Health insurance carrier standards and responsibilities

Each health carrier that delivers, issues for delivery, renews, amends or continues any individual or group health insurance policy or certificate in this state that uses a provider network shall: (1) Contract with the appropriate type and number of health care providers to ensure that each person covered by such health carrier under such a plan or certificate has reasonable access to participating providers located near such covered person's place of residence or employment. Reasonable access includes maintaining a sufficient number and appropriate types of participating providers that predominately serve, without unreasonable travel or delay: (A) Low income individuals; (B) Medically underserved individuals; (C) Individuals with serious, chronic or complex illnesses; and (D) Individuals with physical or mental disabilities. (2) Make additional arrangements to meet the needs of persons covered by such health carrier under such a health insurance policy or certificate if the requirements of subdivision (1) cannot be met, including the needs of: (A) Low-income individuals; (B) Children and adults with serious, chronic or complex conditions or physical or mental disabilities; or (C) Individuals with limited English proficiency. (3) Establish and maintain a process to ensure that each person covered by such health carrier under such a health insurance policy or certificate receives a covered benefit at an in-network level, including an in-network level of cost-sharing, from a nonparticipating provider, or shall make other arrangements acceptable to the commissioner, when: (A) The health carrier has a sufficient network but does not have available: (i) A type of participating provider to provide the covered benefit to the covered person; or (ii) A participating provider to provide the covered benefit to the covered person without unreasonable travel or delay; or (B) The health carrier has an insufficient number or type of participating providers available to provide the covered benefit to the covered person without unreasonable travel or delay or within the standard timeframes recommended by the commissioner. (4) Monitor, on an ongoing basis, compliance with provider contracts, and the ability, clinical capacity and legal authority of its participating providers to provide all covered benefits to its covered persons. (5) Establish and maintain procedures by which a participating provider shall be notified, on an ongoing basis, of the specific covered health care services for which such participating provider shall be responsible, including any limitations on, or conditions of, such services. (6) Notify participating providers of their obligations, if any: (A) To collect applicable coinsurance, deductibles or copayments from a person covered pursuant to such a plan or certificate; (B) To hold covered persons harmless from balance billing beyond any contractual cost-sharing amounts; (C) Regarding surprise billing practices; (D) To notify each covered person, prior to delivery of health care services if possible, of such covered person's financial obligations, if any, for non-covered benefits; (E) To provide at least sixty (60) days' advance notice to such health carrier when the participating provider leaves such health carrier's provider network; and (F) To provide to such health carrier, not later than thirty (30) days after the health carrier receives the notice of termination described in subparagraph (E) of this subdivision, a list of the participating provider's patients who are covered under a health insurance policy or certificate delivered, issued for delivery, renewed, amended or continued by such health carrier in this state. (7) Establish and maintain procedures by which a participating provider may determine, in a timely manner, at the time benefits are provided whether an individual is a covered person or is within a grace period during which such health carrier may hold a claim for health care services pending receipt of payment of any premium by such health carrier. (8) Timely notify a health care provider or facility, when the health carrier has included the health care provider or facility as a participating provider for any of such health carrier's health insurance policies or certificates, of such health care provider's or facility's network participation status. (9) Notify each participating provider of the participating provider's responsibilities with respect to such health carrier's applicable administrative policies and programs, including, but not limited to, payment terms, hold harmless agreements, utilization review, quality assessment and improvement programs, credentialing, grievance and appeals processes, data reporting requirements, reporting requirements for timely notice of changes in practice such as discontinuance of accepting new patients, notice of termination as a network provider, confidentiality requirements, any applicable federal or state programs and obtaining necessary approval of referrals to nonparticipating providers. (10) Establish and maintain procedures for the resolution of administrative, payment or other disputes between such health carrier and participating providers. (11) Provide at least sixty (60) days' advance written notice to a participating provider before such health carrier removes the participating provider from such health carrier's participating provider network. (12) Make a good faith effort to provide written notice, not later than thirty (30) days from receipt of the list of the participating providers' patients who are covered persons, to all covered persons who are patients being treated on a regular basis by such provider. For purposes of this subsection, "treated on a regular basis" means receiving treatment at least once during the twelve (12) months immediately prior to provision of the thirty (30) day notice described in this subdivision. (13) Require that any subcontracted network meets the standards set forth in this section, including all network adequacy standards, and monitor compliance with those standards. (14) Disclose to a person covered under such a policy or certificate issued by such health carrier the process to request a covered benefit from a nonparticipating provider, when: (A) The covered person is diagnosed with a condition or disease that requires specialty care; and (B) The health carrier: (i) Does not have a participating provider of the required specialty with the professional training and expertise to treat or provide health care services for the condition or disease; or (ii) Cannot provide reasonable access to a participating provider of the required specialty with the professional training and expertise to treat or provide health care services for the condition or disease without unreasonable travel or delay. (15) Make a reasonable effort to contract with centers of excellence, mobile clinics, technological and specialty care services, walk-in clinics, urgent care facilities and regionalized specialty care providers, as applicable. (16) Establish procedures to meet network adequacy standards. (17) Establish and document any issues of non-compliance and corrective actions.