Choice of Provider

Video Transcript

Explanation

ACA provides that if a group health plan, or a health insurance issuer offering group or individual health insurance coverage, requires or provides for designation of a participating primary care provider, then the plan or issuer must permit the designation of any participating primary care provider (or any participating pediatrician for child member if plan requires designation of PCP for child) who is available to accept a participant, beneficiary, or enrollee. 

In addition, plans and issuers that provide coverage for obstetrical or gynecological (ob/gyn) care, and that require the designation of a participating primary care provider, must allow direct access to ob/gyn care provided by a participating health care professional.

Aetna’s take and action

For most plans, Aetna already is in compliance with these regulations. No changes are required at this time, except that we have developed language to be included with plan documents.

Questions and answers

• Can any participating primary care provider be chosen as a primary care provider? 
• Can a plan require members to obtain a referral or prior authorization before seeking care from a participating ob-gyn provider? 
• Does this requirement apply to grandfathered group plans? 

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