§1185k Other Patient Protections

Summary

If a group health plan or its insurer requires you to pick a primary care doctor, you must be allowed to choose any in‑network primary care doctor who is available. If a child on the plan needs a primary care doctor, the 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 any limits the plan already has on paying for pediatric care. If the plan covers obstetric or gynecologic care and it requires you to pick a primary care doctor, a female plan member can see an in‑network obstetrician‑gynecologist without getting a referral or prior approval from the plan, the insurer, or the primary care doctor. The OB‑GYN must follow the plan’s rules, and any tests or services the OB‑GYN orders count as if the primary care doctor approved them. This does not change coverage limits, and the plan may still require the OB‑GYN to tell the primary care doctor or the plan about treatment decisions.