1. Any insurer proposing to issue individual or group accident and sicknessinsurance policies providing hospital, medical and surgical or major medicalcoverage on an expense incurred basis;
2. Any corporation providing individual or group accident and sicknesssubscription contracts;
3. Any health maintenance organization providing health care plans for healthcare services;
4. Any corporation offering prepaid dental or optometric services plans; or
5. Any other person or organization that provides health benefit planssubject to state regulation, and includes an entity that arranges a providerpanel for compensation.
"Enrollee" means any person entitled to health care services from a carrier.
"Provider" means a hospital, physician or any type of provider licensed,certified or authorized by statute to provide a covered service under thehealth benefit plan.
"Provider panel" means those providers with which a carrier contracts toprovide health care services to the carrier's enrollees under the carrier'shealth benefit plan. However, such term does not include an arrangementbetween a carrier and providers in which any provider may participate solelyon the basis of the provider's contracting with the carrier to provideservices at a discounted fee-for-service rate.
B. Any such carrier that offers a provider panel shall establish and use itin accordance with the following requirements:
1. Notice of the development of a provider panel in the Commonwealth or localservice area shall be filed with the Department of Health Professions.
2. Carriers shall provide a provider application and the relevant terms andconditions to a provider upon request.
C. A carrier that uses a provider panel shall establish procedures for:
1. Notifying an enrollee of:
a. The termination from the carrier's provider panel of the enrollee'sprimary care provider who was furnishing health care services to theenrollee; and
b. The right of an enrollee upon request to continue to receive health careservices for a period of up to 90 days from the date of the primary careprovider's notice of termination from a carrier's provider panel, except whena provider is terminated for cause.
2. Notifying a provider at least 90 days prior to the date of the terminationof the provider, except when a provider is terminated for cause.
3. Providing reasonable notice to primary care providers in the carrier'sprovider panel of the termination of a specialty referral services provider.
4. Notifying the purchaser of the health benefit plan, whether such purchaseris an individual or an employer providing a health benefit plan, in whole orin part, to its employees and enrollees of the health benefit plan of:
a. A description of all types of payment arrangements that the carrier usesto compensate providers for health care services rendered to enrollees,including, but not limited to, withholds, bonus payments, capitation andfee-for-service discounts; and
b. The terms of the plan in clear and understandable language that reasonablyinforms the purchaser of the practical application of such terms in theoperation of the plan.
D. Whenever a provider voluntarily terminates his contract with a carrier toprovide health care services to the carrier's enrollees under a healthbenefit plan, he shall furnish reasonable notice of such termination to hispatients who are enrollees under such plan.
E. A carrier may not deny an application for participation or terminateparticipation on its provider panel on the basis of gender, race, age,religion or national origin.
F. 1. For a period of at least 90 days from the date of the notice of aprovider's termination from the carrier's provider panel, except when aprovider is terminated for cause, the provider shall be permitted by thecarrier to render health care services to any of the carrier's enrollees who:
a. Were in an active course of treatment from the provider prior to thenotice of termination; and
b. Request to continue receiving health care services from the provider.
2. Notwithstanding the provisions of subdivision 1, any provider shall bepermitted by the carrier to continue rendering health services to anyenrollee who has entered the second trimester of pregnancy at the time of aprovider's termination of participation, except when a provider is terminatedfor cause. Such treatment shall, at the enrollee's option, continue throughthe provision of postpartum care directly related to the delivery.
3. Notwithstanding the provisions of subdivision 1, any provider shall bepermitted by the carrier to continue rendering health services to anyenrollee who is determined to be terminally ill (as defined under § 1861(dd)(3)(A) of the Social Security Act) at the time of a provider'stermination of participation, except when a provider is terminated for cause.Such treatment shall, at the enrollee's option, continue for the remainder ofthe enrollee's life for care directly related to the treatment of theterminal illness.
4. A carrier shall reimburse a provider under this subsection in accordancewith the carrier's agreement with such provider existing immediately beforethe provider's termination of participation.
G. 1. A carrier shall provide to a purchaser upon enrollment and makeavailable to existing enrollees at least once a year a list of members in itsprovider panel, which list shall also indicate those providers who are notcurrently accepting new patients. Such list may be made available in a formother than a printed document, provided the purchaser or existing enrollee isgiven the means to request and receive a printed copy of such list.
2. The information provided under subdivision 1 shall be updated at leastonce a year if in paper form, and monthly if in electronic form.
H. No contract between a carrier and a provider may require that the providerindemnify the carrier for the carrier's negligence, willful misconduct, orbreach of contract, if any.
I. No contract between a carrier and a provider shall require a provider, asa condition of participation on the panel, to waive any right to seek legalredress against the carrier.
J. No contract between a carrier and a provider shall prohibit, impede orinterfere in the discussion of medical treatment options between a patientand a provider.
K. A contract between a carrier and a provider shall permit and require theprovider to discuss medical treatment options with the patient.
L. Any carrier requiring preauthorization for medical treatment shall havepersonnel available to provide such preauthorization at all times when suchpreauthorization is required.
M. Carriers shall provide to their group policyholders written notice of anybenefit reductions during the contract period at least 60 days before suchbenefit reductions become effective. Group policyholders shall, in turn,provide to their enrollees written notice of any benefit reductions duringthe contract period at least 30 days before such benefit reductions becomeeffective. Such notice shall be provided to the group policyholder as aseparate and distinct notification, and may not be combined with any othernotification or marketing materials.
N. No contract between a provider and a carrier shall include provisions thatrequire a health care provider or health care provider group to deny coveredservices that such provider or group knows to be medically necessary andappropriate that are provided with respect to a specific enrollee or group ofenrollees with similar medical conditions.
O. If a provider panel contract between a provider and a carrier, or otherentity that provides hospital, physician or other health care services to acarrier, includes provisions that require a provider, as a condition ofparticipating in one of the carrier's or other entity's provider panels, toparticipate in any other provider panel owned or operated by that carrier orother entity, the contract shall contain a provision permitting the providerto refuse participation in one or more such other provider panels at the timethe contract is executed. If a provider contracts with a carrier or otherentity that subsequently contracts with one or more unaffiliated carriers toinclude such provider in the provider panels of such unaffiliated carriers,and which permits an unaffiliated carrier to impose participation terms withrespect to such provider that differ materially in reimbursement rates or inmanaged care procedures, such as conducting economic profiling or requiring apatient to obtain primary care physician referral to a specialist, from theterms agreed to by the provider in the original contract, the provider panelcontract shall contain a provision permitting the provider to refuseparticipation with any such unaffiliated carrier. Utilization review pursuantto Article 1.2 (§ 32.1-137.7 et seq.) of Chapter 5 of Title 32.1 shall notconstitute a materially different managed care procedure. This subsectionshall apply to provider panels utilized by health maintenance organizationsand preferred provider organizations. For purposes of this subsection,"preferred provider organization" means a carrier that offers preferredprovider contracts or policies as defined in § 38.2-3407 or preferredprovider subscription contracts as defined in § 38.2-4209. The status of aphysician as a member of or as being eligible for other existing or newprovider panels shall not be adversely affected by the exercise of such rightto refuse participation. This subsection shall not apply to the Medallion IIand children's health insurance plan administered by or pursuant to contractwith the Department of Medical Assistance Services.
P. A carrier that rents or leases its provider panel to unaffiliated carriersshall make available, upon request, to its providers a list of unaffiliatedcarriers that rent or lease its provider panel. Such list if available inelectronic format shall be updated monthly. The provider shall be given themeans to request and receive a printed copy of such list.
Q. The Commission shall have no jurisdiction to adjudicate controversiesarising out of this section.
R. The requirements of this section shall apply to all insurance policies,contracts, and plans delivered, issued for delivery, reissued, or extended onor after July 1, 1996. However, the 90-day period referred to in subdivisionsC 1 b and C 2 of this section, the requirements set forth in subdivisions F 2and F 3, and the requirements set forth in subsections L, M, and N shallapply to contracts between carriers and providers that are entered into orrenewed on or after July 1, 1999, the requirements set forth in subsection Oshall apply to contracts between carriers and providers that are enteredinto, reissued, extended or renewed on or after July 1, 2001, and therequirements set forth in subsection P shall be effective on and afterJanuary 1, 2007.
(1996, c. 776; 1999, cc. 643, 649; 2000, cc. 862, 922, 934; 2001, c. 239;2004, c. 715; 2006, c. 398.)
1. Any insurer proposing to issue individual or group accident and sicknessinsurance policies providing hospital, medical and surgical or major medicalcoverage on an expense incurred basis;
2. Any corporation providing individual or group accident and sicknesssubscription contracts;
3. Any health maintenance organization providing health care plans for healthcare services;
4. Any corporation offering prepaid dental or optometric services plans; or
5. Any other person or organization that provides health benefit planssubject to state regulation, and includes an entity that arranges a providerpanel for compensation.
"Enrollee" means any person entitled to health care services from a carrier.
"Provider" means a hospital, physician or any type of provider licensed,certified or authorized by statute to provide a covered service under thehealth benefit plan.
"Provider panel" means those providers with which a carrier contracts toprovide health care services to the carrier's enrollees under the carrier'shealth benefit plan. However, such term does not include an arrangementbetween a carrier and providers in which any provider may participate solelyon the basis of the provider's contracting with the carrier to provideservices at a discounted fee-for-service rate.
B. Any such carrier that offers a provider panel shall establish and use itin accordance with the following requirements:
1. Notice of the development of a provider panel in the Commonwealth or localservice area shall be filed with the Department of Health Professions.
2. Carriers shall provide a provider application and the relevant terms andconditions to a provider upon request.
C. A carrier that uses a provider panel shall establish procedures for:
1. Notifying an enrollee of:
a. The termination from the carrier's provider panel of the enrollee'sprimary care provider who was furnishing health care services to theenrollee; and
b. The right of an enrollee upon request to continue to receive health careservices for a period of up to 90 days from the date of the primary careprovider's notice of termination from a carrier's provider panel, except whena provider is terminated for cause.
2. Notifying a provider at least 90 days prior to the date of the terminationof the provider, except when a provider is terminated for cause.
3. Providing reasonable notice to primary care providers in the carrier'sprovider panel of the termination of a specialty referral services provider.
4. Notifying the purchaser of the health benefit plan, whether such purchaseris an individual or an employer providing a health benefit plan, in whole orin part, to its employees and enrollees of the health benefit plan of:
a. A description of all types of payment arrangements that the carrier usesto compensate providers for health care services rendered to enrollees,including, but not limited to, withholds, bonus payments, capitation andfee-for-service discounts; and
b. The terms of the plan in clear and understandable language that reasonablyinforms the purchaser of the practical application of such terms in theoperation of the plan.
D. Whenever a provider voluntarily terminates his contract with a carrier toprovide health care services to the carrier's enrollees under a healthbenefit plan, he shall furnish reasonable notice of such termination to hispatients who are enrollees under such plan.
E. A carrier may not deny an application for participation or terminateparticipation on its provider panel on the basis of gender, race, age,religion or national origin.
F. 1. For a period of at least 90 days from the date of the notice of aprovider's termination from the carrier's provider panel, except when aprovider is terminated for cause, the provider shall be permitted by thecarrier to render health care services to any of the carrier's enrollees who:
a. Were in an active course of treatment from the provider prior to thenotice of termination; and
b. Request to continue receiving health care services from the provider.
2. Notwithstanding the provisions of subdivision 1, any provider shall bepermitted by the carrier to continue rendering health services to anyenrollee who has entered the second trimester of pregnancy at the time of aprovider's termination of participation, except when a provider is terminatedfor cause. Such treatment shall, at the enrollee's option, continue throughthe provision of postpartum care directly related to the delivery.
3. Notwithstanding the provisions of subdivision 1, any provider shall bepermitted by the carrier to continue rendering health services to anyenrollee who is determined to be terminally ill (as defined under § 1861(dd)(3)(A) of the Social Security Act) at the time of a provider'stermination of participation, except when a provider is terminated for cause.Such treatment shall, at the enrollee's option, continue for the remainder ofthe enrollee's life for care directly related to the treatment of theterminal illness.
4. A carrier shall reimburse a provider under this subsection in accordancewith the carrier's agreement with such provider existing immediately beforethe provider's termination of participation.
G. 1. A carrier shall provide to a purchaser upon enrollment and makeavailable to existing enrollees at least once a year a list of members in itsprovider panel, which list shall also indicate those providers who are notcurrently accepting new patients. Such list may be made available in a formother than a printed document, provided the purchaser or existing enrollee isgiven the means to request and receive a printed copy of such list.
2. The information provided under subdivision 1 shall be updated at leastonce a year if in paper form, and monthly if in electronic form.
H. No contract between a carrier and a provider may require that the providerindemnify the carrier for the carrier's negligence, willful misconduct, orbreach of contract, if any.
I. No contract between a carrier and a provider shall require a provider, asa condition of participation on the panel, to waive any right to seek legalredress against the carrier.
J. No contract between a carrier and a provider shall prohibit, impede orinterfere in the discussion of medical treatment options between a patientand a provider.
K. A contract between a carrier and a provider shall permit and require theprovider to discuss medical treatment options with the patient.
L. Any carrier requiring preauthorization for medical treatment shall havepersonnel available to provide such preauthorization at all times when suchpreauthorization is required.
M. Carriers shall provide to their group policyholders written notice of anybenefit reductions during the contract period at least 60 days before suchbenefit reductions become effective. Group policyholders shall, in turn,provide to their enrollees written notice of any benefit reductions duringthe contract period at least 30 days before such benefit reductions becomeeffective. Such notice shall be provided to the group policyholder as aseparate and distinct notification, and may not be combined with any othernotification or marketing materials.
N. No contract between a provider and a carrier shall include provisions thatrequire a health care provider or health care provider group to deny coveredservices that such provider or group knows to be medically necessary andappropriate that are provided with respect to a specific enrollee or group ofenrollees with similar medical conditions.
O. If a provider panel contract between a provider and a carrier, or otherentity that provides hospital, physician or other health care services to acarrier, includes provisions that require a provider, as a condition ofparticipating in one of the carrier's or other entity's provider panels, toparticipate in any other provider panel owned or operated by that carrier orother entity, the contract shall contain a provision permitting the providerto refuse participation in one or more such other provider panels at the timethe contract is executed. If a provider contracts with a carrier or otherentity that subsequently contracts with one or more unaffiliated carriers toinclude such provider in the provider panels of such unaffiliated carriers,and which permits an unaffiliated carrier to impose participation terms withrespect to such provider that differ materially in reimbursement rates or inmanaged care procedures, such as conducting economic profiling or requiring apatient to obtain primary care physician referral to a specialist, from theterms agreed to by the provider in the original contract, the provider panelcontract shall contain a provision permitting the provider to refuseparticipation with any such unaffiliated carrier. Utilization review pursuantto Article 1.2 (§ 32.1-137.7 et seq.) of Chapter 5 of Title 32.1 shall notconstitute a materially different managed care procedure. This subsectionshall apply to provider panels utilized by health maintenance organizationsand preferred provider organizations. For purposes of this subsection,"preferred provider organization" means a carrier that offers preferredprovider contracts or policies as defined in § 38.2-3407 or preferredprovider subscription contracts as defined in § 38.2-4209. The status of aphysician as a member of or as being eligible for other existing or newprovider panels shall not be adversely affected by the exercise of such rightto refuse participation. This subsection shall not apply to the Medallion IIand children's health insurance plan administered by or pursuant to contractwith the Department of Medical Assistance Services.
P. A carrier that rents or leases its provider panel to unaffiliated carriersshall make available, upon request, to its providers a list of unaffiliatedcarriers that rent or lease its provider panel. Such list if available inelectronic format shall be updated monthly. The provider shall be given themeans to request and receive a printed copy of such list.
Q. The Commission shall have no jurisdiction to adjudicate controversiesarising out of this section.
R. The requirements of this section shall apply to all insurance policies,contracts, and plans delivered, issued for delivery, reissued, or extended onor after July 1, 1996. However, the 90-day period referred to in subdivisionsC 1 b and C 2 of this section, the requirements set forth in subdivisions F 2and F 3, and the requirements set forth in subsections L, M, and N shallapply to contracts between carriers and providers that are entered into orrenewed on or after July 1, 1999, the requirements set forth in subsection Oshall apply to contracts between carriers and providers that are enteredinto, reissued, extended or renewed on or after July 1, 2001, and therequirements set forth in subsection P shall be effective on and afterJanuary 1, 2007.
(1996, c. 776; 1999, cc. 643, 649; 2000, cc. 862, 922, 934; 2001, c. 239;2004, c. 715; 2006, c. 398.)
1. Any insurer proposing to issue individual or group accident and sicknessinsurance policies providing hospital, medical and surgical or major medicalcoverage on an expense incurred basis;
2. Any corporation providing individual or group accident and sicknesssubscription contracts;
3. Any health maintenance organization providing health care plans for healthcare services;
4. Any corporation offering prepaid dental or optometric services plans; or
5. Any other person or organization that provides health benefit planssubject to state regulation, and includes an entity that arranges a providerpanel for compensation.
"Enrollee" means any person entitled to health care services from a carrier.
"Provider" means a hospital, physician or any type of provider licensed,certified or authorized by statute to provide a covered service under thehealth benefit plan.
"Provider panel" means those providers with which a carrier contracts toprovide health care services to the carrier's enrollees under the carrier'shealth benefit plan. However, such term does not include an arrangementbetween a carrier and providers in which any provider may participate solelyon the basis of the provider's contracting with the carrier to provideservices at a discounted fee-for-service rate.
B. Any such carrier that offers a provider panel shall establish and use itin accordance with the following requirements:
1. Notice of the development of a provider panel in the Commonwealth or localservice area shall be filed with the Department of Health Professions.
2. Carriers shall provide a provider application and the relevant terms andconditions to a provider upon request.
C. A carrier that uses a provider panel shall establish procedures for:
1. Notifying an enrollee of:
a. The termination from the carrier's provider panel of the enrollee'sprimary care provider who was furnishing health care services to theenrollee; and
b. The right of an enrollee upon request to continue to receive health careservices for a period of up to 90 days from the date of the primary careprovider's notice of termination from a carrier's provider panel, except whena provider is terminated for cause.
2. Notifying a provider at least 90 days prior to the date of the terminationof the provider, except when a provider is terminated for cause.
3. Providing reasonable notice to primary care providers in the carrier'sprovider panel of the termination of a specialty referral services provider.
4. Notifying the purchaser of the health benefit plan, whether such purchaseris an individual or an employer providing a health benefit plan, in whole orin part, to its employees and enrollees of the health benefit plan of:
a. A description of all types of payment arrangements that the carrier usesto compensate providers for health care services rendered to enrollees,including, but not limited to, withholds, bonus payments, capitation andfee-for-service discounts; and
b. The terms of the plan in clear and understandable language that reasonablyinforms the purchaser of the practical application of such terms in theoperation of the plan.
D. Whenever a provider voluntarily terminates his contract with a carrier toprovide health care services to the carrier's enrollees under a healthbenefit plan, he shall furnish reasonable notice of such termination to hispatients who are enrollees under such plan.
E. A carrier may not deny an application for participation or terminateparticipation on its provider panel on the basis of gender, race, age,religion or national origin.
F. 1. For a period of at least 90 days from the date of the notice of aprovider's termination from the carrier's provider panel, except when aprovider is terminated for cause, the provider shall be permitted by thecarrier to render health care services to any of the carrier's enrollees who:
a. Were in an active course of treatment from the provider prior to thenotice of termination; and
b. Request to continue receiving health care services from the provider.
2. Notwithstanding the provisions of subdivision 1, any provider shall bepermitted by the carrier to continue rendering health services to anyenrollee who has entered the second trimester of pregnancy at the time of aprovider's termination of participation, except when a provider is terminatedfor cause. Such treatment shall, at the enrollee's option, continue throughthe provision of postpartum care directly related to the delivery.
3. Notwithstanding the provisions of subdivision 1, any provider shall bepermitted by the carrier to continue rendering health services to anyenrollee who is determined to be terminally ill (as defined under § 1861(dd)(3)(A) of the Social Security Act) at the time of a provider'stermination of participation, except when a provider is terminated for cause.Such treatment shall, at the enrollee's option, continue for the remainder ofthe enrollee's life for care directly related to the treatment of theterminal illness.
4. A carrier shall reimburse a provider under this subsection in accordancewith the carrier's agreement with such provider existing immediately beforethe provider's termination of participation.
G. 1. A carrier shall provide to a purchaser upon enrollment and makeavailable to existing enrollees at least once a year a list of members in itsprovider panel, which list shall also indicate those providers who are notcurrently accepting new patients. Such list may be made available in a formother than a printed document, provided the purchaser or existing enrollee isgiven the means to request and receive a printed copy of such list.
2. The information provided under subdivision 1 shall be updated at leastonce a year if in paper form, and monthly if in electronic form.
H. No contract between a carrier and a provider may require that the providerindemnify the carrier for the carrier's negligence, willful misconduct, orbreach of contract, if any.
I. No contract between a carrier and a provider shall require a provider, asa condition of participation on the panel, to waive any right to seek legalredress against the carrier.
J. No contract between a carrier and a provider shall prohibit, impede orinterfere in the discussion of medical treatment options between a patientand a provider.
K. A contract between a carrier and a provider shall permit and require theprovider to discuss medical treatment options with the patient.
L. Any carrier requiring preauthorization for medical treatment shall havepersonnel available to provide such preauthorization at all times when suchpreauthorization is required.
M. Carriers shall provide to their group policyholders written notice of anybenefit reductions during the contract period at least 60 days before suchbenefit reductions become effective. Group policyholders shall, in turn,provide to their enrollees written notice of any benefit reductions duringthe contract period at least 30 days before such benefit reductions becomeeffective. Such notice shall be provided to the group policyholder as aseparate and distinct notification, and may not be combined with any othernotification or marketing materials.
N. No contract between a provider and a carrier shall include provisions thatrequire a health care provider or health care provider group to deny coveredservices that such provider or group knows to be medically necessary andappropriate that are provided with respect to a specific enrollee or group ofenrollees with similar medical conditions.
O. If a provider panel contract between a provider and a carrier, or otherentity that provides hospital, physician or other health care services to acarrier, includes provisions that require a provider, as a condition ofparticipating in one of the carrier's or other entity's provider panels, toparticipate in any other provider panel owned or operated by that carrier orother entity, the contract shall contain a provision permitting the providerto refuse participation in one or more such other provider panels at the timethe contract is executed. If a provider contracts with a carrier or otherentity that subsequently contracts with one or more unaffiliated carriers toinclude such provider in the provider panels of such unaffiliated carriers,and which permits an unaffiliated carrier to impose participation terms withrespect to such provider that differ materially in reimbursement rates or inmanaged care procedures, such as conducting economic profiling or requiring apatient to obtain primary care physician referral to a specialist, from theterms agreed to by the provider in the original contract, the provider panelcontract shall contain a provision permitting the provider to refuseparticipation with any such unaffiliated carrier. Utilization review pursuantto Article 1.2 (§ 32.1-137.7 et seq.) of Chapter 5 of Title 32.1 shall notconstitute a materially different managed care procedure. This subsectionshall apply to provider panels utilized by health maintenance organizationsand preferred provider organizations. For purposes of this subsection,"preferred provider organization" means a carrier that offers preferredprovider contracts or policies as defined in § 38.2-3407 or preferredprovider subscription contracts as defined in § 38.2-4209. The status of aphysician as a member of or as being eligible for other existing or newprovider panels shall not be adversely affected by the exercise of such rightto refuse participation. This subsection shall not apply to the Medallion IIand children's health insurance plan administered by or pursuant to contractwith the Department of Medical Assistance Services.
P. A carrier that rents or leases its provider panel to unaffiliated carriersshall make available, upon request, to its providers a list of unaffiliatedcarriers that rent or lease its provider panel. Such list if available inelectronic format shall be updated monthly. The provider shall be given themeans to request and receive a printed copy of such list.
Q. The Commission shall have no jurisdiction to adjudicate controversiesarising out of this section.
R. The requirements of this section shall apply to all insurance policies,contracts, and plans delivered, issued for delivery, reissued, or extended onor after July 1, 1996. However, the 90-day period referred to in subdivisionsC 1 b and C 2 of this section, the requirements set forth in subdivisions F 2and F 3, and the requirements set forth in subsections L, M, and N shallapply to contracts between carriers and providers that are entered into orrenewed on or after July 1, 1999, the requirements set forth in subsection Oshall apply to contracts between carriers and providers that are enteredinto, reissued, extended or renewed on or after July 1, 2001, and therequirements set forth in subsection P shall be effective on and afterJanuary 1, 2007.
(1996, c. 776; 1999, cc. 643, 649; 2000, cc. 862, 922, 934; 2001, c. 239;2004, c. 715; 2006, c. 398.)
