Effective 28 Aug 1997

354.615. Referrals to appropriate providers, when. — 1. If a health carrier determines that it does not have a health care provider with appropriate training and experience in its panel or network to meet the particular health care needs of an enrollee, the health carrier shall make a referral to an appropriate provider, pursuant to a treatment plan approved by the health carrier in consultation with the primary care provider, the nonparticipating provider and the enrollee or enrollee's designee, at no additional cost to the enrollee beyond what the enrollee would otherwise pay for services received within the network.

2. A health carrier shall have a procedure by which an enrollee who needs ongoing care from a specialist may receive a standing referral to such specialist. If the health carrier, or the primary care provider in consultation with the medical director of the health carrier and an appropriate specialist, determines that such a standing referral is warranted, the carrier shall make such a referral to a specialist. In no event shall a health carrier be required to permit an enrollee to elect to have a nonparticipating specialist, except pursuant to the provisions of subsection 1 of this section. Such referral shall be pursuant to a treatment plan approved by the health carrier in consultation with the primary care provider, the specialist, and the enrollee or the enrollee'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.

3. A health carrier shall have a procedure by which a new enrollee upon enrollment, or an enrollee upon diagnosis, with a life-threatening condition or disease or 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 enrollee's primary and specialty care. If the health carrier, or primary care provider in consultation with a medical director of the health carrier and an appropriate specialist, determines that the enrollee's care would most appropriately be coordinated by such a specialist, the health carrier shall refer the enrollee to such specialist. In no event shall a health carrier be required to permit an enrollee to elect to have a nonparticipating specialist, except pursuant to the provisions of subsection 1 of this section. Such referral shall be pursuant to a treatment plan approved by the health carrier, in consultation with the primary care provider if appropriate, the specialist, and the enrollee or the enrollee's designee. Such specialist shall be permitted to treat the enrollee without a referral from the enrollee's primary care provider and may authorize such referrals, procedures, tests and other medical services as the enrollee's primary care provider would otherwise be permitted to provide or authorize, subject to the terms of the treatment plan. If a health carrier refers an enrollee to a nonparticipating provider, services provided pursuant to the approved treatment plan shall be provided at no additional cost to the enrollee beyond what the enrollee would otherwise pay for services received within the network.

4. A health carrier shall have a procedure by which an enrollee with a life-threatening condition or disease, or 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 health carrier, or the primary care provider or a specialist designated pursuant to this section, in consultation with a medical director of the health carrier, determines that the enrollee's care would most appropriately be provided by such a specialty care center, the health carrier shall refer the enrollee to such center. In no event shall a health carrier be required to permit an enrollee to elect to have a nonparticipating specialty care center, unless the health carrier does not have an appropriate specialty care center to treat the enrollee'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 health carrier, in consultation with the primary care provider, if any, or a specialist designated pursuant to subsection 3 of this section, and the enrollee or the enrollee's designee. If a health carrier refers an enrollee to a specialty care center that does not participate in the health carrier's network, services provided pursuant to the approved treatment plan shall be provided at no additional cost to the enrollee beyond what the enrollee 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.

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(L. 1997 H.B. 335)