Notice Requirement:If a group health plan requires the designation by a participant or beneﬁciary of a primary care provider, the plan must provide a notice informing each participant of the terms of the plan or health insurance coverage regarding designation of a primary care provider; that any participating primary care provider who is available to accept the participant or beneﬁciary can be designated. Including obstetrical or gynecological care by a participating health care professional who specializes in obstetrics or gynecology. This notice must be provided anytime the plan provides a participant with an SPD or other similar description of beneﬁts under the plan.
Note: Effective for plan years beginning on or after September 23, 2010; applies non-grandfathered plans only.
Choice of Healthcare Professional
Non-grandfathered health plans must allow flexibility when requiring the designation of a primary care provider.
A plan that requires a participant to designate a participating primary care provider (PCP) must permit each participant to designate any participating primary care provider (PCP) who is available to accept the participant.
For a plan that requires the designation of a participating primary care provider (PCP) for a child by a participant, the plan must permit the participant to designate a physician (allopathic or osteopathic) who specializes in pediatrics as the child's primary care provider (PCP) if the provider participates in the network of the plan and is available to accept the child.
A group health plan that provides obstetrical or gynecological (OB/GYN) care and requires the designation of an in-network primary care provider, may not require authorization or referral by the plan, or any person (including a primary care provider) for a female participant who seeks coverage for OB/GYN care provided by a participating health care professional who specializes in obstetrics and gynecology. (This includes any individual authorized under State law to provide OB/GYN care, including a person other than a physician).
This specific provision is mostly relevant for fully-insured plans as a majority of self-funded plans do not require the designation of a PCP.
Non-grandfathered health plans are required to cover out-of-network emergency services similar to network emergency services.
If the emergency services are provided out-of-network, the plan must provide the emergency services without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from network providers.
A plan must provide coverage for emergency services without the need for any prior authorization determination, even if the emergency services are provided on an out-of-network basis.
A plan must provide coverage for emergency services without regard to whether the health care provider furnishing the emergency services is a participating network provider with respect to the services.
Any cost-sharing requirement expressed as a copayment amount or coinsurance rate imposed with respect to a participant for out-of-network emergency services cannot exceed the cost-sharing requirement imposed with respect to a participant or beneﬁciary if the services were provided in-network. However, a participant may be required to pay, in addition to the in-network cost sharing, the excess of the amount the out-of-network provider charges over the amount the plan is required to pay (balance-billed charges).
A plan must provide coverage for emergency services without regard to any other term or condition of the coverage, other than the exclusions or coordination of beneﬁts, an afﬁliation or waiting period, or applicable cost sharing.
A plan complies with these requirements if it provides beneﬁts with respect to an emergency service in an amount equal to the greatest of the following three amounts (which are adjusted for in-network cost-sharing requirements):
The amount negotiated with in-network providers for the emergency service furnished, excluding any in-network copayment or coinsurance imposed.
The amount for the emergency service calculated using the same method the plan generally uses to determine payments for out-of-network services (such as the usual, customary, and reasonable amounts), excluding any in-network copayment or coinsurance imposed.
The amount that would be paid under Medicare for the emergency service, excluding any in-network copayment or coinsurance imposed.
TIP: Any other cost-sharing requirement, such as a deductible or out-of-pocket maximum, may be imposed with respect to out-of-network emergency services only if the cost-sharing requirement generally applies to out-of-network beneﬁts.