Specialty and Emergency Care Needs
Specialty Care Needs
The Managed Care Act includes some special provisions for people with specialized health care needs.
To meet these needs, health plans must have procedures through which:
- A member who needs ongoing care from a specialist may obtain a standing referral to the specialist.
- A member suffering from a life-threatening or disabling and degenerative disease or condition may receive permission to use a specialist as his/her coordinator of care and/or receive permission for a referral to a specialty care center.
- A member can, in specific situations, access a provider not in the network. In cases where a plan doesn’t have a provider with the training and/or experience to treat a particular condition, you have the right to be referred to an appropriate provider outside the plan’s network.
In Case of Emergency
All health plans cover emergency care. The big question for many consumers, however, is how the term “emergency” is defined.
To help answer that question, health plans generally instruct members to contact their primary care provider or the plan’s 24-hour-phone line for urgent health care problems. However, you do not need to call if symptoms start suddenly and are so severe or painful that an ordinary person with an average knowledge of medicine and health could believe that not getting immediate medical care would cause serious health problems or damage to a person’s body. This is known as the “prudent lay person” definition for emergency care. For example, if you experience severe chest pains and go to the emergency room believing you are having a heart attack, your health plan will cover that emergency visit even if it turns out you only had serious indigestion. For mental health problems, the “prudent lay person” standard applies if you or someone else believes you would harm yourself or someone else.