42 U.S.C. § 300gg–19a — Patient protections

(a) Choice of health care professional. If a group health plan or issuer requires or allows enrollees to pick a participating primary care provider, it must let each enrollee choose any participating primary care provider who is accepting patients. (b) Coverage of emergency services. (1) In general. If a plan or issuer covers any emergency-room benefits at all, it must cover emergency services (defined below) in these ways: (A) with no need for prior authorization; (B) no matter whether the provider is in-network; (C) so that, whether the patient goes to a nonparticipating provider with or without prior authorization, (i) the plan cannot impose stricter prior-authorization rules or coverage limits on that out-of-network ER visit than it applies to in-network ER visits, and (ii) if the services are out-of-network, the patient's cost-sharing (copay or coinsurance) must be the same amount it would be in-network; and (D) without adding other conditions on coverage — except for exclusions, coordination-of-benefits rules, affiliation or waiting periods otherwise allowed by law, and normal cost-sharing. (2) Definitions. (A) "Emergency medical condition" means symptoms severe enough — including severe pain — that an average person without medical training would reasonably expect that not getting immediate care could seriously endanger the person's health, seriously impair a body function, or seriously damage a body part or organ. (B) "Emergency services" means (i) the medical screening exam required at a hospital's emergency department, including any tests the ER routinely uses to check for an emergency, and (ii) whatever further exam and treatment the hospital's staff and facilities can provide to stabilize the patient. (C) "To stabilize" has the meaning already given elsewhere in federal law for emergency care. (c) Access to pediatric care. (1) If a plan or issuer requires designating a primary care provider, and a covered child's parent wants to designate a doctor who specializes in pediatrics, the plan must allow that, as long as the pediatrician participates in the plan's network. (2) This doesn't waive any coverage exclusions that otherwise apply to pediatric care. (d) Access to obstetrical and gynecological care. (1) General rights. (A) A plan or issuer described in paragraph (2) cannot require prior authorization or a referral before a female enrollee gets obstetric or gynecological care from a participating OB/GYN specialist — though that specialist must still follow the plan's other rules, like referrals for further care or getting prior authorization for a treatment plan. (B) The plan must treat care given this way as if the primary care provider had already authorized it. (2) This applies to a plan or issuer that (A) covers OB/GYN care and (B) requires designating a primary care provider. (3) This doesn't (A) waive any coverage exclusions for OB/GYN care, or (B) stop a plan from requiring the OB/GYN provider to tell the primary care provider or the plan about treatment decisions. (e) Application. This entire section stopped applying to group health plans, issuers, and group or individual coverage for plan years beginning on or after January 1, 2022.