(1) With respect to a health insurance policy or managed care organization contract that does not allow an insured to have direct access to a health care specialist, the insurer shall establish and implement a procedure by which an insured may obtain a standing referral to a health care specialist.
(2) The procedure established under Subsection (1): (a) shall provide for a standing referral to a specialist if the insured's primary care provider determines, in consultation with the specialist, that the insured needs continuing care from the specialist; and (b) may require the insurer's approval of a treatment plan designed by the specialist, in consultation with the primary care provider and the insured, which may include: (i) a limit on the number of visits to the specialist; (ii) a time limit on the duration of the referral; and (iii) mandatory updates on the insured's condition.
(a) shall provide for a standing referral to a specialist if the insured's primary care provider determines, in consultation with the specialist, that the insured needs continuing care from the specialist; and
(b) may require the insurer's approval of a treatment plan designed by the specialist, in consultation with the primary care provider and the insured, which may include: (i) a limit on the number of visits to the specialist; (ii) a time limit on the duration of the referral; and (iii) mandatory updates on the insured's condition.
(i) a limit on the number of visits to the specialist;
(ii) a time limit on the duration of the referral; and
(iii) mandatory updates on the insured's condition.
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