ER Access & Doctor Choice

The Affordable Care Act helps preserve your choice of doctors by guaranteeing that you can choose the primary care doctor or pediatrician you want from your health plan’s provider network. It guarantees that you can see an OB-GYN doctor without needing a referral from another doctor. The law also ensures that you can seek emergency care at a hospital outside your plan’s network without prior approval from your health plan.

What This Means for You

  • You select the doctor: The new rules permit you to choose any available participating primary care provider as your doctor and to choose any available participating pediatrician as your child’s primary care doctor.
  • No health plan barriers to OB-GYN services: The new rules also prohibit health plans from requiring a referral from a primary care provider before you can seek coverage for obstetrical or gynecological (OB-GYN) care from a participating OB-GYN specialist.
  • Access to out-of-network emergency room services: In the past, some health plans would limit payment for emergency room services provided outside of a plan’s preselected network of emergency health care providers. Or they would require you to get your plan’s prior approval for emergency care at hospitals outside its networks. This could mean financial hardship if you get sick or injured while away from home. The new rules prevent health plans from requiring higher copayments or co-insurance for out-of-network emergency room services. The new rules also prohibit health plans from requiring you to get prior approval before seeking emergency room services from a provider or hospital outside your plan’s network.

Some Important Details

  • These rules apply to all group health plans and individual health insurance policies created or issued after March 23, 2010.
  • These rules do not apply to “grandfathered health plans.”
  • If your health plan or health insurance policy was created or issued after March 23, 2010, your plan will be affected as soon as it begins a new “plan year” or “policy year” on or after September 23, 2010.
  • Please note that you still may be responsible for the difference between the amount billed by the provider for out-of-network emergency room services and the amount paid by your health plan.

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