N.Y. Insurance Law § 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.

* NB Effective until January 1, 2027

* (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

ninety days from the effective date of enrollment. If the insured is

pregnant at the time of enrollment, the transitional period shall

include the provision of care for the duration of the pregnancy and

postpartum 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.

* NB Effective January 1, 2027