Quiero saber acerca de...

jbell on DSKJLSW7X2PROD with RULES2

Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations gynecological services from C, an out-ofnetwork provider.
2 Conclusion. In this Example 2, the group health plan has not violated the requirements of this paragraph a3 by requiring prior authorization because C
is not a participating health care provider.
C Example 31 Facts. Same facts as Example 1 paragraph a3ivA of this section except that the group health plan only requires B to inform As designated primary care physician of treatment decisions.
2 Conclusion. In this Example 3, the group health plan has not violated the requirements of this paragraph a3
because A has direct access to B without prior authorization. The fact that the group health plan requires the designated primary care physician to be notified of treatment decisions does not violate this paragraph a3.
D Example 41 Facts. A group health plan requires each participant to designate a physician to serve as the primary care provider for the participant and the participants family. The group health plan requires prior authorization before providing benefits for uterine fibroid embolization.
2 Conclusion. In this Example 4, the plan requirement for prior authorization before providing benefits for uterine fibroid embolization does not violate the requirements of this paragraph a3
because, though the prior authorization requirement applies to obstetrical services, it does not restrict access to any providers specializing in obstetrics or gynecology.
4 Notice of right to designate a primary care provideri In general. If a group health plan or health insurance issuer requires the designation by a participant, beneficiary, or enrollee of a primary care provider, the plan or issuer must provide a notice informing each participant in the individual market, primary subscriber of the terms of the plan or health insurance coverage regarding designation of a primary care provider and of the rights A Under paragraph a1i of this section, that any participating primary care provider who is available to accept the participant, beneficiary, or enrollee can be designated;
B Under paragraph a2i of this section, with respect to a child, that any participating physician who specializes in pediatrics can be designated as the primary care provider; and C Under paragraph a3i of this section, that the plan may not require authorization or referral for obstetrical or gynecological care by a participating health care professional who specializes in obstetrics or gynecology.

VerDate Sep<11>2014

20:26 Jul 12, 2021

Jkt 253001

ii Timing. In the case of a group health plan or group health insurance coverage, the notice described in paragraph a4i of this section must be included whenever the plan or issuer provides a participant with a summary plan description or other similar description of benefits under the plan or health insurance coverage. In the case of individual health insurance coverage, the notice described in paragraph a4i of this section must be included whenever the issuer provides a primary subscriber with a policy, certificate, or contract of health insurance.
iii Model language. The following model language can be used to satisfy the notice requirement described in paragraph a4i of this section:
A For plans and issuers that require or allow for the designation of primary care providers by participants, beneficiaries, or enrollees, 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.

B 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.

C For plans and issuers that provide coverage for obstetric or gynecological care and require the designation by a participant, beneficiary, or enrollee 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.

b Applicability date. The provisions of this section are applicable with respect to plan years in the individual market, policy years beginning on or after January 1, 2022.

PO 00000

Frm 00110

Fmt 4701

Sfmt 4700

36981

Subpart EHealth Care Provider, Health Care Facility, and Air Ambulance Service Provider Requirements 149.410 Balance billing in cases of emergency services.

a In general. In the case of a participant, beneficiary, or enrollee with benefits under a group health plan or group or individual health insurance coverage offered by a health insurance issuer and who is furnished emergency services for which benefits are provided under the plan or coverage with respect to an emergency medical condition with respect to a visit at an emergency department of a hospital or an independent freestanding emergency department 1 A nonparticipating emergency facility must not bill, and must not hold liable, the participant, beneficiary, or enrollee for a payment amount for such emergency services as defined in 26
CFR 54.98164Tc2, 29 CFR
2590.7164c2, and 149.110c2, as applicable that exceeds the cost-sharing requirement for such services as determined in accordance with 26 CFR
54.98164Tb3ii and iii, 29 CFR
2590.7164b3ii and iii, and 149.110b3ii and iii, as applicable.
2 A nonparticipating provider must not bill, and must not hold liable, the participant, beneficiary, or enrollee for a payment amount for an emergency service as defined in 26 CFR 54.9816
4Tc2, 29 CFR 2590.7164c2, and 149.110c2, as applicable furnished to such individual by such provider with respect to such emergency medical condition and visit for which the individual receives emergency services at the hospital or independent freestanding emergency department that exceeds the cost-sharing requirement for such service as determined in accordance with 26 CFR 54.9816
4Tb3ii and iii, 29 CFR 2590.716
4b3ii and iii, and 149.110b3ii and iii, as applicable.
b Notice and consent to be treated by a nonparticipating provider or nonparticipating emergency facility.
The requirements in paragraph a of this section do not apply with respect to items and services described in 26 CFR, 54.98164Tc2iiA, 29 CFR
2590.7164c2iiA, 149.110c2iiA, as applicable, and are not included as emergency services if all of the following conditions are met:
1 The attending emergency physician or treating provider determines that the participant,
E:FRFM13JYR2.SGM

13JYR2