Section 4305 - Quality of careA carrier offering or renewing a health plan that subjects payment of benefits for otherwise covered services to review for clinical necessity, appropriateness, efficacy or efficiency must meet the following requirements relating to quality of care. [2007, c. 199, Pt. B, §14(AMD).]
1.Internal quality assurance program. A health plan must have an ongoing quality assurance program for the health care services provided or reimbursed by the health plan. [1995, c. 673, §1(NEW); 1995, c. 673, §2(AFF).]
2.Written standards. The standards of quality of care must be described in a written document, which must be available for examination by the superintendent or by the Department of Health and Human Services. [1995, c. 673, §1(NEW); 1995, c. 673, §2(AFF); 2003, c. 689, Pt. B, §6(REV).]
3.Coverage decisions. Following a determination that a particular service is covered, a carrier may not deny payment for that service based on the enrollee's age, nature of disability or degree of medical dependency. [1995, c. 673, §1(NEW); 1995, c. 673, §2(AFF).]
1995, c. 673, §C1 (NEW) . 1995, c. 673, §C2 (AFF) . 1999, c. 742, § 14 (AMD) . 2003, c. 689, §B6 (REV) . 2007, c. 199, Pt. B, §14 (AMD) .