42 U.S.C. § 300gg–19a: Patient protections

Summary

Health plans and insurance companies must let each covered person pick any participating primary care doctor who will accept them. If a plan covers hospital emergency care, it must pay for emergency services without needing prior approval and whether the doctor is in-network or not. If emergency care is out-of-network, the patient’s copay or coinsurance must be the same as if the care were in-network. Parents can choose a pediatrician as their child’s primary care doctor if that pediatrician is in the plan’s network. Women can see a participating obstetrician/gynecologist directly for OBGYN care without a referral, and that specialist’s orders count as the primary care provider’s approval. Providers must follow the plan’s usual rules, and allowed exceptions include coverage exclusions, coordination of benefits, waiting periods, and normal cost-sharing. These rules do not apply to plan years beginning on January 1, 2022. Definitions — emergency medical condition: serious, sudden symptoms a reasonable person would think need immediate care; emergency services: the ER screening and the treatment needed to evaluate and stabilize the patient; stabilize: the legal standard for making the patient no longer in immediate danger.

Title 42, §300gg–19a

The Public Health and Welfare, Source: USLM XML via OLRC

(a)Choice of health care professional

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

(b)Coverage of emergency services

(1)In general

If a group health plan, or a health insurance issuer offering group or individual health insurance issuer, provides or covers any benefits with respect to services in an emergency department of a hospital, the plan or issuer shall cover emergency services (as defined in paragraph (2)(B))—

(A)without the need for any prior authorization determination;

(B)whether the health care provider furnishing such services is a participating provider with respect to such services;

(C)in a manner so that, if such services are provided to a participant, beneficiary, or enrollee—

(i)by a nonparticipating health care provider with or without prior authorization; or

(ii)(I)such services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the providing of services that is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan; and

(II)if such services are provided out-of-network, the cost-sharing requirement (expressed as a copayment amount or coinsurance rate) is the same requirement that would apply if such services were provided in-network;

(D)without regard to any other term or condition of such coverage (other than exclusion or coordination of benefits, or an affiliation or waiting period, permitted under section 2701 of this Act, section 1181 of title 29, or section 9801 of title 26, and other than applicable cost-sharing).

(2)Definitions

In this subsection: (A) Emergency medical condition

(B)Emergency services

The term “emergency services” means, with respect to an emergency medical condition—

(i)a medical screening examination (as required under section 1395dd of this title) that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition, and

(ii)within the capabilities of the staff and facilities available at the hospital, such further medical examination and treatment as are required under section 1395dd of this title to stabilize the patient.

(C)Stabilize

The term “to stabilize”, with respect to an emergency medical condition (as defined in subparagraph (A)), has the meaning give in section 1395dd(e)(3) of this title.

(c)Access to pediatric care

(1)Pediatric care

In the case of a person who has a child who is a participant, beneficiary, or enrollee under a group health plan, or health insurance coverage offered by a health insurance issuer in the group or individual market, if the plan or issuer requires or provides for the designation of a participating primary care provider for the child, the plan or issuer 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 or issuer.

(2)Construction

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

(d)Patient access to obstetrical and gynecological care

(1)General rights

(A)Direct access

A group health plan, or health insurance issuer offering group or individual health insurance coverage, 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, beneficiary, or enrollee 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 or issuer’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 or issuer.

(B)Obstetrical and gynecological care

A group health plan or health insurance issuer 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)Application of paragraph (3) Construction

A group health plan, or health insurance issuer offering group or individual health insurance coverage, described in this paragraph is a group health plan or coverage that—

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

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

(e)Application

The provisions of this section shall not apply with respect to a group health plan, health insurance issuers, or group or individual health insurance coverage with respect to plan years beginning on or on January 1, 2022.

Notes & Related Subsidiaries

Editorial Notes

References in Text

section 2701 of this Act, referred to in subsec. (b)(1)(D), is a reference to section 2701 of act

July 1, 1944. section 2701, which was classified to section 300gg of this title, was renumbered section 2704, effective for plan years beginning on or after Jan. 1, 2014, with certain exceptions, and amended, by Pub. L. 111–148, title I, §§ 1201(2), 1563(c)(1), formerly § 1562(c)(1), title X, § 10107(b)(1), Mar. 23, 2010, 124 Stat. 154, 264, 911, and was transferred to section 300gg–3 of this title. A new section 2701 of act

July 1, 1944, related to fair health insurance premiums, was added, effective for plan years beginning on or after Jan. 1, 2014, and amended, by Pub. L. 111–148, title I, § 1201(4), title X, § 10103(a), Mar. 23, 2010, 124 Stat. 155, 892, and is classified to section 300gg of this title. Codification Pub. L. 111–148, which directed amendment of subpart II of part A of “title XVIII” of act

July 1, 1944, by inserting section 2719A after section 2719, was executed by making the insertion in subpart II of part A of title XXVII of the Act, to reflect the probable intent of Congress.

Amendments

2020—Subsec. (e). Pub. L. 116–260 added subsec. (e).

Statutory Notes and Related Subsidiaries

Effective Date

of 2020 AmendmentAmendment by Pub. L. 116–260 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 a note under section 8902 of Title 5, Government Organization and Employees.

§300gg–19a Patient Protections