Patient Protections

(Note : For the next few weeks, Health Reform Talk will focus on detailed explanations for specific provisions in the new health reform law.)

So what’s included in Sec. 10101(h) of the Affordable Care Act, concerning patient protections?

Group and individual health insurance plans must allow plan enrollees to select, when the plan requires it, any primary care provider that participates in the plan’s network.

Pediatric care access. An individual or group health plan that requires enrollees to designate a primary care physician (PCP) must allow parents or legal guardians of a child enrollee to designate a physician who specializes in pediatric care as the child’s PCP if that physician participates in the plan’s network. This provision does not waive any exclusions of coverage under the terms and conditions of the plan or health insurance coverage with respect to coverage of pediatric care.

OB/GYN specialist. Plans must allow female enrollees to obtain OB/GYN specialist services without seeking a PCP referral. The OB/GYN specialist must adhere to the health plan’s or insurer’s policies and procedures for referrals and prior authorization and provide services according to a treatment plan approved by the plan or insurer. For a plan or insurance policy that covers OB/GYN services and that requires an enrollee to designate a PCP, provision of OB/GYN care and related services will be treated the same as authorization of the PCP. However, the plan or insurer’s terms and conditions for OB/GYN coverage still apply and the plan or insurer may require the OB/GYN to notify the patient’s PCP of treatment decisions.

Coverage of emergency services. When services are provided in an emergency services department of a hospital, emergency services must be covered:

(1) without any required prior authorization;

(2) regardless of whether or not the provider participates in the plan’s network; and

(3) nonparticipating provider services must be covered without any limitations and in the same manner, with the same cost-sharing requirements, as coverage for emergency services from a participating provider.

Effective date. This provision is effective for plan years beginning on or after Sept. 23, 2010 (six months after the date of enactment).

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