Highlights
Choice of Primary Care Provider
Plans or issuers that require designation of a primary care provider must allow the participant to choose any participating primary care provider that is able to accept the participant and is in-network.
OB/GYN Care
Plans that provide coverage for ob-gyn care and require designation of an in-network primary care provider may not require preauthorization or referral for a female participant seeking ob-gyn care.
Emergency Services
Plans and issuers that provide hospital emergency room benefits must provide those benefits without requiring prior authorization, and without regard to whether the provider is in-network.
Among other reforms, the Affordable Care Act (ACA) imposes three requirements on group health plans and group or individual health insurance coverage—referred to as “patient protections”—related to:
- The choice of a health care professional; and
- Requirements relating to benefits for emergency services.
The ACA’s patient protections do not apply to grandfathered plans. Also, the rules regarding choice of health care professional apply only to plans that have a network of providers.
The ACA’s patient protection requirements took effect for plan years beginning on or after Sept. 23, 2010.
This ACA Overview provides a summary of the ACA’s three patient protection requirements.
Links and Resources
- On June 28, 2010, the Departments of Labor (DOL), Health and Human Services (HHS) and Treasury (Departments) issued interim final regulations regarding these patient protections.
- On Nov. 18, 2015, the Departments published final regulations to finalize provisions in the interim final regulations without substantial change, incorporating clarifications issued by the Departments in frequently asked questions (FAQs) and other sub-regulatory guidance.
Choice of Primary Care Provider
If a group health plan or group or individual health insurer requires a participant to designate a primary care provider, the participant must be able to choose any participating primary care provider who:
- Is able to accept the participant as a patient; and
- Participates in the plan or issuer’s network.
This includes the designation of a physician who specializes in pediatrics (including pediatric subspecialties) as the primary care provider for a child. For this purpose, the classification of who is considered a “primary care provider” is determined under the terms of the plan or coverage (and in accordance with applicable state law).
However, plans and issuers are not prohibited from applying reasonable and appropriate geographic limitations with respect to which participating primary care providers are considered “available” for purposes of selection as primary care providers, in accordance with the terms of the plan, the underlying provider contracts and applicable state law.
OB-GYN Care
Plans that provide coverage for obstetrical and/or gynecological care (OB-GYN care) and require the patient to designate an in-network primary care provider may not require preauthorization or referral for a female participant of any age seeking OB-GYN care. For this purpose, a health care professional specializing in ob-gyn is any individual who is authorized under applicable state law to provide OB-GYN care and is not limited to a physician.
However, a plan may still require the OB-GYN provider to follow any policies or procedures regarding referrals, prior authorization for treatments and the provision of services.
Notice Requirement
The plan must provide a notice informing each participant of the plan’s terms regarding primary care provider designation. The notice must be provided when a summary plan description (SPD) or other similar description of plan benefits is provided to a participant or beneficiary. The interim final rules include model language for this notice.
Emergency Services
The ACA also requires plans and health insurance issuers that provide hospital emergency room benefits to provide those benefits without requiring prior authorization, and without regard to whether the provider is an in-network provider. Also, the plan or issuer may not impose requirements or limitations on out-of-network emergency services that are more restrictive than those applicable to in-network emergency services. Cost-sharing requirements (such as copayments or coinsurance rates imposed for out-of-network emergency services) cannot exceed the cost-sharing requirements for in-network emergency services.
For this purpose, the term “emergency services” is defined under the Emergency Medical Treatment and Labor Act (EMTALA), and includes:
- An appropriate medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition exists; and
- Such further medical examination and such treatment as may be required to stabilize the medical condition.
- A plan or issuer cannot set a time limit within which to seek emergency services, and must provide coverage for any emergency services that meet the definition of “emergency services” under EMTALA.
Balance Billing
Despite this rule, out-of-network providers may bill patients for the difference between the providers’ billed charges and the amount collected from the plan or issuer and the amount collected from the patient in the form of a copayment or coinsurance amount (referred to as “balance billing”), as long as the plan or issuer has paid a reasonable amount for the services. For this purpose, a plan or issuer has paid a reasonable amount for services if it provides benefits for out-of-network emergency services in an amount equal to the greatest of the following three possible amounts:
- The median amount negotiated with in-network providers for the emergency service;
- The amount for the emergency service calculated using the same method the plan generally uses to determine payments for out-of-network services (such as the usual, customary and reasonable amount); or
- The amount that would be paid under Medicare for the emergency service (minimum payment standards).
Each of these three amounts is calculated excluding any in-network copayment or coinsurance imposed. Also, other cost-sharing requirements, such as deductibles or out-of-pocket maximums, may be imposed on out-of-network emergency services if the cost-sharing requirement generally applies to out-of-network benefits.
An FAQ clarified that this minimum payment standard was developed to protect patients from being financially penalized for obtaining emergency services on an out-of-network basis. If state law prohibits balance billing, plans and issuers are not required to satisfy the payment minimum above. Similarly, if a plan or issuer is contractually responsible for any amounts balanced billed by an out-of-network emergency services provider, the plan or issuer is not required to satisfy the payment minimum.
In both situations, however, a plan or issuer may not impose any copayment or coinsurance requirement for out-of-network emergency services that is higher than the copayment or coinsurance requirement that would apply if the services were provided in-network. In addition, a plan or issuer must provide an enrollee or beneficiary adequate and prominent notice of their lack of financial responsibility with respect to amounts balance billed in order to prevent inadvertent payment by an enrollee or beneficiary.
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