsman.
16.
Aetna agrees to make the following disclosures, or a mutually agreed upon
substitute, in preenrollment
marketing
materials:
This
plan does not pay for all health care expenses and includes exclusions and
limitations.
These exclusions will be clearly and unambiguously disclosed in your
certificate
of coverage. Read your certificate of coverage carefully to determine
which
health care services are covered benefits and to what extent. Services and
supplies
that are generally not covered benefits (depending on the specific benefits
mandated
in your state or offered by your employer) usually include, but are not
necessarily
limited to: cosmetic surgery, including breast reduction; special duty
nursing
unless medically necessary and preauthorized by Aetna; custodial care,
dental
care and dental x-rays (unless covered by a dental plan); experimental and
investigational
procedures; special equipment, including crutches and braces;
immunizations
for travel or work; hearing aids; orthotics; long-term rehabilitation
therapy;
orthoptic therapy (vision exercises); prescription drugs (unless covered by
a
prescription plan) and over-the-counter medications (except as provided in a
hospital);
oral or topical drugs used for sexual dysfunction or performance; lifestyle
enhancing
drugs; substance abuse rehabilitation, and, in certain prescription plans,
prescription
drugs on the ‘Formulary Exclusions’ list available at
www.aetnaushc.com.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 10
Nothing
in this Section I.16. of this AVC shall prevent Aetna from describing
exclusions and
limitations
of coverage with more specificity than the disclosure above.
II.
IMPROVING
THE QUALITY AND INTEGRITY
OF
THE PHYSICIAN-PATIENT RELATIONSHIP
A.
Capitation
and Other Financial Incentive Arrangements
1.
Aetna agrees that Network Providers are required to provide the same standard
of care to all
patients
regardless of the Network Provider’s Financial Incentive Arrangement or the
patient’s
particular
health care coverage or insurer. Aetna agrees to include such a requirement in
Network
Provider
contracts.
2.
(a) Aetna agrees in accordance with appropriate practices, consistent with
applicable
Texas
law, Art. 20A.14(l), TEX. INS. CODE,
not to use any Financial Incentive Arrangement in
Aetna’s
contracts with Individual Physicians, Individual Health Care Providers, or
Primary Care
Physician
Groups that provides additional compensation for not exceeding certain budgets
or
penalizes
Individual Physicians, Individual Health Care Providers, or Primary Care
Physician
Groups
for incurring expenses that are medically necessary or make additional
compensation
available
for limiting medically necessary health care services. Further, Aetna agrees
that Financial
Incentive
Arrangements in Aetna’s contracts with Individual Physicians, Individual Health
Care
Providers,
or Primary Care Physician Groups will not be affected by the actual (as opposed
to
projected)
costs of services incurred by Aetna or by the actual rate of utilization of
services during
that
contract year, except as specifically otherwise provided within this AVC.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 11
(b)
Aetna agrees not to use any Financial Incentive Arrangement in contracts with
all
other
Network Providers not identified in Section II.A.2(a) of this AVC, that
provides additional
compensation
for not exceeding certain budgets or penalizes Individual Physicians,
Individual
Health
Care Providers, or Primary Care Physician Groups for incurring expenses that
are medically
necessary
or make additional compensation available for limiting medically necessary
health care
services.
Further, Aetna agrees that Financial Incentive Arrangements in contracts with
all other
Network
Providers will not be affected by the actual (as opposed to projected) costs of
services
incurred
by Aetna or by the actual rate of utilization of services during that contract
year, except as
specifically
otherwise provided within this AVC.
(c)
Aetna agrees that it will contractually require all Network Providers to
implement
the
conditions agreed to by Aetna in Section II.A.2 (a) and 2(b) of this AVC in the
Network
Providers’
Downstream Contracts with other Network Providers.
(d)
Aetna agrees that if a Network Provider refuses to contractually commit to
implement
the
provisions in Section II.A.2(b) and 2(c) of this AVC within that Network
Provider’s contract
with
Aetna or within that Network Provider’s Downstream Contracts with other Network
Providers,
then
Aetna will contractually require the Network Provider to disclose any Financial
Incentive
Arrangements
in that Network Provider’s contracts to Aetna and Aetna’s Members in a form
acceptable
to the Attorney General and shall report the identity of that Network Provider
to the
Attorney
General. If any Network Provider refuses to provide this disclosure, then Aetna
shall
identify
to Aetna’s Members which Network Providers have refused to disclose Financial
Incentive
Arrangements
and Aetna will report to the Attorney General the identities of those Network
Providers.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 12
3.
Aetna agrees that it will not use any Financial Incentive Arrangement that is
not actuarially
sound.
Aetna agrees that a qualified actuary retained by Aetna must certify that the
formula or
method
for calculating the actuarial soundness of a Financial Incentive Arrangement
with a Network
Provider
is, based on reasonable assumptions, actuarially sufficient to compensate the
Network
Provider
for the risk being assumed. The certification required by this Section II.A.3.
of this AVC
will
not constitute or be part of the Network Provider’s contract and will not be a
guaranty,
representation,
or warranty to the Network Provider. Aetna further agrees that an actuary is
qualified
if that actuary is knowledgeable regarding Physician and Health Care Provider
compensation
and is either a member of the American Academy of Actuaries or is a fellow of
the
Society
of Actuaries. Aetna agrees that it will contractually require all Network
Providers to
implement
the conditions agreed to by Aetna in this Section II.A.3. of this AVC in the
Network
Provider’s
Downstream Contracts with other Network Providers.
4.
Aetna agrees it will not enter into any Financial Incentive Arrangement with a
Risk Bearing
Network
Provider unless the arrangement includes a means such as specific and aggregate
stop loss
insurance,
reinsurance, or some other method that will, in case Member care imposes
extraordinary
costs
upon the Risk Bearing Network Provider, reasonably protect Members from any
inducement
to
limit medically necessary covered services resulting from those extraordinary
costs. Aetna agrees
that
it will contractually require all Risk Bearing Network Providers to implement
the conditions
agreed
to by Aetna in this Section II.A.4. of this AVC in the Risk Bearing Network
Providers’
Downstream
Contracts with other Risk Bearing Network Providers.
5.
(a) Aetna agrees that directly contracted Individual primary care physicians
and directly
contracted
Primary Care Physician Groups that are to be compensated on a capitated basis
will be
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 13
offered
the option to be paid pursuant to a set amount per office visit as provided in
this Section
II.A.5.
of this AVC. Aetna agrees that if, after at least six months of participating
as a capitated
provider,
the directly contracted Individual primary care physician or directly
contracted Primary
Care
Physician Group determines that, as of September 30 of a particular calendar
year during
which
it was open to new members, it has less than 100 Aetna Members for which it
received
capitation,
the directly contracted Individual primary care physician or directly
contracted Primary
Care
Physician Group may determine whether additional funds would be owed if it were
paid
pursuant
to the set amount per office visit for that calendar year. The directly
contracted Individual
primary
care physician or directly contracted Primary Care Physician Group must
exercise the
option
to be paid any additional funds that would be due under the set amount per
office visit within
60
days of the end of the calendar year. The set amount per office visit shall be
no less than the
average
fee paid for an intermediate office visit by a primary care physician under
Aetna’s usual and
customary
HMO fee for service schedule for the relevant geographic area. Aetna agrees
that it will
contractually
require all Risk Bearing Network Providers to implement the conditions agreed
to by
Aetna
in this Section II.A.5.(a) of this AVC in the Risk Bearing Network Provider’s
Downstream
Contracts
with other Network Providers.
(b)
On June 1, 2000 Aetna agrees it will meet and report to the Attorney General,
based
on
Texas Commercial HMO patient encounter data for the most recent six months of
data available,
indicating
whether the option in Section II.A.5.(a) of this AVC adequately assures
sufficient
compensation
to primary care physicians for the provision of medically necessary covered
services
to
Aetna Members, and agrees, if necessary to accomplish the goals and principles
of this AVC, to
negotiate
with the Attorney General to increase the capitation rate or the maximum number
of
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 14
Members
under capitation a primary care physician may have in order to exercise the
option
provided
in Section II.A.5(a) of this AVC.
6.
Aetna agrees that it will not compensate any Individual Physician through a
Financial
Incentive
Arrangement for any services other than those directly provided by the
Individual
Physician,
the Physician’s staff, or if applicable, the Primary Care Physician Group.
Aetna agrees
that
it will contractually require all Risk Bearing Network Providers to implement
the conditions
agreed
to by Aetna in this Section II.A.6. of this AVC in the Risk Bearing Network
Provider’s
Downstream
Contracts with other Network Providers.
7.
Aetna agrees that, in order to encourage participating Physicians to provide
preventive care
to
Members, the Financial Incentive Arrangements for directly capitated primary
care physicians
and
Primary Care Physician Groups may include additional compensation for: (a)
prescribing ACE
inhibitors
for Members with congestive heart failure; (b) prescribing anti-inflammatory
drugs for
Members
with asthma; (c) performing skin biopsies; (d) providing immunizations; (e)
providing
allergy
desensitization injections; (f) seeing Members at least once every twelve
months; (g)
providing
asthma treatment; (h) referring Members with complex asthma to Specialists; (j)
providing
Members with cardiac disease an influenza vaccine; (k) encouraging Members with
hypertension
or congestive heart failure to take medications; (m) providing annual retinal
eye
examinations
for Members with diabetes; and, (n) encouraging Members with diabetes to take
medications.
Aetna agrees to develop additional Financial Incentive Arrangements for
directly
capitated
primary care physicians and directly capitated Primary Care Physician Groups to
provide
appropriate
preventive care. Aetna agrees that it will contractually require all Network
Providers
to
implement effective preventive care programs.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 15
8.
Aetna agrees that all services to be provided in exchange for a Financial
Incentive
Arrangement
will be clearly and unambiguously disclosed in the contracts with Network
Providers.
Aetna
agrees that Network Providers and prospective Network Providers will, at their
option, be
given
no less than 30 days to evaluate all information necessary to determine whether
or not they
may
assume the risks and obligations associated with entering a proposed contract
without
compromising
patient care. Aetna agrees that it will contractually require all Network
Providers to
implement
the conditions agreed to by Aetna in the first sentence of this Section II.A.8.
of this AVC
in
the Network Provider’s Downstream Contracts with other Network Providers.
9.
Aetna agrees that it will disclose and describe the methods by which it
compensates Network
Providers
in Aetna’s Member Handbook. Aetna also agrees that it will include the
following
statement,
or a mutually agreed upon substitute, in pre-enrollment marketing materials:
If
you have any questions about how your physician or other health care providers
are
compensated, you should call Aetna’s toll-free number for member services
listed
on your member identification card. Aetna encourages you to discuss this
issue
with your physician or other provider.
One
of the purposes of managed care is to reduce and control the costs of health
care.
Financial incentives in compensation arrangements with physicians and health
care
providers are one method by which Aetna attempts to reduce and control the
costs
of health care.
Appropriate
financial incentives are intended to reduce waste in the application of
medical
resources. Appropriate financial incentives can be applied to eliminate
inefficiencies
which may lead to artificial inflation of health care costs. Appropriate
financial
incentives can be tailored to encourage physicians and health care
providers
to practice preventive medicine and focus on improving the long-term
health
of patients. Appropriate financial incentives can also be used to direct
attention
to patient satisfaction. Appropriate financial incentives can improve the
efficient
delivery of quality health care services without compromising the quality
and
integrity of the physician-patient relationship. Only appropriate financial
incentives
will be used to compensate physicians and providers treating Aetna
members.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 16
Capitation
is an example of a financial incentive that, when used appropriately, can
be an
effective means of improving the delivery of health care services without
compromising
the physician-patient relationship. Under capitation, a physician,
physician
group, independent practice association, or other health care provider is
paid
a predetermined set amount to cover all costs of providing certain medically
necessary
covered benefits to members whether or not the actual costs of providing
those
medically necessary covered benefits is greater or lesser than the
predetermined
set amount. In its capitation arrangements with an individual
physician
or provider, Aetna provides capitation payments only for those services
the
physician or provider provides to you. However, in a capitation arrangement
with
a group of physicians or providers, Aetna may provide capitation payments for
additional
health care services such as hospitalization, use of specialists, tests, and
prescription
drugs. Under either capitation arrangement, your physician or provider
has a
financial incentive to reduce and control the costs of providing medical care.
Financial
incentives should not be used improperly to encourage the denial of
medically
necessary covered benefits. An improperly used financial incentive may
encourage
a physician to provide a patient with a less effective treatment because it
is
less expensive.
Aetna
will not improperly use financial incentives to compensate physicians and
providers
for treatments and services provided to Aetna members.
If
you are considering enrolling in our plan, you are entitled to ask if the plan,
or any
provider
group serving Aetna members, has compensation arrangements with
participating
physicians and providers that can create a financial incentive to reduce
or
control the costs of providing medically necessary covered services. A summary
of
the compensation arrangements known to Aetna relating to a particular physician
or
provider will be made available upon request by calling the member services
telephone
number on your ID card. If you are not currently an Aetna Member, you
may
contact your employer’s employee benefits manager for the same information.
Alternatively,
you may contact the provider group directly to find out about
compensation
arrangements between the provider group and any participating
physician
or provider. You may also wish to ask what arrangements your physician
has
made in case the costs of your medical care are extraordinary.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 17
II.
B.
The
Physician-Patient Relationship
1.
Aetna agrees that it will not terminate or penalize a Network Provider because
the Network
Provider
provides or proposes to provide medically necessary care that is more than that
which is
(a)
projected; (b) the statistical norm; (c) provided or proposed to be provided by
peers; or (d)
established
as a goal.
2.
Aetna agrees that profiling of Network Providers will be the product of
qualified and
objective
peer review, utilizing criteria directly related to the quality of patient
care. Aetna agrees
that
it will not use economic profiling to discourage Network Providers from
providing medically
necessary
care to Members.
3.
Aetna agrees to provide any Individual Physician or other Individual Health
Care Provider
with
72 hours advanced written notice of which treatment requests and decisions of
that Individual
Physician
or other Individual Health Care Provider will be evaluated and discussed at a
utilization
review
committee meeting, if such meetings are held. Aetna also agrees to disclose all
information
that
will be used in these utilization review committee meetings to the Individual
Physician or other
Individual
Health Care Provider 72 hours prior to any such meeting. Aetna agrees to
provide the
results,
including all information used to reach such results, of any such committee’s
review to the
Individual
Physician or Individual Health Care Provider within ten days after such
decision is
reached.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 18
4.
Aetna agrees that it will not discriminate against a Member based on a Member's
acute,
chronic,
disabling, or life threatening illness or condition. Aetna agrees it will
develop and
implement
policies and procedures designed to detect and prevent patterns of
discrimination against
Aetna
Members with acute, chronic, disabling, or life threatening illnesses or
conditions by Network
Providers.
Aetna agrees that these policies and procedures will be submitted to and
approved by
unbiased
professionals in the field, such as the National Committee for Quality
Assurance, or any
other
group of qualified, unbiased professionals if approved by the Attorney General
of Texas or
the
Texas Department of Insurance. Aetna agrees that the Ombudsman, provided for in
Section IV
of
this AVC, will monitor the implementation of these policies and procedures and
will assist Aetna
Members
who believe they may have been discriminated against because they have acute,
chronic,
disabling,
or life threatening illnesses or conditions.
5.
Aetna agrees that it will contractually require all Network Providers to
implement the
conditions
agreed to by Aetna in Sections II.B.(1)-(4) of this AVC, in the Network
Provider’s
Downstream
Contracts with other Network Providers.
6.
Aetna agrees that a copy of a contract, policy, guideline or criteria with
which a Network
Provider
is obligated to comply pursuant to a contractual agreement with Aetna will be
mailed or
otherwise
made available to any Network Provider within ten business days of receipt of a
written
request
for a copy of such contract, policy, guideline or criteria, to the extent
permissible by
applicable
copyright, trademark, or intellectual property law, contract, or relevant
licensing
agreement.
7.
Aetna agrees that any such policy, guideline or criteria relating to a Network
Provider’s
performance
of duties pursuant to a contractual agreement with Aetna will not be amended
except
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 19
upon
90 days prior written notice and opportunity to comment to all Network
Providers unless a
shorter
notice period is necessary to protect patient safety. The notice shall allow
the Network
Provider
to compare the proposed policies, guidelines, or criteria with the existing
policies,
guidelines,
or criteria.
8.
Aetna agrees to use Aetna’s utilization review system to develop and implement
policies
designed
to detect and prevent patterns of Clinically Inappropriate Underutilization of
health care
services
by Network Providers or Members, particularly women Members, minority Members
and
Members
with acute, chronic, disabling, or life-threatening illnesses or conditions.
II.
C.
Participation
by Physicians in Aetna Health Care Products
1.
Aetna agrees to offer all Individual Physicians, Individual Health Care
Providers and
Primary
Care Physician Groups of 10 Physicians or fewer, and non-Primary Care Physician
Groups
of 25
Physicians or fewer, (hereafter in Section II.C. of this AVC "Small
Groups") the option of
participating
in each Aetna health care product without accepting the All Products Provision
as a
condition
of participation in a product. For purposes of Section II.C. of this AVC, a
"Product Line"
is
defined as either: (a) all HMO and HMO-based products, or (b) all non-HMO and
non-HMObased
products.
For purposes of Section II.C. of this AVC, HMO and HMO-based plans or products
shall
have the same meaning as "health care plan" at Art. 20A.02(l), TEX. INS. CODE ANN.
2.
Nothing in this AVC shall prevent Aetna from requiring an Individual Physician,
Individual
Health
Care Provider or Small Group that elects to participate only in the HMO
products, to
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 20
participate
in all Aetna HMO and HMO-based plans and products so long as the products are
existing,
enumerated, and explained in writing before execution of the contract with the
Individual
Physician,
Individual Health Care Provider or Small Group, or with respect to a contract
in effect
as of
the effective date of this AVC, plans and products existing at that time. For
example, if an
Individual
Physician, Individual Health Care Provider or Small Group elects not to
participate in
all
products but wants to participate only in the Aetna HMO product, this AVC shall
not prohibit
Aetna
from requiring that Individual Physician, Individual Health Care Provider or
Small Group
to
participate in all Aetna HMO and HMO-based plans and products, such as Medicare
HMO,
USAccess,
and Quality Point of Service, so long as those HMO and HMO-based plans and
products
are
existing, enumerated and explained to that Individual Physician, Individual
Health Care
Provider
or Small Group before execution of the contract with that Individual Physician,
Individual
Health
Care Provider or Small Group. Nothing in this AVC shall prevent Aetna from
requiring an
Individual
Physician, Individual Health Care Provider or Small Group that elects to
participate only
in
non-HMO or non-HMO-based products, to participate in all Aetna non-HMO or
non-HMO-based
plans
and products so long as the plans or products are existing, enumerated, and
explained in
writing
before execution of the contract with that Individual Physician, Individual
Health Care
Provider
or Small Group.
3.
The parties agree that nothing in this AVC shall be construed to prohibit or
limit Aetna's
ability
to use different capitation rates or fee schedules for an Individual Physician,
Individual
Health
Care Provider or Small Group based upon whether or not that Individual
Physician,
Individual
Health Care Provider or Small Group chooses to accept all Product Lines or
chooses to
continue
to accept all Product Lines.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 21
4.
Aetna agrees that nothing in Section II.C.3. of this AVC shall permit Aetna to
compensate
an
Individual Physician, Individual Health Care Provider or Small Group with any
Financial
Incentive
Arrangement which does not meet the requirements of Section II.A. of this AVC.
5.
Aetna agrees that by 90 days written notice delivered to Aetna, at any time, an
Individual
Physician,
Individual Health Care Provider or Small Group subject to the All Products
Provision,
may
choose not to participate in all Product Lines. Individual Physicians,
Individual Health Care
Providers
or Small Groups may choose to participate in all Product Lines upon written
notice at any
time
to Aetna, provided they meet Aetna’s participation criteria and execute the
appropriate
contract.
Effective July 1, 2000, Aetna agrees not to enforce any All Products Provision
in any
existing
Individual Physician, Individual Health Care Provider or Small Group contract
except
according
to the terms of this Section II.C.5 of this AVC. Nothing in this Section II.C.5
of this
AVC
shall relieve an Individual Physician, Individual Health Care Provider or Small
Group of any
obligation
under applicable law or agreement to continue to provide care to Aetna Members
previously
under the Individual Physician, Individual Health Care Provider or Small
Group’s care.
6.
Aetna agrees that Aetna's material breach of a contract term applicable to one
of Aetna’s
Product
Lines, uncured after at least 90 days prior written notice and opportunity to
cure, will be
a valid
ground for any Network Provider bound by an All Products Provision to terminate
that
particular
Aetna Product Line without violating the terms of the All Products Provision.
As of the
effective
date of this AVC, Aetna agrees not to enforce any All Products Provision in any
existing
contract
with any Network Provider except according to the terms of this Section II.C.6.
of this
AVC.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 22
7.
Aetna will not enforce any Aetna patient mandatory acceptance provision in any
contract
with
an Individual Physician, Individual Health Care Provider or Small Group except
that Aetna
may
require the Individual Physician, Individual Health Care Provider or Small
Group to accept
any
of that Individual Physician, Individual Health Care Provider or Small Group’s
current patients,
or
Members who were patients of that Individual Physician, Individual Health Care
Provider or
Small
Group within the 12 months immediately prior to joining an Aetna plan, who
enroll in an
Aetna
health care product in which that Individual Physician, Individual Health Care
Provider or
Small
Group participates.
8.
Aetna agrees that in any contract between Aetna and a Primary Care Physician
Group of
more
than 10 Physicians or non-Primary Care Physician Group of more than 25
Physicians
(hereafter
in Section II.C. of this AVC referred to as "Large Groups"), once 25%
or more of that
Large
Group’s total HMO and non-HMO patient population consists of Aetna Members,
that Large
Group,
upon 60 days notice and written certification to Aetna, may stop accepting new
patients who
are
Aetna Members, who were not patients of that Large Group within the12 months
immediately
prior
to joining an Aetna plan so long as that Large Group also stops accepting new patients
who
are
members of any other payor, who were not patients of that Large Group within
the 12 months
immediately
prior to joining that other payor’s plan if that payor’s members comprise 25%
or more
of
that Large Group’s total patient population.
9. Aetna
agrees that it will not unilaterally amend Aetna’s contracts with Individual
Physicians,
Individual
Health Care Providers or Small Groups except that, if specifically provided by
contract,
Aetna
may propose an amended capitation rate or fee schedule to the Individual
Physician,
Individual
Health Care Provider or Small Group as permitted within this Section II.C.9. of
this
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 23
AVC.
Aetna agrees to provide 90 days written notice to an Individual Physician,
Individual Health
Care
Provider or Small Group of Aetna’s intent to amend any applicable capitation
rate or fee
schedule.
The notice shall include the new capitation rate or fee schedule and the
services to be
provided
according to the new capitation rate or schedule. In the event of such notice
by Aetna, the
Individual
Physician, Individual Health Care Provider or Small Group shall have the option
of
terminating
the contract without penalty upon 60 days written notice to Aetna, unless
longer notice
is
specifically required by state law, prior to implementation of the new terms if
the Individual
Physician,
Individual Health Care Provider or Small Group reasonably believes the new
capitation
rate
or fee schedule does not provide adequate compensation. Should an Individual
Physician,
Individual
Health Care Provider or Small Group terminate the contract or relationship with
Aetna
pursuant
to this Section II.C.9. of this AVC, nothing in this AVC shall relieve that
Individual
Physician,
Individual Health Care Provider or Small Group of any obligation under
applicable law
or
agreement to continue to provide care to Aetna Members previously under the
Individual
Physician,
Individual Health Care Provider or Small Group’s care. Aetna agrees it will not
implement
retroactive amendments to Aetna’s contracts with Individual Physicians,
Individual
Health
Care Providers or Small Groups. The prohibitions in this Section II.C.9. of
this AVC shall
not
apply to amendments otherwise required by law or this AVC.
10.
Aetna agrees that it will not unilaterally amend Aetna’s contracts with Network
Providers
other
than Individual Physicians, Individual Health Care Providers or Small Groups
except as
specifically
otherwise agreed to within the contract. The prohibitions in this Section
II.C.10. of this
AVC
shall not apply to unilateral amendments otherwise required by law or this AVC.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 24
11.
Aetna and the Attorney General agree that if the provisions of Section II.C. of
this AVC
have,
or would have an adverse impact on Texas Consumers’ access to health care
coverage through
Aetna’s
HMOs, the Attorney General and Aetna will amend Section II.C. of this AVC. Aetna
agrees
to meet and report to the Attorney General on the impact of Section II.C. of
this AVC by
December
1, 2000.
12.
Aetna and the Attorney General agree that, except for Sections II.C.6. and
II.C.10. of this
AVC,
the provisions of Section II.C. of this AVC shall not apply to hospital-based
Physicians, e.g.,
anesthesiologists,
pathologists, radiologists and emergency room Physicians.
II.
D.
PATIENT
PROTECTION FROM PROVIDER
INABILITY
TO PAY PHYSICIANS
1.
Aetna agrees to include in any contract between Aetna and a Risk Bearing
Network Provider,
compensated
directly by Aetna through a Financial Incentive Arrangement, a provision to
maintain
continuity
of care to Aetna Members in the event such a Risk Bearing Network Provider is
unable,
for
any reason, other than one of short or limited duration, to make timely payment
to its
participating
Network Providers for medically necessary covered benefits provided to Aetna
Members.
2.
Aetna agrees that such a provision in contracts with Aetna’s Risk Bearing
Network
Providers
shall expressly authorize Aetna to directly contract with participating Network
Providers
for
medically necessary covered benefits the participating Network Providers
provide to Aetna
Members.
Aetna agrees that contracts with Risk Bearing Network Providers will recite
that the
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 25
authorization
is a material condition of the contract. Aetna also agrees that contracts with
Risk
Bearing
Network Providers will require such Risk Bearing Network Provider to agree not
to seek,
directly
or indirectly, any injunctive relief prohibiting Aetna from making direct
payments to
participating
Network Providers, pursuant to Aetna’s direct contract with those Network
Providers,
in
case the Risk Bearing Network Provider is for any reason, other than one of
short or limited
duration,
unable to make timely payment to participating Network Providers for medically
necessary
covered
benefits.
3.
Aetna agrees that for purposes of Section II.D. of this AVC, the term
“participating Network
Provider”
designates those Network Providers who are employed by, partners of, contracted
with,
or
otherwise associated with a Risk Bearing Network Provider compensated directly
by Aetna
through
a Financial Incentive Arrangement. Aetna also agrees that for purposes of
Section II.D. of
this
AVC, “timely payment” shall be payment made within the time allowed by the
contract between
the
Risk Bearing Network Provider and the participating Network Provider.
4.
Aetna agrees that if the Risk Bearing Network Provider refuses to agree to the
contractual
provisions
required by Section II.D., then 90 days before Aetna contracts with the Risk Bearing
Network
Provider, Aetna will give written notice to the Attorney General of the Risk
Bearing
Network
Provider’s refusal to agree.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 26
III.
IMPROVING
MEMBER CHOICE OF AND
ACCESS
TO QUALITY HEALTH CARE
A.
Health
Care Providers
1.
Aetna agrees to publish a Physician and Health Care Provider directory on the
Internet and
will
update the Internet directory weekly to reflect changes to the list of
participating Physicians
and
Health Care Providers. Aetna agrees to inform Aetna’s group contract holders
that upon request
they
may obtain a copy of an updated printed Physician and Health Care Provider
directory. Aetna
agrees
to comply promptly with any such request.
2.
Aetna agrees that if the relationship between Aetna and a Member’s primary care
physician
or
Specialist, for which the Member has a standing referral, (the Specialist and
the primary care
physician
are referred to in this Section III.A.2. of this AVC collectively as Physician)
terminates
or
expires prior to the end of the Member’s plan year then that Member may choose
a new Physician
or
agree with the Member’s current Physician to continue to be cared for by that
Physician under
the
terms of the Member’s plan through the end of the plan year unless the
termination is justified
by
imminent harm to patient health, challenges to the Physician’s license to
practice medicine,
fraud,
or failure to satisfy credentialing criteria.
(a)
Aetna agrees that if the Member and Physician agree as provided above and Aetna
and
the Physician had a direct contractual relationship, or if the Physician
continues to be associated
with
a Network Provider that had a direct contractual relationship with Aetna, then
Aetna shall
continue
to pay for the Member’s medically necessary covered benefits at the contract
rate until the
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 27
earlier
of the end of the Member’s plan year or the expiration date of the Physician’s
contract. If
the
expiration date of the Physician’s contract is prior to the end of the Member’s
plan year, then
subsequent
to the expiration date of the Physician’s contract, Aetna will compensate the
Physician
for
the Member’s medically necessary covered benefits according to Aetna’s usual
and customary
HMO
fee for service schedule until the end of the Member’s plan year.
(b)
Aetna agrees that if the Member and Physician agree as provided above and Aetna
and
the Physician had no direct contractual relationship and if the Physician is
not associated with
a
Network Provider that had a direct contractual relationship with Aetna, then
Aetna shall
compensate
the Physician according to Aetna’s usual and customary HMO fee for service
schedule
until
the end of the Member’s plan year.
(c)
Aetna agrees that nothing in Section III.A.2. of this AVC shall limit Aetna’s
obligations,
or any Member’s entitlements, under Aetna’s evidence of coverage, Aetna’s
Physician
and
Health Care Provider contracts, or under the TEXAS
INSURANCE CODE or rules promulgated
thereunder.
Aetna agrees that it will inform Members of their option to continue with or
choose a
new
Physician when Aetna notifies the Member of the Physician’s termination.
(d)
Aetna and the Attorney General agree that nothing in Section III.A.2. of this
AVC
shall
require the Physician to continue to care for an Aetna Member should that
Physician’s
relationship
with Aetna expire or terminate. Aetna and the Attorney General agree that
nothing in
Section
III.A.2. of this AVC creates any liability of Aetna for the refusal of a
Physician to continue
to
provide health care services to an Aetna Member after the expiration or
termination of the
Physician’s
relationship with Aetna.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 28
3.
Aetna agrees that if a Network Provider’s relationship with Aetna’s network
will expire or
terminate,
Aetna will notify the Network Provider’s Member patients receiving care from
such
Network
Provider at the earliest practical date, but no later than 30 days before the
effective date
of
the termination, unless immediate termination is justified by imminent harm to
patient health,
challenges
to the Physician’s license to practice medicine, fraud, or failure to satisfy
credentialing
criteria.
Aetna agrees that any such notice shall inform the Aetna Member that the Member
may
choose
a new Physician or, unless the Physician was subject to immediate termination,
agree with
the
Member’s current Physician to continue to be cared for by that Physician under
the terms of the
Member's
plan through the end of the plan year. Any such notice shall also inform the
Member that
under
Art. 20A.18A(c), TEX. INS. CODE ANN, as amended by Act of 1997, 75th Leg., ch.
1026, Sec.
19,
eff. Sept. 1, 1997, the Member may under certain circumstances have the
right to continue to
see
the Member's current Physician beyond the end of the plan year so long as the
Member
continues
to be enrolled in the plan. The notice will encourage the Member to contact the
Physician,
Aetna's
toll free number for Member services or the Texas Department of Insurance with
questions
about
this option.
4.
Aetna agrees that if medically necessary covered benefits are not available
within Aetna’s
Network,
Aetna will treat a request by a Member for a referral to a Physician or Health
Care
Provider
outside Aetna’s Network in the same manner as a request by a “Network Physician
or
Provider”
as described in 28 TEX. ADMIN. CODE §
11.506(15). Aetna’s Office of Ombudsman may
assist
the Member in making such a request.
5.
Aetna agrees that if a medically necessary covered benefit is not available
through the
limited
provider network to which the Member’s primary care physician belongs, but is
available
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 29
within
Aetna’s network, then upon the request of a Network Provider, or if a Network
Provider
should
fail to make such a request, upon the request of the Member, Aetna will
authorize payment
for a
referral to a Network Provider outside the limited provider group at the
contract rate. Aetna
agrees
it will authorize payment for such a referral within the time appropriate to
the circumstances
relating
to the delivery of the benefits and the condition of the patient, but in no
event to exceed five
business
days after receipt of reasonably requested documentation. Aetna’s Office of
Ombudsman
may
assist the Member in making such a request. Aetna agrees that, notwithstanding
anything to
the
contrary in this AVC, Aetna will provide for a utilization review by a
Specialist of the same
specialty
or a similar specialty as the type of Physician or Health Care Provider to whom
a referral
is
requested pursuant to this Section III.A.5 of this AVC before Aetna may deny
the request.
6.
Aetna agrees that, if a Member is admitted to an in-patient facility, Aetna
will not assign a
Physician
other than that Member’s primary care physician to direct and oversee the
Member’s
inpatient
care in place of the Member’s primary care physician if that Member objects to
the
assignment.
Aetna agrees to notify the Member of the right to object.
7.
Aetna agrees that Aetna shall approve a request for a standing referral to a
participating
Specialist
for a Member with a chronic, disabling, or life-threatening illness or
condition if it is
medically
necessary for the Specialist to care for the Member on a continuing basis.
Aetna’s Office
of
Ombudsman may assist the Member in making such a request. Nothing in this
Section III.A.7.
of
this AVC shall prevent Aetna from placing reasonable limits on the duration and
scope of the
standing
referral.
8.
Aetna agrees that once Aetna communicates approval of payment for a particular
procedure,
service,
product, or supply under the Member’s health plan, then Aetna will pay for that
procedure,
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 30
service,
product, or supply absent fraud or materially changed condition of the Member
and
provided
the Member is a Member of the health plan at the time such care is delivered.
9.
Aetna agrees to develop and implement programs that encourage Physicians to
provide and
encourage
Members to seek and receive preventive health care. Such programs will include
but are
not
limited to the following: (a) Financial Incentive Arrangements to primary care
physicians to
provide
preventive and quality care; (b) retinal eye examination reminders to Members
with
diabetes;
(d) identification of Members with asthma and providing asthma educational
materials and
peak
flow meters to such Members; (d) contraindictation programs with pharmacies to
prevent
Members
from taking contrary medications; (e) reminders to female Members age 40 and
older to
have
mammograms and perform breast self-examinations; (f) reminders to female
Members age 18
and
over to have pap screening; (g) reminders to parents of infants to get
appropriate immunizations;
(h)
reminders to Members age 65 and older to get influenza and pneumococcal vaccines;
and (i)
reminders
and screening kits to Members age 50 and older for early detection of
colorectal cancer.
10.
Aetna acknowledges that 28 TEX. ADMIN. CODE §
11.1600 (b)(11)(A) requires HMOs to
notify
their Members that in most instances they will not be allowed to receive
services from any
Physician
or Health Care Provider outside the limited provider network to which their
primary care
physician
belongs. Aetna agrees it will add the following disclosure, or a mutually
agreed upon
substitute,
to the notice required by 28 TEX. ADMIN. CODE §
11.1600 (b)(11)(A):
If
medically necessary covered services are not otherwise available, a member has
the
right to a referral to a specialist or provider outside Aetna's network of
physicians
or
providers, and outside the limited provider network to which the member's
primary
care physician may belong.
If
medically necessary covered services you wish to receive are available through
your
primary care physician's limited provider network, but you want to receive
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 31
these
services from an Aetna network provider who is not within your primary care
physician's
limited provider network, you may change your primary care physician
in
order to select a primary care physician within the same limited provider
network
from
which you want to receive medically necessary covered services.
III.
B.
Prescription
Drugs
1. In
addition to Art. 21.52J, TEX. INS. CODE ANN. which protects Members’ access to
prescription
drugs during the Members’ current plan year, Aetna agrees to provide Aetna’s
Members
notice
of any modification or deletion of coverage for prescription drugs in the
Members’ next plan
year.
Aetna agrees not to modify (e.g., increase the copayment obligation of
the Member) or delete
Aetna’s
coverage of any prescription drug during the last 90 days of any Member's plan
year. Aetna
agrees
that Members who have been prescribed and are covered by Aetna for prescription
drugs
during
a plan year will receive written notice of any modification or deletion of
coverage for the
drug
effective at the beginning of the next plan year no less than 90 days prior to
the end of that
Member's
plan year. Aetna agrees that this notice will direct Members to examine the new
formulary
listing, and the Members’ plan-specific materials, to determine whether
coverage for any
particular
prescription drug has changed. This notice will direct Members to inform their
treating
Physicians
of the coverage changes.
2.
Aetna agrees that it will give 90 days notice to all Physicians and Health Care
Providers
prescribing
drugs to Members covered by that plan of any modifications or deletions of
prescription
drug
coverage.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 32
3.
Aetna agrees to make Aetna’s formularies available to consumers and providers
through
publication
on the Internet. The Internet site will direct Members to their summaries of
benefits to
determine
their plan-specific coverage. The Internet site will be updated as soon as
changes to the
formulary
are made.
4.
Aetna agrees that Aetna’s determination of whether a drug represents an
important
therapeutic
advance will be done without regard to cost, price, volume discount
arrangements,
rebates,
or other agreements or financial arrangements between Aetna and pharmaceutical
companies
or drug manufacturers.
5.
Aetna agrees that a determination of whether to include any single source
branded drug
representing
an important therapeutic advance on Aetna’s formulary will be made without
regard
to
cost, price, or volume discount arrangements between Aetna and pharmaceutical
companies or
drug
manufacturers.
6.
Subject to the terms and conditions of the plan, Aetna agrees that if a
Member’s treating
Physician
determines that it is medically necessary to treat the Member with a
prescription drug
excluded
from that Member’s formulary, and Aetna determines that it is medically
necessary to treat
the
Member with the excluded drug, the excluded drug will be covered.
7.
Aetna and the Attorney General agree that nothing in this AVC shall prohibit
Aetna from
excluding
coverage for a drug that: (a) is deemed unsafe by the FDA or another regulatory
agency;
or
(b) is determined by Aetna or the manufacturing pharmaceutical company to be
unsafe based
upon
scientific and medical evidence as defined at 28 TEX.
ADMIN. Code § 12.5.
8.
Aetna agrees that any pharmacy, pharmacist or pharmaceutical benefit manager
involved in
the
delivery of prescription drugs to Aetna Members shall not have any financial
incentive to
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 33
encourage
the substitution of any particular Aetna formulary drug in place of the drug
prescribed
for a
Member by the treating Physician. However nothing in this Section III.B.8. of
this AVC shall
prevent
Aetna from providing Financial Incentive Arrangements to any pharmacy,
pharmacist or
pharmaceutical
benefit manager to alert a treating Physician to any hazards posed by the
prescribed
drug
or to a drug more effective than the prescribed drug, nor shall anything in
this Section III.B.8.
of
this AVC prevent Aetna from providing Financial Incentive Arrangements to any
pharmacy,
pharmacist
or pharmaceutical benefit manager for encouraging the substitution of a
clinically
equivalent
generic drug for the brand name drug as allowed by the prescribing Physician.
9.
Aetna agrees that it will contractually require all Network Providers to agree
to the
conditions
agreed to by Aetna in Section III.B. of this AVC.
III.
C.
Experimental
and Investigational Therapies and Clinical Trials
1.
Aetna agrees that, notwithstanding any exclusion of coverage, Aetna will cover
as a benefit
experimental
or investigational therapies and clinical trials according to the provisions of
Section
III.C.
of this AVC.
2.
Aetna and the Attorney General agree that for a Member to qualify for this
benefit a
Member’s
Physician must determine that the Member has a current diagnosis that has a
probability
of
causing death within two years and for which standard therapies have not been
effective in
significantly
improving the condition of the Member or for which standard therapies would not
be
medically
appropriate.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 34
3.
Aetna and the Attorney General agree that the Member’s Physician must state in
writing: (a)
that
he has recommended a drug, device, procedure or other therapy that is likely to
be more
beneficial
to the Member than available standard therapies; or (b) that the Member or a
board
certified
or board eligible Physician qualified to practice in the area of practice
appropriate to treat
the
Member’s condition, has requested a therapy that, based on two documents from
the medical
and
scientific evidence, as described in Section III.C.4. of this AVC, is likely to
be more beneficial
for
the enrollee than any available standard therapy. The Physician’s statement
pursuant to this
Section
III.C.3. of this AVC shall include a description of the evidence relied upon by
the Physician
in
making the recommendation.
4.
Aetna and the Attorney General agree that, for the purposes of Section III.C.3.
of this AVC,
medical
and scientific evidence means the following sources:
(a)
Peer-reviewed scientific studies published in or accepted for publication by
medical
journals that meet nationally recognized requirements for scientific
manuscripts
and that submit most of their published articles for review by
experts
who are not part of the editorial staff.
(b)
Peer-reviewed literature, biomedical compendia, and other medical literature
that
meet the criteria of the National Institute of Health’s National Library
of
Medicine for indexing in index Medicus, Excerpta Medicus (EMBASE),
Medline,
and MEDLARS database Health Services Technology Assessment
Research
(STAR).
(c)
Medical journals recognized by the Secretary of Health and Human Services,
under
Section 1861(t)(2) of the Social Security Act (42 U.S.C. 1395x).
(d)
The following standard reference compendia:
i.
The American Hospital formulary Service-Drug Information,
ii.
The American Medical Association Drug Evaluation,
iii.
The American Dental Association Accepted Dental Therapeutics, and
iv.
The United States Pharmacopoeia-Drug Information.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 35
(e)
Findings, studies, or research conducted by or under the auspices of federal
government
agencies and nationally recognized federal research institutes
including
the:
i.
Federal Agency for Healthcare Research and Quality,
ii.
National Institutes of Health,
iii.
National Cancer Institute,
iv.
National Academy of Sciences,
v.
Health Care Financing Administration, and
vi.
any national board recognized by the National Institutes of Health for
the
purpose of evaluating the medical value of health services.
(f)
Peer-reviewed abstracts accepted for presentation at major medical
association
meetings.
5.
Aetna agrees that it will contractually require all Network Providers to agree
to the
conditions
agreed to by Aetna in Section III.C. of this AVC.
III.
D.
Emergency
Care
1.
Aetna agrees to pay fees for emergency department screening and stabilization
services, in
and
out of Network, without prior authorization by Aetna or the Member’s primary
care physician,
in
accordance with TEX. INS. CODE art.
20A.04(a)(16) and the prudent lay person standard as
identified
in TEX. INS.
CODE art. 21.58A, § 2(6).
2.
Aetna agrees to encourage emergency room Physicians to exercise their own
independent
professional
judgment in providing medically necessary care to treat and stabilize a Member
on an
emergency
basis.
3.
Aetna agrees that any ambulance services participating in Aetna’s Network or
with which
it
contracts will be required to deliver the patient who requires emergency
medical care to the
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 36
nearest
medical facility where the medically necessary care can be provided in a timely
fashion,
unless
otherwise specifically instructed by the Member, the Member’s family, or the
Member’s
Physician.
IV.
THE
OFFICE OF OMBUDSMAN
1.
Aetna agrees to establish an Office of Ombudsman, hire an Ombudsman-Director of
the
Office
of Ombudsman, no later than June 1, 2000, and reasonably and sufficiently fund
and staff
that
office on behalf of Aetna's Texas HMO Members to accomplish the goals and
principles
enumerated
in this AVC. Aetna agrees that the Ombudsman will report directly to the Board
of
Directors
of each Aetna HMO. Aetna agrees that the duties and responsibilities of this
Office are
to
independently represent the interests of Aetna’s HMO Members and work on their
behalf.
2.
Aetna agrees to inform Aetna’s Members of the creation of the Office of
Ombudsman.
Aetna
agrees that the Office of Ombudsman shall be responsible for educating Aetna's
Members and
assuring
that these Members are given the opportunity to fully understand Aetna's HMO
plans, the
coverage
provided by these plans and the Network Providers participating in these plans.
The
Ombudsman
shall advocate on behalf of Members, assist Members in obtaining medically
necessary
care,
and perform other functions as determined by the Ombudsman.
3.
Aetna agrees that the Office of Ombudsman may assist plan Members during
internal
appeals,
independent review organization proceedings and external reviews. The
availability of this
assistance
will be communicated to plan Members as part of their notification of the
appeals process.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 37
4.
Aetna agrees that the Office of Ombudsman shall monitor and advise Aetna on
compliance
with
this AVC and assist the Attorney General by investigating any complaints
forwarded by the
Attorney
General and reporting back within 30 days, unless the situation requires fewer
days as
determined
by the Attorney General.
5.
Aetna agrees that the parameters and additional duties of this Office of
Ombudsman shall
be
further negotiated and developed with the Attorney General, and these
parameters and additional
duties
will be liberally construed in order to carry out the goals and principles of
this AVC.
V.
ADMINISTRATIVE
PROVISIONS
1.
Aetna agrees that this AVC becomes effective upon execution by the parties.
(a)
Aetna agrees that as soon as possible, but no later than 30 days after
execution of this
AVC,
it will submit any filings necessary to implement this AVC to the Texas
Department of
Insurance
and other government agencies and seek their prompt approval. Aetna agrees that
all of
Aetna’s
contracts executed or renegotiated subsequent to execution of this AVC will
comply with
the
requirements of this AVC. Aetna agrees that subsequent to the execution of this
AVC, it will
not
renew or exercise options to extend existing contracts or allow existing
contracts to continue past
a
renewal date unless those contracts comply with the requirements of this AVC.
Aetna and the
Attorney
General agree that during the time between execution of this AVC and any
regulatory
approval
required by the Texas Department of Insurance of any contractual terms imposed
by this
AVC:
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 38
(i)
Aetna’s contracts with Aetna’s customers will comply with all provisions of
this AVC
that
do not require approval by the Texas Department of Insurance and Aetna will
advise the
customer
of the existence of this AVC and the pending regulatory approval, and after
approval by
the
Texas Department of Insurance, give the customer the option of modifying its
contract with
Aetna
to incorporate the contract terms approved by the Texas Department of
Insurance, and
(ii)
Aetna’s contracts with Network Providers will comply with all provisions of
this AVC
that
do not require contract approval by the Texas Department of Insurance; after
approval by the
Texas
Department of Insurance of the contractual provisions requiring approval by the
Texas
Department
of Insurance, Aetna will modify Aetna’s contracts with Network Providers to
include
the
contractual provisions approved by Texas Department of Insurance; and terminate
the contract
with
a Network Provider that refuses to accept the modified contract or report to
the Attorney
General
the identity of any Network Provider as required by this AVC.
(b)
Aetna agrees that it will promptly implement all other commitments in this AVC
that
are
within Aetna’s control and complete implementation of these commitments within
90 days after
the
execution of this AVC, unless a different implementation date is expressly
provided for in this
AVC.
2.
Aetna agrees to meet and report to the Attorney General regarding Aetna’s
implementation
of
this AVC, and Aetna’s operations thereunder, on July 1, 2000, December 1, 2000,
July 1, 2001,
December
1, 2001, and July 1, 2002, unless other dates are mutually agreed upon by Aetna
and the
Attorney
General. Prior to such meetings the Attorney General may require that Aetna
produce
specific
information regarding particular provisions of the AVC at the meeting. Aetna
agrees that
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 39
at
any time during this AVC, the Attorney General may require Aetna to produce
information
pursuant
to this AVC.
3.
Aetna and the Attorney General agree that this AVC shall terminate and be of no
force or
effect
at 11:59 p.m., December 31, 2002 central standard time. Provided, however, that
with 180
days
prior written notice to Aetna, the Attorney General may dissolve this AVC,
except for the
dismissal
with prejudice contained herein, if, in the Attorney General’s sole discretion
the Attorney
General
determines that it is no longer beneficial to the citizens of Texas.
4.
Aetna and the Attorney General agree that any requirement that a notice or
communication
be in
writing may be satisfied by e-mail or other electronic communication if all
parties to the
communication
or notice have agreed to e-mail or other electronic communication or, if any
party
does
not agree, then that party shall be provided a paper copy of the notice or
communication.
Aetna
agrees to maintain a copy of all e-mail or other electronic communications
required by this
AVC
for the same period applicable under the law or Aetna’s internal policies to
comparable written
communications.
5.
This AVC applies exclusively and solely to all of Aetna’s Commercial HMOs and
HMO
products
operating in Texas unless otherwise stated. Notwithstanding any other provision
in this
AVC,
Aetna also agrees to implement promptly this AVC with respect to Prudential
Health Care
Plan,
Inc.’s Commercial HMOs and HMO products operating in Texas (“Prudential”).
However,
no
later than January 1, 2001, Aetna shall have completed implementation of this
AVC with respect
to
Prudential. Aetna agrees that this AVC shall be binding on Aetna’s affiliates,
successors,
acquirers,
purchasers, assigns, designees, and delegees.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 40
6.
Aetna agrees that if after a good-faith effort by Aetna to secure a contractual
commitment
a
Network Provider refuses to contractually commit to implement the provisions
listed in this
Section
V.6. of this AVC within that Network Provider's Downstream Contracts with other
Network
Providers,
then 90 days prior to Aetna's contracting with that Network Provider Aetna will
provide
the
Attorney General with: (a) written notice of the name of the Network Provider;
and (b) a list of
the
provisions listed within this Section V.6. of this AVC that the Network
Provider refuses to
contractually
commit to include in its Downstream Contracts with other Network Providers. The
provisions
that this Section V.6. of this AVC applies to are specifically and exclusively:
the
prohibition
against utilization based compensation as specified in Section II.A.2(b),
(c)and (d) of
this
AVC; the requirement for stop loss insurance or similar measures as specified
in Section II.A.4
of
this AVC; the option to be paid per office visit as specified in Section
II.A.5.(a) of this AVC; the
prohibition
against compensating an Individual Physician through a Financial Incentive
Arrangement
for services provided by others as specified in Section II.A.6 of this AVC; the
requirement
that Network Providers implement effective preventive care programs as
specified in
Section
II.A.7 of this AVC; and the requirement that services provided pursuant to a
financial
incentive
agreement be clearly and unambiguously disclosed as specified in Section II.A.8
of this
AVC.
Aetna agrees that it will not contract with any Network Provider that refuses
to contractually
commit
to implement any agreements that Aetna is required by this AVC to obtain from
Network
Providers,
except those specific exceptions allowed by Section II.D. and this Section V.6.
of this
AVC.
7.
Aetna agrees that it will use its best efforts to obtain certification as of
March 1st of each
year
from each Network Provider that the Network Provider is in compliance with
Aetna’s
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 41
standards,
this AVC, and applicable law. Aetna agrees to take corrective action, as
necessary, to
ensure
that each Network Provider complies with Aetna’s standards, this AVC, and
applicable law.
8.
This AVC may only be modified by Aetna and the Attorney General as set forth
below:
(a)
Aetna or the Attorney General may seek a court order modifying this AVC
only
after obtaining written agreement to the proposed modification by the
other
party. Neither Aetna nor the Attorney General shall unreasonably
withhold
consent to the request for such a modification of this AVC if the
modification
better serves the goals and principles of this AVC. Aetna
agrees
not to use this subparagraph to circumvent the requirements of the
next
subparagraph and it shall not be unreasonable for the Attorney General
to
withhold consent to the requested modification if the next subparagraph
is or
was applicable to the requested modification and Aetna fails or failed
to
comply with the terms of the next subparagraph.
(b)
The Attorney General will seek Assurances of Voluntary Compliance from
other
Commercial HMOs on terms substantially similar to the terms in this
AVC.
In the event the Attorney General obtains court approval of any such
Assurance
of Voluntary Compliance with another Commercial HMO, the
Attorney
General shall supply Aetna a copy of that Assurance of Voluntary
Compliance
promptly upon approval by the court. Within 20 business days
of
Aetna’s receipt of that Assurance of Voluntary Compliance, Aetna shall
give
written notice to the Attorney General of the specific terms, if any, in
that
Assurance of Voluntary Compliance that Aetna wishes to request the
court
to substitute or insert in this AVC. Within 20 business days of the
receipt
of Aetna’s notice, the Attorney General shall give Aetna written
notice
of the specific terms, if any, in that Assurance of Voluntary
Compliance
that the Attorney General will require to be substituted or
included
in this AVC as a condition to agreeing to the substitution or
insertion
of the terms noticed by Aetna. If Aetna gives written notice of
Aetna’s
agreement to the terms, if any, noticed by the Attorney General
within
20 business days of Aetna’s receipt of the notice, then Aetna and the
Attorney
General shall request the court to modify this AVC by the insertion
or
substitution of the terms noticed by Aetna and the Attorney General
respectively.
(c)
Aetna agrees that if it enters into any settlement agreement or similar
agreement,
relating to the issues addressed in this AVC and affecting Texas
Commercial
HMO Members, which contains terms more favorable to Aetna
Members
or health care consumers than those contained in this AVC, the
Attorney
General may, upon 30 days notice, elect to incorporate those terms
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 42
in
this AVC, except for terms requiring Aetna to make monetary payment.
Aetna
agrees to provide the Attorney General a copy of any such other
settlement
agreement within 10 business days of entering any such other
settlement
agreement.
9.
Aetna and the Attorney General agree that nothing in this AVC may be taken as
or construed
to be
an admission or concession of any violation of any law, or of any other matter
of fact or law
or of
any liability or wrongdoing, all of which Aetna expressly denies. Specifically,
the Attorney
General
acknowledges that Aetna denies the allegations of Cause No. 98-13972, The
State of Texas
v.
Aetna U.S. Healthcare, Inc.; Aetna Health Plans of North Texas, Inc.; NYLCare
Health Plans of
the
Southwest, Inc.; and NYLCare Health Plans of the Gulf Coast, Inc.;
pending in the 250th Judicial
District
Court of Travis County, Texas.
10.
Aetna and the Attorney General agree that nothing in this AVC shall be
construed as a
waiver
or creation or enlargement of a private right of action of any person not a
party to this AVC.
This
AVC does not create any rights or claims to any third parties nor do the
parties intend to confer
standing
on any third party to enforce the terms of this AVC. Aetna and the Attorney
General agree
that
only Aetna and the Attorney General may enforce this AVC. Aetna and the
Attorney General
agree
that there are no intended or unintended third party beneficiaries to this AVC.
11.
Aetna and the Attorney General agree that this AVC does not create any standard
of care,
obligation,
or duty in any private cause of action brought by any person not a party to
this AVC.
Aetna
and the Attorney General agree that this AVC shall not be construed as evidence
of any
violation
of any law and shall not be admissible in any judicial or quasi-judicial
proceeding except
as
between Aetna and the Attorney General related to enforcement, modification,
dissolution or
interpretation
of this AVC.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 43
12.
Aetna agrees that Aetna will comply with all provisions of Texas law applicable
to Texas
Commercial
HMOs in effect on the date this AVC is entered.
13.
Aetna and the Attorney General agree that the sole remedies for enforcement of
this AVC
are
mediation, specific performance, injunctive relief, civil and criminal
contempt, plus reasonable
and
necessary attorney’s fees payable to the Attorney General, costs of court and
fines or penalties.
Aetna
agrees that it will waive any preemption defense based on Sec. 514 of ERISA 29
U.S.C.A.
§
1144) (West 1999) to the Attorney General’s enforcement of this AVC, or
enforcement of any
provision
of this AVC. Aetna agrees that this waiver of ERISA preemption defense is to be
broadly
construed
in order to carry out the goals and principles of this AVC.
14.
Aetna shall not be subject to contempt proceedings with respect to any
construction or
interpretation
of this AVC to which it did not have actual or constructive notice, or any
breach as
to
which it did not have at least 30 days opportunity to cure after written notice
of the breach.
15.
Aetna and the Attorney General agree that mediation is a remedy only upon
mutual
agreement
of the parties to this AVC with the cost of that mediation borne solely by
Aetna.
16.
Aetna and the Attorney General agree that, with respect to all motions, suits
and actions
concerning
this AVC, jurisdiction and venue reside solely in the District Court of Travis
County,
Texas.
17.
Aetna and the Attorney General agree that nothing in this AVC shall be deemed
to permit
or
authorize any violation of any Texas or federal law or otherwise be construed
to relieve Aetna
of
any duty, including any duty imposed by this AVC to comply with any applicable
Texas or
federal
law, nor shall anything be deemed to constitute permission to engage in any act
or practice
prohibited
by any Texas or federal law.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 44
18.
Aetna agrees that nothing in this AVC shall in any way limit the authority of
the Texas
Department
of Insurance or the Texas Commissioner of Insurance.
19.
Aetna agrees that nothing in this AVC gives rise to any defense or objection to
any
investigation,
request for information, or any enforcement action of any type initiated or
brought
by or
on behalf of the Texas Department of Insurance or the Texas Commissioner of
Insurance.
20.
Aetna and the Attorney General agree that if any Texas or federal law or
regulation is
enacted
such that compliance with this AVC would cause Aetna to violate that law, then
this AVC
shall
be automatically modified only to the extent needed to eliminate the conflict.
If any terms,
sections,
or subsections of this AVC are so modified or if a court of competent
jurisdiction voids
or
rules any part of the AVC invalid or unlawful or void for any reason, the
remaining terms,
sections,
or subsections of this AVC will continue in effect. Aetna agrees to notify the
Attorney
General
within 30 days of Aetna’s determination of such conflict and specify how the
AVC is
modified
and by what authority.
21.
Aetna and the Attorney General agree that if Aetna certifies that compliance
with this AVC
has
placed it at a substantial competitive disadvantage or that the AVC is failing
to accomplish its
goals
and objectives, the Attorney General agrees to meet with Aetna to reevaluate
the AVC.
22.
Aetna and the Attorney General agree to act in good faith to implement and
enforce this
AVC.
Aetna and the Attorney General agree that the provisions of this AVC are to be
broadly
construed
in order to give full force and effect to the goals and principles of this AVC.
Aetna and
the
Attorney General agree to cooperate fully, to execute any and all reasonable
supplementary
documents
necessary to effect implementation of this AVC, and to take all additional
actions which
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 45
may
be necessary and appropriate to give full force and effect to the goals and
principles of this
AVC.
23.
Aetna and the Attorney General agree that all authority granted to the Attorney
General by
this
AVC is discretionary and shall be exercised or not exercised in the Attorney
General’s sole
discretion.
24.
Aetna and the Attorney General agree that the failure of the Attorney General
or Aetna to
enforce
at any time any provisions of this AVC shall not be construed to be a waiver of
such
provision,
nor in any way affect the validity of this AVC or any part of it or the right
of the Attorney
General
or Aetna to enforce each and every provision. No waiver of any breach of this
AVC shall
be
held to constitute a waiver of any other breach.
25.
Aetna agrees that Aetna employees will be notified as necessary of the terms of
this AVC
and
trained as necessary to implement the terms of this AVC into Aetna customer and
Member
service
policies.
26.
Aetna and the Attorney General agree that each of the undersigned warrants that
this person
is an
authorized representative of the party designated, is authorized to bind such
party, and is
authorized
to execute this AVC.
27.
Aetna and the Attorney General agree that in consideration of execution of this
AVC, the
claims
against Aetna will be dismissed with prejudice in Cause No. 98-13972, The
State of Texas
v.
Aetna U.S. Healthcare, Inc.; Aetna Health Plans of North Texas, Inc.; NYLCare
Health Plans of
the
Southwest, Inc.; and NYLCare Health Plans of the Gulf Coast, Inc.;
pending in the 250th Judicial
District
Court of Travis County, Texas.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 46
28.
Aetna agrees to meet and report 180 days prior to the termination of this AVC
to the
Attorney
General of what action Aetna plans to take in furtherance of the goals and
principles of this
AVC
upon its termination. The Attorney General shall have 60 days from the date of
this meeting
to
submit questions to Aetna regarding Aetna’s plans upon termination of this AVC.
Aetna agrees
to
provide a response to any such questions from the Attorney General within 30
days of receipt of
such
questions.
VI.
DEFINITIONS
1.
Except as used in disclosures required by this AVC, the terms used in this AVC,
unless
otherwise
stated, shall have the same meaning as in Texas Health Maintenance
Organization Act,
Art.
20A of the TEX. INS. CODE (Vernon 1981 &
Supp. 2000) and the Texas Department of
Insurance’s
rules on HMOs and utilization review found at 28 TEX.
ADMIN. CODE §§
11.1 - 11.2405
and
§§ 19.1701 - 19.1722 as of the effective date of this AVC.
2. Adverse
Determination - as defined at Art. 20A.02(a) of the TEXAS INS. CODE, a
determination
by a health maintenance organization or a utilization review agent that the
health care
services
furnished or proposed to be furnished to a patient are not medically necessary.
3. Aetna
Patient Mandatory Acceptance Provision - any provision having the effect of
mandating
a Network Provider to accept new Aetna patients covered by a particular Aetna
health
care
plan or product, so long as that Network Provider is accepting any other new
patients covered
by a
health care plan or product similar to the Aetna plan or product; e.g.,
so long as a Network
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 47
Provider
is accepting any new HMO patients, the Aetna patient mandatory acceptance provision
would
require that Network Provider to continue accepting new patients covered by an
Aetna HMO.
4. Aetna
- Aetna U.S. Healthcare, Inc. (a Texas corporation); Aetna U.S. Healthcare
of North
Texas,
Inc.; and Prudential Health Care Plan, Inc.
5. All
Products Provision - any provision in a contract between Aetna and any
Network
Provider
which operates to give Aetna the right to require Network Providers to
participate in more
than
one Aetna plan or product; or which operates to give Aetna the right to
introduce new plans
or
products during the course of the contract and operates to give Aetna the right
to require Network
Providers
to participate in such plans or products. For purposes of this definition,
participate shall
mean
the acceptance and treatment of plan or product Members as patients or the
designation of a
Network
Provider as participating in a plan or product.
6. Clinically
Inappropriate Underutilization - underutilization which may indicate a
failure
to
provide or obtain medically necessary services.
7. Commercial
HMO- any insured HMO plan operating in Texas other than plans covering
federal
employees or involving Medicaid or Medicare programs.
8. Coverage
Policy Bulletin - Any statement of Aetna policy used by Aetna in
determining
medical
necessity, covered health care services or excluded health care services.
9. Downstream
Contracts - a contract between a Risk Bearing Network Provider and another
Network
Provider to provide medically necessary covered health care services to Aetna
Members.
10. Financial
Incentive Arrangement - any method other than fee for service, including
capitation,
of compensating Network Providers which creates a financial incentive to reduce
or
control
the costs of providing medically necessary covered benefits.
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 48
11. Health
Care Provider - has the same meaning as “provider” as defined in TEX. INS. CODE
20A.02(t).
12. Individual
- when used to modify a Physician, Member, or Health Care Provider, as in
“individual
physician” or “individual health care provider”, means a single, natural
person.
13. Member
- an Individual enrolled in Aetna’s health care plan, including covered
dependents.
14. Network
- “health maintenance organization delivery network” as defined in TEX. INS. CODE
Art.
20A.02(w), as amended by Act of 1997, 75th Leg., ch. 1026, Sec. 3.
15. Network
Providers - any Physician, Physician group, independent practice
association,
other
Health Care Provider, or other HMO, bound by contract or agreement to accept or
treat Aetna
Members
as patients; any Physician, Physician group, independent practice association,
other Health
Care
Provider or other HMO designated by Aetna as participating in an Aetna
commercial HMO.
16. Physician
- refers to both primary care physicians and Specialists.
17. Primary
Care Physician Group - a partnership, association, corporation, individual
practice
association, or other group of primary care physicians, including
pediatricians, internists,
family
practitioners, general practitioners, and obstetricians/gynecologists, which
accepts no risk
for
referral services, and that (a) distributes income from the practice of primary
care medicine
among
its associated primary care physicians, or (b) contracts with HMOs on behalf of
its member
primary
care physicians.
18. Referral
Services - any specialty, inpatient, outpatient, or laboratory services or
pharmaceutical
benefits that a Network Provider orders or arranges, but does not furnish
directly.
This
definition is to be interpreted as consistent with 42 C.F.R § 417.479 (c).
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 49
19. Risk
Bearing Network Provider - (a) a Network Provider which assumes risk for
Referral
Services,
or (b) an entity meeting the criteria of Art. 21.52F § 1(2) of the TEX. INS. CODE (Vernon
1981
& Supp. 2000), or (c) a provider HMO.
20. Specialist(s)
- “referral specialist(s)” as defined at 28 TEX.
ADMIN. CODE §
11.2(37) (1999).
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ASSURANCE OF VOLUNTARY COMPLIANCE PAGE 50
SIGNED
in multiple originals this ______day of April, 2000.
AGREED
TO AND APPROVED
AS TO
FORM AND SUBSTANCE:
__________________________________
JOHN
CORNYN
Attorney
General of Texas
ANDY
TAYLOR
First
Assistant Attorney General
LINDA
S. EADS
Deputy
Attorney General for Litigation
DAVID
C. MATTAX
Chief,
Financial Litigation Division
DAVID
A. TALBOT
Chief,
Consumer Protection Division
ROSE
ANN REESER
Deputy
Chief, Consumer Protection Division
WILLIAM
C. HUNTER
Assistant
Attorney General
Texas
State Bar No. 10304400
Financial
Litigation Division
P.O.
Box 12548
Austin,
Texas 78711-2548
Phone:
(512) 463-2018
Telecopy:
(512) 477-2348
Attorney
in Charge
ROBERT
C. ROBINSON, III
Assistant
Attorney General
Consumer
Protection Division
CHARLES
B. McDONALD
Assistant
Attorney General
Financial
Litigation Division
__________________________________
C.
TIMOTHY BROWN
Aetna
U.S. Healthcare, Inc.
Aetna
U.S. Healthcare of North Texas, Inc.
Prudential
Health Care Plan, Inc.
__________________________________
MICHAEL
S. HULL
Texas
State Bar No. 10253400
LOCKE, LIDDELL &
SAPP, LLP
100
Congress, Suite 300
Austin,
Texas 78701
Phone:
(512) 305-4700
Telecopy:
(512) 305-4800
Attorneys
for:
Aetna
U.S. Healthcare, Inc.
Aetna
U.S. Healthcare of North Texas, Inc.
Prudential
Health Care Plan, Inc.
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