                                 CODE OF VIRGINIA

ACCESS TO SPECIALISTS; STANDING REFERRALS (§ 38.2-3407.11:1)

A. Each (i) insurer proposing to issue individual or group accident and sickness
insurance policies providing hospital, medical and surgical or major medical
coverage on an expense-incurred basis, (ii) corporation providing individual or
group accident and sickness subscription contracts, and (iii) health maintenance
organization providing a health care plan for health care services shall permit
any individual covered thereunder a standing referral, as provided in subsection
B, to the health care services of a participating specialist (i) authorized to
provide services under such policy, contract or plan and (ii) selected by such
individual.

B. If the care of a covered individual who has an ongoing special condition
would, as determined by the primary care physician, most appropriately be
coordinated by a specialist for such condition, each insurer, corporation, or
health maintenance organization, in connection with the provision of health
insurance coverage, shall have a procedure by which such individual shall, after
consultation with the primary care physician, receive a referral to a specialist
for such condition. Within the treatment period authorized by the referral, such
specialist shall be permitted to treat the individual for the special condition
without a further referral from the individual&#8217;s primary care provider and
may authorize such referrals, procedures, tests, and other medical services
related to the special condition as the individual&#8217;s primary care provider
would otherwise be permitted to provide or authorize. For the purposes of this
section, &#8220;special condition&#8221; means a condition or disease that is
(i) life-threatening, degenerative, or disabling and (ii) requires specialized
medical care over a prolonged period of time.

C. An insurer, corporation, or health maintenance organization, in connection
with the provision of health insurance coverage, shall have a procedure by which
an individual who is a participant, beneficiary, or enrollee and who has an
ongoing special condition that requires ongoing care from a specialist may
receive a standing referral to a participating specialist for the treatment of
the special condition. If the plan or issuer, or if the primary care provider in
consultation with the plan or issuer and the participating specialist, 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 health
maintenance organization from requiring a participating specialist to provide
written notification to the covered individual&#8217;s primary care physician of
any visit to such specialist. Such notification may include a description of the
health care services rendered at the time of the visit.

E. Each insurer, corporation or health maintenance organization subject to the
provisions of this section shall inform subscribers of the provisions of this
section. Such notice shall be provided in writing, and included in the policy 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, or
extended or at any time when any term of any such policy, contract, or plan is
changed or any premium adjustment is made. The provisions of this section shall
not apply to short-term travel or accident-only policies, to short-term
nonrenewable policies of not more than six months&#8217; duration, or policies
or contracts issued to persons eligible under Title XVIII of the Social Security
Act, known as Medicare, or any other similar coverage under state or federal
governmental plans.

HISTORY: 1999, cc. 643, 649; 2000, c. 922.