§ 4804. Access to specialty care. (a) If an insurer offering a managed\ncare product determines that it does not have a health care provider in\nthe in-network benefits portion of its network with appropriate training\nand experience to meet the particular health care needs of an insured,\nthe insurer shall make a referral to an appropriate provider, pursuant\nto a treatment plan approved by the insurer in consultation with the\nprimary care provider, the non-participating provider and the insured or\nthe insured's designee, at no additional cost to the insured beyond what\nthe insured would otherwise pay for services received within the\nnetwork.\n (b) An insurer offering a managed care product shall have a procedure\nby which an insured enrolled in such managed care product who needs\nongoing care from a specialist may receive a standing referral to such\nspecialist. If the insurer, or the primary care provider in consultation\nwith the insurer and the specialist, determines that such a standing\nreferral is appropriate, the insurer shall make such a referral to a\nspecialist. In no event shall an insurer be required to permit an\ninsured to elect to have a non-participating specialist, except pursuant\nto the provisions of subsection (a) of this section. Such referral shall\nbe pursuant to a treatment plan approved by the insurer in consultation\nwith the primary care provider, the specialist, and the insured or the\ninsured's designee. Such treatment plan may limit the number of visits\nor the period during which such visits are authorized and may require\nthe specialist to provide the primary care provider with regular updates\non the specialty care provided, as well as all necessary medical\ninformation.\n (c) An insurer shall have a procedure by which a new insured upon\nenrollment in a managed care product, or an insured in a managed care\nproduct upon diagnosis, with (1) a life-threatening condition or disease\nor (2) a degenerative and disabling condition or disease, either of\nwhich requires specialized medical care over a prolonged period of time,\nmay receive a referral to a specialist with expertise in treating the\nlife-threatening or degenerative and disabling disease or condition who\nshall be responsible for and capable of providing and coordinating the\ninsured's primary and specialty care. If the insurer, or primary care\nprovider in consultation with the insurer and the specialist, if any,\ndetermines that the insured's care would most appropriately be\ncoordinated by such a specialist, the insurer shall refer the insured to\nsuch specialist. In no event shall an insurer be required to permit an\ninsured to elect to have a non-participating specialist, except pursuant\nto the provisions of subsection (a) of this section. Such referral shall\nbe pursuant to a treatment plan approved by the insurer, in consultation\nwith the primary care provider if appropriate, the specialist, and the\ninsured or the insured's designee. Such specialist shall be permitted to\ntreat the insured without a referral from the insured's primary care\nprovider and may authorize such referrals, procedures, tests and other\nmedical services as the insured's primary care provider would otherwise\nbe permitted to provide or authorize, subject to the terms of the\ntreatment plan. If an insurer refers an insured to a non-participating\nprovider, services provided pursuant to the approved treatment plan\nshall be provided at no additional cost to the insured beyond what the\ninsured would otherwise pay for services received within the network.\n (d) An insurer offering a managed care product shall have a procedure\nby which an insured enrolled in such managed care product with (1) a\nlife-threatening condition or disease or (2) a degenerative and\ndisabling condition or disease, either of which requires specialized\nmedical care over a prolonged period of time, may receive a referral to\na specialty care center with expertise in treati
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