State Codes and Statutes

Statutes > New-york > Isc > Article-48 > 4804

§ 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-threateningor  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 relatedto 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.

State Codes and Statutes

Statutes > New-york > Isc > Article-48 > 4804

§ 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-threateningor  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 relatedto 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.

State Codes and Statutes

State Codes and Statutes

Statutes > New-york > Isc > Article-48 > 4804

§ 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-threateningor  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 relatedto 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.

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