Referral and Specialty Care Requirements
(1) Procedures for referrals must be clearly outlined in the access plan, in literature provided to all enrollees, and in literature or contracts provided to all participating providers.
(2) Women and adolescent females who do not designate a gynecological health care provider as their PCP must be allowed direct access (without prior authorization or referral from a PCP) to a participating provider whose area of specialization is gynecology for routine gynecological care no less frequently than one time per year.
(3) Pregnant females must be allowed direct access, without prior authorization or referral from a PCP, to a participating provider whose area of specialization is obstetrics.
(4) An enrollee must be allowed to designate a participating pediatrician, family practice physician, or, if the health carrier allows a mid-level provider to be a PCP, a mid-level provider specializing in primary care of children as the PCP for the enrollee’s children and/or adolescents who are covered by the health carrier.
(5) The access plan must include a process to address and correct instances where a health carrier has an insufficient number or type of participating providers accessible to enrollees to provide a covered benefit. In these instances, the health carrier must ensure that covered services are provided at no greater cost to the enrollee than if the services were obtained from a participating provider.
(6) The access plan must include policies and procedures by which an enrollee with a condition that requires ongoing care from a specialist may obtain a standing referral to a participating specialty provider. For purposes of this rule, standing referral means a referral for ongoing care to be provided by a participating specialty care provider that authorizes a series of visits with the specialist for either a specific time period or a limited number of visits, and which is provided according to a treatment plan approved by the carrier and developed by the enrollee’s PCP, the specialty provider, and the enrollee.