Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter H - POINT-OF-SERVICE PRODUCTS GROUP SPECIFIC COMMUNITY RATING-STATEMENT OF POLICY › Section 301.203 - Filing requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Along
				  with the submission of adequate reserving methodology, an HMO shall submit a
				  formal product filing to the Division of HMOs/PPOs of the Department and the
				  Bureau of Health Financing and Program Development of the Department of
				  Health.
(b) HMOs will be permitted
				  to offer a point-of-service product subject to the following conditions.
(1) Filing requirements-all products:
(i) Two copies shall be submitted to each
				  Department.
(ii) The filing shall
				  include an appropriate rate filing.
(iii) The filing should contain incentives
				  for HMO members to utilize basic HMO services, stay within the HMO panel of
				  participating providers, and utilize the services of designated primary care
				  physicians. Minimum requirements for indemnity reimbursement for out-of-network
				  claims should be:
(A) Minimum deductible of
				  $250 per individual/$500 per family per calendar year.
(B) Minimum coinsurance of 20%.
(C) Total out-of-pocket expenses for use of
				  nonnetwork providers should be in the following ranges:
(I) Individual annual out-of-pocket expense,
				  excluding calendar year deductible: minimum-$2,000; maximum-$5,000.
(II) Family annual out-of-pocket expense,
				  excluding calendar year deductible: minimum-$4,000; maximum-$10,000.
(III) The lifetime maximum for
				  point-of-service out-of-network claims per person shall be at least
				  $250,000.
(iv)
				  Clear and adequate disclosure is an absolute necessity because of the
				  complexity of the point-of-service product and great potential for enrollees to
				  misunderstand it. The evidence of coverage shall contain adequate disclosure of
				  coverage limitations and conditions, including member liability for
				  deductibles, copayments and differences between the HMO's UCR reimbursement and
				  actual charges of out-of-network providers.
(v) Primary care services shall only be
				  reimbursable within the HMO network when rendered at or by direction of the
				  member's primary care physician. Primary care services shall be services which
				  the primary care physician is requested to provide under the provisions of the
				  contract with the HMO.
(vi) An HMO
				  may require precertification of out-of-network nonemergency hospital
				  admissions.
(vii) Emergency
				  coverage shall be provided under provisions of the basic HMO coverage without
				  application of out-of-network deductibles or coinsurance.
(viii) The filing shall include an
				  explanation of how the HMO will meet its continuity of care requirements under
				  the act and 28 Pa. Code (relating to health and safety).
(ix) The HMO shall require that either the
				  member's PCP or the HMO itself issue a claim form or other notice for use by
				  the member in claiming reimbursement for out-of-network care. The claim form or
				  other notice shall be submitted for review and approval of the Departments and
				  the Department of Health. The claim form or notice shall require the signature
				  of the member and contain adequate disclosure that the member understands that
				  by voluntarily seeking care out-of-network the member is assuming substantial
				  financial liability for the care, and that the care if provided within the HMO
				  network would be provided at a much lower out-of-pocket expense to the
				  member.
(x) The HMO is responsible
				  for furnishing claims information to the primary care physician concerning the
				  member's usage of out-of-network health services. The objective of this
				  requirement is to provide critical information to the patient's primary care
				  physician so that when the member returns in-network, the PCP has adequate
				  knowledge to maintain continuity of care.
(xi) Other methods to accomplish the
				  objective in subparagraph (x) may be proposed in the filing and will be
				  reviewed on a case by case basis.
(xii) An information system shall be included
				  by which the HMO will track the claims payments by PCP for out-of-network
				  services. The HMO shall commit itself to monitoring out-of-network usage and to
				  promptly investigate any PCP practice whose enrolled members are utilizing
				  substantially higher levels of out-of-network care than average. Therefore,
				  written policies and procedures shall be included in the filing to ensure that
				  PCPs are not subtlety or otherwise encouraging members to use out-of-network
				  providers.
(xiii) The filing shall
				  describe in detail the HMO's claims payment system. This description shall
				  include staffing for paying out-of-network indemnity claims and capability for
				  establishing adequate tracking, estimation and reserving for incurred but not
				  reported claims.
(xiv) The HMO's
				  data/information system shall be capable of paying out-of-network claims in a
				  timely manner, tracking incurred but not reported expenses, adequately
				  forecasting projections, calculating the 10% limit, adequately interfacing
				  between membership and eligibility files and between the HMO's systems and
				  those of an applicable affiliated insurer, and generating required Department
				  reports.
(xv) Nongroup conversions
				  are not required to include a point-of-service benefit.
(xvi) Approvals for point-of-service products
				  will be subject to a 1-year probationary period during which time the HMO will
				  have to establish a track record of successfully administering a
				  point-of-service product. During the 1-year probationary period, enrollment in
				  the point-of-service may not exceed 5% of the HMO's private sector
				  enrollment.