§ 4804 — Access to specialty care

§ 4804. Access to specialty care. (a) If an insurer offering a managed\ncare product determines that it does not have a health care provider in\nthe in-network benefits portion of its network with appropriate training\nand experience to meet the particular health care needs of an insured,\nthe insurer shall make a referral to an appropriate provider, pursuant\nto a treatment plan approved by the insurer in consultation with the\nprimary care provider, the non-participating provider and the insured or\nthe insured's designee, at no additional cost to the insured beyond what\nthe insured would otherwise pay for services received within the\nnetwork.\n (b) An insurer offering a managed care product shall have a procedure\nby which an insured enrolled in such managed care product who needs\nongoing care from a specialist may receive a standing referral to such\nspecialist. If the insurer, or the primary care provider in consultation\nwith the insurer and the specialist, determines that such a standing\nreferral is appropriate, the insurer shall make such a referral to a\nspecialist. In no event shall an insurer be required to permit an\ninsured to elect to have a non-participating specialist, except pursuant\nto the provisions of subsection (a) of this section. Such referral shall\nbe pursuant to a treatment plan approved by the insurer in consultation\nwith the primary care provider, the specialist, and the insured or the\ninsured's designee. Such treatment plan may limit the number of visits\nor the period during which such visits are authorized and may require\nthe specialist to provide the primary care provider with regular updates\non the specialty care provided, as well as all necessary medical\ninformation.\n (c) An insurer shall have a procedure by which a new insured upon\nenrollment in a managed care product, or an insured in a managed care\nproduct upon diagnosis, with (1) a life-threatening condition or disease\nor (2) a degenerative and disabling condition or disease, either of\nwhich requires specialized medical care over a prolonged period of time,\nmay receive a referral to a specialist with expertise in treating the\nlife-threatening or degenerative and disabling disease or condition who\nshall be responsible for and capable of providing and coordinating the\ninsured's primary and specialty care. If the insurer, or primary care\nprovider in consultation with the insurer and the specialist, if any,\ndetermines that the insured's care would most appropriately be\ncoordinated by such a specialist, the insurer shall refer the insured to\nsuch specialist. In no event shall an insurer be required to permit an\ninsured to elect to have a non-participating specialist, except pursuant\nto the provisions of subsection (a) of this section. Such referral shall\nbe pursuant to a treatment plan approved by the insurer, in consultation\nwith the primary care provider if appropriate, the specialist, and the\ninsured or the insured's designee. Such specialist shall be permitted to\ntreat the insured without a referral from the insured's primary care\nprovider and may authorize such referrals, procedures, tests and other\nmedical services as the insured's primary care provider would otherwise\nbe permitted to provide or authorize, subject to the terms of the\ntreatment plan. If an insurer refers an insured to a non-participating\nprovider, services provided pursuant to the approved treatment plan\nshall be provided at no additional cost to the insured beyond what the\ninsured would otherwise pay for services received within the network.\n (d) An insurer offering a managed care product shall have a procedure\nby which an insured enrolled in such managed care product with (1) a\nlife-threatening condition or disease or (2) a degenerative and\ndisabling condition or disease, either of which requires specialized\nmedical care over a prolonged period of time, may receive a referral to\na specialty care center with expertise in treating the life-threatening\nor degenerative and disabling disease or condition. If the insurer, or\nthe primary care provider or the specialist designated pursuant to\nsubsection (c) of this section, in consultation with the insurer,\ndetermines that the insured's care would most appropriately be provided\nby such a specialty care center, the insurer shall refer the insured to\nsuch center. In no event shall an insurer be required to permit an\ninsured to elect to have a non-participating speciality care center,\nunless the insurer does not have an appropriate specialty care center to\ntreat the insured's disease or condition within its network. Such\nreferral shall be pursuant to a treatment plan developed by the\nspecialty care center and approved by the insurer, in consultation with\nthe primary care provider, if any, or a specialist designated pursuant\nto subsection (c) of this section, and the insured or the insured's\ndesignee. If an insurer refers an insured to a specialty care center\nthat does not participate in the insurer's managed care provider\nnetwork, services provided pursuant to the approved treatment plan shall\nbe provided at no additional cost to the insured beyond what the insured\nwould otherwise pay for services received within the network. For\npurposes of this subsection, a specialty care center shall mean only\nsuch centers as are accredited or designated by an agency of the state\nor federal government or by a voluntary national health organization as\nhaving special expertise in treating the life-threatening disease or\ncondition or degenerative and disabling disease or condition for which\nit is accredited or designated.\n (e) (1) If an insured's health care provider leaves the insurer's\nin-network benefits portion of its network of providers for a managed\ncare product for reasons other than those for which the provider would\nnot be eligible to receive a hearing pursuant to paragraph one of\nsubsection (b) of section forty-eight hundred three of this chapter, the\ninsurer shall provide written notice to the insured of the provider's\ndisaffiliation and permit the insured to continue an ongoing course of\ntreatment with the insured's current health care provider during a\ntransitional period of: (A) ninety days from the later of the date of\nthe notice to the insured of the provider's disaffiliation from the\ninsurer's network or the effective date of the provider's disaffiliation\nfrom the insurer's network; or (B) if the insured is pregnant at the\ntime of the provider's disaffiliation, the duration of the pregnancy and\npost-partum care directly related to the delivery.\n (2) During the transitional period the health care provider shall: (A)\ncontinue to accept reimbursement from the insurer at the rates\napplicable prior to the start of the transitional period, and continue\nto accept the in-network cost-sharing from the insured, if any, as\npayment in full; (B) adhere to the insurer's quality assurance\nrequirements and provide to the insurer necessary medical information\nrelated to such care; and (C) otherwise adhere to the insurer's policies\nand procedures including, but not limited to, procedures regarding\nreferrals and obtaining pre-authorization and a treatment plan approved\nby the insurer.\n (f) If a new insured whose health care provider is not a member of the\ninsurer's in-network benefits portion of the provider network enrolls in\nthe managed care product, the insurer shall permit the insured to\ncontinue an ongoing course of treatment with the insured's current\nhealth care provider during a transitional period of up to sixty days\nfrom the effective date of enrollment, if (1) the insured has a\nlife-threatening disease or condition or a degenerative and disabling\ndisease or condition or (2) the insured has entered the second trimester\nof pregnancy at the time of enrollment, in which case the transitional\nperiod shall include the provision of post-partum care directly related\nto the delivery. If an insured elects to continue to receive care from\nsuch health care provider pursuant to this paragraph, such care shall be\nauthorized by the insurer for the transitional period only if the health\ncare provider agrees (A) to accept reimbursement from the insurer at\nrates established by the insurer as payment in full, which rates shall\nbe no more than the level of reimbursement applicable to similar\nproviders within the in-network benefits portion of the insurer's\nnetwork for such services; (B) to adhere to the insurer's quality\nassurance requirements and agrees to provide to the insurer necessary\nmedical information related to such care; and (C) to otherwise adhere to\nthe insurer's policies and procedures including, but not limited to\nprocedures regarding referrals and obtaining pre-authorization and a\ntreatment plan approved by the insurer. In no event shall this\nsubsection be construed to require an insurer to provide coverage for\nbenefits not otherwise covered or to diminish or impair pre-existing\ncondition limitations contained within the insured's contract.\n