Prohibited practices; definition

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20-1061.  Prohibited practices; definition

A.  Chapter 2, article 6 of this title relating to unfair trade practices and frauds applies to health care services organizations, except to the extent the director determines that the nature of health care services organizations renders particular provisions inappropriate.

B.   A person subject to this article shall not:

1.  Restrict or prohibit, by means of a policy or contract, whether written or otherwise, a licensed health care professional's good faith communication with the health care professional's patient concerning the patient's health care or medical needs, treatment options, health care risks or benefits.

2.  Terminate a contract with or refuse to renew a contract with a health care professional solely because the professional in good faith does any of the following:

(a)  Advocates in private or in public on behalf of a patient.

(b)  Assists a patient in seeking reconsideration of a decision made by the person to deny coverage for a health care service.

(c)  Reports a violation of law to an appropriate authority.

C.  A contract between the health care services organization and a health care professional shall not contain a financial incentive plan that includes a specific payment made to or withheld from the health care professional as an inducement to deny, reduce, limit or delay medically necessary care that is covered by the evidence of coverage with an enrollee or group of enrollees for a specific disease or condition. This section does not prohibit per diem or per case payments, diagnostic related grouping payments, or financial incentive plans, including capitation payments or shared risk arrangements, that are not connected to specific medical decisions relating to an enrollee or a group of enrollees for a specific disease or condition. Each health care services organization shall file with its annual report a written statement with the director that certifies that the health care services organization is in compliance with this subsection.

D.  Unless preempted under federal law or unless federal law imposes greater requirements than this section, this section applies to a provider sponsored health care services organization.

E.  For the purposes of this section, "health care professional" has the same meaning prescribed in section 20 3151.

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