Pennsylvania Code
Title 28 - HEALTH AND SAFETY
Part I - General Health
Chapter 9 - MANAGED CARE ORGANIZATIONS
Subchapter H - AVAILABILITY AND ACCESS
Section 9.685 - Standards for approval of point-of-service products
Universal Citation: 28 PA Code ยง 9.685
Current through Register Vol. 54, No. 44, November 2, 2024
(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.
Disclaimer: These regulations may not be the most recent version. Pennsylvania may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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