§ 63-2550.2. Referral to and treatment by specialist.

A.  A managed care plan that has no participating provider for a covered benefit requiring a specialist shall arrange for a referral to a specialist with expertise in treating the covered benefit.  The specialist shall agree to abide by the terms of the plan’s provider contract if the terms are commensurate with the terms of contracts for similar specialists.

B.  1.  A managed care plan shall include procedures by which a covered person in a managed care plan, upon diagnosis by a primary care provider of a condition that without specialized treatment would result in deleterious outcomes that would threaten life or limb or a degenerative and disabling condition or disease, either of which requires specialized medical care over a prolonged period of time, may be referred to a specialist with expertise in treating such condition or disease.

2.  The specialist may be responsible for and may provide and coordinate the covered person’s primary and specialty care only if the specialist is willing to abide by the terms of the plan’s contract and capable of providing such care.

3.  If the managed care plan, or the primary care provider in consultation with the managed care plan and the specialist, if any, determines that the most appropriate coordinator of the covered person’s care is a specialist, the managed care plan shall authorize a referral of the covered person to the specialist.  In no event shall a managed care plan be required to permit a covered person to elect treatment by a nonparticipating specialist, except pursuant to the provisions of subsection A of this section.

C.  1.  A referral pursuant to this section shall be pursuant to a treatment plan agreed to by the managed care plan, the specialist and the primary care provider which complies with the covered benefits of the health plan and which is developed in consultation with the primary care provider, if appropriate, the specialist, and the covered person or the designee of the covered person.

2.  Subject to the terms of the treatment plan agreed to by the managed care plan, the specialist and the primary care provider and subject to the terms of the plan’s contract, a specialist shall be permitted to treat the covered person without a referral from the covered person’s primary care provider and may authorize referrals, procedures, tests and other medical services as the covered person’s primary care provider would otherwise be permitted to provide or authorize.

3.  If a managed care plan refers a covered person to a nonparticipating specialist, services provided pursuant to the treatment plan shall be provided pursuant to the provisions of subsection A of this section at no additional cost to the covered person beyond what the covered person would otherwise pay for services received within the network of the managed care plan.

D.  A managed care plan shall implement procedures for a standing referral to a specialist if the primary care provider determines in consultation with the specialist and the managed care plan that a covered person needs continuing care from a specialist.  The referral shall be made pursuant to a treatment plan that complies with covered benefits of the managed care plan.

Added by Laws 1999, c. 361, § 2, eff. Nov. 1, 1999.