26 U.S.C. § 9822 — Other patient protections

(a) Choice of health care professional. If a group health plan^* requires or allows a participant or beneficiary to designate a participating primary-care provider, the plan must allow each participant and beneficiary to designate any participating primary-care provider who is available and willing to accept that person.

(b) Access to pediatric care. (1) If a person has a child who is a participant or beneficiary under a group health plan, and the plan requires or allows the child to designate a participating primary-care provider, the plan must allow the person to designate an allopathic or osteopathic physician who specializes in pediatrics as the child’s primary-care provider if that physician participates in the plan’s network. (2) Nothing in paragraph (1) waives any exclusion of coverage under the plan’s terms and conditions for pediatric care.

(c) Patient access to obstetrical and gynecological care. (1)(A) Direct access. A group health plan described in paragraph (2) may not require authorization or a referral by the plan, issuer, or any person, including a primary-care provider described in paragraph (2)(B), when a female participant or beneficiary seeks covered obstetrical or gynecological care from a participating health care professional who specializes in obstetrics or gynecology. The professional must otherwise follow the plan’s policies and procedures, including referral and prior-authorization procedures and any treatment plan approved by the plan. (B) The plan must treat that professional’s obstetrical or gynecological care, and the ordering of related obstetrical and gynecological items and services, under the direct access in subparagraph (A) as the primary-care provider’s authorization. (2) This paragraph applies to a group health plan that provides coverage for obstetric or gynecologic care and requires a participant or beneficiary to designate a participating primary-care provider. (3) Nothing in paragraph (1) waives any exclusion of coverage under the plan’s terms and conditions for obstetrical or gynecological care, or prevents the group health plan from requiring the obstetrical or gynecological provider to notify the primary-care health care professional or the plan or issuer of treatment decisions.