38.2-5805 - Provider contracts.
§ 38.2-5805. Provider contracts.
A. Each health carrier subject to subsection B of § 38.2-5801 shall file withthe Commission a list of the current providers who have executed a contractdirectly with the health carrier or indirectly through an intermediaryorganization for the purpose of providing health care services pursuant to anMCHIP or for the benefit of a covered person of an MCHIP. The list shallinclude the names and localities of the providers. The list shall be updatedby the health carrier at least annually and more frequently as required bythe Commission in accordance with provisions in this title or by the StateHealth Commissioner in accordance with provisions in Title 32.1.
B. Every contract with a provider of health care services enabling an MCHIPto provide health care services shall be in writing.
C. When the health carrier is a health maintenance organization, thecontracts with providers enabling the MCHIP to provide health care servicesto the covered persons shall contain a "hold harmless" clause setting forththat, in the event such health carrier fails to pay for health care servicesas set forth in the contract, the covered persons shall not be liable to theprovider for any sums owed by the health carrier. The following requirementsshall apply to such contracts:
1. Such contracts shall require that if the provider terminates theagreement, the provider shall give the health carrier at least sixty days'advance notice of termination.
2. No provider party to such a contract, or agent, trustee or assigneethereof, may maintain any action at law against a covered person to collectsums owed by the health carrier.
3. If there is an intermediary organization enabling a health carrier subjectto subsection B of § 38.2-5801 to provide health care services by means ofthe intermediary organization's own contracts with health care providers, thecontracts between the intermediary organization and its providers shall be inwriting.
4. The contracts shall set forth that, in the event either the health carrieror the intermediary organization fails to pay for health care services as setforth in the contracts between the intermediary organization and itsproviders, or in the contract between the intermediary organization and thehealth carrier, the covered person shall not be liable to the provider forany sums owed by either the intermediary organization or the health carrier.
5. No provider party to such a contract, or agent, trustee or assigneethereof, may maintain any action at law against a covered person to collectsums owed by the health carrier or the intermediary organization.
6. An agreement to provide health care services between an intermediaryorganization and a health carrier subject to subsection B of § 38.2-5801shall require that if the intermediary organization terminates the agreement,the intermediary organization shall give the health carrier at least sixtydays' advance notice of termination.
7. An agreement to provide health care services between an intermediaryorganization and a provider shall require that if the provider terminates theagreement, the provider shall give the intermediary organization at leastsixty days' advance notice of termination.
8. Each such health carrier and intermediary organization shall beresponsible for maintaining its executed contracts enabling it to providehealth care services. These contracts shall be available for the Commission'sreview and examination for a period of five years after the expiration of anysuch contract.
9. The "hold harmless" clause required by this section shall readessentially as set forth in this subdivision. The health carrier may use acorresponding provision of different wording approved by the Commission thatis not less favorable in any respect to the covered persons.
Hold Harmless Clause
[Provider] hereby agrees that in no event, including, but not limited tononpayment by the MCHIP or its health carrier, the insolvency of the [healthcarrier], or breach of this agreement, shall [Provider] bill, charge, collecta deposit from; seek compensation, remuneration or reimbursement from; orhave any recourse against subscribers or persons other than the healthcarrier for services provided pursuant to this Agreement. This provisionshall not prohibit collection of any applicable copayments or deductiblesbilled in accordance with the terms of the subscriber agreement for the MCHIP.
[Provider] further agrees that (i) this provision shall survive thetermination of this Agreement regardless of the cause giving rise to suchtermination and shall be construed to be for the benefit of the plan'ssubscribers and (ii) this provision supersedes any oral or written agreementto the contrary now existing or hereafter entered into between [Provider] andthe subscriber or persons acting on the subscriber's behalf.
10. If there is an intermediary organization between the health carrier andthe health care providers, the hold harmless clause set forth in subdivision5 shall be amended to include nonpayment by the plan, the health carrier, andthe intermediary organization and shall be included in any contract betweenthe intermediary organization and health care providers and in any contractbetween the health carrier on behalf of the MCHIP and the intermediaryorganization.
D. The Commission may specify for each type of health carrier other than ahealth maintenance organization the circumstances, if any, under which ahealth carrier for an MCHIP shall contract with a provider with the "holdharmless" clause described in subsection C. The Commission may specify alsothe extent to which certain accounting treatment, reserves, net worth orsurplus shall be required for liabilities arising from provider contractswithout the "hold harmless" clause.
(1998, c. 891.)