§1185k Other patient protections

Summary

Plans must let each person covered by a group health plan pick any participating primary care provider (PCP) who is willing to accept them. If a parent or guardian has a child on the plan, the plan must allow the parent to pick a pediatrician (a doctor who treats children) as the child’s PCP if that pediatrician is in the plan’s network. This does not change any rules the plan has about what pediatric care it does or does not pay for. If the plan covers obstetric or gynecologic care and requires people to name a PCP, women may go directly to a participating OB/GYN without getting a referral or prior okay from the plan or PCP. The OB/GYN must follow the plan’s rules about referrals, prior authorizations, and approved treatment plans, and care given this way counts as the PCP’s authorization. This does not change coverage limits the plan already has, and the plan may still require the OB/GYN to tell the PCP or the plan about treatment choices.