40-3230. Continuity of treatment upon termination of provider from plan.
40-3230
40-3230. Continuity of treatment upon termination of provider from plan.A health maintenance organization shall establish reasonableprocedures for assuring a transition of enrollees to physicians or health careproviders and for continuity of treatment, including providing immediate noticeto the enrollee and making available to the enrollee a current listing ofpreferred providers, in the eventa provider's participation in the plan is terminated for any reason. The planshall include provisions for the continuation of care to enrollees fora period up to 90 days by a provider who is terminated from a network in thosecases where the continuation of such care is medically necessary and inaccordance with the dictates of medical prudence and where the enrollee hasspecial circumstances such as a disability, a life threatening illness or is inthe third trimester of pregnancy. The provisions for the continuation of careshall include guarantees that the enrollee will not be liable to the providerfor any amounts owed for medical care other than any deductibles or copaymentamounts specified in the certificate of coverage or other contract between theenrollee and the health maintenance organization. In the event the terminatedprovider is authorized to continue treating the enrollee pursuant to thissubsection, the health maintenance organization shall have an obligation topay the terminated provider at the previously contracted rate for servicesprovided to the enrollee.
History: L. 1996, ch. 169, § 14; July 1.