Voglio sapere a riguardo di…

jbell on DSKJLSW7X2PROD with RULES2

36980

Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations
ii Construction. Nothing in paragraph a1i of this section is to be construed to prohibit the application of reasonable and appropriate geographic limitations with respect to the selection of primary care providers, in accordance with the terms of the plan or coverage, the underlying provider contracts, and applicable State law.
iii Example. The rules of this paragraph a1 are illustrated by the following example:
A Facts. A group health plan requires individuals covered under the plan to designate a primary care provider. The plan permits each individual to designate any primary care provider participating in the plans network who is available to accept the individual as the individuals primary care provider. If an individual has not designated a primary care provider, the plan designates one until the individual has made a designation. The plan provides a notice that satisfies the requirements of paragraph a4 of this section regarding the ability to designate a primary care provider.
B Conclusion. In this Example, the plan has satisfied the requirements of paragraph a of this section.
2 Designation of pediatrician as primary care provideri In general. If a group health plan, or a health insurance issuer offering group or individual health insurance coverage, requires or provides for the designation of a participating primary care provider for a child by a participant, beneficiary, or enrollee, the plan or issuer must permit the participant, beneficiary, or enrollee to designate a physician allopathic or osteopathic who specializes in pediatrics including pediatric subspecialties, based on the scope of that providers license under applicable State law as the childs primary care provider if the provider participates in the network of the plan or issuer and is available to accept the child. In such a case, the plan or issuer must comply with the rules of paragraph a4 of this section by informing each participant in the individual market, primary subscriber of the terms of the plan or health insurance coverage regarding designation of a pediatrician as the childs primary care provider.
ii Construction. Nothing in paragraph a2i of this section is to be construed to waive any exclusions of 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:

VerDate Sep<11>2014

20:26 Jul 12, 2021

Jkt 253001

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 or individual 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, beneficiary, or enrollee 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 in the individual market, primary subscriber 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 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
PO 00000

Frm 00109

Fmt 4701

Sfmt 4700

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 or individual 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, beneficiary, or enrollee 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 provider prior to obtaning gynecological services.
B Example 21 Facts. Same facts as Example 1 paragraph a3ivA of this section except that A seeks
E:FRFM13JYR2.SGM

13JYR2