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What Are the Notice Requirements for a Health Plan that Requires Primary Care Provider Referrals?



QUESTION: Our group health plan has a gatekeeper feature that requires participants to coordinate their health care through a primary care provider. We understand that there is a special notice requirement if our plan has this feature. What is the notice, and when and how do we give it?

ANSWER: Group health plans that require designation of a primary care physician must provide a notice describing the plan’s requirements and the related rights of participants and beneficiaries. As background, a group health plan that requires designation of a primary care physician must permit each participant or beneficiary to designate any available participating primary care physician. For a child, it must permit designation of any available physician (allopathic or osteopathic) who specializes in pediatrics. Furthermore, a group health plan may not require preauthorization or referral (by the plan or any person, including a primary care physician) for a female participant or beneficiary seeking obstetrical or gynecological care from a participating provider who specializes in obstetrics or gynecology. Plans may include reasonable and appropriate geographic limitations when determining whether primary care providers are “available.”

The required notice must be provided to each plan participant describing the plan’s primary care physician requirement and the rights explained in the preceding paragraph. It must be provided whenever a summary plan description (SPD) or other similar description of plan benefits is provided to a participant. (See our Checkpoint Question of the Week on when to provide the SPD.) It is unclear what the phrase “similar description of plan benefits” means for this purpose. Cautious employers will want to assume an expansive meaning until this is clarified.

The agencies have provided model language that can be used to meet this notice requirement. It includes a mention of any automatic designation that may occur if a participant does not choose a primary care physician, as well as an explanation of how to obtain a list of participating primary care physicians.

For more information and to see a stand-alone Sample Notice, see EBIA’s Group Health Plan Mandates manual at Section XIII.B (“Patient Protections”). See also EBIA’s Health Care Reform manual at Section XII.B (“Patient Protections”) and EBIA’s Self-Insured Health Plans manual at Sections XI.B (“Provider Networks”) and XIII.C.6 (“Patient Protections”).

Contributing Editors: EBIA Staff.

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