Section 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 permit the  insured  to  continue  an  ongoing  course  of
  treatment  with  the  insured's  current  health  care provider during a
  transitional period of (i) up to ninety days from the date of notice  to
  the insured of the provider's disaffiliation from the insurer's network;
  or  (ii) if the insured has entered the second trimester of pregnancy at
  the time of the provider's disaffiliation,  for  a  transitional  period
  that  includes the provision of post-partum care directly related to the
  delivery.
    (2)  Notwithstanding  the  provisions  of  paragraph   one   of   this
  subsection,  such  care  shall  be  authorized by the insurer during the
  transitional period only if the  health  care  provider  agrees  (i)  to
  continue   to  accept  reimbursement  from  the  insurer  at  the  rates
  applicable prior to the start of the transitional period as  payment  in
  full; (ii) to adhere to the insurer's quality assurance requirements and
  to  provide to the insurer necessary medical information related to such
  care; and (iii) 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.
    (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.