Health Reform Action Center
Ob-Gyn Direct Access
ACA includes an ob-gyn direct access mandate. This is the first nationwide ob-gyn direct access health insurance standard. The scope of the new mandate - at least initially - is narrow, applying only to new health plans that formed after ACA passed and not to plans already operating prior to ACA. This means that women who had insurance coverage prior to the enactment of ACA won’t have direct access, UNLESS their State already has a direct access law. For new plans post-ACA, the direct access mandate went into effect beginning in the first full plan year after September 2010.
Heath plans in existence prior to ACA, so-called “grandfathered” plans, do not have to comply with the ob-gyn direct access mandate UNLESS the insurer makes a change to its policies, in which case it loses its grandfathered status. It is expected that, over time, most “grandfathered” plans will lose their grandfathered status and therefore will be required to comply with the ob-gyn direct access mandate.
43 States already have ob-gyn direct access requirements. These are still in effect. In many States, the mandates are more rigorous than ACA and include specific provisions designed to ensure that women have meaningful access and compel insurer compliance. For example, State mandates specify no age restriction, no restriction on choice of provider, no additional cost-sharing, require adequate numbers of participating ob-gyns in each plan, and prohibit limits on the number of visits and services. The ACA mandate does not include these patient protections. An interim rule issued by HHS in the fall of 2010 also failed to adopt these tested and proven patient protections already in place in most states.
ACOG supports federal and state ob-gyn direct access mandates. A national standard would guarantee that all women in all plans can self-refer directly to the ob-gyn of their choice for the full range of ob-gyn care without costly and burdensome delays. A national standard is necessary because most state mandates do not apply to self-insured plans which in some states are the major insurer.
Read ACOG’s comment letter on the HHS interim rule implementing the ob-gyn direct access mandate. This rule, issued by HHS in the fall of 2010, failed to adopt tested and proven patient protections already in place under most State direct access laws. This is an ongoing concern.
States will need to monitor health plan compliance with the direct access mandate.