354.615. Referrals to appropriate providers, when. - Missouri Statutes

Referrals to appropriate providers, when.

354.615. 1. If a health carrier determines that it does not have ahealth care provider with appropriate training and experience in its panel ornetwork to meet the particular health care needs of an enrollee, the healthcarrier shall make a referral to an appropriate provider, pursuant to atreatment plan approved by the health carrier in consultation with the primarycare provider, the nonparticipating provider and the enrollee or enrollee'sdesignee, at no additional cost to the enrollee beyond what the enrollee wouldotherwise pay for services received within the network.

2. A health carrier shall have a procedure by which an enrollee whoneeds ongoing care from a specialist may receive a standing referral to suchspecialist. If the health carrier, or the primary care provider inconsultation with the medical director of the health carrier and anappropriate specialist, determines that such a standing referral is warranted,the carrier shall make such a referral to a specialist. In no event shall ahealth carrier be required to permit an enrollee to elect to have anonparticipating specialist, except pursuant to the provisions of subsection 1of this section. Such referral shall be pursuant to a treatment plan approvedby the health carrier in consultation with the primary care provider, thespecialist, and the enrollee or the enrollee's designee. Such treatment planmay limit the number of visits or the period during which such visits areauthorized and may require the specialist to provide the primary care providerwith regular updates on the specialty care provided, as well as all necessarymedical information.

3. A health carrier shall have a procedure by which a new enrollee uponenrollment, or an enrollee upon diagnosis, with a life-threatening conditionor disease or a degenerative and disabling condition or disease, either ofwhich requires specialized medical care over a prolonged period of time, mayreceive a referral to a specialist with expertise in treating thelife-threatening or degenerative and disabling disease or condition who shallbe responsible for and capable of providing and coordinating the enrollee'sprimary and specialty care. If the health carrier, or primary care providerin consultation with a medical director of the health carrier and anappropriate specialist, determines that the enrollee's care would mostappropriately be coordinated by such a specialist, the health carrier shallrefer the enrollee to such specialist. In no event shall a health carrier berequired to permit an enrollee to elect to have a nonparticipating specialist,except pursuant to the provisions of subsection 1 of this section. Suchreferral shall be pursuant to a treatment plan approved by the health carrier,in consultation with the primary care provider if appropriate, the specialist,and the enrollee or the enrollee's designee. Such specialist shall bepermitted to treat the enrollee without a referral from the enrollee's primarycare provider and may authorize such referrals, procedures, tests and othermedical services as the enrollee's primary care provider would otherwise bepermitted to provide or authorize, subject to the terms of the treatment plan. If a health carrier refers an enrollee to a nonparticipating provider,services provided pursuant to the approved treatment plan shall be provided atno additional cost to the enrollee beyond what the enrollee would otherwisepay for services received within the network.

4. A health carrier shall have a procedure by which an enrollee with alife-threatening condition or disease, or a degenerative and disablingcondition or disease, either of which requires specialized medical care over aprolonged period of time, may receive a referral to a specialty care centerwith expertise in treating the life-threatening or degenerative and disablingdisease or condition. If the health carrier, or the primary care provider ora specialist designated pursuant to this section, in consultation with amedical director of the health carrier, determines that the enrollee's carewould most appropriately be provided by such a specialty care center, thehealth carrier shall refer the enrollee to such center. In no event shall ahealth carrier be required to permit an enrollee to elect to have anonparticipating specialty care center, unless the health carrier does nothave an appropriate specialty care center to treat the enrollee's disease orcondition within its network. Such referral shall be pursuant to a treatmentplan developed by the specialty care center and approved by the healthcarrier, in consultation with the primary care provider, if any, or aspecialist designated pursuant to subsection 3 of this section, and theenrollee or the enrollee's designee. If a health carrier refers an enrolleeto a specialty care center that does not participate in the health carrier'snetwork, services provided pursuant to the approved treatment plan shall beprovided at no additional cost to the enrollee beyond what the enrollee wouldotherwise pay for services received within the network. For purposes of thissubsection, a specialty care center shall mean only such centers as areaccredited or designated by an agency of the state or federal government or bya voluntary national health organization as having special expertise intreating the life-threatening disease or condition or degenerative anddisabling disease or condition for which it is accredited or designated.

(L. 1997 H.B. 335)