§ 4804. Access to specialty care. (a) If an insurer offering a managed
care product determines that it does not have a health care provider in
the in-network benefits portion of its network with appropriate training
and experience to meet the particular health care needs of an insured,
the insurer shall make a referral to an appropriate provider, pursuant
to a treatment plan approved by the insurer in consultation with the
primary care provider, the non-participating provider and the insured or
the insured's designee, at no additional cost to the insured beyond what
the insured would otherwise pay for services received within the
network.

(b) An insurer offering a managed care product shall have a procedure
by which an insured enrolled in such managed care product who needs
ongoing care from a specialist may receive a standing referral to such
specialist. If the insurer, or the primary care provider in consultation
with the insurer and the specialist, determines that such a standing
referral is appropriate, the insurer shall make such a referral to a
specialist. In no event shall an insurer be required to permit an
insured to elect to have a non-participating specialist, except pursuant
to the provisions of subsection (a) of this section. Such referral shall
be pursuant to a treatment plan approved by the insurer in consultation
with the primary care provider, the specialist, and the insured or the
insured's designee. Such treatment plan may limit the number of visits
or the period during which such visits are authorized and may require
the specialist to provide the primary care provider with regular updates
on the specialty care provided, as well as all necessary medical
information.

(c) An insurer shall have a procedure by which a new insured upon
enrollment in a managed care product, or an insured in a managed care
product upon diagnosis, with (1) a life-threatening condition or disease
or (2) a degenerative and disabling condition or disease, either of
which requires specialized medical care over a prolonged period of time,
may receive a referral to a specialist with expertise in treating the
life-threatening or degenerative and disabling disease or condition who
shall be responsible for and capable of providing and coordinating the
insured's primary and specialty care. If the insurer, or primary care
provider in consultation with the insurer and the specialist, if any,
determines that the insured's care would most appropriately be
coordinated by such a specialist, the insurer shall refer the insured to
such specialist. In no event shall an insurer be required to permit an
insured to elect to have a non-participating specialist, except pursuant
to the provisions of subsection (a) of this section. Such referral shall
be pursuant to a treatment plan approved by the insurer, in consultation
with the primary care provider if appropriate, the specialist, and the
insured or the insured's designee. Such specialist shall be permitted to
treat the insured without a referral from the insured's primary care
provider and may authorize such referrals, procedures, tests and other
medical services as the insured's primary care provider would otherwise
be permitted to provide or authorize, subject to the terms of the
treatment plan. If an insurer refers an insured to a non-participating
provider, services provided pursuant to the approved treatment plan
shall be provided at no additional cost to the insured beyond what the
insured would otherwise pay for services received within the network.

(d) An insurer offering a managed care product shall have a procedure
by which an insured enrolled in such managed care product with (1) a
life-threatening condition or disease or (2) a degenerative and
disabling condition or disease, either of which requires specialized
medical care over a prolonged period of time, may receive a referral to
a specialty care center with expertise in treating the life-threatening
or degenerative and disabling disease or condition. If the insurer, or
the primary care provider or the specialist designated pursuant to
subsection (c) of this section, in consultation with the insurer,
determines that the insured's care would most appropriately be provided
by such a specialty care center, the insurer shall refer the insured to
such center. In no event shall an insurer be required to permit an
insured to elect to have a non-participating speciality care center,
unless the insurer does not have an appropriate specialty care center to
treat the insured's disease or condition within its network. Such
referral shall be pursuant to a treatment plan developed by the
specialty care center and approved by the insurer, in consultation with
the primary care provider, if any, or a specialist designated pursuant
to subsection (c) of this section, and the insured or the insured's
designee. If an insurer refers an insured to a specialty care center
that does not participate in the insurer's managed care provider
network, services provided pursuant to the approved treatment plan shall
be provided at no additional cost to the insured beyond what the insured
would otherwise pay for services received within the network. For
purposes of this subsection, a specialty care center shall mean only
such centers as are accredited or designated by an agency of the state
or federal government or by a voluntary national health organization as
having special expertise in treating the life-threatening disease or
condition or degenerative and disabling disease or condition for which
it is accredited or designated.

(e) (1) If an insured's health care provider leaves the insurer's
in-network benefits portion of its network of providers for a managed
care product for reasons other than those for which the provider would
not be eligible to receive a hearing pursuant to paragraph one of
subsection (b) of section forty-eight hundred three of this chapter, the
insurer shall provide written notice to the insured of the provider's
disaffiliation and permit the insured to continue an ongoing course of
treatment with the insured's current health care provider during a
transitional period of: (A) ninety days from the later of the date of
the notice to the insured of the provider's disaffiliation from the
insurer's network or the effective date of the provider's disaffiliation
from the insurer's network; or (B) if the insured is pregnant at the
time of the provider's disaffiliation, the duration of the pregnancy and
post-partum care directly related to the delivery.

(2) During the transitional period the health care provider shall: (A)
continue to accept reimbursement from the insurer at the rates
applicable prior to the start of the transitional period, and continue
to accept the in-network cost-sharing from the insured, if any, as
payment in full; (B) adhere to the insurer's quality assurance
requirements and provide to the insurer necessary medical information
related to such care; and (C) otherwise adhere to the insurer's policies
and procedures including, but not limited to, procedures regarding
referrals and obtaining pre-authorization and a treatment plan approved
by the insurer.

(f) If a new insured whose health care provider is not a member of the
insurer's in-network benefits portion of the provider network enrolls in
the managed care product, the insurer shall permit the insured to
continue an ongoing course of treatment with the insured's current
health care provider during a transitional period of up to sixty days
from the effective date of enrollment, if (1) the insured has a
life-threatening disease or condition or a degenerative and disabling
disease or condition or (2) the insured has entered the second trimester
of pregnancy at the time of enrollment, in which case the transitional
period shall include the provision of post-partum care directly related
to the delivery. If an insured elects to continue to receive care from
such health care provider pursuant to this paragraph, such care shall be
authorized by the insurer for the transitional period only if the health
care provider agrees (A) to accept reimbursement from the insurer at
rates established by the insurer as payment in full, which rates shall
be no more than the level of reimbursement applicable to similar
providers within the in-network benefits portion of the insurer's
network for such services; (B) to adhere to the insurer's quality
assurance requirements and agrees to provide to the insurer necessary
medical information related to such care; and (C) to otherwise adhere to
the insurer's policies and procedures including, but not limited to
procedures regarding referrals and obtaining pre-authorization and a
treatment plan approved by the insurer. In no event shall this
subsection be construed to require an insurer to provide coverage for
benefits not otherwise covered or to diminish or impair pre-existing
condition limitations contained within the insured's contract.