NY Ins L § 4804 (2021)
2021 New York Laws ISC - Insurance Article 48 - Managed Care Health Insurance Contracts 4804 - Access to Specialty Care.

§ 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.