§ 24-A §4303 — Plan requirements

A carrier offering or renewing a health plan in this State must meet the following requirements.
1.
Demonstration of adequate access to providers.
A carrier offering or renewing a managed care plan shall provide to its members reasonable access to health care services. A carrier may provide incentives to members to use designated providers based on cost or quality, but may not require members to use designated providers of health care services.
2.
Credentialing.
The credentialing of providers by a carrier is governed by this subsection.
2-A.
Payment to provider for services rendered during pendency of credentialing.
A carrier offering or renewing a health plan in the State shall pay claims for services rendered to an enrollee by a provider prior to credentials being granted from the date a complete application for credentialing is submitted to the carrier as long as credentials are granted to that provider by the carrier in accordance with the requirements of subsection 2. A provider intending to submit a claim pursuant to this subsection may not submit the claim until the provider has been notified by the carrier whether the provider has been credentialed and of the effective date of any credentials. If a claim is submitted prior to the date credentials are granted, the carrier may process that claim in the same manner as a claim submitted by a provider that has not been credentialed.
3.
Provider's right to advocate for medically appropriate care.
A carrier offering or renewing a managed care plan may not terminate or otherwise discipline a participating provider because the provider advocates for medically appropriate health care. A carrier may not restrict a provider from disclosing to any enrollee any information the provider determines appropriate regarding the nature of treatment and any risks or alternatives to treatment, the availability of other therapy, consultations or tests or the decision of any plan to authorize or deny health care services or benefits.
3-A.
Termination of participating providers.
A carrier offering or renewing a managed care plan may not terminate or nonrenew a contract with a participating provider unless the carrier provides the provider with a written explanation prior to the termination or nonrenewal of the reasons for the proposed contract termination or nonrenewal and provides an opportunity for a review or hearing in accordance with this subsection. The existence of a termination without cause provision in a carrier's contract with a provider does not supersede the requirements of this subsection. This subsection does not apply to termination cases involving imminent harm to patient care, a final determination of fraud by a governmental agency, a final disciplinary action by a state licensing board or other governmental agency that impairs the ability of a provider to practice. A review or hearing of proposed contract termination must meet the following requirements.
3-B.
Prohibition on financial incentives.
A carrier offering or renewing a managed care plan may not offer or pay any type of material inducement, bonus or other financial incentive to a participating provider to deny, reduce, withhold, limit or delay specific medically necessary health care services covered under the plan to an enrollee. This subsection may not be construed to prohibit pilot projects authorized pursuant to section 4320‑H or to prohibit contracts that contain incentive plans that involve general payments such as capitation payments or risk-sharing agreements that are made with respect to providers or groups of providers or that are made with respect to groups of enrollees.
3-C.
Provider's right to engage in legally protected health care activity.
A carrier offering or renewing a health plan in this State may not terminate or nonrenew a contract with a participating provider or impose any monetary penalties or financial disincentives on a participating provider on the sole basis that the participating provider engages in legally protected health care activity or aids and assists legally protected health care activity.
4.
Grievance procedure for enrollees.
A carrier offering or renewing a health plan in this State shall establish and maintain a grievance procedure that meets standards developed by the superintendent to provide for the resolution of claims denials, prior authorization denials or other matters by which enrollees are aggrieved.
5.
Identification of services provided by certified nurse practitioners, certified midwives and certified nurse midwives.
All claims for coverage of services provided by certified nurse practitioners, certified midwives and certified nurse midwives must identify the certified nurse practitioners, certified midwives and certified nurse midwives who provided those services. A carrier offering or renewing a health plan in this State shall assign identification numbers or codes to certified nurse practitioners, certified midwives and certified nurse midwives who provide covered services for enrollees covered under that plan. A claim submitted for payment to a carrier by a health care provider or facility must include the identification number or code of the certified nurse practitioner, certified midwife or certified nurse midwife who provided the service and may not be submitted using the identification number or code of a physician or other health care provider who did not provide the covered service.
6.
Standing referrals to specialists.
A carrier shall establish and maintain a procedure to allow an enrollee with a special condition requiring ongoing care from a specialist to receive a standing referral to a specialist participating in the carrier's network for treatment of that special condition. If the carrier or the enrollee's primary care provider, in consultation with the carrier's medical director, determines that a standing referral is appropriate, the carrier shall ensure that the enrollee receives such a referral to a specialist. If a specialist able to treat the enrollee's special condition does not participate in the carrier's network, then the carrier shall ensure that the enrollee receives a standing referral to a nonparticipating specialist. A standing referral must be made pursuant to a treatment plan approved by the carrier's medical director in consultation with the enrollee's primary care provider. After the standing referral is made, the specialist is authorized to provide health care services to the enrollee in the same manner as the enrollee's primary care provider, subject to the terms of the treatment plan.
7.
Continuity of care.
If a contract between a carrier and a provider is terminated or benefits or coverage provided by a provider is terminated because of a change in the terms of provider participation in a health plan and an enrollee is undergoing a course of treatment from the provider at the time of termination, the carrier shall provide continuity of care in accordance with the requirements in paragraphs A to C. This section does not apply to provider terminations exempt from the requirements of subsection 3‑A.
7-A.
Continuity of prescriptions.
If an enrollee has been undergoing a course of treatment with a prescription drug by prior authorization of a carrier and the enrollee’s coverage with one carrier is replaced with coverage from another carrier pursuant to section 2849‑B, the replacement carrier shall honor the prior authorization for that prescription drug and provide coverage in the same manner as the previous carrier until the replacement carrier conducts a review of the prior authorization for that prescription drug with the enrollee’s prescribing provider. Policies must include a notice of the right to request a review with the enrollee’s provider, and the replacing carrier must honor the prior carrier’s authorization for a period not to exceed 6 months if the enrollee’s provider participates in the review and requests the prior authorization be continued. The replacing carrier is not required to provide benefits for conditions or services not otherwise covered under the replacement policy, and cost sharing may be based on the copayments and coinsurance requirements of the replacement policy.
8.
Maximum allowable charges.
All policies, contracts and certificates executed, delivered and issued by a carrier under which the insured or enrollee may be subject to balance billing when charges exceed a maximum considered usual, customary and reasonable by the carrier or that contain contractual language of similar import must be subject to the following.
8-A.
Protection from balance billing by participating providers.
An enrollee's responsibility for payment under a managed care plan must be limited as provided in this subsection.
9.
Notice of amendments to provider agreements.
A carrier offering or renewing a health plan in this State shall notify a participating provider of a proposed amendment to a provider agreement at least 60 days prior to the amendment's proposed effective date and may file such notice of a proposed amendment to a provider agreement only 4 times per calendar year on January 1st, April 1st, July 1st and October 1st, except that, at any time, a carrier may file a notice of a proposed amendment in response to a requirement of the State or Federal Government or due to a change in current procedural terminology codes used by the American Medical Association. If an amendment that has substantial impact on the rights and obligations of providers is made to a manual, policy or procedure document referenced in the provider agreement, such as material changes to fee schedules or material changes to procedural coding rules specified in the manual, policy or procedure document, the carrier shall provide 60 days' notice to the provider. If the change is to a reimbursement policy and the estimated aggregate change to participating provider reimbursement as a result of the change is more than $500,000 per year, the notice must include the carrier's good faith estimate of the total annual financial impact of the amendment on the aggregate amount of reimbursement payments made by the carrier to all providers within the State with whom the carrier has a provider agreement. After the 60-day notice period has expired, the amendment to a manual, policy or procedure document becomes effective and binding on both the carrier and the provider subject to any applicable termination provisions in the provider agreement, except that the carrier and provider may mutually agree to waive the 60-day notice requirement. This subsection may not be construed to limit the ability of a carrier and provider to mutually agree to the proposed change at any time after the provider has received notice of the proposed amendment. If the notice required by this subsection is provided by electronic communication, the subject line of the electronic communication must indicate that notice of an amendment to a provider agreement or manual, policy or procedure document is included in the communication and the notice of the amendment must be provided as an attachment to the communication, as a separate document. As part of the notice required under this subsection, a carrier shall provide a copy of the revised provider agreement, manual, policy or procedure document without changes being noted and a copy of the revised provider agreement, manual, policy or procedure document with changes being noted by underlining added language and by striking through deleted language.
10.
Limits on retrospective denials.
Except as provided in paragraphs C and D, a carrier offering a health plan in this State may not impose on any provider any retrospective denial of a previously paid claim or any part of that previously paid claim unless the carrier has provided the reason for the retrospective denial in writing to the provider and the time that has elapsed since the date of payment of the previously paid claim does not exceed 12 months.
11.
(REALLOCATED FROM T. 24-A, §4303, sub-§9) Absolute discretion clauses.
The use and enforcement of an absolute discretion clause is governed by this subsection.
12.
Publication of policies by carriers.
A carrier must publish at least 5 individual health plans with the highest level of enrollment and at least 5 small group health plans with the highest level of enrollment on the carrier’s publicly accessible website in a manner that will allow consumers to review the coverage offered under each policy. The policies posted on the website must be updated when changes are made to the policies by the carrier. The appearance of the policy on the website must duplicate the appearance of a paper copy of the policy. The bureau shall provide a link from its website to each carrier’s website. A carrier must review annually which policies to post and make any necessary changes on its website. A carrier must post the required policies on its website within 90 days after the effective date of this subsection.
13.
Explanation of benefits.
A carrier offering an individual expense-incurred health plan to residents of this State or an expense-incurred group health plan to an employer in this State shall provide individual policyholders and group certificate holders with clear written explanations of benefit documents in response to the filing of any claim providing for coverage of hospital or medical expenses. The explanation of benefits must include all of the following information:
14.
Policy terms.
The superintendent may by rule define standard policy terms that must be used in all policies issued by carriers offering health plans in the State. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A.
15.
Uniform explanation of coverage documents and standardized definitions.
A carrier offering a health plan in this State shall:
16.
Language and culture.
All notices to applicants, enrollees and policyholders or certificate holders subject to the requirements of the federal Affordable Care Act must be provided in a culturally and linguistically appropriate manner consistent with the requirements of the federal Affordable Care Act.
17.
(REALLOCATED FROM T. 24-A, §4303, sub-§15) Prohibition on "most favored nation" clauses.
Participation agreements between carriers and providers are governed by this subsection.
18.
Provider contract requirements.
A carrier offering a health plan must meet the requirements of this subsection with respect to a contract offered by the carrier to a provider, including a contract offered through a preferred provider arrangement, as defined in section 2671, subsection 7. This subsection does not apply to dental or vision plans.
19.
Information about provider networks.
A carrier offering a managed care plan shall prominently disclose to applicants, prospective enrollees and enrollees information about the carrier's provider network for the applicable managed care plan, including whether there are hospitals, health care facilities, physicians or other providers not included in the plan's network and any differences in an enrollee's financial responsibilities for payment of covered services to a participating provider and to a provider not included in a provider network. The superintendent may adopt rules that set forth the manner, content and required disclosure of the information in accordance with this subsection. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A.
20.
Information about prescription drugs.
Consistent with the requirements of the federal Affordable Care Act, a carrier offering a health plan in this State shall provide the following information to prospective enrollees and enrollees with respect to prescription drug coverage on its publicly accessible website.
21.
Health care price transparency tools.
Beginning January 1, 2018, a carrier offering a health plan in this State shall comply with the following requirements.
22.
Denial of referral by out-of-network provider prohibited.
Beginning January 1, 2018, a carrier may not deny payment for any health care service covered under an enrollee's health plan based solely on the basis that the enrollee's referral was made by a direct health care provider who is not a member of the carrier's provider network. A carrier may not apply a deductible, coinsurance or copayment greater than the applicable deductible, coinsurance or copayment that would apply to the same health care service if the service was referred by a participating primary care provider. A carrier may require a direct health care provider making a referral who is not a member of the carrier's provider network to provide information demonstrating that the provider is a direct health care provider through a written attestation or copy of a direct health care service agreement with an enrollee and may request additional information necessary to implement this subsection. As used in this subsection, "direct health care provider" has the same meaning as in Title 22, section 1771, subsection 1, paragraph B.
22-A.
Denial of referral during urgent care visit prohibited.
A carrier may not deny payment for any behavioral health care service or physical therapy service covered under an enrollee's health plan based solely on the basis that the enrollee's referral was not made by the enrollee's primary care provider as long as the enrollee's referral is made by a provider during an urgent care visit and the provider notifies the enrollee’s primary care provider of the referral. A carrier may not apply a deductible, coinsurance or copayment greater than the applicable deductible, coinsurance or copayment that would apply to the same health care service if the service was referred by the enrollee's primary care provider. A carrier may require a provider of urgent care that is making a referral to provide additional information necessary to implement this subsection.
23.
Duplicative or incorrect claims payments.
If a carrier has made a duplicative or incorrect payment on a claim with respect to a health plan:
24.
Practice or facility-wide prepayment review of providers.
A practice or facility-wide prepayment review of the documentation or records of a provider conducted by a carrier for the purposes of identifying fraud, waste or abuse, determining whether the documentation is appropriate or adequate to support a claim for covered health care services or determining whether health care services are or were medically necessary health care as a condition of payment must be conducted in accordance with the following requirements.
25.
Second opinion.
An enrollee in a health plan may not be required to obtain a 2nd opinion from a provider that practices in the same office location as the enrollee's provider. Notwithstanding any provision of this Title to the contrary, if the 2nd opinion is obtained from an out-of-network provider because a network provider is not available in accordance with section 4303, subsection 1 and Bureau of Insurance Rule Chapter 850: Health Plan Accountability, a carrier may not apply a deductible, coinsurance or copayment for the 2nd opinion in an amount greater than the deductible, coinsurance or copayment that would apply to the same health care service if the service were obtained from a network provider, and the amount of any coinsurance or copayment must be applied to the enrollee's in-network deductible.
26.
(REALLOCATED FROM T. 24-A, §4303, sub-§25) Disclosure to enrollees of cash price.
A carrier may not prohibit a provider from providing an enrollee with the option of paying the provider's discounted cash price for health care services. For the purposes of this subsection, "discounted cash price" means:

Legislative History

PL 1995, c. 673, Pt. C, §1 (NEW). PL 1995, c. 673, Pt. C, §2 (AFF). PL 1997, c. 163, §§1, 2 (AMD). PL 1999, c. 396, §5 (AMD). PL 1999, c. 396, §7 (AFF). PL 1999, c. 742, §§6-10 (AMD). PL 2001, c. 288, §5 (AMD). PL 2001, c. 410, Pt. B, §5 (AMD). RR 2003, c. 1, §21 (COR). PL 2003, c. 108, §1 (AMD). PL 2003, c. 110, §1 (AMD). PL 2003, c. 218, §9 (AMD). PL 2003, c. 309, §1 (AMD). PL 2003, c. 469, Pt. E, §20 (AMD). PL 2003, c. 689, Pt. B, §6 (REV). PL 2007, c. 106, §1 (AMD). PL 2007, c. 199, Pt. B, §§4-11 (AMD). PL 2009, c. 357, §1 (AMD). PL 2009, c. 439, Pt. A, §§3-5 (AMD). PL 2009, c. 439, Pt. F, §1 (AMD). PL 2009, c. 652, Pt. A, §33 (AMD). RR 2011, c. 1, §§41, 42 (COR). PL 2011, c. 90, Pt. F, §7 (AMD). PL 2011, c. 238, Pt. A, §1 (AMD). PL 2011, c. 270, §1 (AMD). PL 2011, c. 364, §§25-27 (AMD). PL 2011, c. 451, §1 (AMD). PL 2011, c. 451, §2 (AFF). PL 2013, c. 383, §4 (AMD). PL 2013, c. 399, §1 (AMD). PL 2013, c. 535, §1 (AMD). PL 2015, c. 84, §§1, 2 (AMD). PL 2015, c. 260, §1 (AMD). PL 2017, c. 232, §§6, 7 (AMD). PL 2019, c. 5, Pt. A, §20 (AMD). PL 2019, c. 30, §1 (AMD). PL 2019, c. 178, §1 (AMD). PL 2021, c. 79, §5 (AMD). PL 2021, c. 79, §6 (AFF). PL 2021, c. 272, §1 (AMD). PL 2021, c. 272, §2 (AFF). PL 2021, c. 311, §1 (AMD). PL 2021, c. 311, §2 (AFF). PL 2021, c. 603, Pt. B, §1 (AMD). PL 2023, c. 80, §2 (AMD). PL 2023, c. 80, §3 (AFF). PL 2023, c. 119, §3 (AMD). PL 2023, c. 119, §4 (AFF). PL 2023, c. 348, §1 (AMD). PL 2023, c. 348, §2 (AFF). PL 2023, c. 382, §1 (AMD). RR 2023, c. 1, Pt. A, §22 (COR). PL 2023, c. 574, §§1, 2 (AMD). PL 2023, c. 584, Pt. A, §5 (AMD). PL 2023, c. 648, Pt. E, §§8-10 (AMD). PL 2023, c. 680, Pt. A, §3 (AMD). PL 2023, c. 680, Pt. A, §10 (AFF). RR 2023, c. 2, Pt. A, §37 (COR). PL 2025, c. 295, §1 (AMD). PL 2025, c. 358, §3 (AMD).