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Wednesday, September 22, 2010

Choosing Your Own Provider—New Protections for Kids and Adults

Finding the right health care professional to provide primary care can be a challenge—we’re all looking for the right balance of expertise, compassion, communication skills, and availability.  So no one likes it when an insurance company steps in to limit our choice when it comes to picking an available primary care provider.  One of the new protections added by the Affordable Care Act, and going into effect for new plans this month, aims to ensure choice of providers—and it includes special safeguards for children.

Some health plans require enrollees to choose a primary care provider (PCP) who serves as a gatekeeper for other types of care; to see a specialist or get certain tests, enrollees need to get the approval of the PCP.  Under the new law, new plans (though not grandfathered plans) that have this requirement must allow enrollees to choose any PCP who participates in the plan and who is available to take new patients.  Under the Patients’ Bill of Rights regulations, plans must notify enrollees of this right.  This prevents insurance companies from limiting the choice of PCP to a subset of their network providers. 

For children, all participating pediatricians (who are taking new patients) must be available as choices for a child’s PCP.  This is an important provision for children as regular pediatric care has been proven to improve child health outcomes, avert preventable health care costs, and limit delays in care.  Moreover, parents want to be able to choose a pediatrician they trust.  A way to take this important advance one step further would be to include pediatric subspecialists in the definition of pediatricians that can be designated as a primary care provider. 

For some children with serious chronic conditions, pediatric subspecialists can provide children with their routine and ongoing care as well as needed specialty treatment. This improves continuity of care for the child and the ease of receiving treatment for the family.  A family with a child who is receiving cancer treatment, for example, could designate their pediatric oncologist as the PCP for their child.   Families should be afforded the ability to designate these kinds of clinicians as the primary care provider if they choose.

The choice of health care professionals helps to shift control over care to consumers and away from insurance companies.  Together with the other provisions that take effect September 23, it adds valuable protections that will benefit millions of Americans immediately and millions more as health care reform is fully phased in over the next four years.    



This post was written by The Center for Children and Families (CCF), an independent, nonpartisan policy and research center whose mission is to expand and improve health coverage for America's children and families.  CCF is based at Georgetown University's Health Policy Institute.  Find out more at or read our blog at