Standards; payments or reimbursement for noncontracting provider of covered services; filing requirements for unlicensed entities; provision for payment solely to provider
See text in bold below:
(a) Notwithstanding any provisions of law to the contrary, any health care insurer may enter into preferred provider arrangements as provided in this article. Such arrangements shall:
(1) Establish the amount and manner of payment to the preferred provider;
(2) Include fair, reasonable, and equitable mechanisms for the assignment and payment of benefits to nonpreferred providers;
(3)(A) Include mechanisms which are designed to minimize the cost of the health benefit plan such as the review or control of utilization of health care services.
(B) Include procedures for determining whether health care services rendered are medically necessary;
(4) Provide to covered persons eligible to receive health care services under that arrangement a statement of benefits under the arrangement and, at least every 60 days, an updated listing of physicians who are preferred providers under the arrangement, which statement and listing may be made available by mail or by publication on an Internet service site made available by the health care insurer at no cost to such covered persons; and
(5) Require that the covered person, or that person’s agent, parent, or guardian if the covered person is a minor, be permitted to appeal to a physician agent or employee of the health care insurer any decision to deny coverage for health care services recommended by a physician.
(b) Such arrangements shall not:
(1) Unfairly deny health benefits for medically necessary covered services;
(2) Have differences in benefit levels payable to preferred providers compared to other providers which unfairly deny benefits for covered services;
(3) Have differences in coinsurance percentages applicable to benefit levels for services provided by preferred and nonpreferred providers which differ by more than 30 percentage points;
(4) Have a coinsurance percentage applicable to benefit levels for services provided by nonpreferred providers which exceeds 40 percent of the benefit levels under the policy for such services;
(5) Have an adverse effect on the availability or the quality of services; and
(6) Be a result of a negotiation with a primary care physician to become a preferred provider unless that physician shall be furnished, beginning on and after January 1, 2001, with a schedule showing common office based fees payable for services under that arrangement.
(1) Notwithstanding the provisions of paragraphs (3) and (4) of subsection (b) of this Code section, health benefit plans providing incentives for covered persons to use pharmaceutical or dental services of preferred providers shall contain a provision which clearly identifies that the payment or reimbursement for a noncontracting provider of covered pharmaceutical or dental services shall be the same as the payment or reimbursement for a preferred provider of covered pharmaceutical or dental services; provided, however, the health benefit plan shall not be required to make payment or reimbursement in an amount which is greater than the actual fee charged by the provider for the dental or pharmaceutical services rendered.
(2) Notwithstanding any provisions of this title to the contrary, paragraphs (3) and (4) of subsection (b) of this Code section shall not apply to routine physical examinations covered under a health benefit plan.
(d) If an entity enters into a contract providing covered services with a health care provider, but is not engaged in activities which would require it to be licensed as a health care insurer, such entity shall file with the Commissioner information describing its activities and a description of the contract or agreement it has entered into with the health care providers. Employers who enter into contracts with health care providers for the exclusive benefit of their employees and dependents are exempt from this requirement.
(e) Any other provision of law to the contrary notwithstanding, if a covered person provides in writing to a health care provider, whether the health care provider is a preferred provider or not, that payment for health care services shall be made solely to the health care provider and be sent directly to the health care provider by the health care insurer, and the health care provider certifies to same upon filing a claim for the delivery of health care services, the health care insurer shall make payment solely to the health care provider and shall send said payment directly to the health care provider. This subsection shall not be construed to extend coverages or to require payment for services not otherwise covered.