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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 referral of insured to specialists under certain conditions; exceptions to requirements. (a) A health insurer providing a health benefit plan shall maintain a provider network that is sufficient in numbers and types of providers to assure that all covered services to an insured will be accessible without unreasonable delay. Sufficiency of the provider network shall be determined in accordance with the requirements of this section, and may be established by reference to any reasonable criteria used by the health insurer, including but not limited to: provider-insured ratios by specialty; primary care provider-insured ratios; geographic accessibility; waiting times for appointments with participating providers; hours of operation; and the availability of technological and specialty services to serve the needs of insureds requiring technologically advanced or specialty care.

(b) A health insurer shall have a plan by which an insured with a life-threatening, chronic, degenerative or disabling condition or disease, which requires specialized medical care over a prolonged period of time, may receive a referral to a specialist with expertise in treating such disease or condition who shall be responsible for and capable of providing and coordinating the insured's specialty care.

(c) Nothing in this section shall require a health insurer to provide benefits not otherwise covered by the terms of the health benefits plan.

(d) A provider network shall not be determined to be insufficient for failure to contract with any provider unwilling to contract under the same terms and conditions, including reimbursement levels, as such health insurer offers to other similarly situated health care providers.

History: L. 1997, ch. 190, ยง 22; July 1.


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