Choice of and Access to Providers of Specialty Care
(a) Each health carrier shall establish policies and procedures through which a member with a condition that requires care from a specialist may obtain a referral to a network specialist or specialist group practice, subject to the utilization review procedures used by the health carrier. For purposes of this provision, “referral” means a referral for care to be provided by a network specialist or specialist group practice that authorizes a visit or series of visits with the specialist or specialist group practice for either a specific time period or a limited number of visits and which is provided according to a treatment plan developed by the covered person’s primary care provider, a specialist, the covered person, and the plan. The carrier shall not require an additional referral to the same specialist or specialist group practice within 6 months, when the patient is expected by the referring provider to need care for at least this period of time. The carrier shall accept a referral that is made to a specialist group practice and shall not require the referring provider to specify an individual practitioner in the referral.
(b) Each health carrier shall ensure that covered persons may obtain a referral to a health care provider outside of the health carrier’s network when the health carrier does not have a health care provider with appropriate training and experience within its network who can meet the particular health care needs of the covered person. Services provided by out-of-network providers shall be subject to the utilization review procedures used by the health carrier. The covered person shall not be responsible for any additional costs incurred by the health carrier under this paragraph other than any applicable co-payment, coinsurance, or deductible.