Section 991.2111 - Responsibilities of managed care plansA managed care plan shall do all of the following:
(1) Assure availability and accessibility of adequate health care providers in a timely manner, which enables enrollees to have access to quality care and continuity of health care services.(2) Consult with health care providers in active clinical practice regarding professional qualifications and necessary specialists to be included in the plan.(3) Adopt and maintain a definition of medical necessity used by the plan in determining health care services.(4) Ensure that emergency services are provided twenty-four (24) hours a day, seven (7) days a week and provide reasonable payment or reimbursement for emergency services.(5) Adopt and maintain procedures by which an enrollee can obtain health care services outside the plan's service area.(6) 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: (i) a standing referral to a specialist with clinical expertise in treating the disease or condition; or(ii) the designation of a specialist to provide and coordinate the enrollee's primary and specialty care. The referral to or designation of a specialist shall be pursuant to a treatment plan approved by the managed care plan, in consultation with the primary care provider, the enrollee and, as appropriate, the specialist. When possible, the specialist must be a health care provider participating in the plan.
(7) Provide direct access to obstetrical and gynecological services by permitting an enrollee to select a health care provider participating in the plan to obtain maternity and gynecological care, including medically necessary and appropriate follow-up care and referrals for diagnostic testing related to maternity and gynecological care, without prior approval from a primary care provider. The health care services shall be within the scope of practice of the selected health care provider. The selected health care provider shall inform the enrollee's primary care provider of all health care services provided.(8) Adopt and maintain a complaint process as set forth in subarticle (g).(9) Adopt and maintain a grievance process as set forth in subarticle (i).(10) Adopt and maintain credentialing standards for health care providers as set forth in subarticle (d).(11) Ensure that there are participating health care providers that are physically accessible to people with disabilities and can communicate with individuals with sensory disabilities in accordance with Title III of the Americans with Disabilities Act of 1990 ( Public Law 101-336, 42 U.S.C. § 12181 et seq.).(12) Provide a list of health care providers participating in the plan to the department every two (2) years or as may otherwise be required by the department. The list shall include the extent to which health care providers in the plan are accepting new enrollees.(13) Report to the department and the Insurance Department in accordance with the requirements of this article. Such information shall include the number, type and disposition of all complaints and grievances filed with the plan.1921, May 17, P.L. 682, No. 284, § 2111, added 1998, June 17, P.L. 464, No. 68, § 1, effective 1/1/1999.