reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.5 - Review of application by the Secretary

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Upon receipt of a complete application
				  for approval for operation as a risk-assuming preferred provider organization,
				  the Secretary will review the submitted materials in accordance with §
										152.4 (relating to scope of
				  Department of Health review of a preferred provider organization).
(b) If the Secretary determines that the
				  applicant meets the standards in §
										152.4, the Secretary will notify
				  the applicant and the Commissioner of the findings.
(c) If the Secretary determines that an
				  applicant does not meet the standards in § 152.4, the Secretary will
				  notify the applicant and the Commissioner of the disapproval and the reasons,
				  in writing.
(d) Within 30 days from
				  the date of mailing of a notice of disapproval to the preferred provider
				  organization, the preferred provider organization may take written application
				  to the Secretary for a hearing. The hearing shall be held within 30 days after
				  receipt of the application. The procedure before the Secretary will be under
				  the adjudication procedure in
				  2
				  Pa.C.S. §§
											501-508 and
				  701-704 (relating to the
				  Administrative Agency Law). The preferred provider organization is entitled to
				  judicial review as provided by statute.
This section cited in 31 Pa. Code §
												152.23 (relating to commencing
						operations).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.6 - Provider contracts

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Changes
				  in standard form contracts with physicians or providers enabling a
				  risk-assuming preferred provider organization to offer preferred provider
				  arrangements shall be submitted to the Secretary within 10 days of
				  implementation. The Secretary may review the provider contract changes to
				  ascertain whether the changes may lead to undertreatment or poor quality health
				  services.
(b) If the Secretary
				  determines that the changes to the provider contract may lead to undertreatment
				  or poor quality health services, the Secretary will notify the risk-assuming
				  preferred provider organization and the Commissioner of the disapproval and the
				  reasons in writing.
(c) Within 30
				  days from the date of mailing of a notice of disapproval to the preferred
				  provider organization, the preferred provider organization may make written
				  application to the Secretary for a hearing. The hearing will be held within 30
				  days after receipt of the application. The procedure before the Secretary will
				  be under adjudication procedure in
				  2
				  Pa.C.S. §§
											501-508 and
				  701-704 (relating to the
				  Administrative Agency Law). The preferred provider organization is entitled to
				  judicial review as provided by statute.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.7 - Restricted benefit-limited purpose preferred provider organizations

Current through Register Vol. 54, No. 28, July 13, 2024
A risk-assuming preferred provider organization which
					 limits its arrangements to only one class of preferred providers for the
					 purpose of providing a limited scope or range of covered services to covered
					 persons (for example, a dental benefits preferred provider organization or
					 vision service benefits preferred provider organization) shall reflect the fact
					 in the structure and function of its quality assurance
					 system.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.8 - Compliance with Health Maintenance Organization Act (40 P. S. Section Section 1551-1567)

Current through Register Vol. 54, No. 28, July 13, 2024
If, in the review of the application of a risk-assuming
					 preferred provider organization, the Secretary determines that the preferred
					 provider organization is in fact engaging or proposing to engage in the
					 business of a health maintenance organization as defined in the Health
					 Maintenance Organization Act, the Secretary will so inform the applicant and
					 the Commissioner and require the preferred provider organization to seek
					 licensure as a health maintenance organization. In determining whether or not a
					 risk-assuming preferred provider organization is doing the business of a health
					 maintenance organization, the Department of Health will evaluate and consider
					 the following:
(1) The type and amount
				  of economic risk being assumed by preferred providers.
(2) The degree to which the delivery of
				  health care is organized and managed by the preferred provider
				  organization.
(3) The degree of
				  freedom of provider choice offered to enrollees.
(4) The degree of contractual responsibility
				  assumed by participating primary care physicians for the management of health
				  care of enrollees.
(5) The degree
				  to which preferred providers may share in the financial gains or losses arising
				  from preferred provider arrangements.
(6) The extent to which the preferred
				  provider organization provides basic health services as defined in the Health
				  Maintenance Organization Act and 28 Pa. Code Chapter 9 (relating to health
				  maintenance organizations).
(7) The
				  extent to which the preferred provider organization combines the delivery and
				  financing of health care.
(8) The
				  extent to which the preferred provider organization agrees to provide, arrange
				  for the provision of or pay for health services for a fixed pre-paid
				  fee.
This section cited in 31 Pa. Code §
												152.103 (relating to HMO and PPO
						differentiation).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.9 - Minimum capital and reserves

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
General.
Unless the Commissioner determines that additional
				  capital or reserves are required for the protection of policyholders,
				  enrollees, creditors or the public, a risk-assuming preferred provider
				  organization which is not a licensed insurer shall be deemed to have adequate
				  working capital and reserves if its admitted assets exceed its liabilities by
				  $50,000 in excess of the minimum capital and surplus required of a stock
				  casualty insurer with accident and health powers at the time it commences
				  operations, and if it thereafter maintains its admitted assets in excess of
				  liabilities by at least the minimum capital and surplus required of a stock
				  casualty insurer with accident and health powers.
(b)
Exemption.
If the
				  risk-assuming preferred provider organization which is not a licensed insurer
				  only provides or covers limited health care services (for example, dental or
				  vision care services), or is only liable for incentive payments to providers or
				  physicians, the Commissioner may exempt it from the requirements of subsection
				  (a) and establish a lower capital and reserve requirement.
This section cited in 31 Pa. Code §
												152.11 (relating to review of
						application by the Commissioner).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.10 - Qualification of officers and directors

Current through Register Vol. 54, No. 28, July 13, 2024
This section applies to risk-assuming preferred provider
					 organizations which are not licensed insurers.
(1) The responsibility, character and general
				  fitness for the preferred provider organization's operations of a person who is
				  chosen, elected or appointed as an officer or director shall be such as to
				  command the confidence of the public and warrant the belief that the preferred
				  provider organization's operations will be honestly and efficiently conducted
				  in accordance with the intent of section 630.
(2) If the Commissioner determines, after a
				  proper investigation, that an officer or director of a preferred provider
				  organization does not meet the qualifications stated in paragraph (1), the
				  person shall cease serving as an officer or director, or both.
(3) The procedure before the Commissioner for
				  the determination stated in paragraph (2) shall be under the adjudication
				  procedure set forth in
				  2
				  Pa.C.S. §§
											501-508 and
				  701-704 (relating to the
				  Administrative Agency Law). The officer or director is entitled to judicial
				  review as provided by statute.
This section cited in 31 Pa. Code §
												152.11 (relating to review of
						application by the Commissioner).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.11 - Review of application by the Commissioner

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Upon receipt of a complete application
				  for approval for operation as a risk-assuming preferred provider organization,
				  the Commissioner will review the submitted materials to determine that the
				  following exist:
(1) The applicant is a
				  licensed insurer or has adequate working capital and reserves as defined in
				  §
											152.9 (relating to minimum capital
				  and reserves).
(2) The applicant's
				  enrollee literature adequately discloses provisions, limitations and conditions
				  of benefits available.
(3) The
				  applicant's policy forms provide for emergency services as described in §
											152.15 (relating to emergency
				  services).
(4) If the applicant is
				  not a licensed insurer, that:
(i) Its
				  preferred provider arrangements contain provisions to assure insolvency
				  protection as described in §
												152.14 (relating to insolvency
				  protection).
(ii) Its policy forms
				  provide for a preexisting condition limitation as described in §
												152.16 (relating to preexisting
				  condition limitation).
(iii) Its
				  officers and directors meet the qualifications in §
												152.10(a)
				  (relating to qualification of officers and
				  directors).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.12 - Provider organizations governed and regulated under ERISA

Current through Register Vol. 54, No. 28, July 13, 2024
A preferred provider organization which is governed and
					 regulated under the Employee Retirement Income Security Act of 1974
					 (29 U.S.C.A. §§
											301-309 and
					 1001-1461) (ERISA) shall
					 file a certificate to that effect with the Commissioner and, to the extent that
					 it is regulated under ERISA, is not subject to other provisions of this
					 chapter.
This section cited in 31 Pa. Code §
												152.3 (relating to content of an
						application for approval); and 31 Pa. Code §
												153.3 (relating to simplified
						review of company merger, assumption or name change form and rate
						filings-statement of policy).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.13 - Investments

Current through Register Vol. 54, No. 28, July 13, 2024
Investments by risk-assuming preferred provider
					 organizations which are not licensed insurers shall be made under the statutes
					 governing the investments of domestic life insurance companies. See The
					 Insurance Company Law of 1921 (40 P. S. §§
											341-991).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.14 - Insolvency protection

Current through Register Vol. 54, No. 28, July 13, 2024
Preferred provider arrangements with providers or
					 physicians, or both, shall contain provisions to assure, in the event of an
					 insolvency, that the enrollees of a risk-assuming preferred provider
					 organization which is not a licensed insurer are not held liable for expenses
					 which were to have been assumed by the preferred provider
					 organization.
This section cited in 31 Pa. Code §
												152.11 (relating to review of
						application by the Commissioner).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.15 - Emergency services

Current through Register Vol. 54, No. 28, July 13, 2024
If an enrollee requires emergency health care services, and
					 cannot reasonably be attended to by a preferred provider or physician, the
					 preferred provider arrangement shall pay for the emergency health care services
					 so that the enrollee is not liable for a greater out-of-pocket expense than if
					 the enrollee were attended to by a preferred provider or
					 physician.
This section cited in 31 Pa. Code §
												152.11 (relating to review of
						application by the Commissioner).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.16 - Preexisting condition limitation

Current through Register Vol. 54, No. 28, July 13, 2024
A risk-assuming preferred provider organization which is
					 not a licensed insurer may not use a policy or contract which contains a
					 preexisting condition limitation which is more restrictive than the following:
					 a preexisting condition is a disease or physical condition for which medical
					 advice or treatment has been received within 90 days immediately prior to
					 becoming covered under the preferred provider arrangement. The condition is
					 covered after the individual has been covered for more than 12 months under the
					 group contract.
This section cited in 31 Pa. Code §
												152.11 (relating to review of
						application by the Commissioner).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.17 - Approval of enrollee literature after commencement of operations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Except for
				  enrollee literature which has been reviewed and approved as part of its
				  application for approval, no enrollee literature may be used by a preferred
				  provider organization until the forms of the literature have been submitted to
				  and formally approved by the Commissioner.
(b) Forms of enrollee literature will be
				  deemed approved at the expiration of 60 days after filing, unless earlier
				  approved or disapproved by the Commissioner. The approval becomes void upon
				  subsequent notice of disapproval from the Commissioner.
(c) If the Commissioner determines that the
				  literature does not adequately disclose the provisions, limitations and
				  conditions of benefits available to enrollees, the Commissioner will notify the
				  preferred provider organization, in writing, of the objections.
(d) Upon disapproval, the Commissioner will
				  notify the preferred provider organization and the Secretary, in writing,
				  specifying the reason for the disapproval. Within 30 days from the date of
				  mailing of the notice to the preferred provider organization, the preferred
				  provider organization may make written application to the Commissioner for a
				  hearing. The hearing shall be held within 30 days after receipt of the
				  application. The procedure before the Commissioner will be under the
				  adjudication procedure in
				  2
				  Pa.C.S. §§
											501-508 and
				  701-704 (relating to the
				  Administrative Agency Law). The preferred provider organization is entitled to
				  judicial review as provided by statute.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.18 - Policy review after commencement of operations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Except for policies which have been
				  reviewed and approved as part of its application for approval, no policies,
				  contracts or agreements between a risk-assuming preferred provider organization
				  which is not a licensed insurer and its insureds may be used until the
				  policies, contracts or agreements have been submitted to and formally approved
				  by the Commissioner.
(b) Forms of
				  policies will be deemed approved at the expiration of 60 days after filing,
				  unless approved or disapproved earlier by the Commissioner. The approval
				  becomes void until subsequent notice of disapproval from the
				  Commissioner.
(c) Upon disapproval,
				  the Commissioner will notify the preferred provider organization, in writing,
				  specifying the reason for the disapproval. Within 30 days from the date of
				  mailing of the notice to the preferred provider organization, the preferred
				  provider organization may make written application to the Commissioner for a
				  hearing. The hearing will be held within 30 days after receipt of the
				  application. The procedure before the Commissioner will be under the
				  adjudication procedure in
				  2
				  Pa.C.S. §§
											501-508 and
				  701-704 (relating to the
				  Administrative Agency Law). The preferred provider organization is entitled to
				  judicial review as provided by statute.
This section cited in 31 Pa. Code §
												153.3 (relating to simplified
						review of company merger, assumption or name change form and rate
						filings-statement of policy).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.19 - Annual reporting requirements

Current through Register Vol. 54, No. 28, July 13, 2024
An approved risk-assuming preferred provider organization
					 shall file with the Secretary and the Commissioner on or before March 31 of
					 each year an annual report of its activities during the prior calendar year.
					 Annual reports include:
(1) A copy of
				  the annual financial statement required by §
										152.21 (relating to financial
				  statements and examinations).
(2) A
				  description of results in its quality assurance activities undertaken during
				  the year.
(3) A summary of the
				  number of covered persons in the preferred provider organization.
(4) A summary of total number of grievances
				  handled, a compilation of causes underlying the grievances and the resolution
				  of grievances.
(5) A summary of
				  utilization experience of the preferred provider organization.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.20 - Investigations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Commissioner and the Secretary may investigate a preferred provider
				  organization in order to determine whether it is complying with this
				  chapter.
(b) The Commissioner, the
				  Secretary and their deputies, agents and examiners will have free access to the
				  books, records, papers and documents of a preferred provider
				  organization.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.21 - Financial statements and examinations

Current through Register Vol. 54, No. 28, July 13, 2024
A risk-assuming preferred provider organization which is
					 not a licensed insurer shall be governed by the statutes and regulations
					 applicable to the filing and preparation of financial statements and the
					 frequency and conduct of examinations by the Commissioner and deputies which
					 apply to licensed domestic insurers, including adherence to statutory
					 accounting practices and establishing reserves on a sound actuarial
					 basis.
This section cited in 31 Pa. Code §
												152.19 (relating to annual
						reporting requirements); and 31 Pa. Code §
												152.22 (relating to
						fees).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.22 - Fees

Current through Register Vol. 54, No. 28, July 13, 2024
This section applies to a risk-assuming preferred provider
					 organization which is not a licensed insurer.
(1) If an investigation or examination is
				  undertaken under §§
										152.11 (relating to review of
				  application by the Commissioner) or 152.21 (relating to financial statements
				  and examinations), the preferred provider organization will be assessed the
				  expenses incurred by the Department, including compensation of Department
				  employes or consultants acting on behalf of the Department, and expenses of the
				  persons for travel, lodging and food. The amounts shall be assessed under 4 Pa.
				  Code Chapter 40 (relating to travel and subsistence).
(2) Fees assessed under this section are
				  assessed and billed to preferred provider organizations under established
				  Department procedures and this title.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.23 - Commencing operations

Current through Register Vol. 54, No. 28, July 13, 2024
A preferred provider organization may not commence
					 operations until one of the following occurs:
(1) The Commissioner approves its application
				  under §
										152.11 (relating to review of
				  application by the Commissioner) and, if a risk-assuming preferred provider
				  organization, the Secretary approves its application under §
										152.5 (relating to review of
				  application by the Secretary).
(2)
				  The Commissioner determines that it is governed by and regulated under the
				  Employee Retirement Income Security Act of 1974 (29 U.S.C.A. §§
											301-309 and
				  1001-1461) and it has
				  filed a certificate to that effect with the Commissioner.
(3) The preferred provider organization has
				  complied with the filing requirements of this chapter and 60 days have elapsed
				  without the issuance of a disapproval or notice of deficiencies from the
				  Commissioner or the Secretary.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.24 - Cease and desist orders and orders to cease operations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A cease and desist order or an order to
				  cease all or a part of the operations of a preferred provider organization, or
				  both, may be issued if the preferred provider organization violates this
				  chapter.
(b) Before the
				  Commissioner or the Secretary, whichever is appropriate, will take an action
				  under subsection (a), written notice will be given to the preferred provider
				  organization stating specifically the nature of the alleged violation and
				  fixing a time and place, at least 10 days thereafter, when a hearing on the
				  matter will be held. Hearing procedure and appeals from decisions of the
				  Commissioner or Secretary will be provided under
				  2
				  Pa.C.S. §§
											501-508 and
				  701-704 (relating to the
				  Administrative Agency Law).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.25 - Application of insurance laws to preferred provider organizations and their agents

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A preferred
				  provider organization which is a licensed insurer, and its agents, remain
				  subject to statutes, rules and regulations which apply to licensed insurers and
				  their agents in this Commonwealth.
(b) A risk-assuming preferred provider
				  organization which is not a licensed insurer is subject to the following
				  statutes and regulations promulgated thereunder:
(1) Article V of The Insurance Department Act
				  of one thousand nine hundred and twenty-one (40 P. S. §§
												221.1-221.63).
(2) The Unfair Insurance Practices Act
				  (40
				  P. S. §§
												1171.1-1171.15).
(3) The act of August 1, 1975 (P. L. 157, No.
				  81) (40 P. S. §§
												771-774).
(4) Article VI-A of the act (40 P. S.
				  §§
												908-1-908-8).
(5) Section
				  621.2(a)(6) and
				  (d) of the act of May 17, 1921 (P. L. 682,
				  No. 284) (40 P. S. §
												756.2(a)(6) and
				  (d)).
(6) The act of December 23, 1981 (P. L. 583,
				  No. 168) (40 P. S. §§
												3001-3003).
(7) The act of December 27, 1965 (P. L. 1247,
				  No. 506) (40 P. S. §§
												1501-1503).
(8) The act of April 18, 1978 (P. L. 33, No.
				  16) (40 P. S. §§
												767-769).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › PRIMARY CARE GATEKEEPER PPO PRODUCTS- STATEMENT OF POLICY › Section 152.101 - Scope

Current through Register Vol. 54, No. 28, July 13, 2024
A PPO product filing by an approved PPO complying with this
					 chapter is acceptable. A preferred provider agreement filing by a nonprofit
					 hospital corporation or a nonprofit professional health service plan
					 corporation, or both, otherwise complying with 40 Pa.C.S. Chapter 61 or 63, or
					 both (relating to rules of evidence; juvenile matters) and complying with this
					 chapter is acceptable.
This section cited in 31 Pa. Code §
												152.102 (relating to
						definitions).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › PRIMARY CARE GATEKEEPER PPO PRODUCTS- STATEMENT OF POLICY › Section 152.102 - 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:
ERISA-exempt PPO
-A PPO which, in
					 accordance with §
										152.3(d)
					 (relating to content of an application for approval), has submitted and
					 received joint Department and Department of Health approval of an
					 ERISA-exemption certificate.
Gatekeeper product
-A product offered by a
					 PPO which requires an enrollee to preselect a particular primary care physician
					 from among a list of participating primary care physicians, and to receive from
					 the physician, as a condition for receipt of a higher level of benefits or
					 reimbursement level, or both, referrals for nonemergency specialty, hospital
					 and other services.
HMO
-Health maintenance organization.
PPO
-Preferred provider
					 organization.
Passive gatekeeper product
-A product
					 offered by a PPO which does not require an enrollee to preselect a particular
					 primary care physician, but requires, as a condition for receipt of a higher
					 level of benefits or reimbursement level, or both, that an enrollee receive
					 care from or a referral from a participating preferred primary care physician.
					 The products are permissible if their restrictions are adequately disclosed to
					 enrollees and receive appropriate approval of the Department. However, since
					 they do not lock enrollees into use of a particular primary care physician,
					 they are not subject to §§
										152.101,
					 152.103-152.105 and this section (relating
					 to primary care gatekeeper PPO products-statement of policy).
This section cited in 28 Pa. Code §
												9.502 (relating to
						definitions).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › PRIMARY CARE GATEKEEPER PPO PRODUCTS- STATEMENT OF POLICY › Section 152.103 - HMO and PPO differentiation

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
General
. Under the time provisions of §
										152.8 (relating to compliance with
				  Health Maintenance Organization Act (40 P. S. §§
											1551-1567)), the Secretary of Health will
				  determine when a PPO is engaging in the business of an HMO and required to seek
				  licensure as such. The use of a primary care gatekeeper is a feature associated
				  with HMOs, and is a required feature, under Department of Health HMO
				  regulations at 28 Pa. Code Chapter 9 (relating to health maintenance
				  organizations) of licensed HMOs. A PPO using a primary care gatekeeper feature,
				  otherwise meeting the standards of this chapter, will not be considered an HMO
				  by the Secretary or be required to obtain an HMO certificate of authority prior
				  to commencement of operations if it meets the following standards:
(1) Preferred primary care physicians are
				  reimbursed solely on a fee-for-service basis.
(2) Preferred primary care physicians are not
				  at financial risk for the provision for health service utilization to enrollees
				  through use of risk incentive withhold pools or other means of financial reward
				  for utilization control.
(3) The
				  PPO is not an exclusive provider organization.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › PRIMARY CARE GATEKEEPER PPO PRODUCTS- STATEMENT OF POLICY › Section 152.104 - Filing requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A PPO
				  desiring to offer a gatekeeper product 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. Two copies shall be filed
				  with each Department and shall include:
(1)
				  The group master policy, certificate and enrollee literature. Adequate primary
				  care benefits shall be provided when an enrollee seeks care from the enrollee's
				  primary care physician. Copayments may not be so high as to act as a barrier to
				  an enrollee's use of the primary care physician.
(2) Initial rates and rating
				  methodology.
(3) Copies of
				  preferred provider contracts, which should contain features required by the
				  Department of Health in HMO contracts, including:
(i) NAIC/National Association of HMO
				  Regulators enrollee hold harmless language.
(ii) A provision for a preferred provider to
				  participate in activities of and abide by the decisions of the PPO's quality
				  assurance and utilization review committee.
(iii) A provision for a preferred provider to
				  cooperate with and abide by the decisions of the PPO's enrollee grievance
				  system.
(iv) A provision for the
				  preferred provider to abide by PPO rules and regulations for preferred
				  providers, including those regarding hospital privileges, credentialing,
				  in-office reviews and similar rules.
(v) A provision for the provider to provide
				  the PPO and the Department of Health with access to enrollee medical records
				  for the purposes of quality oversight and grievance resolution.
(vi) A provision for immediate termination of
				  participation and preferred status if the provider is found to be harming
				  patients.
(4) Provisions
				  of the proposed quality assurance and utilization review systems, including
				  staffing and professional qualifications of the medical director, quality
				  assurance, utilization review and provider relations staff.
(5) A description of the proposed grievance
				  system.
(6) A description of the
				  PPO's ability to collect data and meet the annual and quarterly reporting
				  requirements of the Department of Health.
(7) A copy of a notice form to be used when
				  an enrollee seeks care without first obtaining a referral from the enrollee's
				  primary care physician, adequately disclosing the benefit or reimbursement
				  advantages, or both, of seeking care by or through the enrollee's primary care
				  physician.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › PRIMARY CARE GATEKEEPER PPO PRODUCTS- STATEMENT OF POLICY › Section 152.105 - Delivery system and quality of care oversight

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The use of a gatekeeper product by a PPO
				  restricts enrollee freedom of provider choice and is an arrangement which may
				  lead to undertreatment or poor quality care, since enrollee access to specialty
				  and other needed care is restricted. Gatekeeper PPOs, in order to adequately
				  address the issue of potential undertreatment or poor quality care and to
				  protect their enrollees, and in return for the privilege of being permitted use
				  of gatekeepers, shall:
(1) Establish and
				  maintain compliance with the same Department of Health standards regarding
				  quality of care oversight as required of HMOs in 28 Pa. Code §§ 9.74,
				  9.75 and 9.93 (Reserved).
(2)
				  Establish and maintain compliance with the same Department of Health standards
				  regarding enrollee grievance systems as required of HMOs in 28 Pa. Code §
				  9.73 (Reserved).
(3) Establish and
				  maintain data systems capable of making quarterly and annual reports to the
				  Departments substantially equivalent to those required of HMOs as found in 28
				  Pa. Code §§ 9.91 and 9.92 (Reserved).
(4) Submit and receive prior approval from
				  the Department and the Department of Health of advertising, marketing and
				  enrollee literature which adequately explains the role of the primary care
				  gatekeeper and the limitations of coverage.
(5) Submit evidence of compliance with the
				  Department of Health's accessibility and availability standards equal to these
				  established for HMOs, and evidence of sufficient trained and experienced staff
				  to monitor and control the delivery system on an appropriate local or regional
				  basis.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 153 - STATEMENTS OF POLICY › Section 153.2 - Permission to file accident and health, life and annuity insert pages-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				Insurance Department (Department) notifies the insurance industry that they may
				continue to file insert pages to modify or revise previously approved group
				policies and certificates. Additionally, they may immediately begin to file
				insert pages to modify or revise previously approved individual
				policies.
(b) The inclusion of an
				insert page in a previously approved group policy, certificate or individual
				policy may not result in a change in the form number appearing in the lower
				left corner of the first page of the policy or certificate.
(c) An insert page filing shall include the
				following:
(1) Two copies of the insert
				pages.
(2) A letter of submission
				including the following:
(i) A statement
				identifying by form number and approval date the policy or certificate being
				modified or revised by the insert pages.
(ii) An explanation of the modifications or
				revisions being made by the insert pages in the previously approved policy or
				certificate. In lieu of providing an explanation the insurer may submit a third
				copy of the insert pages with the modifications or revisions
				highlighted.
(3) A
				duplicate copy of the letter of submission.
(4) One of the following:
(i) A certification signed by a company
				officer that after approval of the insert pages, the policy or certificate in
				which the insert pages will be included will be issued only with the insert
				pages and that the replaced pages will no longer be issued with the policy or
				certificate.
(ii) An explanation
				providing justification as to why both the insert pages and the pages modified
				by the insert pages are necessary and under what conditions the pages would be
				issued.
(5) A revised
				actuarial memorandum if the insert pages affect the previously filed actuarial
				memorandum.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 153 - STATEMENTS OF POLICY › Section 153.3 - Simplified review of company merger, assumption or name change form and rate filings-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Solicitation in this
				Commonwealth.
(1) The Insurance
				Department (Department) notifies the insurance industry and the general public
				that it has required and will continue to require that prior to solicitation in
				this Commonwealth:
(i) When two or more
				insurers merge or an insurer assumes the business of another insurer, the
				surviving or assuming insurer shall obtain Department approval of forms or
				rates of the merged or assumed insurer that it will solicit in this
				Commonwealth.
(ii) When an insurer
				changes its name, the insurer shall reprint its previously approved forms to
				reflect the new company name and obtain Department approval of the reprinted
				forms.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 154 - QUALITY HEALTH CARE ACCOUNTABILITY AND PROTECTION › GENERAL PROVISIONS › Section 154.1 - Applicability and purpose

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This
				  chapter governs quality health care accountability and protection and applies
				  to managed care plans and licensed insurers subject to the act. The Department
				  and the Department of Health both have regulatory authority under the act. This
				  chapter does not apply to health care services and claims processed under
				  automobile and worker's compensation policies.
(b) The terms and conditions of group and
				  individual contract renewals and new business written by managed care plans on
				  or after January 1, 1999, shall conform to the act.
(c) An entity, including an IDS,
				  subcontracting with a managed care plan to provide services to enrollees shall
				  meet the requirements of the act and this chapter for services provided to
				  those enrollees.
(d) Policies which
				  partially insure an entity's risk, shall meet the requirements of the act if
				  they are issued by a managed care plan.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 154 - QUALITY HEALTH CARE ACCOUNTABILITY AND PROTECTION › GENERAL PROVISIONS › Section 154.2 - 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
-Article XXI of The Insurance Company
					 Law of 1921 (40 P. S. §§
											991.2101-991.2193).
Ancillary service plan
-As defined in
					 section 2102 of the act (40 P. S. §
											991.2102).
Clean claim
-As defined in section 2102 of
					 the act.
Commissioner
-The Insurance Commissioner of
					 the Commonwealth.
Complaint
-As defined in section 2102 of
					 the act.
Department
-The Insurance Department of the
					 Commonwealth.
Emergency service
-As defined in section
					 2102 of the act.
Enrollee
-A policyholder, subscriber,
					 covered person or other individual who is entitled to receive health care
					 services under a managed care plan. For purposes of the complaint and grievance
					 processes, the term includes parents of minor enrollees as well as designees or
					 legal representatives who are entitled or authorized to act on behalf of an
					 enrollee.
Gatekeeper
-A primary care provider
					 selected by an enrollee or appointed by a managed care plan, or the plan or an
					 agent of the plan serving as the primary care provider, from whom an enrollee
					 shall obtain covered health care services, a referral, or approval for covered,
					 nonemergency health services as a precondition to receiving the highest level
					 of coverage available under the managed care plan.
Grievance
-As defined in section 2102 of
					 the act.
Health care provider
-As defined in
					 section 2102 of the act.
Health care service
-As defined in section
					 2102 of the act.
IDS-Integrated Delivery System
-
(i) A partnership, association, corporation
				  or other legal entity which does the following:
(A) Enters into a contractual arrangement
				  with a managed care plan.
(B)
				  Employs or has contracts with providers (participating providers).
(C) Agrees under its arrangements with a
				  managed care plan to do the following:
(I)
				  Provide or arrange for the provision of a defined set of health care services
				  to managed care plan members covered under a managed care plan benefits
				  contract principally through its participating providers.
(II) Assume under the arrangements some
				  responsibility for conduct, in conjunction with the managed care plan and under
				  compliance monitoring of the managed care plan's quality assurance, utilization
				  review, credentialing, provider relations or related functions.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 154 - QUALITY HEALTH CARE ACCOUNTABILITY AND PROTECTION › GENERAL PROVISIONS › Section 154.3 - Changes, modifications and disclosures in subscriber and other contracts and in other materials

Current through Register Vol. 54, No. 28, July 13, 2024
Managed care plans shall implement changes, modifications
					 and disclosures to subscriber and other contracts, marketing materials, member
					 handbooks and other appropriate materials to meet the requirements of the act.
					 Modifications can be implemented in several different ways including contract
					 endorsements, contract amendments and modification to the contract then in
					 effect.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 154 - QUALITY HEALTH CARE ACCOUNTABILITY AND PROTECTION › REQUIRED PROVISIONS AND ENROLLEE DISCLOSURES › Section 154.11 - Managed care plan requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Managed care plans shall adopt and maintain procedures by which an enrollee
				  with a life-threatening, degenerative or disabling disease or condition shall,
				  upon request, receive an evaluation, and, if the plan's established standards
				  are met, be permitted to receive approval for either:
(1) A standing referral to a specialist with
				  clinical expertise in treating the disease or condition.
(2) The designation of a specialist to
				  provide and coordinate the enrollee's primary and specialty care.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 154 - QUALITY HEALTH CARE ACCOUNTABILITY AND PROTECTION › REQUIRED PROVISIONS AND ENROLLEE DISCLOSURES › Section 154.12 - Direct enrollee access to obstetrical and gynecological services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Managed care
				  plans shall permit enrollees direct access to obstetrical and gynecological
				  services for maternity and gynecological care, including medically necessary
				  and appropriate follow-up care and referrals, for diagnostic testing related to
				  maternity and gynecological care from participating health care providers
				  without prior approval from a primary care provider. No time restrictions shall
				  apply to the direct accessing of these services by enrollees.
(b) A managed care plan may require a
				  provider of obstetrical or gynecological services to obtain prior authorization
				  for selected services such as diagnostic testing or subspecialty care-for
				  example, reproductive endocrinology, oncologic gynecology and maternal and
				  fetal medicine.
(c) A directly
				  accessed participating health care provider providing services to an enrollee
				  who has direct access to the provider in accordance with section 2111(7) of the
				  act (40 P. S. §
											991.2111(7)) and this
				  section, shall inform the enrollee's primary care provider, of all health care
				  services provided to the enrollee. The health care provider shall communicate
				  the information within 30 days of the services being provided under procedures
				  established by the managed care plan. For routine obstetrical services, an
				  initial notification and final notification, subsequent to the postpartum
				  visit, shall meet the notification requirements.
(d) Managed care plans may not have different
				  reimbursement levels for covered services because an enrollee obtains these
				  services through direct access rather than with the prior approval of a primary
				  care provider.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 154 - QUALITY HEALTH CARE ACCOUNTABILITY AND PROTECTION › REQUIRED PROVISIONS AND ENROLLEE DISCLOSURES › Section 154.13 - Managed care plan reporting of complaints and grievances

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Section 2111(13) of the act
				  (40
				  P. S. §
											991.2111(13))
				  requires managed care plans to report specific information to the Department of
				  Health and the Department with respect to the number, type and disposition of
				  all complaints and grievances filed with the managed care plan.
(b) Managed care plans shall report the
				  information in subsection (a) to the Departments based on the format as
				  required by the Departments.
(c)
				  Notice of changes or amendments to the format for reporting complaint and
				  grievance information will be published by the Department in the
Pennsylvania Bulletin.
The notice will provide for a 30-day
				  public comment period. Changes in format will become effective 30 days after
				  publication of the revised format in a subsequent edition of the
Pennsylvania Bulletin.