Substitute House Bill No. 5383
Public Act No. 18-115
AN ACT CONCERNING DISPUTES BETWEEN HEALTH CARRIERS AND PARTICIPATING PROVIDERS THAT ARE HOSPITALS.
Be it enacted by the Senate and House of Representatives in General Assembly convened:
Section 1. Subsection (g) of section 38a-472f of the 2018 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2018):
(g) (1) (A) A health carrier and participating provider shall provide at least [sixty] ninety days' written notice to each other before the health carrier removes a participating provider from the network or the participating provider leaves the network. Each participating provider that receives a notice of removal or issues a departure notice shall provide to the health carrier a list of such participating provider's patients who are covered persons under a network plan of such health carrier.
(B) A health carrier shall make a good faith effort to provide written notice, not later than thirty days after the health carrier receives or issues a written notice under subparagraph (A) of this subdivision, to all covered persons who are patients being treated on a regular basis by or at the participating provider being removed from or leaving the network, irrespective of whether such removal or departure is for cause.
(C) For each contract entered into, renewed, amended or continued on or after July 1, 2018, between a health carrier and a participating provider that is a hospital, as defined in section 38a-493, or a parent corporation of a hospital, if the contract is not renewed or is terminated by either the health carrier or the participating provider, the health carrier and the participating provider shall continue to abide by the terms of such contract, including reimbursement terms, for a period of sixty days from the date of termination or, in the case of a nonrenewal, from the end of the contract period. Except as otherwise agreed between such health carrier and such participating provider, the reimbursement terms of any contract entered into by such health carrier and such participating provider during said sixty-day period shall be retroactive to the date of termination or, in the case of a nonrenewal, the end date of the contract period. This subparagraph shall not apply if the health carrier and participating provider agree, in writing, to the termination or nonrenewal of the contract and the health carrier and participating provider provide the notices required under subparagraphs (A) and (B) of this subdivision.
(2) (A) For the purposes of this subdivision:
(i) "Active course of treatment" means (I) a medically necessary, ongoing course of treatment for a life-threatening condition, (II) a medically necessary, ongoing course of treatment for a serious condition, (III) medically necessary care provided during the second or third trimester of pregnancy, or (IV) a medically necessary, ongoing course of treatment for a condition for which a treating health care provider attests that discontinuing care by such health care provider would worsen the covered person's condition or interfere with anticipated outcomes;
(ii) "Life-threatening condition" means a disease or condition for which the likelihood of death is probable unless the course of such disease or condition is interrupted;
(iii) "Serious condition" means a disease or condition that requires complex ongoing care such as chemotherapy, radiation therapy or postoperative visits, which the covered person is currently receiving; and
(iv) "Treating provider" means a covered person's treating health care provider or a facility at which a covered person is receiving treatment, that is removed from or leaves a health carrier's network pursuant to subdivision (1) of this subsection.
(B) (i) Each health carrier shall establish and maintain reasonable procedures to transition a covered person, who is in an active course of treatment with a participating health care provider or at a participating facility that becomes a treating provider, to another participating provider in a manner that provides for continuity of care.
(ii) In addition to the notice required under subparagraph (B) of subdivision (1) of this subsection, the health carrier shall provide to such covered person (I) a list of available participating providers in the same geographic area as such covered person who are of the same health care provider or facility type, and (II) the procedures for how such covered person may request continuity of care as set forth in this subparagraph.
(iii) Such procedures shall provide that:
(I) Any request for a continuity of care period shall be made by the covered person or the covered person's authorized representative;
(II) A request for a continuity of care period, made by a covered person who meets the requirements under subparagraph (B)(i) of this subdivision or such covered person's authorized representative and whose treating provider was not removed from or did not leave the network for cause, shall be reviewed by the health carrier's medical director after consultation with such treating provider; and
(III) For a covered person who is in the second or third trimester of pregnancy, the continuity of care period shall extend through the postpartum period.
(iv) The continuity of care period for a covered person who is undergoing an active course of treatment shall extend to the earliest of the following: (I) Termination of the course of treatment by the covered person or the treating provider; (II) ninety days after the date the participating provider is removed from or leaves the network, unless the health carrier's medical director determines that a longer period is necessary; (III) the date that care is successfully transitioned to another participating provider; (IV) the date benefit limitations under the health benefit plan are met or exceeded; or (V) the date the health carrier determines care is no longer medically necessary.
(v) The health carrier shall only grant a continuity of care period as provided under subparagraph (B)(iv) of this subdivision if the treating provider agrees, in writing, (I) to accept the same payment from such health carrier and abide by the same terms and conditions as provided in the contract between such health carrier and treating provider when such treating provider was a participating provider, and (II) not to seek any payment from the covered person for any amount for which such covered person would not have been responsible if the treating provider was still a participating provider.
Approved June 6, 2018