TITLE 27
Insurance
CHAPTER 27-18
Accident and Sickness Insurance Policies
SECTION 27-18-44
§ 27-18-44 Primary and preventive
obstetric and gynecological care.
(a) Any insurer or health plan, nonprofit health medical service plan, or
nonprofit hospital service plan that provides coverage for obstetric and
gynecological care for issuance or delivery in the state to any group or
individual on an expense-incurred basis, including a health plan offered or
issued by a health insurance carrier or a health maintenance organization,
shall permit a woman to receive an annual visit to an in-network
obstetrician/gynecologist for routine gynecological care without requiring the
woman to first obtain a referral from a primary care provider.
(b)(1)(A) Any health plan, nonprofit medical service plan or
nonprofit hospital service plan, including a health insurance carrier or a
health maintenance organization which requires or provides for the designation
by a covered person of a participating primary health care professional shall
permit each covered person to:
(i) Designate any participating primary care health care
professional who is available to accept the covered person; and
(ii) For a child, designate any participating physician who
specializes in pediatrics as the child's primary care health care professional
and is available to accept the child.
(2) The provisions of subdivision (1) of this subsection
shall not be construed to waive any exclusions of coverage under the terms and
conditions of the health benefit plan with respect to coverage of pediatric
care.
(c)(1) If a health plan, nonprofit medical service plan or
nonprofit hospital service plan, including a health insurance carrier or a
health maintenance organization, provides coverage for obstetrical or
gynecological care and requires the designation by a covered person of a
participating primary care health care professional, then it:
(A) Shall not require any person's, including a primary care
health care professional's, prior authorization or referral in the case of a
female covered person who seeks coverage for obstetrical or gynecological care
provided by a participating health care professional who specializes in
obstetrics or gynecology; and
(B) Shall treat the provision of obstetrical and
gynecological care, and the ordering of related obstetrical and gynecological
items and services, pursuant to subdivision (A) of this subdivision (c)(1), by
a participating health care professional who specializes in obstetrics or
gynecology as the authorization of the primary care health care professional.
(2)(A) A health plan, nonprofit medical service plan or
nonprofit hospital service plan, including a health insurance carrier or a
health maintenance organization may require the health care professional to
agree to otherwise adhere to its policies and procedures, including procedures
relating to referrals, obtaining prior authorization, and providing services in
accordance with a treatment plan, if any, approved by the plan, carrier or
health maintenance organization.
(B) purposes of subdivision (A) of this subdivision (c)(1), a
health care professional, who specializes in obstetrics or gynecology, means
any individual, including an individual other than a physician, who is
authorized under state law to provide obstetrical or gynecological care.
(3) The provisions of subdivision (A) of this subdivision
(c)(1) shall not be construed to:
(A) Waive any exclusions of coverage under the terms and
conditions of the health benefit plan with respect to coverage of obstetrical
or gynecological care; or
(B) Preclude the health plan, nonprofit medical service plan
or nonprofit hospital service plan, including a health insurance carrier or a
health maintenance organization involved from requiring that the participating
health care professional providing obstetrical or gynecological care notify the
primary care health care professional or the plan, carrier or health
maintenance organization of treatment decisions.
(d) Notice Requirements:
(1) A health plan, nonprofit medical service plan or
nonprofit hospital service plan, including a health insurance carrier or a
health maintenance organization subject to this section shall provide notice to
covered persons of the terms and conditions of the plan related to the
designation of a participating health care professional and of a covered
person's rights with respect to those provisions.
(2)(A) In the case of group health insurance coverage, the
notice described in subdivision (1) of this subsection shall be included
whenever the a participant is provided with a summary plan description or other
similar description of benefits under the health benefit plan.
(B) In the case of individual health insurance coverage, the
notice described in subdivision (1) of this subsection shall be included
whenever the primary subscriber is provided with a policy, certificate or
contract of health insurance.
(C) A health plan, nonprofit medical service plan or
nonprofit hospital service plan, including a health insurance carrier or a
health maintenance organization, may use the model language in federal
regulation 45 CFR § 147.138(a)(4)(iii) to satisfy the requirements of this
subsection.
(e) The requirements of subsections (b), (c), and (d) shall
not apply to grandfathered health plans. This section shall not apply to
insurance coverage providing benefits for: (1) hospital confinement indemnity;
(2) disability income; (3) accident only; (4) long term care; (5) Medicare
supplement; (6) limited benefit health; (7) specified disease indemnity; (8)
sickness or bodily injury or death by accident or both; and (9) other limited
benefit policies.
History of Section.
(P.L. 1997, ch. 166, § 1; P.L. 1997, ch. 174, § 1; P.L. 2012, ch.
256, § 3; P.L. 2012, ch. 262, § 3.)
