Must Our Group Plan Provide Notice of its Primary Care Physician Gatekeeper Requirement?

Question: Our group health plan has a gatekeeper feature that requires participants to designate and coordinate covered health care through a primary care physician. Do we have any special notice requirements associated with this plan requirement?

Answer: Yes, group health plans that require designation of a primary care physician (PCP) must provide a notice describing the requirement and certain related rights. The Affordable Care Act (ACA) established new patient protections, which took effect starting with plan years beginning on or after Sept. 23, 2010, that apply when group health plans (or health insurers) require a PCP to function as a gatekeeper to covered care.

Offer a choice

Group health plans that require designation of a PCP must permit each participant or beneficiary to designate any available participating PCP. For a child enrolled in such a plan, the plan must permit any available physician (allopathic or osteopathic) who specializes in pediatrics to be designated.

Furthermore, a group health plan may not require preauthorization or referral by the plan or any person, including a PCP, for a female participant or beneficiary to obtain obstetrical or gynecological care from a participating provider who specializes in obstetrics or gynecology.

Provide notice

A notice must be provided to each plan participant describing the plan’s PCP requirement and participants’ and beneficiaries’ rights to:

  • Designate any participating PCP who’s available to accept the participant or beneficiary,
  • Choose, for any participant or beneficiary that’s a child, a PCP who’s a pediatrician, and
  • Receive obstetrical or gynecological care without preauthorization or referral.

The notice is required to be provided whenever a summary plan description or other similar description of plan benefits is provided to a participant or beneficiary. It’s unclear what the phrase “similar description of plan benefits” means for this purpose. Cautious employers will want to assume an expansive meaning until this is clarified.

The Department of Labor (DOL) offers a standalone model of the required notice here. It contains suggested language and some additional background information in the agency’s own words.

Be absolutely sure

If you choose to use the DOL’s model notice — or particularly if you modify it or draft your own language — ask your legal and benefits advisors to review the document before sending it out. Otherwise, you risk not fully complying with this little-discussed ACA requirement.

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