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Provider Nondiscrimination

For plan years beginning on or after January 1, 2014, non-grandfathered group health plans and issuers may not discriminate against any provider, with respect to participation under the plan, who is acting within the scope of their license to practice. At its most basic, this prevents health plans from denying a benefits claim for a service outside a provider’s typical specialty area.

This requirement does not require health plans or insurers to contract with any provider willing to abide by the terms and conditions for participation. Also, it does not prevent group health plans or insurers from establishing varying rates of reimbursement based on quality or performance measures.