Source: https://www.pacode.com/secure/data/028/chapter9/subchapHtoc.html
Timestamp: 2019-03-26 04:37:31
Document Index: 795199524

Matched Legal Cases: ['§ 991', '§ 1551', '§ 764', '§ 9', '§ 9', '§ 991', '§ 9', '§ 9', '§ 991', '§ 9', '§ 991', '§ 9', '§ 9', '§ 9', '§ 9', '§ 9', '§ 9', '§ 9']

Subchapter H. AVAILABILITY AND ACCESS
9.671. Applicability.
9.672. Emergency services.
9.673. Plan provision of prescription drug benefits to enrollees.
9.674. Quality assurance standards.
9.675. Delegation of medical management.
9.676. Enrollee rights.
9.677. Requirements of definitions of medical necessity.
9.678. PCPs.
9.679. Access requirements in service areas.
9.680. Access for persons with disabilities.
9.681. Health care providers.
9.682. Direct access for obstetrical and gynecological care.
9.683. Standing referrals or specialists as primary care providers.
9.684. Continuity of care.
9.685. Standards for approval of point-of-service products.
The provisions of this Subchapter H issued under Article XXI of The Insurance Company Law (40 P. S. § § 991.2101991.2193); the HMO Act (40 P. S. § § 15511568); and the section 630 of the PPO Act (40 P. S. § 764a), unless otherwise noted.
The provisions of this Subchapter H adopted June 8, 2001, effective June 9, 2001, 31 Pa.B. 3043, unless otherwise noted.
§ 9.671. Applicability.
This subchapter is applicable to managed care plans, including HMOs and gatekeeper PPOs, and subcontractors of managed care plans, including IDSs, for services provided to enrollees.
§ 9.672. Emergency services.
(a) A plan shall utilize the definition of emergency service in section 2102 of the act (40 P. S. § 991.2102) in administering benefits, adjudicating claims and processing complaints and grievances.
(b) A plan may not deny any claim for emergency services on the basis that the enrollee did not receive permission, prior approval, or referral prior to seeking emergency service.
(c) A plan shall apply the prudent layperson standard to the enrollees presenting symptoms and services provided in adjudicating related claims for emergency services.
(d) Coverage for emergency services provided during the period of the emergency, shall include evaluation, testing, and if necessary, stabilization of the condition of the enrollee, emergency transportation and related emergency care provided by a licensed ambulance service. Use of an ambulance as transportation to an emergency facility for a condition that does not satisfy the definition of emergency service does not constitute an emergency service and does not require coverage as an emergency service.
(e) A plan may not require an enrollee to utilize any particular emergency transportation services organization or a participating emergency transportation services organization for emergency care.
(f) The emergency health care provider shall notify the enrollees managed care plan of the provision of emergency services and the condition of the enrollee.
(g) If the enrollee is admitted to a hospital or other health care facility, the emergency health care provider shall notify the enrollees managed care plan of the emergency services delivered within 48 hours or on the next business day, whichever is later. An exception to this requirement will be made where the medical condition of the patient precludes the provider from accurately determining the identity of the enrollees managed care plan within 48 hours of admission.
(h) If the enrollee is not admitted to a hospital or other health care facility, the claim for reimbursement for emergency services provided shall serve as notice to the enrollees managed care plan of the emergency services provided by the emergency health care provider.
This section cited in 28 Pa. Code § 9.651 (relating to HMO provision and coverage of basic health services to enrollees).
§ 9.673. Plan provision of prescription drug benefits to enrollees.
(a) A plan providing prescription drug benefit coverage to enrollees, either as a basic benefit or through the purchase of a rider or additional benefit package, and using a drug formulary which lists the plans preferred therapeutic drugs, shall clearly disclose in its marketing material and enrollee literature that restrictions in drug availability may result from use of a formulary.
(b) An enrollee, a prospective enrollee, or health care provider may make a written or verbal inquiry to a plan asking whether a specific drug is on the plans formulary. The plan shall respond in writing to the request within 30 days from the date of its receipt of the request. If the drug that is the subject of the inquiry is not on the plans formulary, the plans response shall include a listing of the drugs in the same class that are on the formulary or instruct the enrollee how to access the formulary.
(c) A plan utilizing a drug formulary shall have a written policy that includes an exception process by which a health care provider may prescribe and obtain coverage for the enrollee for specific drugs, drugs used for an off-label purpose, biologicals and medications not included in the formulary for prescription drugs or biologicals when the formularys equivalent has been ineffective in the treatment of the enrollees disease or if the drug causes or is reasonably expected to cause adverse or harmful reactions to the enrollee. The following standards apply when an exception is sought:
(1) Exception requests are to be considered requests for prospective UR decisions and shall be processed within 2-business days.
(2) If the exception is granted, the plan shall provide coverage in the amount disclosed by the plan for the nonformulary alternative under section 2136(a)(1) of the act (40 P. S. § 991.2136(a)(1)).
(3) A letter denying the request shall include the basis and clinical rationale for the denial and instructions on how to file a complaint or a grievance.
(d) The plan shall distribute its policy and process to each participating health care provider who prescribes. A plan shall provide a description of the process to be used to obtain coverage of a drug that is an exception to the formulary to an enrollee or prospective enrollee upon request. If a drug, class of drugs or drugs used to treat a specific condition are specifically excluded from coverage in the enrollee contract, appeals for coverage of specific exclusions shall be considered complaints. If no specific exclusion exists, the appeal of a denial of a physicians request for an exception to the formulary based on medical necessity and appropriateness, shall be considered to be a grievance.
(e) A plan shall provide at least 30 days notice of formulary changes to health care providers, except when the change is due to approval or withdrawal of approval of the Food and Drug Administration of a drug.
§ 9.675. Delegation of medical management.
(a) A plan may contract with an entity for the performance of medical management relating to the delivery of health care services to enrollees. The plan shall be responsible for assuring that the medical management contract meets the requirements of all applicable laws. The plan shall submit the medical management contract to the Department for review and approval. The Department will review a medical management contract within 45 days of receipt of the contract. If the Department does not approve or disapprove a contract within 45 days of receipt, the plan may use the contract and it shall be presumed to meet the requirements of all applicable laws. If, at any time, the Department finds that a contract is in violation of law, the plan shall correct the violation. Reimbursement information submitted to the Department under this paragraph may not be disclosed or produced for inspection or copying to a person other than the Secretary or the Secretarys representatives without the consent of the plan which provided the information, unless otherwise ordered by a court.
(b) If the contractor is to perform UR, the contractor shall be certified in accordance with Subchapter K (relating to CREs).
(c) To secure Department approval, a medical management contract shall include the following:
(1) Reimbursement methods being used to reimburse the contractor which comply with section 2152(b) of the act (40 P. S. § 991.2152(b)) which relates to operational standards for CREs compensation.
(2) The standards for the plans oversight of the contractor.
(d) Acceptable plan oversight shall include:
(1) Written review and approval by the plan of the explicit standards to be utilized by the contractor in conducting quality assurance, UR or related medical management activities.
(2) Reporting by the contractor to the plan on at least a quarterly basis regarding the delegated activities concerning the arrangement or provision of health care services and the impact of the delegated activities on the quality and delivery of health care services to the plans enrollees.
(3) Annual random sample re-review and validation of the results of delegated responsibilities to ensure that the decisions made and activities undertaken by the contractor meet the agreed-upon standards in the contract.
(4) A written description of the relationship between the plans medical management staff and the contractors medical management staff.
(5) A requirement that the contractor will cooperate with and participate in quality assurance activities and studies undertaken by the plan that pertain to the enrollee populations served by the contractor, including submitting written reports of activities and accomplishments on plan directed and any contractor initiated activities to the plans quality assurance committee on at least a quarterly basis.
(e) With respect to medical management arrangements involving an HMO, the medical management contract shall include a statement by the contractor agreeing to submit itself to review as a part of the HMOs external quality assurance assessment. See § 9.654 (relating to HMO external quality assurance assessment). A contractor may receive a separate review of its operations by an external quality review organization approved by the Department. The Department will consider the results of the review in its overall assessment provided the review satisfies the requirements of § 9.674 (relating to quality assurance standards).
This section cited in 28 Pa. Code § 9.634 (relating to delegation of HMO operations); and 28 Pa. Code § 9.724 (relating to plan-IDS contracts).
§ 9.676. Enrollee rights.
(a) A plan shall have a written policy that shall state the plans commitment to treating an enrollee in a manner that respects the enrollees rights and shall include the plans expectations of a members responsibilities.
(b) An HMO shall offer to each enrollee, who becomes ineligible to continue as a part of a group subscriber agreement, a nongroup subscription agreement offering the same level of benefits as are available to a group subscriber.
(c) An HMO may not expel or refuse to reenroll an enrollee solely because of the enrollees health care needs, nor refuse to enroll individual subscribers of a group on the basis of health status or health care needs of the individuals.
§ 9.677. Requirements of definitions of medical necessity.
The definition of medical necessity shall be the same in the plans provider contracts, enrollee contracts and other materials used to evaluate appropriateness and to determine coverage of health care services. The definition shall comply with the HMO Act, the PPO Act, Act 68 and this chapter.
§ 9.685. Standards for approval of point-of-service products.
(a) If a plan offers a point-of-service product, it shall submit a formal product filing for the POS product to the Department and the Insurance Department.
(b) A plan may offer POS options to groups and enrollees, if the plan:
(1) Has a system for tracking, monitoring and reporting enrollee self-referrals for the following purposes:
(i) To ensure that self-referral activity is not occurring because of an access problem, a deliberate attempt to force an enrollee to bypass a primary care provider for nonmedical reasons or over restrictive or burdensome plan requirements.
(ii) To promptly investigate any PCP practice in which enrollees are utilizing substantially higher levels of non-PCP referred care than average, to ensure that enrollee self-referrals are not a reflection of access or quality problems on the part of the PCP practice, inappropriate patient direction or burdensome plan requirements.
(2) Provides clear disclosure to enrollees of out-of-pocket expenses.
(3) Does not directly or indirectly encourage enrollees to seek care without a PCP referral or from out-of-network providers due to an inadequate network of participating providers in any given specialty.