Contract requirements; enrollee coverage; payment of provider; application
(a) A contract between a health maintenance organization and a participating provider of health care services:
(1) must be in writing;
Anti-gag Clause
(2) may not prohibit the participating provider from disclosing:
(A) the terms of the contract as it relates to financial or other incentives to limit medical services by the participating provider; or
(B) all treatment options available to an insured, including those not covered by the insured’s policy;
Anti-retaliation
(3) may not provide for a financial or other penalty to a provider for making a disclosure permitted under subdivision (2); and
(4) must provide that in the event the health maintenance organization fails to pay for health care services as specified by the contract, the subscriber or enrollee is not liable to the participating provider for any sums owed by the health maintenance organization.
(b) An enrollee is not entitled to coverage of a health care service under a group or an individual contract unless that health care service is included in the enrollee’s contract.
(c) A provider is not entitled to payment under a contract for health care services provided to an enrollee unless the provider has a contract or an agreement with the carrier.
(d) This section applies to a contract entered, renewed, or modified after June 30, 1996.