33-20E-24. Access to contracted healthcare; assessing coverage; limitations on insurer’s authority; regulation.

The requirements of this Code section shall not apply to a health maintenance organization, as defined in Code Section 33-21-1, possessing a valid certificate of authority obtained in accordance with Code Section 33-21-2.#

1. (1)

   An insurer providing a network plan shall contract with and maintain a network of participating providers in sufficient number and appropriate type, including primary care and specialty care, pharmacies, clinical laboratories, and facilities, throughout such plan’s service area to ensure covered persons have access to the full scope of benefits and services covered under such plan.#

2. (2)

   An insurer providing coverage for mental health or substance use disorders as part of a network plan shall contract with and maintain a network of participating providers that specialize in mental health and substance use disorder services in sufficient number and appropriate type throughout such plan’s service area to ensure covered persons have access to the full scope of mental health and substance use disorder benefits and services covered under such plan.#

The Commissioner shall determine and may further assess the adequacy and breadth of a network plan using appropriate qualitative and quantitative criteria, which may include but are not limited to federal rules and regulations for network plans promulgated annually by the Center for Consumer Information and Insurance Oversight in the Notice of Benefit and Payment Parameters issued to qualified health plans, the ability of the network to meet the needs of all covered persons, the availability of participating providers that are within a reasonable time and distance to covered persons and accepting patients, appointment wait times, and the availability of other healthcare service delivery system options.#

An insurer shall not deny preauthorization for healthcare services to be performed by a participating provider solely because the covered person’s referral to such provider was made by a nonparticipating provider.#

An insurer shall not:#

1. (1)

   Require prior authorization, medical review, or administrative clearance for a telehealth service that would not be required if such service were provided in person;#

2. (2)

   Require demonstration that it is necessary to provide a service to a covered person through telehealth;#

3. (3)

   Require a provider to be employed by another provider or agency in order to provide a telehealth service that would not be required if such service were provided in person;#

4. (4)

   Restrict or deny coverage of a telehealth service based solely on the communication technology or application used to deliver such service;#

5. (5)

   Require a provider to be part of a telehealth network;#

6. (6)

   Require a covered person to utilize telehealth or telemedicine in lieu of a nonparticipating provider accessible for in-person consultation or contact; or#

7. (7)

   Be required to pay a facility fee to a hospital for telehealth services unless the hospital is the originating site as defined in subsection (b) of Code Section 33-24-56.4.#

The Commissioner shall adopt rules and regulations to implement and administer this Code section.#