Provider Access
Health Care Reform includes a number of provider access requirements, and regulations impose notice requirements. The following provider access rules apply to non-grandfathered plans for plan years beginning on or after September 23, 2010:
Choice of PCP
Non-grandfathered plans can require participants to designate a primary care physician (PCP) or pediatrician, but participants of non-grandfathered plans must be permitted to designate any PCP or pediatrician participating in the plan's provider network.
Access to OB/GYN
Non-grandfathered plans cannot require females to receive preauthorization for services from obstetricians or gynecologists.
Coverage of Emergency Services
Non-grandfathered plans cannot require preauthorization for emergency services, limit coverage to only in-network providers, or impose higher cost-sharing for emergency services from an out-of-network provider.
Note: The provider access requirements only apply to certain types of health plans, such as major medical insurance. They do not apply to HIPAA excepted benefits, such as disability, cancer, hospital indemnity, or accident insurance. Click here for more information about the types of benefits that are exempt from the Health Care Reform plan design mandates.
-
Additional Resources
-
Notice Requirements
Summary of provider access notice requirements
-
Model Notice
Model provider access notices
-
Prohibition on Provider Discrimination
Additional provider requirement that applies beginning in 2014
-
American Fidelity Assurance Company does not provide tax or legal advice.
