§9822 Other Patient Protections

Summary

Group health plans that let or require people to pick a primary care doctor must allow each person to choose any in-network primary care provider who will accept them. If a covered child needs a primary care doctor, a parent may choose a pediatrician in the plan’s network. Letting someone choose a provider does not change what the plan will pay for; any coverage limits or exclusions still apply. If a plan covers obstetric or gynecologic care and requires a primary care doctor, women can see an in-network OB/GYN without getting a referral or prior authorization from the plan or their primary doctor. The OB/GYN must follow the plan’s rules (such as prior authorization or approved treatment plans). The plan must treat that direct visit as if the primary care doctor approved it, and it may require the OB/GYN to notify the primary doctor or the plan about care given.