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Can Our Plan Require Preauthorization for OB/GYN Services?

04.22.2015

?????????????????????????????????????????Question: Our company’s self-insured group health plan requires preauthorization for certain obstetrical and gynecological (OB/GYN) services. Is this plan design permissible under the patient protection provisions of the Affordable Care Act (ACA)?

Answer: Yes, so long as the preauthorization requirement applies to specific OB/GYN services and doesn’t restrict access to any providers specializing in obstetrics or gynecology.

The ACA’s patient protections require a choice of health care professionals, including OB/GYN providers. A group health plan may not require preauthorization or referral by the plan or any person, including a primary care physician, when a female participant or beneficiary seeks OB/GYN care provided by a participating provider who specializes in obstetrics or gynecology (which may include nonphysician health care professionals authorized under state law to provide OB/GYN care).

However, a plan may require that all other plan policies and procedures be followed, including obtaining preauthorization for certain services. For example, a plan could require preauthorization for a particular service — uterine fibroid embolization, for instance — so long as it doesn’t restrict access to any participating providers specializing in OB/GYN.

Present_RonTo discuss your health care plan strategy, contact Ron Present, Partner and Health Care Industry Group Leader, at 314.983.1358 or rpresent@bswllc.com

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