{"identifier":"/us/usc/t42/s300gg\u201319a","title":42,"num":"\u00a7\u202f300gg\u201319a.","heading":"Patient protections","text":"\u00a7\u202f300gg\u201319a.\nPatient protections\n(a)\nChoice of health care professional\nIf a group health plan, or a health insurance issuer offering group or individual health insurance coverage, requires or provides for designation by a participant, beneficiary, or enrollee of a participating primary care provider, then the plan or issuer shall permit each participant, beneficiary, and enrollee to designate any participating primary care provider who is available to accept such individual.\n(b)\nCoverage of emergency services\n(1)\nIn general\nIf a group health plan, or a health insurance issuer offering group or individual health insurance issuer,\n(A) without the need for any prior authorization determination;\n(B) whether the health care provider furnishing such services is a participating provider with respect to such services;\n(C) in a manner so that, if such services are provided to a participant, beneficiary, or enrollee\u2014\n(i) by a nonparticipating health care provider with or without prior authorization; or\n(ii)\n(I) such services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the providing of services that is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan; and\n(II) if such services are provided out-of-network, the cost-sharing requirement (expressed as a copayment amount or coinsurance rate) is the same requirement that would apply if such services were provided in-network;\n2\n2 So in original. The word \u201cand\u201d probably should appear.\n(D) without regard to any other term or condition of such coverage (other than exclusion or coordination of benefits, or an affiliation or waiting period, permitted under section 2701\n3\n3 See References in Text note below.\nsection 1181 of title 29\nsection 9801 of title 26\n(2)\nDefinitions\nIn this subsection:\n(A)\nEmergency medical condition\nThe term \u201cemergency medical condition\u201d means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in clause (i), (ii), or (iii) of\nsection 1395dd(e)(1)(A) of this title\n(B)\nEmergency services\nThe term \u201cemergency services\u201d means, with respect to an emergency medical condition\u2014\n(i) a medical screening examination (as required under\nsection 1395dd of this title\n(ii) within the capabilities of the staff and facilities available at the hospital, such further medical examination and treatment as are required under\nsection 1395dd of this title\n(C)\nStabilize\nThe term \u201cto stabilize\u201d, with respect to an emergency medical condition (as defined in subparagraph (A)), has the meaning give\n4\n4 So in original. Probably should be \u201cgiven\u201d.\nsection 1395dd(e)(3) of this title\n(c)\nAccess to pediatric care\n(1)\nPediatric care\nIn the case of a person who has a child who is a participant, beneficiary, or enrollee under a group health plan, or health insurance coverage offered by a health insurance issuer in the group or individual market, if the plan or issuer requires or provides for the designation of a participating primary care provider for the child, the plan or issuer shall permit such person to designate a physician (allopathic or osteopathic) who specializes in pediatrics as the child\u2019s primary care provider if such provider participates in the network of the plan or issuer.\n(2)\nConstruction\nNothing in paragraph (1) shall be construed to waive any exclusions of coverage under the terms and conditions of the plan or health insurance coverage with respect to coverage of pediatric care.\n(d)\nPatient access to obstetrical and gynecological care\n(1)\nGeneral rights\n(A)\nDirect access\nA group health plan, or health insurance issuer offering group or individual health insurance coverage, described in paragraph (2) may not require authorization or referral by the plan, issuer, or any person (including a primary care provider described in paragraph (2)(B)) in the case of a female participant, beneficiary, or enrollee who seeks coverage for obstetrical or gynecological care provided by a participating health care professional who specializes in obstetrics or gynecology. Such professional shall agree to otherwise adhere to such plan\u2019s or issuer\u2019s policies and procedures, including procedures regarding referrals and obtaining prior authorization and providing services pursuant to a treatment plan (if any) approved by the plan or issuer.\n(B)\nObstetrical and gynecological care\nA group health plan or health insurance issuer described in paragraph (2) shall treat the provision of obstetrical and gynecological care, and the ordering of related obstetrical and gynecological items and services, pursuant to the direct access described under subparagraph (A), by a participating health care professional who specializes in obstetrics or gynecology as the authorization of the primary care provider.\n(2)\nApplication of paragraph\nA group health plan, or health insurance issuer offering group or individual health insurance coverage, described in this paragraph is a group health plan or coverage that\u2014\n(A) provides coverage for obstetric or gynecologic care; and\n(B) requires the designation by a participant, beneficiary, or enrollee of a participating primary care provider.\n(3)\nConstruction\nNothing in paragraph (1) shall be construed to\u2014\n(A) waive any exclusions of coverage under the terms and conditions of the plan or health insurance coverage with respect to coverage of obstetrical or gynecological care; or\n(B) preclude the group health plan or health insurance issuer involved from requiring that the obstetrical or gynecological provider notify the primary care health care professional or the plan or issuer of treatment decisions.\n(e)\nApplication\nThe provisions of this section shall not apply with respect to a group health plan, health insurance issuers, or group or individual health insurance coverage with respect to plan years beginning on or on\n5\n5 So in original.\nJanuary 1, 2022","url":"https://projectusc.org/usc/t42/s300gg\u201319a.html","content":[{"t":"sec","id":"/us/usc/t42/s300gg\u201319a","children":[{"t":"num","text":"\u00a7\u202f300gg\u201319a."},{"t":"heading","text":"Patient protections"},{"t":"subsec","id":"/us/usc/t42/s300gg\u201319a/a","children":[{"t":"num","text":"(a)"},{"t":"heading","text":"Choice of health care professional"},{"t":"content","children":[{"t":"p","text":"If a group health plan, or a health insurance issuer offering group or individual health insurance coverage, requires or provides for designation by a participant, beneficiary, or enrollee of a participating primary care provider, then the plan or issuer shall permit each participant, beneficiary, and enrollee to designate any participating primary care provider who is available to accept such individual.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s300gg\u201319a/b","children":[{"t":"num","text":"(b)"},{"t":"heading","text":"Coverage of emergency services"},{"t":"para","id":"/us/usc/t42/s300gg\u201319a/b/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"In general"},{"t":"chapeau","text":"If a group health plan, or a health insurance issuer offering group or individual health insurance issuer,","children":[{"t":"ref","text":"1"},{"t":"num","text":"1","tail":"\u202fSo in original. Probably should be \u201ccoverage,\u201d."},{"t":"text","text":"\u202fSo in original. Probably should be \u201ccoverage,\u201d.","tail":" provides or covers any benefits with respect to services in an emergency department of a hospital, the plan or issuer shall cover emergency services (as defined in paragraph (2)(B))\u2014"}]},{"t":"subpara","id":"/us/usc/t42/s300gg\u201319a/b/1/A","children":[{"t":"num","text":"(A)"},{"t":"content","text":" without the need for any prior authorization determination;","tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s300gg\u201319a/b/1/B","children":[{"t":"num","text":"(B)"},{"t":"content","text":" whether the health care provider furnishing such services is a participating provider with respect to such services;","tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s300gg\u201319a/b/1/C","children":[{"t":"num","text":"(C)"},{"t":"chapeau","text":" in a manner so that, if such services are provided to a participant, beneficiary, or enrollee\u2014"},{"t":"clause","id":"/us/usc/t42/s300gg\u201319a/b/1/C/i","children":[{"t":"num","text":"(i)"},{"t":"content","text":" by a nonparticipating health care provider with or without prior authorization; or","tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s300gg\u201319a/b/1/C/ii","children":[{"t":"num","text":"(ii)"},{"t":"subclause","id":"/us/usc/t42/s300gg\u201319a/b/1/C/ii/I","children":[{"t":"num","text":"(I)"},{"t":"content","text":" such services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the providing of services that is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan; and","tail":"\n"}],"tail":"\n"},{"t":"subclause","id":"/us/usc/t42/s300gg\u201319a/b/1/C/ii/II","children":[{"t":"num","text":"(II)"},{"t":"content","text":" if such services are provided out-of-network, the cost-sharing requirement (expressed as a copayment amount or coinsurance rate) is the same requirement that would apply if such services were provided in-network;\u202f","children":[{"t":"ref","text":"2"},{"t":"num","text":"2","tail":"\u202fSo in original. The word \u201cand\u201d probably should appear."},{"t":"text","text":"\u202fSo in original. The word \u201cand\u201d probably should appear."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s300gg\u201319a/b/1/D","children":[{"t":"num","text":"(D)"},{"t":"content","text":" without regard to any other term or condition of such coverage (other than exclusion or coordination of benefits, or an affiliation or waiting period, permitted under section 2701\u202f","children":[{"t":"ref","text":"3"},{"t":"num","text":"3","tail":"\u202fSee References in Text note below."},{"t":"text","text":"\u202fSee References in Text note below.","tail":" of this Act, "},{"t":"ref","text":"section 1181 of title 29","href":"/us/usc/t29/s1181","tail":", or "},{"t":"ref","text":"section 9801 of title 26","href":"/us/usc/t26/s9801","tail":", and other than applicable cost-sharing)."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s300gg\u201319a/b/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Definitions"},{"t":"chapeau","text":"In this subsection:"},{"t":"subpara","id":"/us/usc/t42/s300gg\u201319a/b/2/A","children":[{"t":"num","text":"(A)"},{"t":"heading","text":"Emergency medical condition"},{"t":"content","children":[{"t":"p","text":"The term \u201cemergency medical condition\u201d means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in clause (i), (ii), or (iii) of ","children":[{"t":"ref","text":"section 1395dd(e)(1)(A) of this title","href":"/us/usc/t42/s1395dd/e/1/A","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s300gg\u201319a/b/2/B","children":[{"t":"num","text":"(B)"},{"t":"heading","text":"Emergency services"},{"t":"chapeau","text":"The term \u201cemergency services\u201d means, with respect to an emergency medical condition\u2014"},{"t":"clause","id":"/us/usc/t42/s300gg\u201319a/b/2/B/i","children":[{"t":"num","text":"(i)"},{"t":"content","text":" a medical screening examination (as required under ","children":[{"t":"ref","text":"section 1395dd of this title","href":"/us/usc/t42/s1395dd","tail":") that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition, and"}],"tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s300gg\u201319a/b/2/B/ii","children":[{"t":"num","text":"(ii)"},{"t":"content","text":" within the capabilities of the staff and facilities available at the hospital, such further medical examination and treatment as are required under ","children":[{"t":"ref","text":"section 1395dd of this title","href":"/us/usc/t42/s1395dd","tail":" to stabilize the patient."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s300gg\u201319a/b/2/C","children":[{"t":"num","text":"(C)"},{"t":"heading","text":"Stabilize"},{"t":"content","children":[{"t":"p","text":"The term \u201cto stabilize\u201d, with respect to an emergency medical condition (as defined in subparagraph (A)), has the meaning give\u202f","children":[{"t":"ref","text":"4"},{"t":"num","text":"4","tail":"\u202fSo in original. Probably should be \u201cgiven\u201d."},{"t":"text","text":"\u202fSo in original. Probably should be \u201cgiven\u201d.","tail":" in "},{"t":"ref","text":"section 1395dd(e)(3) of this title","href":"/us/usc/t42/s1395dd/e/3","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s300gg\u201319a/c","children":[{"t":"num","text":"(c)"},{"t":"heading","text":"Access to pediatric care"},{"t":"para","id":"/us/usc/t42/s300gg\u201319a/c/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"Pediatric care"},{"t":"content","children":[{"t":"p","text":"In the case of a person who has a child who is a participant, beneficiary, or enrollee under a group health plan, or health insurance coverage offered by a health insurance issuer in the group or individual market, if the plan or issuer requires or provides for the designation of a participating primary care provider for the child, the plan or issuer shall permit such person to designate a physician (allopathic or osteopathic) who specializes in pediatrics as the child\u2019s primary care provider if such provider participates in the network of the plan or issuer.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s300gg\u201319a/c/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Construction"},{"t":"content","children":[{"t":"p","text":"Nothing in paragraph (1) shall be construed to waive any exclusions of coverage under the terms and conditions of the plan or health insurance coverage with respect to coverage of pediatric care.","tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s300gg\u201319a/d","children":[{"t":"num","text":"(d)"},{"t":"heading","text":"Patient access to obstetrical and gynecological care"},{"t":"para","id":"/us/usc/t42/s300gg\u201319a/d/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"General rights"},{"t":"subpara","id":"/us/usc/t42/s300gg\u201319a/d/1/A","children":[{"t":"num","text":"(A)"},{"t":"heading","text":"Direct access"},{"t":"content","children":[{"t":"p","text":"A group health plan, or health insurance issuer offering group or individual health insurance coverage, described in paragraph (2) may not require authorization or referral by the plan, issuer, or any person (including a primary care provider described in paragraph (2)(B)) in the case of a female participant, beneficiary, or enrollee who seeks coverage for obstetrical or gynecological care provided by a participating health care professional who specializes in obstetrics or gynecology. Such professional shall agree to otherwise adhere to such plan\u2019s or issuer\u2019s policies and procedures, including procedures regarding referrals and obtaining prior authorization and providing services pursuant to a treatment plan (if any) approved by the plan or issuer.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s300gg\u201319a/d/1/B","children":[{"t":"num","text":"(B)"},{"t":"heading","text":"Obstetrical and gynecological care"},{"t":"content","children":[{"t":"p","text":"A group health plan or health insurance issuer described in paragraph (2) shall treat the provision of obstetrical and gynecological care, and the ordering of related obstetrical and gynecological items and services, pursuant to the direct access described under subparagraph (A), by a participating health care professional who specializes in obstetrics or gynecology as the authorization of the primary care provider.","tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s300gg\u201319a/d/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Application of paragraph"},{"t":"chapeau","text":"A group health plan, or health insurance issuer offering group or individual health insurance coverage, described in this paragraph is a group health plan or coverage that\u2014"},{"t":"subpara","id":"/us/usc/t42/s300gg\u201319a/d/2/A","children":[{"t":"num","text":"(A)"},{"t":"content","text":" provides coverage for obstetric or gynecologic care; and","tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s300gg\u201319a/d/2/B","children":[{"t":"num","text":"(B)"},{"t":"content","text":" requires the designation by a participant, beneficiary, or enrollee of a participating primary care provider.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s300gg\u201319a/d/3","children":[{"t":"num","text":"(3)"},{"t":"heading","text":"Construction"},{"t":"chapeau","text":"Nothing in paragraph (1) shall be construed to\u2014"},{"t":"subpara","id":"/us/usc/t42/s300gg\u201319a/d/3/A","children":[{"t":"num","text":"(A)"},{"t":"content","text":" waive any exclusions of coverage under the terms and conditions of the plan or health insurance coverage with respect to coverage of obstetrical or gynecological care; or","tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s300gg\u201319a/d/3/B","children":[{"t":"num","text":"(B)"},{"t":"content","text":" preclude the group health plan or health insurance issuer involved from requiring that the obstetrical or gynecological provider notify the primary care health care professional or the plan or issuer of treatment decisions.","tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s300gg\u201319a/e","children":[{"t":"num","text":"(e)"},{"t":"heading","text":"Application"},{"t":"content","children":[{"t":"p","text":"The provisions of this section shall not apply with respect to a group health plan, health insurance issuers, or group or individual health insurance coverage with respect to plan years beginning on or on\u202f","children":[{"t":"ref","text":"5"},{"t":"num","text":"5","tail":"\u202fSo in original."},{"t":"text","text":"\u202fSo in original.","tail":" "},{"t":"text","text":"January 1, 2022","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"text","text":"\n"},{"t":"text","text":"\n"}]}]}