Choice of Provider/Ob-Gyn Direct Access Q&A


Can any participating primary care provider be chosen as a primary care provider?

Yes.  A plan that provides for designation of a primary care provider must allow the choice of any participating primary care provider who is available to accept the participant, beneficiary or enrollee, including pediatricians for children. 

Can a plan require members to obtain a referral or prior authorization before seeking care from a participating ob/gyn provider?

No, a plan may not require authorization or referral for a female patient to receive obstetric or gynecological care from a participating provider who specializes in obstetrics or gynecology, and must treat their authorizations as the authorization of a primary care provider.  A plan may, however, require prior authorization before providing benefits for certain services, such as a uterine fibroid embolization procedure. Also, this requirement does not affect any existing exclusions of coverage under the plan with respect to ob/gyn care.

Do plans have to comply with notice requirements related to the designation of primary care provider and the direct access requirements for ob/gyn care?

Yes.  Under the Final Interim Rules, the plan or issuer that requires or allows for designation of a PCP must provide a notice informing each participant of the terms of the plan or health insurance coverage regarding designation of a primary care provider, including designation of pediatricians for children.  In addition, plans that cover ob/gyn care and require designation of a PCP must inform each participant (in the individual market, primary subscriber) that the plan may not require authorization or referral for obstetrical or gynecological care by a participating health care professional who specializes in obstetrics or gynecology. This notice must be provided whenever the plan or issuer provides a participant with an SPD or other similar description of benefits.

Does this requirement apply to grandfathered group plans?


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