§9822 Other patient protections

Summary

If a group health plan makes you pick a primary care doctor, the plan must let each person choose any in-network primary care doctor who is available. If a child is on the plan, a parent or person responsible for the child can pick a pediatrician who is an MD or DO in the plan’s network. The plan’s normal coverage limits or exclusions still apply. If the plan covers obstetric or gynecologic care and it requires people to pick a primary care doctor, a woman on the plan cannot be required to get a referral or prior approval to see an in-network obstetrician/gynecologist. That OB/GYN must follow the plan’s rules (like referral or prior-authorization procedures and any approved treatment plans). Care and orders from that OB/GYN count as if the primary care doctor authorized them. The plan can still apply coverage limits and can require the OB/GYN to tell the primary care doctor or the plan about treatment.