Kansas Statutes 40-3230. Continuity of treatment upon termination of provider from plan
Terms Used In Kansas Statutes 40-3230
- Certificate of coverage: means a statement of the essential features and services of the health maintenance organization coverage which is given to the subscriber by the health maintenance organization, medicare provider organization or by the group contract holder. See Kansas Statutes 40-3202
- Contract: A legal written agreement that becomes binding when signed.
- Copayment: means an amount an enrollee must pay in order to receive a specific service which is not fully prepaid. See Kansas Statutes 40-3202
- Disability: means an injury or illness that results in a substantial physical or mental limitation in one or more major life activities such as working or independent activities of daily living that a person was able to do prior to the injury or illness. See Kansas Statutes 40-3202
- Enrollee: means a person who has entered into a contractual arrangement or on whose behalf a contractual arrangement has been entered into with a health maintenance organization or the medicare provider organization for health care services. See Kansas Statutes 40-3202
- Health maintenance organization: means an organization which:
(1) Provides or otherwise makes available to enrollees health care services, including at a minimum those basic health care services which are determined by the commissioner to be generally available on an insured or prepaid basis in the geographic area served;
(2) is compensated, except for reasonable copayments, for the provision of basic health care services to enrollees solely on a predetermined periodic rate basis;
(3) provides physician services directly through physicians who are either employees or partners of such organization or under arrangements with a physician or any group of physicians or under arrangements as an independent contractor with a physician or any group of physicians;
(4) is responsible for the availability, accessibility and quality of the health care services provided or made available. See Kansas Statutes 40-3202
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Provider: means any physician, hospital or other person which is licensed or otherwise authorized in this state to furnish health care services. See Kansas Statutes 40-3202
A health maintenance organization shall establish reasonable procedures for assuring a transition of enrollees to physicians or health care providers and for continuity of treatment, including providing immediate notice to the enrollee and making available to the enrollee a current listing of preferred providers, in the event a provider‘s participation in the plan is terminated for any reason. The plan shall include provisions for the continuation of care to enrollees for a period up to 90 days by a provider who is terminated from a network in those cases where the continuation of such care is medically necessary and in accordance with the dictates of medical prudence and where the enrollee has special circumstances such as a disability, a life threatening illness or is in the third trimester of pregnancy. The provisions for the continuation of care shall include guarantees that the enrollee will not be liable to the provider for any amounts owed for medical care other than any deductibles or copayment amounts specified in the certificate of coverage or other contract between the enrollee and the health maintenance organization. In the event the terminated provider is authorized to continue treating the enrollee pursuant to this subsection, the health maintenance organization shall have an obligation to pay the terminated provider at the previously contracted rate for services provided to the enrollee.