Selection of primary care physician (PCP)

Requirement overview

• Members can choose their own PCP (women can choose an OB/GYN and parents can choose a pediatrician for their children), as long as the doctor is accepting patients.
• If a plan requires a PCP, then it can't require referral or authorization for a woman to seek care from an in-network OB/GYN specialist.
• The plan must provide a list of member rights with the summary plan description or summary of benefits.

What Priority Health is doing

• We have always allowed members to choose a PCP that is in the network and accepting new patients, women to choose an OB/GYN as their PCP and parents to choose a pediatrician as their child's PCP.
• We will change our plan documents to include a description of these member rights.

What you need to do

• Fully funded employers don't have to do anything to comply with this requirement.
• Our sales team will work with self-funded employers to review plan designs.
• If your plan requires employees to choose a PCP and your benefits summary does not include a notice telling employees they can choose their own PCP, you must include a notice in your annual enrollment packet. See suggested text below. 

Suggested text to use in your materials

Use this sample notice provided by the U.S. Department of Labor or your own text to meet the health reform requirement to tell all employees about changes to their health care coverage.

For plans and issuers that require or allow for the designation of primary care providers by  participants or beneficiaries, insert:

[Name of group health plan or health insurance issuer] generally [requires/allows] the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. [If the plan or health insurance coverage designates a primary care provider automatically, insert: Until you make this designation, [name of group health plan or health insurance issuer] designates one for you.] For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the [plan administrator or issuer] at [insert contact information].

For plans and issuers that require or allow for the designation of a primary care provider for a child, add:

For children, you may designate a pediatrician as the primary care provider.

For plans and issuers that provide coverage for obstetric or gynecological care and require the designation by a participant or beneficiary of a primary care provider, add:

You do not need prior authorization from [name of group health plan or issuer] or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the [plan administrator or issuer] at [insert contact information].

Source: U.S. Department of Labor