REQUIRED PROVISIONS AND ENROLLEE DISCLOSURES
§ 154.11. Managed care plan requirements.
(a) Managed care plans shall adopt and maintain procedures by which an enrollee with a life-threatening, degenerative or disabling disease or condition shall, upon request, receive an evaluation, and, if the plan’s established standards are met, be permitted to receive approval for either:
(1) A standing referral to a specialist with clinical expertise in treating the disease or condition.
(2) The designation of a specialist to provide and coordinate the enrollee’s primary and specialty care.
(b) A managed care plan’s established standards, as referenced in subsection (a) may include:
(1) Time restrictions on approved treatment plans, as set forth in section 2111(6) of the act (40 P. S. § 991.2111(6)), which include standing referrals or specialist designations.
(2) Requirements that treatment plans be periodically reviewed and reapproved by the plan.
(3) Requirements that the specialist notify the enrollee’s primary care provider of all care provided within 30 days.
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