Patient Protections

Patient Protections

by Posted on: January 20, 2015Categories: HR & Compliance   

Among other reforms, the Affordable Care Act (ACA) imposes three requirements on group health plans and group or individual health insurance coverage that are referred to as “patient protections.” These patient protections relate to the choice of a health care professional and requirements relating to benefits for emergency services, and became effective for plan years beginning on or after Sept. 23, 2010.

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.

On June 28, 2010, the Departments of Health and Human Services (HHS), Labor and the Treasury issued interim final rules regarding these health plan coverage mandates.

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. This rule includes the designation of a pediatrician as the primary care provider for a child.

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.


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 seeking ob-gyn care. 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.

The plan must inform each participant of these rules and must provide the notice when an SPD or other similar description of plan benefits is provided to a participant or beneficiary. Model language for this notice is included in the interim final rules.

Emergency Services

The ACA places additional requirements on plans and health insurance issuers that provide hospital emergency room benefits. Plans and issuers must 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.

Despite this rule, out-of-network providers may balance bill patients, as long as the plan or issuer has paid a reasonable amount for the services. The interim final rules provide that 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 amount negotiated with in-network providers for the emergency service furnished;
  • The amount for the emergency service calculated using the same method the plan generally uses to determine payments for out-of-network services, but substituting the in-network cost-sharing provisions for the out-of-network cost-sharing provisions; or
  • The amount that would be paid under Medicare for the emergency service.

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.


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