ME| Maine Bureau of Insurance Bulletin 490 updates prior guidance so that all licensed physicians and other advanced practitioners who can practice independently may enter into direct health care service agreements, and health carriers must treat referrals from these direct health care providers the same as in-network referrals, even when the referring provider is out of network or practices on a direct care basis, subject to the plan’s usual cost sharing, limits, and clinical review criteria.
Key Points:
- Health carriers may not deny, add extra cost sharing, or impose special conditions on services solely because the referring direct health care provider is out of network or practices under a direct care model, as long as there is a direct health care service agreement with the enrollee.
- The requirement applies only to services referred by the direct health care provider; plans are not required to cover services furnished by the direct health care provider themselves, including the visit in which the referral is made, beyond what the plan already covers.