Common use of Specialty Care Clause in Contracts

Specialty Care. The contractor shall have a procedure by which a new enrollee upon enrollment, or an enrollee upon diagnosis, who requires very complex, highly specialized health care services over a prolonged period of time, or with (i) If the contractor or primary care provider in consultation with the contractor's medical director and a specialist, if any, determines that the enrollee's care would most appropriately be coordinated by such specialist/specialty care center, the contractor shall refer the enrollee. Such referral shall be pursuant to a care plan approved by the contractor, in consultation with the primary care provider if appropriate, the specialist, care manager, and the enrollee (or, where applicable, authorized person). The contractor-participating specialist/specialty care center acting as both primary and specialty care provider shall be permitted to treat the enrollee without a referral from the enrollee's primary care provider and may authorize such referrals, procedures, tests and other medical services as the enrollee's primary care provider would otherwise be permitted to provide or authorize, subject to the terms of the care plan. If the specialist/specialty care center will not be providing primary care, then the contractor's rules for referrals apply. Consideration for policies and procedures should be given for a standing referral when on-going, long-term specialty care is required. If the contractor refers an enrollee to a non contractor-participating provider, services provided pursuant to the approved care plan shall be provided at no additional cost to the enrollee. In no event shall the contractor be required to permit an enrollee to elect to have a non contractor-participating specialist/specialty care center. For purposes of this Article a specialty care center shall mean the Centers of Excellence identified in Section B.4.10 of the Appendices. These centers have special expertise in treating life-threatening diseases/conditions and degenerative /disabling diseases/conditions.

Specialty Care. The contractor shall have a procedure by which a new enrollee upon enrollment, or an enrollee upon diagnosis, who requires very complex, highly specialized health care services over a prolonged period of time, or with (i) a life-threatening condition or disease or (ii) a degenerative and/or disabling condition or disease, either of which requires specialized medical care over a prolonged period of time, may receive a referral to a specialist or a specialty care center with expertise in treating the life-threatening disease or specialized condition, who shall be responsible for and capable of providing and coordinating the enrollee's primary and specialty care. If the contractor or primary care provider in consultation with the contractor's medical director and a specialist, if any, determines that the enrollee's care would most appropriately be coordinated by such specialist/specialty care center, the contractor shall refer the enrollee. Such referral shall be pursuant to a care plan approved by the contractor, in consultation with the primary care provider if appropriate, the specialist, care manager, and the enrollee (or, where applicable, authorized person). The contractor-participating specialist/specialty care center acting as both primary and specialty care provider shall be permitted to treat the enrollee without a referral from the enrollee's primary care provider and may authorize such referrals, procedures, tests and other medical services as the enrollee's primary care provider would otherwise be permitted to provide or authorize, subject to the terms of the care plan. If the specialist/specialty care center will not be providing primary care, then the contractor's rules for referrals apply. Consideration for policies and procedures should be given for a standing referral when on-going, long-term specialty care is required. If the contractor refers an enrollee to a non contractor-contractor- participating provider, services provided pursuant to the approved care plan shall be provided at no additional cost to the enrollee. In no event shall the contractor be required to permit an enrollee to elect to have a non contractor-contractor- participating specialist/specialty care center. For purposes of this Article a specialty care center shall mean the Centers of Excellence identified in Section B.4.10 of the Appendices. These centers have special expertise in treating life-threatening diseases/conditions and degenerative /disabling diseases/conditions.