| (a) An HMO must allow an enrollee with chronic, disabling,
or life threatening illnesses to apply to the HMO's medical director
to use a nonprimary care physician specialist as a primary care physician,
provided that:
(1) the enrollee makes a request for special consideration
that includes:
(A) a certification by the nonprimary care physician
specialist of the medical need for the enrollee to use the nonprimary
care physician specialist as a primary care physician;
(B) a statement signed by the nonprimary care physician
specialist that the specialist is willing to accept responsibility
for the coordination of all of the enrollee's health care needs; and
(C) the signature of the enrollee;
(2) the nonprimary care physician specialist meets
the HMO's requirements for primary care physician participation, including
credentialing;
(3) the HMO has ensured that the contractual obligations
of the nonprimary care physician specialist are consistent with the
contractual obligations of the HMO's primary care physicians; and
(4) the HMO must provide the nonprimary care physician
specialist with a current directory of participating specialist physicians
and providers.
(b) An HMO must approve or deny the request for special
consideration and provide written notification of the decision to
the enrollee not later than 30 days after receiving the request. If
the HMO denies the request, the HMO must provide the reasons for denial
in the written notification. An HMO must establish written criteria
for determining medical need for an enrollee to use a nonprimary care
physician specialist as a primary care provider, and must include
the criteria in the provider manual.
(c) If the HMO denies a request for special consideration,
an enrollee may appeal the decision through the HMO's established
complaint and appeal process.
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