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Patient Protection

Timeline of Provisions

Patient Protections


Beginning Sept. 23, 2010, members can select any participating available primary care provider (PCP) as their PCP, and parents can choose any participating pediatrician as their child's PCP. Members have direct access to participating obstetrics or gynecology (OB-GYN) providers.

There are no prior authorization requirements for emergency services in a true emergency, even if the emergency services are provided by an out-of-network provider. Payment for the emergency service will follow the plan rules for network emergency coverage.

This provision applies to all non-grandfathered fully insured and self-funded group health plans, as well as group and individual health insurance issuers.

Frequently Asked Questions

How will health plan members be advised about their rights to select a PCP, including services from an OBGYN?

Plans and insurance issuers are required to provide notice informing each health plan member (or in the individual market, the primary subscriber) about:

  • The terms of the plan or coverage regarding designation of a primary care provider.
  • The rights of the member to designate a PCP or pediatrician.
  • The fact that the plan or issuer may not require authorization or referral for OB-GYN care by a participating health care professional who specializes in OB-GYN care.

Notice must be provided whenever the plan or issuer provides a participant with a summary plan description or other similar description of benefits under the plan or insurance coverage, or in the individual market, provides a primary subscriber with a policy, certificate or contract of health insurance.

What are the new rules regarding selection of Primary Care providers?

For those plans and health insurance issuers with a network of providers who require or permit a member to designate a PCP, the rules protect the member's ability to designate a PCP, and to direct access to in-network OB-GYN providers.

  • Designation of a PCP. Under the new rules, health plan members are free to designate any available participating primary care provider as their PCP.
  • Designation of a Pediatrician as PCP. The rules also provide that parents may choose any available participating physician who specializes in pediatrics (allopathic or osteopathic) to be their children's PCP.
  • Direct Access to In-Network OB-GYN Providers. Under the rules, plans and insurers are prohibited from requiring a prior authorization or referral to access an in-network health care professional who specializes in obstetrics or gynecology. A health care professional who specializes in OB-GYN care is any individual who is authorized under State law to provide such care, and is not limited to a physician. The direct access requirement does not waive any exclusions of coverage under the plan with respect to coverage of OB-GYN care, or preclude the plan or issuer from requiring the OB-GYN provider from notifying the member's PCP about the treatment plan. However, the treatment and ordering of services by the OB-GYN provider must be treated as authorization by the PCP.
How do the patient protection provisions enhance access to emergency department services?

The rules outlined below apply to plans and health insurance issuers that provide benefits for emergency services in an emergency room of a hospital.

  • Prior Authorization Prohibited. The rules prohibit prior authorization requirements for emergency services, even if the emergency services are provided by an out-of-network provider.
  • Cost Sharing (Coinsurance and Copayment) Restrictions. The rules also prohibit plans and issuers from charging higher cost sharing (copayments or coinsurance) for emergency services that are obtained out of a plan's network.
  • Calculating a Reasonable Allowed Amount with Respect to Balance Billing. The rule does not prohibit balance billing, but requires that a "reasonable amount" be paid before the member is subject to balance bill.
  • Anti-Abuse Rule. The rules include an anti-abuse rule with respect to other cost sharing requirements so that the purpose of limiting copayment and coinsurance amounts for emergency services rendered by out-of-network providers cannot be thwarted by manipulation of other cost-sharing requirements.
  • Application of Other Plan Requirements. The emergency services must be provided without regard to any other term or condition of the plan or health insurance coverage other than the exclusion or coordination of benefits, an affiliation or waiting period permitted under Part 7 of ERISA, Part A of title XXVII of the PHS Act, or Chapter 100 of the Code, or applicable cost-sharing requirements.
  • Prohibition on More Restrictive Administrative Requirements. Plans and issuers may not impose an administrative requirement or limitation on benefits for out-of-network emergency services that is more restrictive than the requirements or limitations that apply to in-network emergency services.

Note, the rules regarding emergency services do not apply to Grandfathered Plans. However, other Federal and State Laws related to these patient protections may apply regardless of Grandfather Status.

Are there specific definitions for emergency medical conditions and emergency services?

In applying the rules related to emergency services, the statute and IFR define the terms emergency medical condition, emergency services and stabilize. These terms are generally defined in accordance with their meaning under the Emergency Medical Treatment and Labor Act (EMTALA). There are, however, some variances from EMTALA. One of these differences is that under PPACA, whether an individual is in an emergency medical condition is determined by reference to a prudent lay person, who possesses an average knowledge of health and medicine (rather than by reference to qualified medical personnel).

Is there model notice language around patient protection provisions?

The following model language from the IFR can be used to satisfy the notice requirements for plans and issuers that require or allow the designation of a PCP:

"[Name of group health plan or health insurance issuer] generally [requires/allows] the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. [If the plan or health insurance coverage designates a primary care provider automatically, insert: Until you make this designation, [name of group health plan or health insurance issuer] designates one for you.] For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the [plan administrator or issuer] at [insert contact information]."

For plans and issuers that require or allow for the designation of a primary care provider for a child, the following model language may be used:

"For children, you may designate a pediatrician as the primary care provider."

For plans and issuers that provide coverage for obstetric or gynecological care and require the designation by a participant or beneficiary of a PCP, the model language is as follows:

"You do not need prior authorization from [name of group health plan or issuer] or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the [plan administrator or issuer] at [insert contact information]."