State Law Contracting Links and Online Resources

ARIZONA

• Ariz. Rev. Stat. Ann. § 36-596 (Coordination of benefits)

• Ariz. Rev. Stat. Ann. § 36-2959 (Reimbursement rates; capitation rates; annual review)

• Ariz. Rev. Stat. Ann. § 23-1062.01 (Timely payment of medical, surgical and hospital benefit billing; content of bills; contracts between providers and carriers; exceptions; definitions)

• Ariz. Rev. Stat. Ann. § 36-2906 (Qualified plan health services contracts; proposals; administration)

• Ariz. Rev. Stat. Ann. § 32-3216 (Health care providers; charges; public availability; direct payment; notice; definitions)

• Ariz. Rev. Stat. Ann. § 20-3102 (Timely payment of health care providers' claims; grievances)

• Ariz. Rev. Stat. Ann. § 36-2943 (Provider subcontracts; hospital reimbursement)

CALIFORNIA

• Cal. Health & Safety Code § 1348.6 (Proscriptions on Payment to Health Care Practitioner to Deny, Limit, or Delay Services)

• Cal. Health & Safety Code § 1375.5 (Contract Provision Requiring Risk-Bearing Organization to be at Financial Risk for Provision of Health Care Services)

• Knox-Keene Health Care Service Plan Act of 1975

• Cal. Health & Safety Code § 1375.6 (Contract Provision Requiring Provider to Accept Certain Rates or Methods of Payment)

• Cal. Health & Safety Code § 1375.7 (Health Care Providers’ Bill of Rights)

• Cal. Health & Safety Code § 1379 (Contracts; Necessity of Writing; Liability for Plan’s Debts; Actions)

• Cal. Health & Safety Code § 1379.5 (Contract Between Plan and Health Care Provider who Provides Health Care Services in Mexico; Requirements; Plan’s obligations)

• Cal. Health & Safety Code § 1395 (Advertising, Contracts with Licensed Professionals, Offices; Misrepresentation by Plan, Compliance by Plan)

• Cal. Health & Safety Code § 1395.5 (Contract to Restrict Health Care Provider’s Advertising)

• Cal. Code Regs. tit. 28, § 1300.67.8 (Contracts with Providers)

• Cal. Code Regs. tit. 28, § 1300.51 (Section K (Contracts with providers) of the Revised Health Care Service Plan Application Form)

• Medi-Cal Managed Care Boilerplate Contracts

COLORADO

• Colo. Rev. Stat. § 25-37-101, et seq. (Contracts with Health Care Providers)

CONNECTICUT

General Statutes of Connecticut, Chapter 700C, Health Insurance:

• Sec. 38a-226a – 226d (Utilization review)

• Sec. 38a-478f (Provider profile development requirements)

• Sec. 38a-478g (Managed Care Contract Requirements; Plan Description Requirements)

• Sec. 38a-478h (Removal of providers. Notice requirements. Retaliatory action prohibited)

• Sec. 38a-478k (Gag clauses prohibited)

• Sec. 38a-478l (Consumer report card required. Content)

• Sec. 38a-478m (Internal grievance procedure) –repealed eff. July 1, 2011

• Sec. 38a-478n (Exhaustion of internal appeal mechanisms. External appeal to commissioner) – repealed eff. July 1, 2011

• Sec. 38a-478p (Expedited utilization review. Standardized process required) – repealed eff. July 1, 2011

• Sec. 38a-478q (Use of laboratories covered by plan required)

• Sec. 38a-479b (Material changes to fee schedules. Return of payment by provider. Appeals. Filing of claim by provider under other applicable insurance coverage)

• Sec. 38a-479aa (Preferred provider networks)

• Sec. 38a-479bb (Requirements for managed care organizations that contract with preferred provider networks. Requirements for preferred provider networks)

• Sec. 38a-479cc (Duties of a preferred provider network when providing services pursuant to a contract with a managed care organization)

• Sec. 38a-479ff (Adverse action or threat of adverse action against complainant prohibited)

DELAWARE

• 18 Del. Code Regs. 1300 (Health Insurance General Provisions)

• 18 Del. Code Regs.§ 1301 (Internal Review and Independent Utilization Review of Health Insurance Claims)

• 18 Del. Code Regs. § 1310 (Standards for Prompt, Fair and Equitable Settlement of Claims for Health Care Services)

• 18 Del. Code Regs. § 1313 (Arbitration of Health Insurance Disputes Between Carriers and Providers)

• 18 Del Code Regs. 1400 (Health Insurance Specific Provisions)

• 18 Del. Code Regs. § 1403 (Managed Care Organizations)

FLORIDA

• Fla. Stat. §641.234 (Administrative, provider, and management contracts)

• Fla. Stat. § 641.2342 (Contract Providers)

• Fla. Stat. § 641.315 (Provider Contracts)

• Fla. Stat. §641.3154 (Organization liability; provider billing prohibited)

• Fla. Stat. § 641.3155 (Prompt payment of claims)

• Fla. Stat. § 641.3156 (Treatment authorization; payment of claims)

• Fla. Stat. § 641.316 (Fiscal Intermediary Services)

• Florida State Medicaid Model Contract

GEORGIA

• Managed Health Care Plans Act, O.C.G.A. § 33-20A-60 (Definitions)

• Managed Health Care Plans Act, O.C.G.A. § 33-20A-61 (Physician Contracts)

• Managed Health Care Plans Act, O.C.G.A. § 33-20A-62 (Payment)

• O.C.G.A. § 33-21-9, Health Maintenance Organizations (Establishment and Maintenance of Complaint System)

• O.C.G.A § 33-21A-1(Medicaid Care Management Organizations Act)

• O.C.G.A. § 33-21A-7 (Bundling of Provider Complaint and Appeals)

• O.C.G.A. § 33-21A-9 (Submission and Payment of Claims)

• O.C.G.A. § 49-4-153 (Administrative hearings and appeals for appeals and grievances)

• O.G.C.A. § 33-24-59.5 (Timely Payment of Health Benefits)

• Medicaid Care Management Organization Contract with the Georgia Department of Community

HAWAII

• Haw. Rev. Stat. 432E (Patients’ Bill of Rights and Responsibilities Act)

• Haw. Rev. Stat. 432E (Health Maintenance Organization Act)

• Haw. Rev. Stat. 334B (Utilization Review and Managed Care of Mental Health, Alcohol, or Drug Abuse Treatment)

ILLINOIS

• 215 Ill. Comp. Stat. 125/2-8 (Provider Agreements)

• 215 Ill. Comp. Stat. 125 (Health Maintenance Organization Act)

• 215 Ill. Comp. Stat. 180 (Health Carrier External Review Act)

• 50 ILAC § 5420 (Managed Care Reform & Patient Rights)

• 50 ILAC § 5421.50 (Contracts, Administrative Arrangements And Material Modifications)

KENTUCKY

• Ky. Rev. Stat. § 304.17A-527 (Filing of Provider Agreements, Risk-Sharing Arrangements, and Subcontract Agreements with Commissioner -- Contents -- Disclosure of Financial information not required)

• Ky. Rev. Stat. § 304.17A-560 (Most Favored Nation Provision)

• Ky. Rev. Stat. § 304.17A-577 (Disclosure of Payment of Fee Schedule to Manage Care Plan Health Care Provider)

• Ky. Rev. Stat. § 304.17A-600 et seq. (Definitions for KRS 304.17A-600 to 304.17A-633, Utilization Review)

• Ky. Rev. Stat. § 304.17A-700 to 304.17A-730 (Payment of Claims)

• 806 Ky. Admin. Regs. 17:300 (Provider agreement and risk-sharing agreement filing requirements)

• Kentucky Medicaid Managed Care Contract

MARYLAND

• Md. Code Ann., Ins. § 19-701 et seq (Title on Health Maintenance Organizations, including § 19-710. Certificate qualifications to qualify as HMO § 19-712. Powers and duties of health maintenance organization; § 19-713.2. Administrative service provider contract plans; § 19713.3. Registration of contracting provider)

• Md. Code Ann., Ins. § 15-112 (Powers and duties of carriers relating to provider panels)

• Md. Code Ann., Ins. § 15-112.2 (Restrictions relating to provider contracts and provider panels)

• Md. Code Ann., Ins. § 15-115 (Providers choosing not to participate in managed care organization)

• Md. Code Ann., Ins. § 15-121 (Reimbursement methodology or methodologies used to reimburse physicians for health care services)

MASSACHUSETTS

• 176G MGL (Health Maintenance Organizations (HMOs)

• 176I MGL (Preferred Provider Arrangements)

• 176O MGL (Health Insurance Consumer Protections)

• 176T MGL (Risk-Bearing Provider Organization)

• 211 CMR 43.00 (Health Maintenance Organizations (HMOs))

• 211 CMR 152.05 (Provider Contracts in Limited, Regional and Tiered Provider Network Plans)

• 211 CMR 155.00 (Risk-Bearing Provider Organizations)

• 211 CMR 52.00 (Managed Care Consumer Protections and Accreditation of Carriers)

• Managed Care Provider Contracts Checklist. See also Mass.gov website for Consumer Affairs and Business Regulation for other Checklists for Managed Care (located towards bottom of web page).

• Bulletin 2012-01(Reporting to the Bureau of Managed Care (the “Bureau”) of Instances Where Insurance Carriers Are Not Consistent with Required Uniform Coding and Billing Standards; Issued 01/25/12 )

• Bulletin 2014-10 (Changes to Massachusetts General Laws Chapter 6D §16 and Chapter 176O §§ 12 and 16 Affecting Disclosure of Medical Necessity Criteria; Issued 11/4/14 )

• Bulletin 2014-05 (Guidelines on Submitting Filing Materials Relative to the Certification of Risk-Bearing Provider Organizations Under Chapter 176T of the General Laws and 211 CMR 155.00; Issued August 15, 2014

• Bulletin 2014-01 (Revised Transitional Rules for Carriers and Provider Organizations Relative to the Certification of Risk-Bearing Provider Organizations - Extended Transition Period; Issued January 17, 2014)

• Bulletin 2015-05 (Access to Services to Treat Substance Use Disorders; Issued July 31, 2015)

• Bulletin 2015-08 (Using Standard Prior Authorization Forms when Reviewing Requests for Behavioral Health Services; Issued November 3, 2015)

• Bulletin 2016-02 (Requirements for Carriers Issuing Written Notices of Adverse Determinations; Issued 1/19/16 )

MICHIGAN

• Mich. Comp. Laws Ann. § 500.3501, et seq. (Health Maintenance Organizations)

• Mich. Comp. Laws Ann. § 550.1201, et seq. (Nonprofit Health Care Corporation Reform Act)

NEW JERSEY

• N.J. Stat. Ann. § 26:2J-2, et seq. (Health Maintenance Organizations)

• N.J. Stat. Ann. § 17:48F-13 (Contracts with providers or subcontracts for services; mandatory provisions)

• N.J. Stat. Ann. § 17:48H-18 (Licensed systems; contract requirements)

• N.J. Stat. Ann. § 26:2S-9 (Contracts between providers and managed care carriers; contents)

NEVADA

• Nev. Rev. Stat. Ann. § 616B.527, et seq. (Organizations for Managed Care)

• Chapter 616B under Nev. Rev. Stat. Ann. addresses a variety of insurance matters.

NEW YORK

• N.Y. Public Health Law §4400 (Health Maintenance Organizations)

• N.Y. Public Health Law §4900 (Utilization Review)

• N.Y. Insurance Law §3224-a (Standards for Prompt, Fair and Equitable Settlement of Claims for Health Care and Payments for Health Care Services)

• N.Y. Insurance Law § 3224-b (Rules Relating to the Processing of Health Claims and Overpayments)

• N.Y. Insurance Law § 3238 (Pre-Authorization of Health Care Services)

• 10 N.Y.C.R.R. Part 98 (Health Maintenance Organizations)

• New York State Department of Health, Provider Contract Guidelines for MCOs and IPAs

• New York Medicaid Model Contracts

NORTH CAROLINA

• G.S. § 28-3-200 (Miscellaneous Insurance and Managed Care Coverage and Network Provisions)

• G.S. § 58-3-225 (Prompt Claim Payments under Health Benefit Plans)

• G.S. § 58-3-265 (Prohibition on Managed Care Provider Incentives)

• G.S. § 58-67 (Health Maintenance Organization Act)

North Carolina Administrative Code, Requirements for Network Plan Carriers:

• 11 N.C. Admin. Code § 20.0101 (Managed Care Definitions)

• 11 N.C. Admin. Code § 20.0201 (Written Contracts)

• 11 N.C. Admin. Code § 20.0202 (Contract Provisions)

• 11 N.C. Admin. Code § 20.0204 (Carrier and Intermediary Contracts)

• 11 N.C. Admin. Code § 20.0205 (Filing Requirements)

• Provider Networks/Managed Care Form & Rate Filings – Contracts

OHIO

• Ohio Rev. Code § 1751.13 (Contracts with Providers and Health Care Facilities)

• Ohio Rev. Code § 3963.01 – 3963.03 (Health Care Contracts, Information Required in Contracts)

• Ohio Admin. Code §5160-26-01 to 5160-26-12 (Medicaid Managed Care)

• Ohio Admin. Code §5160-26-05 (Managed Health Care Programs; Provider Panel and Subcontracting Requirements)

• Model Medicaid Addenda

PENNSYLVANIA

• 40 Pa. Stat. Ann. § 1551, et seq. (Health Maintenance Organization Act)

• 40 Pa. Stat. Ann. § 991.2166 (Prompt payment of claims)

VIRGINIA

• Va. Code § 38.2-5805 (Provider Contracts)

TEXAS

• HMO Physician/Provider Contractual Requirements Checklist

• Tex. Ins. Code §§ 843.361, 843.281, 843.362, 843.306-843.309, 843.310; Chapter 843,

• Subchapter J (Prompt Payment of Claims & Submission of Clean Claims); 843.323 (Rejection of Batched Claims); 843-315 & 843.316 (Capitation); 843.311 (Requirements for Contracts with Podiatrists); 843.3115 (Requirements for Contracts with Dentists)

• Texas Constitution and Statutes

• 28 TAC § 11.901 (Texas Administrative Code Rules Regarding HMO Contracting Arrangements)

• 28 TAC §§ 3.3701-3.3725 (Texas Preferred and Exclusive Provider Benefit Plans)

• Texas Workers Compensation Network Provider Information

• Texas Workers Compensation Provider Contract Requirements and Information

• Texas Health and Human Services – Vendor and Contract Information

• Texas Health and Human Services (Medicaid) Contractual Requirements

• HHSC Provider Contract Requirements Checklist

• Texas Health and Human Services – Texas Medicaid and CHIP Uniform Managed Care Manual – Chapter 4: Marketing Policies and Procedures

• Texas HHSC Uniform Managed Care Terms & Conditions