Patient Protections

Patient Protections

by Clarke & Company Benefits Posted on: September 9, 2014Categories: 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.

Learn More about Patient Protections in our blog this Thursday!