40-4607. Same; provider network required to be sufficient to ensure covered services accessible without unreasonable delay; determination of sufficiency of provider network; plan to provide for referr
40-4607
40-4607. Same; provider network required to be sufficient to ensurecovered services accessible without unreasonable delay; determination ofsufficiency of provider network; plan to provide for referral of insured tospecialists under certain conditions; exceptions to requirements.(a) A health insurer providing a health benefit plan shallmaintain a provider network that is sufficient in numbers and types ofproviders to assure that all covered services to an insured will beaccessible without unreasonable delay. Sufficiency of the provider networkshall be determined in accordance with the requirements of this section, andmay be established by reference to any reasonable criteria used by the healthinsurer, including but not limited to: provider-insured ratios byspecialty; primary care provider-insured ratios; geographicaccessibility; waiting times for appointments with participating providers;hours of operation; and the availability of technological and specialtyservices to serve the needs of insureds requiring technologicallyadvanced or specialty care.
(b) A health insurer shall have a plan by which an insured with alife-threatening, chronic, degenerative or disabling condition or disease,which requires specialized medical care over a prolonged period of time, mayreceive a referral to a specialist with expertise in treating such disease orcondition who shall be responsible for and capable of providing andcoordinating the insured's specialty care.
(c) Nothing in this section shall require a health insurer to providebenefits not otherwise covered by the terms of the health benefits plan.
(d) A provider network shall not be determined to be insufficient forfailure to contract with any provider unwilling to contract under the sameterms and conditions, including reimbursement levels, as such health insureroffers to other similarly situated health care providers.
History: L. 1997, ch. 190, § 22; July 1.