§9822 Other Patient Protections

Summary

If a group health plan makes you pick a participating primary care doctor, the plan must let each person choose any participating primary care doctor who is available to take them. If the plan requires picking a primary care doctor for a child, a parent may choose a pediatrician (a medical doctor or doctor of osteopathy who specializes in children) as the child’s primary care doctor, as long as that pediatrician is in the plan’s network. This does not change what the plan does or does not cover for pediatric care. When a plan covers obstetric or gynecologic care and also requires picking a primary care doctor, a female participant may see a participating OB/GYN directly without needing the plan or a primary care doctor to give prior approval or a referral. The OB/GYN must follow the plan’s rules (for example, about referrals, prior approvals, or treatment plans). The OB/GYN’s care counts as if the primary care doctor authorized it. The plan can still apply its normal coverage rules and may require the OB/GYN to tell the primary care doctor or the plan about treatment.