PRIA, Government Policy, Made Personal

Summary

If your group health plan requires you to pick a primary care provider, it must let you choose any participating provider who is available to accept you. For a child covered by the plan, a parent can pick a participating physician who specializes in pediatrics as the child's primary care provider. A woman does not need a referral or prior authorization to get obstetrical or gynecological care from a participating professional who specializes in that field; the plan must treat that visit as if her primary care provider had authorized it. The plan keeps its normal coverage exclusions, and it can require the OB/GYN to notify the primary care provider or the plan about treatment decisions.

Title 26, §9822

Internal Revenue Code, Source: USLM XML via OLRC

(a)If a group health plan requires or provides for designation by a participant or beneficiary of a participating primary care provider, then the plan shall permit each participant and beneficiary to designate any participating primary care provider who is available to accept such individual.

(b)(1)In the case of a person who has a child who is a participant or beneficiary under a group health plan if the plan requires or provides for the designation of a participating primary care provider for the child, the plan shall permit such person to designate a physician (allopathic or osteopathic) who specializes in pediatrics as the child’s primary care provider if such provider participates in the network of the plan.

(2)Nothing in paragraph (1) shall be construed to waive any exclusions of coverage under the terms and conditions of the plan with respect to coverage of pediatric care.

(c)(1)(A)A group health plan described in paragraph (2) may not require authorization or referral by the plan, issuer, or any person (including a primary care provider described in paragraph (2)(B)) in the case of a female participant or beneficiary who seeks coverage for obstetrical or gynecological care provided by a participating health care professional who specializes in obstetrics or gynecology. Such professional shall agree to otherwise adhere to such plan’s policies and procedures, including procedures regarding referrals and obtaining prior authorization and providing services pursuant to a treatment plan (if any) approved by the plan.

(B)A group health plan described in paragraph (2) shall treat the provision of obstetrical and gynecological care, and the ordering of related obstetrical and gynecological items and services, pursuant to the direct access described under subparagraph (A), by a participating health care professional who specializes in obstetrics or gynecology as the authorization of the primary care provider.

(2)A group health plan described in this paragraph is a group health plan that—

(A)provides coverage for obstetric or gynecologic care; and

(B)requires the designation by a participant or beneficiary of a participating primary care provider.

(3)Nothing in paragraph (1) shall be construed to—

(A)waive any exclusions of coverage under the terms and conditions of the plan with respect to coverage of obstetrical or gynecological care; or

(B)preclude the group health plan involved from requiring that the obstetrical or gynecological provider notify the primary care health care professional or the plan or issuer of treatment decisions.

Notes & Related Subsidiaries

Statutory Notes and Related Subsidiaries

Effective Date

Section applicable with respect to plan years beginning on or after Jan. 1, 2022, see section 102(e) of div. BB of Pub. L. 116–260, set out as an

Effective Date

of 2020 Amendment note under section 8902 of Title 5, Government Organization and Employees.

§9822 Other Patient Protections

Summary

Title 26, §9822

Notes & Related Subsidiaries

Statutory Notes and Related Subsidiaries

Effective Date

Effective Date

Citations & Metadata