Voglio sapere a riguardo di…

jbell on DSKJLSW7X2PROD with RULES2

Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations professional or the plan of treatment decisions.
iv Examples. The rules of this paragraph a3 are illustrated by the following examples:
A Example 11 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. Participant A, a female, requests a gynecological exam with Physician B, an in-network physician specializing in gynecological care. The group health plan requires prior authorization from As designated primary care provider for the gynecological exam.
2 Conclusion. In this Example 1, the group health plan has violated the requirements of this paragraph a3
because the plan requires prior authorization from As primary care provider prior to obtaining gynecological services.
B Example 21 Facts. Same facts as Example 1 paragraph a3ivA of this section except that A seeks 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.

VerDate Sep<11>2014

20:26 Jul 12, 2021

Jkt 253001

4 Notice of right to designate a primary care provideri In general. If a group health plan requires the designation by a participant or beneficiary of a primary care provider, the plan must provide a notice informing each participant of the terms of the plan 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 or beneficiary 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.
ii Timing. In the case of a group health plan, the notice described in paragraph a4i of this section must be included whenever the plan provides a participant with a summary plan description or other similar description of benefits under the plan.
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 that require or allow for the designation of primary care providers by participants or beneficiaries, insert:
Name of group health plan 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 designates a primary care provider automatically, insert: Until you make this designation, name of group health plan 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 at insert contact information.

B For plans 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 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 from any other person including a primary care
PO 00000

Frm 00088

Fmt 4701

Sfmt 4700

36959

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 at insert contact information.

b Applicability date. The provisions of this section are applicable with respect to plan years beginning on or after January 1, 2022.
Department of Labor Employee Benefits Security Administration 29 CFR Chapter XXV
For the reasons set forth in the preamble, the Department of Labor amends 29 CFR part 2590 as set forth below:
PART 2590RULES AND
REGULATIONS FOR GROUP HEALTH
PLANS.
9. The authority citation for part 2590
is revised to read as follows:

Authority: 29 U.S.C. 1027, 1059, 1135, 11611168, 1169, 11811183, 1181 note, 1185, 1185an, 1191, 1191a, 1191b, and 1191c; sec. 101g, Pub. L.104191, 110 Stat.
1936; sec. 401b, Pub. L. 105200, 112 Stat.
645 42 U.S.C. 651 note; sec. 512d, Pub. L.
110343, 122 Stat. 3881; sec. 1001, 1201, and 1562e, Pub. L. 111148, 124 Stat. 119, as amended by Pub. L. 111152, 124 Stat. 1029;
Division M, Pub. L. 113235, 128 Stat. 2130;
Pub. L. 116260 134 Stat. 1182; Secretary of Labors Order 12011, 77 FR 1088 Jan. 9, 2012.

10. Section 2590.7152719A is amended by revising paragraph c to read as follows:

2590.7152719A

Patient protections.

c Applicability date. The provisions of this section are applicable to group health plans and health insurance issuers for plan years beginning before January 1, 2022. See also 2590.716
4 through 2590.7167, 2590.7171, and 2590.722 of this part for rules applicable with respect to plan years beginning on or after January 1, 2022.
Subpart D Redesignated as Subpart E
11. Redesignate subpart D as subpart E and add a new subpart D to read as follows:

E:FRFM13JYR2.SGM

13JYR2