Termination of providers
See bold sections below:
An HMO shall implement a policy governing termination of providers. The policy shall include at least:
(1) Provisions for at least ninety (90) days advance notice of contract termination by either the HMO or the provider, with additional provisions for contract termination by the HMO with less than ninety (90) days notice for cause;
(2) Methods by which the termination policy shall be made known to providers and members at the time of enrollment and on a periodic basis;
(3) Written notification to each member at least thirty (30) days prior to the termination or withdrawal of a member’s primary physician from the HMO’s provider network and of any other physician or provider currently treating the member. The Department may waive the 30-day prior notice requirement if the HMO demonstrates that immediate termination is necessary for the protection of health, safety and welfare of members, or if the HMO demonstrates that the provider has not complied with the termination requirements under the contract; and
Continuity of Care Post Contract
(4) Assurance of continued coverage of services, under certain conditions, consistent with the following:
(A) Every plan shall establish procedures governing termination of a participating provider who is terminated for reasons other than cause. The procedures shall include assurance of continued coverage of services, at the contract terms and price by a terminated provider for up to ninety (90) calendar days from the date of notice to the covered person for a covered person who:
(i) Has a degenerative and disabling condition or disease;
(ii) Has entered the third trimester of pregnancy. Additional coverage of services by the terminated provider shall continue through at lest six (6) weeks of postpartum evaluation; or
(iii) Is terminally ill.
(B) If a participating provider voluntarily chooses to discontinue participation as a network provider in a plan, the plan shall permit a covered person to continue an ongoing course of treatment with the disaffiliated provider during a transitional period:
(i) of up to ninety (90) days from the date of notice to the plan of the provider’s disaffiliation from the plan’s network, or
(ii) that includes delivery and postpartum care if the covered person has entered the third trimester of pregnancy at the time of the provider’s disaffiliation.
(C) If a provider voluntarily chooses to discontinue participation as a network provider participating in a plan, such provider shall give at least a ninety-day notice of the disaffiliation to the plan. The plan shall immediately notify the disaffiliated provider’s patients of that fact.
(D) Notwithstanding the provisions of paragraph 1 of this subsection, continuing care shall be authorized by the plan during the transitional period only if the disaffiliated provider agrees to:
(i) continue to accept reimbursement from the plan at the rates applicable prior to the start of the transitional period s payment in full,
(ii) adhere to the plan’s quality assurance requirements and to provide to the plan necessary medical information related to such care, and
(iii) otherwise adhere to the plan’s policies and procedures, including, but not limited to, policies and procedures regarding references, and obtaining preauthorization and treatment plan approval from the plan.