Patient Protections

Patient Protections

by Clarke & Company Benefits Posted on: September 11, 2014Categories: HR & Compliance   

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.

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 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.

To read more about patient protections visit our blog from this past Tuesday here.