a. In the case of anacute illness, a condition that is serious enough to require medical care ortreatment to avoid a reasonable possibility of death or permanent harm.
b. In the case of achronic illness or condition, a disease or condition that is life‑threatening,degenerative, or disabling, and requires medical care or treatment over aprolonged period of time.
c. In the case ofpregnancy, pregnancy from the start of the second trimester.
d. In the case of aterminal illness, an individual has a medical prognosis that the individual'slife expectancy is six months or less.
(2) "Terminated ortermination". Includes, with respect to a contract, the expiration ornonrenewal of the contract, but does not include a termination of the contractby an HMO for failure to meet applicable quality standards or for fraud.
(b) Termination ofProvider. If a contract between an HMO benefit plan that is not a point‑of‑serviceplan and a health care provider is terminated by the provider or by the HMO, orbenefits or coverage provided by the HMO are terminated because of a change inthe terms of provider participation in a health benefit plan of an HMO that isnot a point‑of‑service plan, and an individual is covered by theplan and is undergoing treatment from the provider for an ongoing specialcondition on the date of the termination, then, the HMO shall:
(1) Upon termination ofthe contract by the HMO or upon receipt by the HMO of written notification oftermination by the provider, notify the individual on a timely basis of thetermination and of the right to elect continuation of coverage of treatment bythe provider under this section if the individual has filed a claim with theHMO for services provided by the terminated provider or the individual isotherwise known by the HMO to be a patient of the provider.
(2) Subject tosubsection (h) of this section, permit the individual to elect to continue tobe covered with respect to the treatment by the provider of the ongoing specialcondition during a transitional period provided under this section.
(c) Newly CoveredInsured. Each health benefit plan offered by an HMO that is not a point‑of‑serviceplan shall provide transition coverage to individuals who are undergoingtreatment from a provider for an ongoing special condition and are newlycovered under the health benefit plan because the individual's employer haschanged health benefit plans, and the HMO shall:
(1) Notify theindividual on the date of enrollment of the right to elect continuation ofcoverage of treatment by the provider under this section.
(2) Subject tosubsection (h) of this section, permit the individual to elect to continue tobe covered with respect to the treatment by the provider of the ongoing specialcondition during a transitional period provided under this section.
(d) TransitionalPeriod: In General. Except as otherwise provided in subsections (e), (f), and(g) of this section, the transitional period under this subsection shall extendup to 90 days, as determined by the treating health care provider, after thedate of the notice to the individual described in subdivision (b)(1) of thissection or the date of enrollment in a new plan described in subdivision (c)(1)of this section.
(e) TransitionalPeriod: Scheduled Surgery, Organ Transplantation, or Inpatient Care. Ifsurgery, organ transplantation, or other inpatient care was scheduled for anindividual before the date of the notice required under subdivision (b)(1) ofthis section, or the date of enrollment in a new plan described in subdivision(c)(1) of this section, or if the individual on that date was on an establishedwaiting list or otherwise scheduled to have the surgery, transplantation, orother inpatient care, the transitional period under this subsection withrespect to the surgery, transplantation, or other inpatient care shall extendbeyond the period under subsection (d) of this section through the date of dischargeof the individual after completion of the surgery, transplantation, or otherinpatient care, and through postdischarge follow‑up care related to thesurgery, transplantation, or other inpatient care occurring within 90 daysafter the date of discharge.
(f) TransitionalPeriod: Pregnancy. If an insured has entered the second trimester ofpregnancy on the date of the notice required under subdivision (b)(1) of thissection, or the date of enrollment in a new plan described in subdivision(c)(1) of this section, and the provider was treating the pregnancy before thedate of the notice, or the date of enrollment in the new plan, the transitionalperiod with respect to the provider's treatment of the pregnancy shall extendthrough the provision of 60 days of postpartum care.
(g) TransitionalPeriod: Terminal Illness. If an insured was determined to be terminally illat the time of a provider's termination of participation under subsection (b)of this section, or at the time of enrollment in the new plan under subdivision(c)(1) of this section, and the provider was treating the terminal illnessbefore the date of the termination or enrollment in the new plan, thetransitional period shall extend for the remainder of the individual's lifewith respect to care directly related to the treatment of the terminal illnessor its medical manifestations.
(h) Permissible Termsand Conditions. An HMO may condition coverage of continued treatment by aprovider under subdivision (b)(2) or (c)(2) of this section upon the followingterms and conditions:
(1) When care isprovided pursuant to subdivision (b)(2) of this section, the provider agrees toaccept reimbursement from the HMO and individual involved, with respect to cost‑sharing,at the rates applicable before the start of the transitional period as paymentin full. When care is provided pursuant to subdivision (c)(2) of this section,the provider agrees to accept the prevailing rate based on contracts theinsurer has with the same or similar providers in the same or similargeographic area, plus the applicable copayment, as reimbursement in full fromthe HMO and the insured for all covered services.
(2) The provider agreesto comply with the quality assurance programs of the HMO responsible forpayment under subdivision (1) of this subsection and to provide to the HMOnecessary medical information related to the care provided. The qualityassurance programs shall not override the professional or ethicalresponsibility of the provider or interfere with the provider's ability toprovide information or assistance to the patient.
(3) The provider agreesotherwise to adhere to the HMO's established policies and procedures forparticipating providers, including procedures regarding referrals and obtainingprior authorization, providing services pursuant to a treatment plan, if any,approved by the HMO, and member hold harmless provisions.
(4) The insured or theinsured's representative notifies the HMO within 45 days of the date of thenotice described in subdivision (b)(1) of this section or the new enrollmentdescribed in subdivision (c)(1) of this section, that the insured elects tocontinue receiving treatment by the provider.
(5) The provider agreesto discontinue providing services at the end of the transition period pursuantto this section and to assist the insured in an orderly transition to a networkprovider. Nothing in this section shall prohibit the insured from continuing toreceive services from the provider at the insured's expense.
(i) Construction. Nothing in this section:
(1) Requires thecoverage of benefits that would not have been covered if the provider involvedremained a participating provider or, in the case of a newly covered insured,requires the coverage of benefits not provided under the new policy under whichthe person is covered.
(2) Requires an HMO tooffer a transitional period when the HMO terminates a provider's contract forreasons relating to quality of care or fraud; and refusal to offer atransitional period under these circumstances is not subject to the grievancereview provisions of G.S. 58‑50‑62.
(3) Prohibits an HMOfrom extending any transitional period beyond that specified in this section.
(4) Prohibits an HMOfrom terminating the continuing services of a provider as described in thissection when the HMO has determined that the provider's continued provision ofservices may result in, or is resulting in, a serious danger to the health orsafety of the insured. Such terminations shall be in accordance with thecontract provisions that the provider would otherwise be subject to if theprovider's contract were still in effect.
(j) Disclosure ofRight to Transitional Period. Each HMO shall include a clear description ofan insured's rights under this section in its evidence of coverage and summaryplan description. (2001‑446,s. 1.)
a. In the case of anacute illness, a condition that is serious enough to require medical care ortreatment to avoid a reasonable possibility of death or permanent harm.
b. In the case of achronic illness or condition, a disease or condition that is life‑threatening,degenerative, or disabling, and requires medical care or treatment over aprolonged period of time.
c. In the case ofpregnancy, pregnancy from the start of the second trimester.
d. In the case of aterminal illness, an individual has a medical prognosis that the individual'slife expectancy is six months or less.
(2) "Terminated ortermination". Includes, with respect to a contract, the expiration ornonrenewal of the contract, but does not include a termination of the contractby an HMO for failure to meet applicable quality standards or for fraud.
(b) Termination ofProvider. If a contract between an HMO benefit plan that is not a point‑of‑serviceplan and a health care provider is terminated by the provider or by the HMO, orbenefits or coverage provided by the HMO are terminated because of a change inthe terms of provider participation in a health benefit plan of an HMO that isnot a point‑of‑service plan, and an individual is covered by theplan and is undergoing treatment from the provider for an ongoing specialcondition on the date of the termination, then, the HMO shall:
(1) Upon termination ofthe contract by the HMO or upon receipt by the HMO of written notification oftermination by the provider, notify the individual on a timely basis of thetermination and of the right to elect continuation of coverage of treatment bythe provider under this section if the individual has filed a claim with theHMO for services provided by the terminated provider or the individual isotherwise known by the HMO to be a patient of the provider.
(2) Subject tosubsection (h) of this section, permit the individual to elect to continue tobe covered with respect to the treatment by the provider of the ongoing specialcondition during a transitional period provided under this section.
(c) Newly CoveredInsured. Each health benefit plan offered by an HMO that is not a point‑of‑serviceplan shall provide transition coverage to individuals who are undergoingtreatment from a provider for an ongoing special condition and are newlycovered under the health benefit plan because the individual's employer haschanged health benefit plans, and the HMO shall:
(1) Notify theindividual on the date of enrollment of the right to elect continuation ofcoverage of treatment by the provider under this section.
(2) Subject tosubsection (h) of this section, permit the individual to elect to continue tobe covered with respect to the treatment by the provider of the ongoing specialcondition during a transitional period provided under this section.
(d) TransitionalPeriod: In General. Except as otherwise provided in subsections (e), (f), and(g) of this section, the transitional period under this subsection shall extendup to 90 days, as determined by the treating health care provider, after thedate of the notice to the individual described in subdivision (b)(1) of thissection or the date of enrollment in a new plan described in subdivision (c)(1)of this section.
(e) TransitionalPeriod: Scheduled Surgery, Organ Transplantation, or Inpatient Care. Ifsurgery, organ transplantation, or other inpatient care was scheduled for anindividual before the date of the notice required under subdivision (b)(1) ofthis section, or the date of enrollment in a new plan described in subdivision(c)(1) of this section, or if the individual on that date was on an establishedwaiting list or otherwise scheduled to have the surgery, transplantation, orother inpatient care, the transitional period under this subsection withrespect to the surgery, transplantation, or other inpatient care shall extendbeyond the period under subsection (d) of this section through the date of dischargeof the individual after completion of the surgery, transplantation, or otherinpatient care, and through postdischarge follow‑up care related to thesurgery, transplantation, or other inpatient care occurring within 90 daysafter the date of discharge.
(f) TransitionalPeriod: Pregnancy. If an insured has entered the second trimester ofpregnancy on the date of the notice required under subdivision (b)(1) of thissection, or the date of enrollment in a new plan described in subdivision(c)(1) of this section, and the provider was treating the pregnancy before thedate of the notice, or the date of enrollment in the new plan, the transitionalperiod with respect to the provider's treatment of the pregnancy shall extendthrough the provision of 60 days of postpartum care.
(g) TransitionalPeriod: Terminal Illness. If an insured was determined to be terminally illat the time of a provider's termination of participation under subsection (b)of this section, or at the time of enrollment in the new plan under subdivision(c)(1) of this section, and the provider was treating the terminal illnessbefore the date of the termination or enrollment in the new plan, thetransitional period shall extend for the remainder of the individual's lifewith respect to care directly related to the treatment of the terminal illnessor its medical manifestations.
(h) Permissible Termsand Conditions. An HMO may condition coverage of continued treatment by aprovider under subdivision (b)(2) or (c)(2) of this section upon the followingterms and conditions:
(1) When care isprovided pursuant to subdivision (b)(2) of this section, the provider agrees toaccept reimbursement from the HMO and individual involved, with respect to cost‑sharing,at the rates applicable before the start of the transitional period as paymentin full. When care is provided pursuant to subdivision (c)(2) of this section,the provider agrees to accept the prevailing rate based on contracts theinsurer has with the same or similar providers in the same or similargeographic area, plus the applicable copayment, as reimbursement in full fromthe HMO and the insured for all covered services.
(2) The provider agreesto comply with the quality assurance programs of the HMO responsible forpayment under subdivision (1) of this subsection and to provide to the HMOnecessary medical information related to the care provided. The qualityassurance programs shall not override the professional or ethicalresponsibility of the provider or interfere with the provider's ability toprovide information or assistance to the patient.
(3) The provider agreesotherwise to adhere to the HMO's established policies and procedures forparticipating providers, including procedures regarding referrals and obtainingprior authorization, providing services pursuant to a treatment plan, if any,approved by the HMO, and member hold harmless provisions.
(4) The insured or theinsured's representative notifies the HMO within 45 days of the date of thenotice described in subdivision (b)(1) of this section or the new enrollmentdescribed in subdivision (c)(1) of this section, that the insured elects tocontinue receiving treatment by the provider.
(5) The provider agreesto discontinue providing services at the end of the transition period pursuantto this section and to assist the insured in an orderly transition to a networkprovider. Nothing in this section shall prohibit the insured from continuing toreceive services from the provider at the insured's expense.
(i) Construction. Nothing in this section:
(1) Requires thecoverage of benefits that would not have been covered if the provider involvedremained a participating provider or, in the case of a newly covered insured,requires the coverage of benefits not provided under the new policy under whichthe person is covered.
(2) Requires an HMO tooffer a transitional period when the HMO terminates a provider's contract forreasons relating to quality of care or fraud; and refusal to offer atransitional period under these circumstances is not subject to the grievancereview provisions of G.S. 58‑50‑62.
(3) Prohibits an HMOfrom extending any transitional period beyond that specified in this section.
(4) Prohibits an HMOfrom terminating the continuing services of a provider as described in thissection when the HMO has determined that the provider's continued provision ofservices may result in, or is resulting in, a serious danger to the health orsafety of the insured. Such terminations shall be in accordance with thecontract provisions that the provider would otherwise be subject to if theprovider's contract were still in effect.
(j) Disclosure ofRight to Transitional Period. Each HMO shall include a clear description ofan insured's rights under this section in its evidence of coverage and summaryplan description. (2001‑446,s. 1.)
a. In the case of anacute illness, a condition that is serious enough to require medical care ortreatment to avoid a reasonable possibility of death or permanent harm.
b. In the case of achronic illness or condition, a disease or condition that is life‑threatening,degenerative, or disabling, and requires medical care or treatment over aprolonged period of time.
c. In the case ofpregnancy, pregnancy from the start of the second trimester.
d. In the case of aterminal illness, an individual has a medical prognosis that the individual'slife expectancy is six months or less.
(2) "Terminated ortermination". Includes, with respect to a contract, the expiration ornonrenewal of the contract, but does not include a termination of the contractby an HMO for failure to meet applicable quality standards or for fraud.
(b) Termination ofProvider. If a contract between an HMO benefit plan that is not a point‑of‑serviceplan and a health care provider is terminated by the provider or by the HMO, orbenefits or coverage provided by the HMO are terminated because of a change inthe terms of provider participation in a health benefit plan of an HMO that isnot a point‑of‑service plan, and an individual is covered by theplan and is undergoing treatment from the provider for an ongoing specialcondition on the date of the termination, then, the HMO shall:
(1) Upon termination ofthe contract by the HMO or upon receipt by the HMO of written notification oftermination by the provider, notify the individual on a timely basis of thetermination and of the right to elect continuation of coverage of treatment bythe provider under this section if the individual has filed a claim with theHMO for services provided by the terminated provider or the individual isotherwise known by the HMO to be a patient of the provider.
(2) Subject tosubsection (h) of this section, permit the individual to elect to continue tobe covered with respect to the treatment by the provider of the ongoing specialcondition during a transitional period provided under this section.
(c) Newly CoveredInsured. Each health benefit plan offered by an HMO that is not a point‑of‑serviceplan shall provide transition coverage to individuals who are undergoingtreatment from a provider for an ongoing special condition and are newlycovered under the health benefit plan because the individual's employer haschanged health benefit plans, and the HMO shall:
(1) Notify theindividual on the date of enrollment of the right to elect continuation ofcoverage of treatment by the provider under this section.
(2) Subject tosubsection (h) of this section, permit the individual to elect to continue tobe covered with respect to the treatment by the provider of the ongoing specialcondition during a transitional period provided under this section.
(d) TransitionalPeriod: In General. Except as otherwise provided in subsections (e), (f), and(g) of this section, the transitional period under this subsection shall extendup to 90 days, as determined by the treating health care provider, after thedate of the notice to the individual described in subdivision (b)(1) of thissection or the date of enrollment in a new plan described in subdivision (c)(1)of this section.
(e) TransitionalPeriod: Scheduled Surgery, Organ Transplantation, or Inpatient Care. Ifsurgery, organ transplantation, or other inpatient care was scheduled for anindividual before the date of the notice required under subdivision (b)(1) ofthis section, or the date of enrollment in a new plan described in subdivision(c)(1) of this section, or if the individual on that date was on an establishedwaiting list or otherwise scheduled to have the surgery, transplantation, orother inpatient care, the transitional period under this subsection withrespect to the surgery, transplantation, or other inpatient care shall extendbeyond the period under subsection (d) of this section through the date of dischargeof the individual after completion of the surgery, transplantation, or otherinpatient care, and through postdischarge follow‑up care related to thesurgery, transplantation, or other inpatient care occurring within 90 daysafter the date of discharge.
(f) TransitionalPeriod: Pregnancy. If an insured has entered the second trimester ofpregnancy on the date of the notice required under subdivision (b)(1) of thissection, or the date of enrollment in a new plan described in subdivision(c)(1) of this section, and the provider was treating the pregnancy before thedate of the notice, or the date of enrollment in the new plan, the transitionalperiod with respect to the provider's treatment of the pregnancy shall extendthrough the provision of 60 days of postpartum care.
(g) TransitionalPeriod: Terminal Illness. If an insured was determined to be terminally illat the time of a provider's termination of participation under subsection (b)of this section, or at the time of enrollment in the new plan under subdivision(c)(1) of this section, and the provider was treating the terminal illnessbefore the date of the termination or enrollment in the new plan, thetransitional period shall extend for the remainder of the individual's lifewith respect to care directly related to the treatment of the terminal illnessor its medical manifestations.
(h) Permissible Termsand Conditions. An HMO may condition coverage of continued treatment by aprovider under subdivision (b)(2) or (c)(2) of this section upon the followingterms and conditions:
(1) When care isprovided pursuant to subdivision (b)(2) of this section, the provider agrees toaccept reimbursement from the HMO and individual involved, with respect to cost‑sharing,at the rates applicable before the start of the transitional period as paymentin full. When care is provided pursuant to subdivision (c)(2) of this section,the provider agrees to accept the prevailing rate based on contracts theinsurer has with the same or similar providers in the same or similargeographic area, plus the applicable copayment, as reimbursement in full fromthe HMO and the insured for all covered services.
(2) The provider agreesto comply with the quality assurance programs of the HMO responsible forpayment under subdivision (1) of this subsection and to provide to the HMOnecessary medical information related to the care provided. The qualityassurance programs shall not override the professional or ethicalresponsibility of the provider or interfere with the provider's ability toprovide information or assistance to the patient.
(3) The provider agreesotherwise to adhere to the HMO's established policies and procedures forparticipating providers, including procedures regarding referrals and obtainingprior authorization, providing services pursuant to a treatment plan, if any,approved by the HMO, and member hold harmless provisions.
(4) The insured or theinsured's representative notifies the HMO within 45 days of the date of thenotice described in subdivision (b)(1) of this section or the new enrollmentdescribed in subdivision (c)(1) of this section, that the insured elects tocontinue receiving treatment by the provider.
(5) The provider agreesto discontinue providing services at the end of the transition period pursuantto this section and to assist the insured in an orderly transition to a networkprovider. Nothing in this section shall prohibit the insured from continuing toreceive services from the provider at the insured's expense.
(i) Construction. Nothing in this section:
(1) Requires thecoverage of benefits that would not have been covered if the provider involvedremained a participating provider or, in the case of a newly covered insured,requires the coverage of benefits not provided under the new policy under whichthe person is covered.
(2) Requires an HMO tooffer a transitional period when the HMO terminates a provider's contract forreasons relating to quality of care or fraud; and refusal to offer atransitional period under these circumstances is not subject to the grievancereview provisions of G.S. 58‑50‑62.
(3) Prohibits an HMOfrom extending any transitional period beyond that specified in this section.
(4) Prohibits an HMOfrom terminating the continuing services of a provider as described in thissection when the HMO has determined that the provider's continued provision ofservices may result in, or is resulting in, a serious danger to the health orsafety of the insured. Such terminations shall be in accordance with thecontract provisions that the provider would otherwise be subject to if theprovider's contract were still in effect.
(j) Disclosure ofRight to Transitional Period. Each HMO shall include a clear description ofan insured's rights under this section in its evidence of coverage and summaryplan description. (2001‑446,s. 1.)
