Required provision concerning coverage for continued medical care.
1. The provisions of this section apply to a health care plan offered or issued by a health maintenance organization if an insured covered by the health care plan receives health care through a defined set of providers of health care who are under contract with the health maintenance organization.
2. Except as otherwise provided in this section, if an insured who is covered by a health care plan described in subsection 1 is receiving medical treatment for a medical condition from a provider of health care whose contract with the health maintenance organization is terminated during the course of the medical treatment, the health care plan must provide that:
(a) The insured may continue to obtain medical treatment for the medical condition from the provider of health care pursuant to this section, if:
(1) The insured is actively undergoing a medically necessary course of treatment; and
(2) The provider of health care and the insured agree that the continuity of care is desirable.
(b) The provider of health care is entitled to receive reimbursement from the health maintenance organization for the medical treatment he provides to the insured pursuant to this section, if the provider of health care agrees:
(1) To provide medical treatment under the terms of the contract between the provider of health care and the health maintenance organization with regard to the insured, including, without limitation, the rates of payment for providing medical service, as those terms existed before the termination of the contract between the provider of health care and the health maintenance organization; and
(2) Not to seek payment from the insured for any medical service provided by the provider of health care that the provider of health care could not have received from the insured were the provider of health care still under contract with the health maintenance organization.
3. The coverage required by subsection 2 must be provided until the later of:
(a) The 120th day after the date the contract is terminated; or
(b) If the medical condition is pregnancy, the 45th day after:
(1) The date of delivery; or
(2) If the pregnancy does not end in delivery, the date of the end of the pregnancy.
4. The requirements of this section do not apply to a provider of health care if:
(a) The provider of health care was under contract with the health maintenance organization and the health maintenance organization terminated that contract because of the medical incompetence or professional misconduct of the provider of health care; and
(b) The health maintenance organization did not enter into another contract with the provider of health care after the contract was terminated pursuant to paragraph (a).
5. An evidence of coverage for a health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2003, has the legal effect of including the coverage required by this section, and any provision of the evidence of coverage or renewal thereof that is in conflict with this section is void.
6. The Commissioner shall adopt regulations to carry out the provisions of this section.
Last modified: February 27, 2006