Treatment of covered person under special circumstances
(1) “Special circumstances” includes a circumstance in which a covered person has a disability, a congenital condition, a life-threatening illness, or is past the twenty-fourth week of pregnancy where disruption of the covered person’s continuity of care could cause medical harm.
(2) Any special circumstance shall be identified by the treating provider, who may request, with the concurrence of the covered person or authorized person, that the covered person be permitted to continue treatment under the provider’s care even when the provider is no longer participating in the network, unless the provider has been terminated for a reason related to quality. The treating, non network provider shall agree to care for the covered person under the same guidelines and payment schedule as required by the plan, and shall report to the plan on the care being provided.
(3) Procedures for resolving disputes regarding the necessity for continued treatment by a provider shall be established by the plan and shall provide for review through the plan’s internal appeal process.
(4) This section does not extend the obligation of the plan to pay a terminated or nonrenewed provider for ongoing treatment of a covered person with “special circumstances”:
(a) Beyond the ninetieth day after the effective date of the termination or nonrenewal;
(b) Beyond nine (9) months in the case of a covered person who at the time of the termination has been diagnosed with a terminal illness; or
(c) If the covered person is beyond the twenty-fourth week of pregnancy, the plan’s obligation to pay for services extends through the delivery of the child, immediate postpartum care, and examination within the first six (6) weeks following delivery.