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5
LEGAL DISCLAIMER:
Information contained in this publication is not legal advice, and
should not be construed as legal advice. If you need legal advice upon which you can rely,
you should seek a legal opinion from your attorney.
Patient Protections –
Reforms That DO NOT Apply To Grandfathered
Plans
The regulations also address reforms that DO NOT apply to grandfathered plans:
choose a primary care provider or a pediatrician when a plan or issuer
requires designation of a primary care physician;
obtain obstetrical or gynecological care without prior authorization.
plan providing emergency services must do so without the individual or the
health care provider having to
obtain prior authorization (even if the
emergency services are provided out of network) and without regard to
whether the health care provider furnishing the emergency services is an in-
network provider with respect to the services.
Concluding Thought
Trustees and Plan professionals now have more guidance on the roadmap to
compliance. Since collectively bargained plans do not have a delayed effective date
for many reforms, the regulations provide help in determining what amendments
must be made to the health plan to bring it into compliance and also provides
valuable help in the new notice requirements on rescissions and annual/lifetime
limits. Hopefully, the regulations defining “essential health benefits” will be issued
soon and fill-in a vital, missing
piece of the puzzle.
We will keep you updated as
new information is posted.
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