§300gg–117 Other Patient Protections

Summary

If a health plan or insurance policy asks you to pick a primary care doctor, it must let each person choose any in-network primary care provider who is available to take them. If a child is covered and the plan requires a primary care choice, the parent or guardian may pick a participating pediatrician as the child’s primary care doctor. These rules do not change what the plan normally excludes from coverage. If a plan covers obstetrics or gynecology and it requires a primary care doctor, a woman can see a participating OB/GYN without getting a referral or prior OK from the plan or her primary doctor. The OB/GYN must follow the plan’s rules (such as prior-authorization steps or approved treatment plans). The plan will treat care given this way as if the primary care doctor authorized it. The plan can still require the OB/GYN to tell the primary doctor or the plan about treatment, and coverage limits still apply.