August 27, 2010 

Office of Consumer Information and Insurance Oversight 

Department of Health and Human Services 

Attention: OCIIO–9994–IFC 

P.O. Box 8016 

Baltimore, MD 21244–1850 

Subject: Comments on Interim Final Regulations Relating to Preexisting Condition 

 Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections 

On behalf of the members of the American College of Nurse-Midwives (ACNM), I am 

submitting the following comments in response to the U.S. Department of Health and Human 

Services (HHS) proposed interim-final rule dated June 28, 2010. ACNM wishes to make 

specific comments relating to Section 2719A regarding new patient protections authorized by the 

Affordable Care Act (ACA). 

D. PHS Act Section 2719A, Patient Protections (26 CFR 54.9815–2719AT, 29 CFR 

2590.715–2719A, 45 CFR 147.138) 

Per the interim final regulation, Section 2719A of the Public Health Service Act imposes, with 

respect to a group health plan, or group or individual health insurance coverage, a set of 

requirements relating to the choice of a health care professional, and to benefits for emergency 

services. The statute and these interim final regulations provide that if a group health plan, or a 

health insurance issuer offering group or individual health insurance coverage, requires or 

provides for designation by a participant, beneficiary, or enrollee of a participating primary care 

provider, then the plan or issuer must permit each participant, beneficiary, or enrollee to 

designate any participating primary care provider who is available to accept the participant, 

beneficiary, or enrollee. Under these interim final regulations, the plan or issuer must provide a 

notice informing each participant (or, in the individual market, the primary subscriber) of the 

terms of the plan or health insurance coverage regarding designation of a primary care provider. 

The statute and these interim final regulations also provide rules for a group health plan, or a 

health insurance issuer offering group or individual health insurance coverage, that provides 

coverage for obstetrical or gynecological care and requires the designation of an in-network 

primary care provider. In such a case, the plan or issuer may not require authorization or referral 

by the plan, issuer, or any person (including a primary care provider) for a female participant, 

beneficiary, or enrollee who seeks obstetrical or gynecological care provided by an in-network 

8403 Colesville Road, Suite 1550, Silver Spring, MD 20910-6374 240.485.1800 www.midwife.org
health care professional who specializes in obstetrics or gynecology. The plan or issuer must 

inform each participant (or, in the individual market, primary subscriber) that the plan or issuer 

may not require authorization or referral for obstetrical or gynecological care by a participating 

health care professional who specializes in obstetrics or gynecology. The plan or issuer must 

treat the provision of obstetrical and gynecological care, and the ordering of related obstetrical 

and gynecological items and services, by the professional who specializes in obstetrics or 

gynecology as the authorization of the primary care provider. For this purpose, a health care 

professional who specializes in obstetrics or gynecology is any individual who is authorized 

under applicable State law to provide obstetrical or gynecological care, and is not limited to a 

physician. 

ACNM strongly supports these regulations as issued by HHS and believes they meet the intent of 

Congress to ensure women unfettered access to primary care and maternal health providers, 

including certified nurse-midwives (CNM) and certified midwives (CM) who have graduated 

from a midwifery education program accredited by the Accreditation Commission for Midwifery 

Education and who are licensed to practice in the State in which they provide services. ACNM 

appreciates the agency’s work to move this section of the law forward as it provides vital 

protections for women seeking access to essential health care services. 

ACNM also appreciates the guidance given in this regulation to health plans on how to 

communicate with enrollees about their rights to: (1) choose a primary care provider; and (2) 

obtain obstetrical or gynecological care without prior authorization. However, ACNM is 

concerned that the examples provided under the new regulations emphasize the selection of a 

“primary care physician” even though eligible primary care providers include CNMs, CMs, 

nurse practitioners, or other professionals with appropriate scope of practice as authorized by 

State law. ACNM encourages HHS to ensure that examples eliminate the reference to physician 

and adopt provider-neutral language such as “Example 1. (i) Facts. A group health plan requires 

each participant to select a primary care provider for the participant and the participant’s 

family.” ACNM supports HHS provision of model language in the rule to aid health plan 

communication with enrollees on their rights to designate the primary care provider of their 

choice and to directly access the services of obstetrical and gynecological professionals, and 

urges uniform incorporation of provider-neutral language.

Thank you for the opportunity to comment on this proposed rule. If you have questions 

regarding specific comments or general questions relating to midwifery services, please contact 

Patrick Cooney, ACNM’s Federal Representative, at (202) 347-0034 or via email at 

patrick@federalgrp.com. 

Sincerely, 

Lorrie Kline Kaplan 

Executive Director