members. [If the plan or health insurance coverage designates a primary care provider Provider automatically, insert: Until you make this designation, [name of group health plan or Requirements health insurance issuer] designates one for you.] For information on how to select a (Cont’d) primary care provider, and for a list of the participating primary care providers, contact the [plan administrator or issuer] at [insert contact information].” For that require or allow for the designation of a primary care provider for a child, add: 45 CFR children, you may designate a pediatrician as the primary care provider.” 147.138(a)(4)(iii)(B) “For For plans that provide coverage for obstetric or gynecological care and require the designation by an enrollee of a primary care provider, add: 45 CFR do not need prior authorization from [name of group health plan or issuer] or from “You 147.138(a)(4)(iii)(C) any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the [plan administrator or issuer] at [insert contact information].” Right to RCW 48.43.515 (2) Does the contract or certificate of coverage permit changing primary care providers at any time, Change PCP WAC 284-43-251(1) becoming effective no later than the beginning of the month following the request? RCW 48.43.515(7) If the plan is subject to an open enrollment period, does the contract allow an enrollee whose WAC 284-43-251(5) PCP’s contract is being terminated from the plan to continue care under the terms of the contract until the end of the next open enrollment period? Continuation If the plan is not subject to an open enrollment period, does the contract allow an enrollee whose Upon PCP’s contract is being terminated from the plan to continue care under the terms of the contract
Provider Requirements (Cont’d) 45 CFR 147.138(a)(4)(iii)(B) 45 CFR 147.138(a)(4)(iii)(C) members. [If the plan or health insurance coverage designates a primary care provider automatically, insert: Until you make this designation, [name of group health plan or health insurance issuer] designates one for you.] For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the [plan administrator or issuer] at [insert contact information].” For that require or allow for the designation of a primary care provider for a child, add: “For children, you may designate a pediatrician as the primary care provider.” For plans that provide coverage for obstetric or gynecological care and require the designation by an enrollee of a primary care provider, add: “You do not need prior authorization from [name of group health plan or issuer] or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the [plan administrator or issuer] at [insert contact information].” Right to Change PCP RCW 48.43.515 (2) WAC 284-43-251(1) Does the contract or certificate of coverage permit changing primary care providers at any time, becoming effective no later than the beginning of the month following the request? Continuation Upon RCW 48.43.515(7) WAC 284-43-251(5) If the plan is subject to an open enrollment period, does the contract allow an enrollee whose PCP’s contract is being terminated from the plan to continue care under the terms of the contract until the end of the next open enrollment period? If the plan is not subject to an open enrollment period, does the contract allow an enrollee whose PCP’s contract is being terminated from the plan to continue care under the terms of the contract