2023 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 provide written notice to the insured  of  the  provider's
disaffiliation  and  permit the insured to continue an ongoing course of
treatment with the insured's  current  health  care  provider  during  a
transitional  period  of:  (A) ninety days from the later of the date of
the notice to the insured of  the  provider's  disaffiliation  from  the
insurer's network or the effective date of the provider's disaffiliation
from  the  insurer's  network;  or (B) if the insured is pregnant at the
time of the provider's disaffiliation, the duration of the pregnancy and
post-partum care directly related to the delivery.
(2) During the transitional period the health care provider shall: (A)
continue  to  accept  reimbursement  from  the  insurer  at  the   rates
applicable  prior  to the start of the transitional period, and continue
to accept the in-network cost-sharing  from  the  insured,  if  any,  as
payment   in  full;  (B)  adhere  to  the  insurer's  quality  assurance
requirements and provide to the insurer  necessary  medical  information
related to such care; and (C) 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.