Pennsylvania Code
Title 28 - HEALTH AND SAFETY
Part I - General Health
Chapter 9 - MANAGED CARE ORGANIZATIONS
Subchapter F - GENERAL
Section 9.606 - Penalties and sanctions

Universal Citation: 28 PA Code ยง 9.606

Current through Register Vol. 54, No. 44, November 2, 2024

(a) For violations of Article XXI and this chapter, the Department may take one or more of the following actions:

(1) Impose a civil penalty of up to $5,000 per violation.

(2) Maintain an action in the name of the Commonwealth for an injunction to prohibit the activity.

(3) Issue an order temporarily prohibiting the plan from enrolling new members.

(b) For violations of the HMO Act and this chapter, the Department may suspend or revoke a certificate of authority or impose a penalty of not more than $1,000 for each unlawful act committed if the Department finds that one or more of the following conditions exist:

(1) The HMO is providing or arranging for inadequate or poor quality care, either directly, through contracted providers or through the operations of the HMO, thereby creating a threat to the health and safety of its enrollees.

(2) The HMO is unable to fulfill its contractual obligations to its enrollees.

(3) The HMO has substantially failed to comply with the HMO Act.

(c) Before the Department may act under subsection (b), the Department will provide the HMO with written notice specifying the nature of the alleged violation and fixing a time and place, at least 10 days thereafter, for a hearing of the matter to be held. Hearing procedures and appeals shall be conducted in accordance with 2 Pa.C.S. (relating to administrative law and procedure).

(d) For violations of the HMO Act, the PPO Act, Act 68 and this chapter, the Department may require a plan to develop and adhere to a plan of correction approved by the Department that the plan shall make available to enrollees upon written request. The Department will monitor compliance with the plan of correction. Failure to comply with the plan of correction may result in the Department's taking action under subsection (a) or (b), as appropriate.

(e) The Department's actions under subsection (a)(1) or (3) are subject to 2 Pa.C.S. Chapter 5, Subchapter A (relating to practice and procedure of Commonwealth agencies).

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