§ 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 that requires
or provides for the designation by a covered person of a participating primary healthcare
professional shall permit each covered person to:
(i) Designate any participating primary care healthcare 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 healthcare professional and is available to accept the child.
(2) The provisions of subsection (b)(1) of this section 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 healthcare professional, then it:
(i) Shall not require any person's, including a primary care healthcare 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 healthcare professional
who specializes in obstetrics or gynecology; and
(ii) Shall treat the provision of obstetrical and gynecological care, and the ordering
of related obstetrical and gynecological items and services, pursuant to subsection
(c)(1)(i) of this section, by a participating healthcare professional who specializes
in obstetrics or gynecology as the authorization of the primary care healthcare professional.
(2)(i) 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 healthcare 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.
(ii) For purposes of subsection (c)(1)(i) of this section, a healthcare 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 subsection (c)(1)(i) of this section shall not be construed to:
(i) 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
(ii) 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 healthcare professional providing obstetrical
or gynecological care notify the primary care healthcare 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 healthcare professional
and of a covered person's rights with respect to those provisions.
(2)(i) In the case of group health insurance coverage, the notice described in subsection
(d)(1) of this section 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.
(ii) In the case of individual health insurance coverage, the notice described in subsection
(d)(1) of this section shall be included whenever the primary subscriber is provided
with a policy, certificate, or contract of health insurance.
(iii) 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 C.F.R. §â€‚147.138(a)(4)(iii) to satisfy the requirements of this subsection (d).
(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.