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.)