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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations coverage under the terms and conditions of the plan or health insurance coverage with respect to coverage of pediatric care.
iii Examples. The rules of this paragraph a2 are illustrated by the following examples:
A Example 11 Facts. A group health plans HMO designates for each participant a physician who specializes in internal medicine to serve as the primary care provider for the participant and any beneficiaries. Participant A
requests that Pediatrician B be designated as the primary care provider for As child. B is a participating provider in the HMOs network and is available to accept the child.
2 Conclusion. In this Example 1, the HMO must permit As designation of B
as the primary care provider for As child in order to comply with the requirements of this paragraph a2.
B Example 21 Facts. Same facts as Example 1 paragraph a2iiiA of this section, except that A takes As child to B for treatment of the childs severe shellfish allergies. B wishes to refer As child to an allergist for treatment. The HMO, however, does not provide coverage for treatment of food allergies, nor does it have an allergist participating in its network, and it therefore refuses to authorize the referral.
2 Conclusion. In this Example 2, the HMO has not violated the requirements of this paragraph a2 because the exclusion of treatment for food allergies is in accordance with the terms of As coverage.
3 Patient access to obstetrical and gynecological carei General rights A Direct access. A group health plan, or a health insurance issuer offering group health insurance coverage, described in paragraph a3ii of this section, may not require authorization or referral by the plan, issuer, or any person including a primary care provider in the case of a female participant or beneficiary who seeks coverage for obstetrical or gynecological care provided by a participating health care professional who specializes in obstetrics or gynecology. In such a case, the plan or issuer must comply with the rules of paragraph a4 of this section by informing each participant 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. The plan or issuer may require such a professional to agree to otherwise adhere to the plans or issuers policies and procedures, including procedures regarding referrals and obtaining prior
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authorization and providing services pursuant to a treatment plan if any approved by the plan or issuer. For purposes of this paragraph a3, a health care professional who specializes in obstetrics or gynecology is any individual including a person other than a physician who is authorized under applicable State law to provide obstetrical or gynecological care.
B Obstetrical and gynecological care. A group health plan or health insurance issuer described in paragraph a3ii of this section must treat the provision of obstetrical and gynecological care, and the ordering of related obstetrical and gynecological items and services, pursuant to the direct access described under paragraph a3iA of this section, by a participating health care professional who specializes in obstetrics or gynecology as the authorization of the primary care provider.
ii Application of paragraph. A group health plan, or a health insurance issuer offering group health insurance coverage, is described in this paragraph a3 if the plan or issuer A Provides coverage for obstetrical or gynecological care; and B Requires the designation by a participant or beneficiary of a participating primary care provider.
iii Construction. Nothing in paragraph a3i of this section is to be construed to A Waive any exclusions of coverage under the terms and conditions of the plan or health insurance coverage with respect to coverage of obstetrical or gynecological care; or B Preclude the group health plan or health insurance issuer involved from requiring that the obstetrical or gynecological provider notify the primary care health care professional or the plan or issuer 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
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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.
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 or beneficiary 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 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
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