§ 36-6933 — Provision of basic health care services directly or by

contract or agreement - Standards and procedures for selection of providers - Chiropractic and vision care services - Referrals. A. A health maintenance organization shall provide basic health care services directly or by contract or agreement with other persons, corporations, institutions, associations, foundations or other legal entities, public or private, in accordance with the laws governing such professions and services. B. Each health maintenance organization shall have a defined set of standards and procedures for selecting providers, including specialists, to serve enrollees. The standards and procedures shall be drafted in such a manner as to be applicable to all categories of providers and shall be utilized by the health maintenance organization in a manner that is without bias for or discrimination against a particular category or categories of providers. C. With respect to chiropractic services, such covered services shall be provided on a referral basis within the network at the request of an enrollee who has a condition of an orthopedic or neurological nature if: 1. A referral is necessitated in the judgment of the primary care physician; and 2. Treatment for the condition falls within the licensed scope of practice of a chiropractic physician. D. 1. Any health maintenance organization that offers services for vision care or medical diagnosis and treatment for the eye shall allow optometrists to be providers of those services. 2. Once a fee schedule has been negotiated, ophthalmologists and optometrists shall be paid equally for the same services so long as the services provided by the optometrists are within the scope of the practice of optometry. 3. No health maintenance organization shall require a provider of vision care or medical diagnosis and treatment for the eye to have hospital privileges if hospital privileges are not usual and customary for the services the provider provides. 4. With respect to optometric services, such covered services shall be provided on a referral basis within the medical group or network at the request of an enrollee who has a condition requiring vision care or medical diagnosis and treatment of the eye if: a. a referral is necessitated in the judgment of the primary care physician, and b. treatment for the condition falls within the licensed scope of practice of an optometrist. 5. Nothing in this subsection shall be construed to: a. prohibit any health maintenance organization that offers services for vision care or medical diagnosis and treatment for the eye from determining the adequacy of the size of its network, b. limit, expand or otherwise affect the scope of practice of optometry, or c. alter, repeal, modify or affect the laws of this state except where such laws are in conflict or are inconsistent with the express provisions of this section. 6. Existing contracts shall comply with the requirements of this subsection upon issuance or renewal on or after the effective date of this act. E. 1. A health maintenance organization shall not: a. engage in the practice of medicine or any other profession except as provided by law, or b. prohibit or restrict a primary care physician from referring a patient to a specialist within the network if such referral is deemed medically necessary in the judgment of the primary care physician. 2. A health maintenance organization shall provide basic health care services in a manner that is reasonably geographically convenient to residents of the service area for which it seeks a license.

Legislative History

Added by Laws 2003, c. 197, § 33, eff. Nov. 1, 2003.