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What Are the Notice Requirements for a Plan That Requires Primary Care Provider Referrals?


Question: Our group health plan has a gatekeeper feature that requires participants to coordinate their health care through a primary care provider. We understand that there’s a special notice requirement if our plan has this feature. What is the notice, and when and how do we give it?

Answer: Group health plans that require designation of a primary care physician must:

  • Provide a notice describing the plan’s requirements and the related rights of participants and beneficiaries, and
  • Permit each participant or beneficiary to designate any available participating primary care physician.

For a child, it must permit designation of any available physician (allopathic or osteopathic) who specializes in pediatrics. Furthermore, a group health plan may not require preauthorization or a referral (by the plan or any person, including a primary care physician) for a female participant or beneficiary seeking obstetrical or gynecological care from a participating provider who specializes in obstetrics or gynecology. Plans may include reasonable and appropriate geographic limitations when determining whether primary care providers are “available.”

Employers must provide each plan participant with the required notice, describing the plan’s primary care physician requirement and the rights explained in the preceding paragraph. Such notice must be provided whenever a summary plan description or other similar description of plan benefits is provided to a participant. 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 agencies have provided model language that you can use to meet this notice requirement. It includes a mention of any automatic designation that may occur if a participant doesn’t choose a primary care physician, as well as an explanation of how to obtain a list of participating primary care physicians. Contact your benefits advisor to obtain the language and further discuss the matter.



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