26:2S-9.1 Managed care plan, continuing treatment of certain patients by physician no longer employed by plan; required.
1. a. Notwithstanding the provisions of any law to the contrary, a carrier which offers a managed care plan shall provide in that plan that if a covered person is receiving post-operative follow-up care, oncological treatment, psychiatric treatment or obstetrical care by a physician who is employed by or under contract with a carrier at the time the treatment is initiated, the covered person may continue to be treated by that physician for the duration of the treatment in the event that the physician is no longer employed by or under contract with the carrier as follows:
(1)for a period not to exceed six months in the case of post-operative follow-up care;
(2)for a period not to exceed one year in the case of oncological treatment and psychiatric treatment; and
(3)through the duration of a pregnancy and up to six weeks after delivery in the case of obstetrical care.
The continuation of treatment by a particular physician as provided for in this subsection shall be at the option of the covered person.
The carrier shall provide that health care benefits or services, as appropriate, shall be provided for the treatment of the conditions provided in this subsection to the same extent as such benefits or services were provided while the physician was employed by or under contract with the carrier. Reimbursement for the health care services shall be pursuant to the same fee schedule used to reimburse for the services when the physician was employed by or under contract with the carrier.
b.A carrier which offers a managed care plan shall also provide in that plan for continued coverage of other health care services by a physician who was employed by or under contract with the carrier at the time the treatment was initiated, but is no longer employed by or under contract with the carrier, for up to 120 calendar days in cases where it is medically necessary for the covered person to continue treatment with that physician.
Health care benefits or services, as applicable, shall be provided by the health benefits plan for medically necessary treatment as provided in this subsection to the same extent as such benefits or services were provided while the physician was employed by or under contract with the carrier. Reimbursement for the health care services shall be pursuant to the same fee schedule used to reimburse for the services when the physician was employed by or under contract with the carrier.
c.During the period of time a covered person is continuing to receive treatment pursuant to subsection a. or b. of this section by a physician who is no longer employed by or under contract with the carrier, the carrier shall provide in its plan for reimbursement for any treatment or services provided or delivered to the covered person in an acute care hospital, regardless of whether the acute care hospital is under contract or agreement with the carrier.
d.The carrier shall not be liable for any inappropriate treatment provided to the covered person by a physician who is no longer employed by or under contract with the carrier.
e.The provisions of this section shall not apply to health care services provided by a physician who is the subject of disciplinary action by the State Board of Medical Examiners.
L.1999,c.390,s.1.
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Last modified: October 11, 2016