Provider Contract Requirements. Health carriers must file all provider contracts and provider compensation agreements with the Office of the Insurance Commissioner (OIC) 30 calendar days before use.  When a carrier and provider negotiate an agreement that deviates from a filed agreement, the specific contract must be filed 30 days prior to use.  Any provider compensation agreements not affirmatively disapproved by OIC are deemed approved, except OIC may extend the approval date an additional 15 days with notice before the initial 30-day period expires.  Changes to the previously filed agreements that modify the compensation or related terms must be filed and are deemed approved upon filing if no other changes are made to the previously approved agreement.  OIC may not base a disapproval of the agreement on the amount of the compensation or other financial arrangements between the carrier and provider, unless the compensation amount causes the underlying health benefit plan to be in violation of state or federal law.

A health carrier and contracting health care provider must provide at least 60 days' written notice to each other before terminating the contract without cause. Whether the termination was for cause, or without cause, the carrier must make a good faith effort to ensure written notice of a termination is provided at least 30 days before the effective date of the termination, or immediately for a termination for cause that results in less than 30 days notice, to all enrollees who are patients seen on a regular basis by a specialist, by a provider for whom they have a standing referral; or by a primary care provider. OIC must approve the notices sent by carriers to enrollees.

Federal No Surprises Act Continuity of Care Requirements. Under the federal No Surprises Act, if a provider or facility ceases to be an in-network provider because of a contract termination, certain continuity of care protections apply to an individual who meets the definition of a continuing care patient. For the continuing care patient whose provider's or facility's contract termination leads to a change in network status, the carrier must:

• timely notify each continuing care patient of the termination and their right to elect continued transitional care from the provider or facility;
• provide each continuing care patient an opportunity to notify the carrier of the need for transitional care; and
• permit the continuing care patient to elect to continue to have the same benefits provided, under the same terms and conditions as would have applied under the plan or coverage had the termination not occurred, with respect to the course of treatment furnished by the provider or facility.

Continuing care patients are defined as individuals who, with respect to a provider or facility, are: 

• undergoing treatment from the provider or facility for a serious and complex condition;
• undergoing a course of institutional or inpatient care from the provider or facility;
• scheduled to undergo nonelective surgery from the provider or facility, including postoperative care from such provider or facility with respect to such a surgery;
• pregnant and undergoing treatment for pregnancy from the provider or facility; or
• terminally ill and receiving treatment for such illness from the provider or facility.

The continued care election may last until the earlier of 90 days or the date on which such individual is no longer a continuing care patient with the provider or facility. A continuing care patient's treating provider or health care facility must accept payment from the carrier and cost sharing from the individual for items and services as payment in full; and continue to adhere to all policies, procedures, and quality standards imposed by the carrier for an individual as if the termination had not occurred.

Health Profession's Discipline. The Uniform Disciplinary Act (UDA) governs health professionals credentialed by the Department of Health (DOH) or one of the health professions' boards or commissions, such as the Medical Commission. Depending on the profession, the disciplining authority may be the Secretary of Health or a board or commission. Under the UDA, a disciplining authority may take action against a license holder for a variety of reasons, including misrepresentation or fraud, unlicensed practice, and the mental or physical inability to practice skillfully or safely. A disciplining authority may initiate disciplinary action after receiving a complaint or if the disciplining authority has reason to believe that the licensee engaged in unprofessional conduct.

Among other acts and conditions, unprofessional conduct is defined under the UDA to include suspension, revocation, or restriction of an individual's license to practice any health care profession in any jurisdiction; violation of any state or federal statute or administrative rule regulating the profession in question; and violations of rules established by any health agency. 

When a contract between a health carrier and a health care provider is expiring by its own terms or for which one party has given notice to the other party of an intended termination without cause in accordance with the terms of the contract, neither the provider, nor the carrier may make or cause to be made public statements, including by directly communicating with impacted individuals, including enrollees and patients, regarding such expiration or termination until 45 days before the termination date, unless:

• such disclosure is to satisfy a legal obligation; or
• the expiration or termination has already been disclosed publicly because of a legal obligation.

Communications exclusively with the Governor, legislators, or state agency staff regarding a potential or intended contract termination does not constitute a public statement. A provider contract expiring or being terminated by an independent individual provider or an independent specialty group practice of five or fewer providers, whether due to a provider's retirement or some other reason, is not subject to the public statement prohibitions.

Public statements and communications with enrollees or patients may not occur before the carrier, facility, or provider gives written notice of the termination to the other party, unless agreed upon by the parties.

By December 1, 2025, OIC, in consultation with health carriers, health care providers, health care facilities, and consumers, must develop standard template language for such notices, which must be posted on OIC's website. The language in the templates, at a minimum, must make reference to the specific facility or facilities by name that would be affected by the potential contract termination or expiration and an indication of whether the potential termination or expiration would apply to hospital-based providers, provide direction to enrollees related to appointments that are scheduled past the date of the potential contract termination or expiration date, and provide information concerning the enrollee's continuity of care rights pursuant to the federal No Surprises Act.

Notices sent to enrollees or patients that solely utilize the template language developed pursuant to this section are not subject to review or approval. Notices that alter or do not use the template language in full must be reviewed and approved by OIC before use.

By January 1, 2027, these requirements must be included in all provider contracts. The insurance commissioner must develop template language for inclusion in provider contracts by rule.

OIC may enforce the requirements related to carriers on or after January 1, 2026. In addition to OIC's existing enforcement authority, OIC may impose a civil penalty up to $100 for each day that a notice has been sent to enrollees in advance of the 45-day period for each enrollee to whom the notice has been sent. If OIC has cause to believe that any provider or facility has violated these requirements, OIC may submit information to DOH, another appropriate health care facility licensing entity, or the appropriate disciplining authority for action. Prior to submitting information to DOH, another appropriate health care facility licensing entity, or a disciplining authority, OIC may provide the facility or provider an opportunity to explain why the actions in question did not violate the prohibitions. DOH, another appropriate health care facility licensing entity, or appropriate disciplining authority may levy a fine or cost recovery upon a provider or facility that has engaged in a pattern of unresolved violations and must notify OIC of the results of any review and enforcement actions taken against a provider or facility. Violation of the notice provisions by a health care provider constitutes unprofessional conduct for purposes of the UDA.