Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.2 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
					 have the following meanings, unless the context clearly indicates
					 otherwise:
Act
-The act of June 11, 1986 (P. L. 226,
					 No. 64), which amends The Insurance Company Law of 1921 (40 P. S.
					 §§
											341-991).
Admitted assets
-Assets set forth in the
					 definition of insolvency in section 503 of The Insurance Department Act of one
					 thousand nine hundred and twenty-one (40 P. S. §
											221.3), as admitted assets.
Commissioner
-The Insurance Commissioner
					 of the Commonwealth.
Department
-The Insurance Department of the
					 Commonwealth.
Enrollee
-An individual entitled to receive
					 the benefits of a preferred provider organization with respect to health care
					 services.
Enrollee literature
-aterials and
					 communications which a preferred provider organization distributes or makes
					 available for advertising or other purposes, which discuss the provisions,
					 limitations or conditions of benefits available to an enrollee of a preferred
					 provider organization.
Health care insurer
-A company which is a
					 risk-assuming preferred provider organization, or licensed to do the business
					 of accident and health insurance in this Commonwealth, or both.
Health care purchaser
-A person,
					 partnership, association, governmental unit or corporation which provides
					 health care coverage to its employes or members and their dependents by
					 reimbursing the covered persons directly for covered health services or by
					 contracting with a health care insurer, nonprofit professional health service
					 corporation, nonprofit hospital plan corporation or health maintenance
					 organization to provide, arrange for the provision of, reimburse or pay for
					 covered health services. The term does not include a health care insurer.
Licensed insurer
-A company licensed to do
					 the business of accident and health insurance in this Commonwealth.
Physician
-An individual licensed under the
					 statutes of this Commonwealth to practice medicine and surgery within the scope
					 of the Osteopathic Medical Practices Act (63 P. S. §§
											271.1-271.18) or the Medical Practice Act of
					 1985 (63 P. S. §§
											422.1-422.45).
Preferred provider arrangement
-
(i) An arrangement established, operated,
				  maintained or underwritten in whole or in part, by or on behalf of or in
				  association with a health care insurer or purchaser in which the insurer or
				  purchaser directly or indirectly does one or more of the following:
(A) Enters into agreements with providers or
				  physicians relating to health care services which may be rendered to enrollees,
				  including agreements relating to the amounts to be charged by the provider or
				  physician for services rendered.
(B) Issues or administers policies or
				  subscriber contracts in this Commonwealth which include incentives for the
				  enrollee to use the services of a provider that has entered into an agreement
				  with the insurer or purchaser.
(C)
				  Issues or administers policies or subscriber contracts in this Commonwealth
				  that provide for reimbursement of services only if the services have been
				  rendered by a provider or physician that has entered into an agreement with the
				  insurer or purchaser.