Regulators test health reform exam standards

If a plan uses a primary care doctor as a gatekeeper, PPACA requires the plan to let a family use a pediatrician as the gatekeeper doctor for a child.

PPACA also requires a plan with a primary care gatekeeper to let women get obstetric and gynecological (ob/gyn) care without first getting referrals from primary care doctors.

The drafters have described the documents that an examiner should review, such as training materials, complaint logs and internal grievance files. The drafters have also described the procedures and criteria examiners should use when reviewing the materials.

The criteria sections include examiner notes. The drafters state in one, for example, that a health carrier can require an ob/gyn care provider to respect policy coverage exclusions and to tell the primary care doctor about treatment decisions.

See also: What should regulators ask about PPACA plans?