38.2-3407.11:1 - Access to specialists; standing referrals
§ 38.2-3407.11:1. Access to specialists; standing referrals.
A. Each (i) insurer proposing to issue individual or group accident andsickness insurance policies providing hospital, medical and surgical or majormedical coverage on an expense-incurred basis, (ii) corporation providingindividual or group accident and sickness subscription contracts, and (iii)health maintenance organization providing a health care plan for health careservices shall permit any individual covered thereunder a standing referral,as provided in subsection B, to the health care services of a participatingspecialist (i) authorized to provide services under such policy, contract orplan and (ii) selected by such individual.
B. If the care of a covered individual who has an ongoing special conditionwould, as determined by the primary care physician, most appropriately becoordinated by a specialist for such condition, each insurer, corporation, orhealth maintenance organization, in connection with the provision of healthinsurance coverage, shall have a procedure by which such individual shall,after consultation with the primary care physician, receive a referral to aspecialist for such condition. Within the treatment period authorized by thereferral, such specialist shall be permitted to treat the individual for thespecial condition without a further referral from the individual's primarycare provider and may authorize such referrals, procedures, tests, and othermedical services related to the special condition as the individual's primarycare provider would otherwise be permitted to provide or authorize. For thepurposes of this section, "special condition" means a condition or diseasethat is (i) life-threatening, degenerative, or disabling and (ii) requiresspecialized medical care over a prolonged period of time.
C. An insurer, corporation, or health maintenance organization, in connectionwith the provision of health insurance coverage, shall have a procedure bywhich an individual who is a participant, beneficiary, or enrollee and whohas an ongoing special condition that requires ongoing care from a specialistmay receive a standing referral to a participating specialist for thetreatment of the special condition. If the plan or issuer, or if the primarycare provider in consultation with the plan or issuer and the participatingspecialist, if any, determines that such a standing referral is appropriate,the plan or issuer shall make such a referral to a specialist.
D. Nothing contained herein shall prohibit an insurer, corporation, or healthmaintenance organization from requiring a participating specialist to providewritten notification to the covered individual's primary care physician ofany visit to such specialist. Such notification may include a description ofthe health care services rendered at the time of the visit.
E. Each insurer, corporation or health maintenance organization subject tothe provisions of this section shall inform subscribers of the provisions ofthis section. Such notice shall be provided in writing, and included in thepolicy or evidence of coverage.
F. The requirements of this section shall apply to all insurance policies,contracts, and plans delivered, issued for delivery, reissued, renewed, orextended or at any time when any term of any such policy, contract, or planis changed or any premium adjustment is made. The provisions of this sectionshall not apply to short-term travel or accident-only policies, to short-termnonrenewable policies of not more than six months' duration, or policies orcontracts issued to persons eligible under Title XVIII of the Social SecurityAct, known as Medicare, or any other similar coverage under state or federalgovernmental plans.
(1999, cc. 643, 649; 2000, c. 922.)