For plan years beginning on or after January 1, 2014, non-grandfathered health plans may not discriminate against health care providers acting within the scope of their licenses. For example, this could prevent a plan from denying benefits solely because a doctor prescribed a drug for an off-label purpose or provided a service outside the doctor's typical specialty area (assuming both acts were within the scope of the doctor's license). The Agencies stated that this provision is self-implementing and they will not issue guidance in the near future.
ACA includes a number of provider access requirements, and regulations impose notice requirements. The following provider access rules apply to non-grandfathered plans for plan years beginning on or after September 23, 2010:
Choice of PCP
Non-grandfathered health plans can require participants to designate a primary care physician (PCP) or pediatrician, but participants of non-grandfathered plans must be permitted to designate any PCP or pediatrician participating in the plan's provider network.
Access to OB/GYN
Non-grandfathered health plans cannot require females to receive preauthorization for services from obstetricians or gynecologists.
Coverage of Emergency Services
Non-grandfathered health plans cannot require preauthorization for emergency services, limit coverage to only in-network providers, or impose higher cost sharing for emergency services from an out-of-network provider.
Note: The provider non-discrimination rule only applies to certain types of health plans, such as major medical insurance. It does not apply to HIPAA excepted benefits, such as disability, cancer, or accident insurance. Click here for more information about the types of benefits that are exempt from the ACA plan design mandates.