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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations
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 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, 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.

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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 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
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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 beginning on or after January 1, 2022.
Department of Health and Human Services 45 CFR Subtitle A, Subchapter B
For the reasons stated in the preamble, the Department of Health and Human Services amends 45 CFR parts 144, 147, 149, and 156 as set forth below:
PART 144REQUIREMENTS
RELATING TO HEALTH INSURANCE
COVERAGE
12. The authority citation for part 144
is revised to read as follows:

Authority: 42 U.S.C. 300gg through 300gg 63, 300gg91, 300gg92, and 300gg111
through 300gg139, as amended.

13. Section 144.101 is amended by:
a. Redesignating paragraphs d and e as paragraphs e and f, respectively; and b. Adding new paragraph d.
The addition reads as follows:

144.101

d Part 149 of this subchapter implements the provisions of parts D
and E of title XXVII of the PHS Act that apply to group health plans, health insurance issuers in the group and individual markets, health care providers and facilities, and providers of air ambulance services.

14. Section 144.102 is revised to read as follows:
Scope and applicability.

a For purposes of 45 CFR parts 144
through 149, all health insurance coverage is generally divided into two marketsthe group market and the individual market. The group market is further divided into the large group market and the small group market.
b The protections afforded under 45
CFR parts 144 through 149 to individuals and employers and other sponsors of health insurance offered in connection with a group health plan are determined by whether the coverage involved is obtained in the small group market, the large group market, or the individual market.
c Coverage that is provided to associations, but not related to employment, and sold to individuals is not considered group coverage under 45

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144.103

Definitions.

For purposes of parts 146 group market, 147 group and individual market, 148 individual market, 149
surprise billing and transparency, and 150 enforcement of this subchapter, the following definitions apply unless otherwise provided:

Basis and purpose.

144.102

CFR parts 144 through 149. If the coverage is offered to an association member other than in connection with a group health plan, the coverage is considered individual health insurance coverage for purposes of 45 CFR parts 144 through 149. The coverage is considered coverage in the individual market, regardless of whether it is considered group coverage under state law. If the health insurance coverage is offered in connection with a group health plan as defined at 45 CFR
144.103, it is considered group health insurance coverage for purposes of 45
CFR parts 144 through 149.
d Provisions relating to CMS
enforcement of parts 146, 147, 148, and 149 are contained in part 150 of this subchapter.
15. Section 144.103 is amended by revising the introductory text to read as follows:

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PART 147HEALTH INSURANCE
REFORM REQUIREMENTS FOR THE
GROUP AND INDIVIDUAL HEALTH
INSURANCE MARKETS
16. The authority citation for part 147
is revised to read as follows:

Authority: 42 U.S.C. 300gg through 300gg 63, 300gg91, 300gg92, and 300gg111
through 300gg139, as amended, and section 3203, Pub. L. 116136, 134 Stat. 281.

17. Section 147.138 is amended by revising paragraph c to read as follows:

147.138

Patient protections.

c Applicability date. The provisions of this section are applicable to group health plans and health insurance issuers for plan years in the individual market, policy years beginning before January 1, 2022. See also subparts B and D of part 149 of this subchapter for rules applicable with respect to plan years in the individual market, policy years beginning on or after January 1, 2022.
18. Add part 149 to read as follows:
PART 149SURPRISE BILLING AND
TRANSPARENCY REQUIREMENTS
Subpart AGeneral Provisions Sec.
149.10 Basis and scope.
149.20 Applicability.

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