New Health Law

women2.tif (399388 bytes) New Health Law for Women

FACTS: Direct Access

Allows Direct Access to visit your OB-GYN without a referral or prior approval

A new Illinois law allows you to designate an obstetrician-gynecologist (ob-gyn) in your insurance plan as your woman's "principal health care provider."

In the last few years, there have been many changes in the way health care is delivered, Managed care plans, such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs), have emerged, bringing with them new and different rules and regulations which govern our care.

Recently, a new law was passed which clears the obstacles some managed care plans had placed between women and their doctors of choice. The law was passed at the urging of the Illinois Section of the American College of Obstetricians and Gynecologists (ACOG) and the Illinois State Medical Society (ISMS).

If you designate Dr. Vijaya Arekapudi in our office (who is in your insurance plan) as your principal health care provider, the plan must allow direct access to Dr. Vijaya Arekapudi without the need for a referral or prior approval.

Senate Bill 1246 took effect on November 14, 1996. This law allows women covered by managed care plans to go directly to their ob-gyn without having to obtain referrals or prior authorization. The ob-gyn must be a participating provider in the managed care plan. A 1993 Gallup Poll found that women who had a physical examination in the previous two years were more likely to have been examined by their ob-gyn than any other type of doctor. The majority of these women consider their ob-gyn to be their primary care physician.

Before this law was enacted, many women with managed care insurance plans wishing to receive obstetric or gynecologic care had to first see their primary care or "gatekeeper" physician who coordinated the patient's care. The gatekeeper would have to make a referral to the ob-gyn physician after receiving prior authorization from the plan. The new law allows women who are asked to select a gatekeeper to also choose an ob-gyn, or woman's principal health care provider. This means that the female patient will have direct access to both the gatekeeper and the woman's principal health care provider. Further, both the gatekeeper and the woman's principal health care provider have the authority to make referrals for additional care if needed, provided the guidelines set by the health plan's benefit package are followed.

Please note your plan may require prior authorization or approval for referrals for additional care/services.

If a woman chooses not to select a principal health care provider, referrals will typically be necessary to receive obstetric or gynecologic services that the primary care physician is not authorized to provide under the plan. All referrals should continue to be covered and paid as they are now.

The creation of this law empowers women with a greater voice in their health care decisions. It protects the rights of a patient to choose a physician who will work with her to ensure all medical needs are appropriately met. This law applies to all health insurance an managed care plans including governmental plans and Medicaid. If you have questions about how this will affect you, ask your doctor.

	The new law asserts that individual or group accident and health insurance policies, as well as managed care plans in Illinois, must allow female enrollees or insureds to designate a participating woman's principal health care provider.
	The plan must give its insureds or enrollees direct access (i.e., patient self referral) to that woman's principal health care provider, without imposing prior approval or referral requirements for access.
	The law defines a woman's principal health care provider as a physician licensed to practice medicine in all of its branches, specializing in obstetrics/gynecology. The law stipulates that the woman's principal health care provider must be a participating provider in the plan.
	Physicians serving as a woman's principal health care provider can refer their patients within the plan for specialty care or additional services without sending patients back to a primary care gatekeeper. However, principal health care providers must meet any plan requirement for prior authorization or approval when referring patients for such additional services.
	Any Illinois individual or group policy of accident and health insurance or a managed care plan amended, issued, delivered or renewed after November 14, 1996 must comply with this new law. This includes Medicaid; the State of Illinois employees' health plan; health plans of counties, municipalities and other governmental bodies; and ERISA-exempt employee or employee or employer organization.
	The law does not require patients to select a woman's principal health care provider. Consequently, patients may choose a single physician to serve both as the woman's principal health care provider and primary care gatekeeper. Alternately, patients are free to choose two separate physicians to fulfill those distinct roles.
	The new law defines a managed care entity as "any entity including a licensed insurance company, hospital or medical service plan, HMO, limited health service organization, PPO, third party administrator, an employer or employee organization, or any person or entity that establishes, operates or maintains a network of participating providers," A managed care plan is a plan operated by a managed care entity that provides for the financing of health care services to persons enrolled in the plan.