by James A. Woehlke, Esq., CPA
General Counsel / COO, MBL Benefits Consulting Corp.
The Patient Protection and Affordable Care Act (the ACA*) was enacted on March 23, 2010. The ACA identifies certain patient protections which need to be incorporated into new plans. These protections are not required for grandfathered plans. The Administration issued guidance on this (and several other) requirement(s) in the form of interim final regulations on June 28, 2010.
The ACA-mandated patient protections relate to selection of one’s personal health care provider and certain emergency services. The requirements regarding choice of health care providers apply only for nongrandfathered plans that participate in a network of providers.
There are three requirements relating to provider choice. First, if the plan participates in a network, the enrollee must be notified of the plan provisions regarding selection of a primary care doctor and must be permitted to select from any of the network providers who are available, that is, taking on new patients. The same notice requirement and selection rights pertain to the identification of a pediatrician for children. Regarding OB/GYN services, the participant must be permitted to select her own OB/GYN and not be required to use one selected for her. Also, OB/GYN services are deemed to be services of a primary care physician.
If a plan provides for emergency services, they may no longer require prior authorization for emergency services. The carrier may not require that emergency services be provided by an in-network provider. There may not be any additional administrative requirement or limitation on benefits that is more restrictive for in-network emergency care than out-of-network care. Also, there may not be a different cost-sharing (co-pay, deductible, etc.) for in-network and out-of-network emergency care. Out-of-network providers may, however, bill the patient for any amount not paid by the carrier. That being said, to avoid abuse, the regulations require that the carriers pay a “reasonable amount” before the patient becomes liable for any balance due. A reasonable amount per the regulations is the greater of
- the in-network amount that would have been paid for the services,
- the amount that would usually be paid for out-of-network services but substituting in-network cost-sharing provisions for the out-of-network provisions, and
- what Medicare would pay for the emergency services.
If you have questions about the new patient protection requirements, please contact your MBL Benefits consultant or the author at firstname.lastname@example.org.
* For simplicity, the Patient Protection and Affordable Care Act and the Health Care and Education Affordability Reconciliation Act are collectively referred to as the Affordable Care Act, or ACA.
Additional resources available at
Official publication of interim final regulations on patient protections: http://www.federalregister.gov/articles/2010/06/28/2010-15278/patient-protection-and-affordable-care-act-preexisting-condition-exclusions-lifetime-and-annual