20-1057.04. Continuity of care; definition

A. A health care services organization shall allow any new enrollee whose health care provider is not a member of the provider network, on written request of the enrollee to the health care services organization, to continue an active course of treatment with that health care provider during a transitional period after the effective date of the enrollment if both of the following apply:

1. The enrollee has either:

(a) A life threatening disease or condition, in which case the transitional period is not more than thirty days after the effective date of the enrollment.

(b) Entered the third trimester of pregnancy on the effective date of the enrollment, in which case the transitional period includes the delivery and any care up to six weeks after the delivery that is related to the delivery.

2. The enrollee's health care provider agrees in writing to do all of the following:

(a) Except for copayment, coinsurance or deductible amounts, accept as payment in full reimbursement from the health care services organization at the rates that are established by the health care services organization and that are not more than the level of reimbursement applicable to similar services by health care providers within the provider network.

(b) Comply with the health care services organization's quality assurance and utilization review requirements and provide to the health care services organization any necessary medical information related to the care.

(c) Comply with the health care services organization's policies and procedures pursuant to this article including procedures relating to referrals and obtaining preauthorization, claims handling and treatment plan approval by the health care services organization.

B. A health care services organization shall allow any enrollee whose health care provider is terminated from the provider network by the health care services organization except for reasons of medical incompetence or unprofessional conduct, on written request of the enrollee to the health care services organization, to continue an active course of treatment with that health care provider during a transitional period after the date of the provider's disaffiliation from the provider network, if both of the following apply:

1. The enrollee has either:

(a) A life threatening disease or condition, in which case the transitional period is not more than thirty days after the date of the provider's disaffiliation from the provider network.

(b) Entered the third trimester of pregnancy on the date of the provider's disaffiliation, in which case the transition period includes the delivery and any care up to six weeks after the delivery that is related to the delivery.

2. The enrollee's health care provider agrees in writing to do all of the following:

(a) Except for copayment, coinsurance or deductible amounts, continue to accept as payment in full reimbursement from the health care services organization at the rates applicable before the beginning of the transitional period.

(b) Comply with the health care services organization's quality assurance and utilization review requirements and provide to the health care services organization any necessary medical information related to the care.

(c) Comply with the health care services organization's policies and procedures pursuant to this article including procedures relating to referrals and obtaining preauthorization, claims handling and treatment plan approval by the health care services organization.

C. This section does not require a health care services organization to provide coverage for benefits that are not covered by the enrollee's evidence of coverage and does not diminish or impair any preexisting condition limitation in the evidence of coverage.

D. This section does not extend to a health care provider who is not a member of the provider network any contractual rights or remedies beyond those rights or remedies related to and necessary for the provision of covered services to the specific enrollee during the required transitional period.

E. For the purposes of this section, "health care provider" means any physician who is licensed in this state pursuant to title 32, chapter 13 or 17.

20-1057.04. Continuity of care; definition

A. A health care services organization shall allow any new enrollee whose health care provider is not a member of the provider network, on written request of the enrollee to the health care services organization, to continue an active course of treatment with that health care provider during a transitional period after the effective date of the enrollment if both of the following apply:

1. The enrollee has either:

(a) A life threatening disease or condition, in which case the transitional period is not more than thirty days after the effective date of the enrollment.

(b) Entered the third trimester of pregnancy on the effective date of the enrollment, in which case the transitional period includes the delivery and any care up to six weeks after the delivery that is related to the delivery.

2. The enrollee's health care provider agrees in writing to do all of the following:

(a) Except for copayment, coinsurance or deductible amounts, accept as payment in full reimbursement from the health care services organization at the rates that are established by the health care services organization and that are not more than the level of reimbursement applicable to similar services by health care providers within the provider network.

(b) Comply with the health care services organization's quality assurance and utilization review requirements and provide to the health care services organization any necessary medical information related to the care.

(c) Comply with the health care services organization's policies and procedures pursuant to this article including procedures relating to referrals and obtaining preauthorization, claims handling and treatment plan approval by the health care services organization.

B. A health care services organization shall allow any enrollee whose health care provider is terminated from the provider network by the health care services organization except for reasons of medical incompetence or unprofessional conduct, on written request of the enrollee to the health care services organization, to continue an active course of treatment with that health care provider during a transitional period after the date of the provider's disaffiliation from the provider network, if both of the following apply:

1. The enrollee has either:

(a) A life threatening disease or condition, in which case the transitional period is not more than thirty days after the date of the provider's disaffiliation from the provider network.

(b) Entered the third trimester of pregnancy on the date of the provider's disaffiliation, in which case the transition period includes the delivery and any care up to six weeks after the delivery that is related to the delivery.

2. The enrollee's health care provider agrees in writing to do all of the following:

(a) Except for copayment, coinsurance or deductible amounts, continue to accept as payment in full reimbursement from the health care services organization at the rates applicable before the beginning of the transitional period.

(b) Comply with the health care services organization's quality assurance and utilization review requirements and provide to the health care services organization any necessary medical information related to the care.

(c) Comply with the health care services organization's policies and procedures pursuant to this article including procedures relating to referrals and obtaining preauthorization, claims handling and treatment plan approval by the health care services organization.

C. This section does not require a health care services organization to provide coverage for benefits that are not covered by the enrollee's evidence of coverage and does not diminish or impair any preexisting condition limitation in the evidence of coverage.

D. This section does not extend to a health care provider who is not a member of the provider network any contractual rights or remedies beyond those rights or remedies related to and necessary for the provision of covered services to the specific enrollee during the required transitional period.

E. For the purposes of this section, "health care provider" means any physician who is licensed in this state pursuant to title 32, chapter 13 or 17.