Current through Register Vol. 54, No. 44, November 2, 2024
(a) A plan shall submit the standard form of
each type of health care provider contract, including any document incorporated
by reference into that contract, to the Department for review and approval. The
plan shall be responsible for assuring that the provider contract meets the
requirements of all applicable laws. The Department will review a provider
contract within 45 days of receipt of the contract. If the Department does not
approve or disapprove the contract within 45 days of receipt, the plan may use
the contract and it shall be presumed to meet the requirements of all
applicable laws. If, at any time, the Department finds that a contract is in
violation of law, the plan shall correct the violation.
(b) The plan shall submit any material change
or amendment to a standard health care provider contract, including a material
change or amendment to any document incorporated by reference into the
contract, to the Department 10 days before implementation of the change or
amendment except for changes required by law or regulation.
(c) To be approved by the Department, a
standard health care provider contract may not contain provisions permitting
the plan to sanction, terminate or fail to renew a health care provider's
participation for any of the following reasons:
(1) Advocating for medically necessary and
appropriate health care services for an enrollee.
(2) Filing a grievance on behalf of and with
the written consent of an enrollee, or helping an enrollee to file a
grievance.
(3) Protesting a plan
decision, policy or practice the health care provider believes interferes with
its ability to provide medically necessary and appropriate health
care.
(4) Taking another action
specifically permitted by sections 2113, 2121 and 2171 of the act
(40
P. S. §§
991.2113,
991.2121 and
991.2171).
(d) To be approved by the Department, a
standard health care provider contract may not contain any provision permitting
the plan to penalize or restrict a health care provider from discussing any of
the information health care providers are permitted to discuss under section
2113 of the act or other information the health care provider reasonably
believes is necessary to provide to an enrollee full information concerning the
health care of the enrollee.
(e) To
be approved by the Department, a standard health care provider contract shall
include the following consumer protection provisions:
(1) Enrollee hold harmless language which
survives the termination of the health care provider contract regardless of the
reason for termination, and includes the following:
(i) A statement that the hold harmless
language is construed for the benefit of the enrollee.
(ii) A statement that the hold harmless
language supersedes any written or oral agreement currently in existence, or
entered into at a later date, between the health care provider and enrollee, or
persons acting in their behalf.
(iii) If the provider contract is a contract
that affects plan enrollees, language to the following effect:
"In no event including, but not limited to, non-payment by
the plan, plan insolvency, or a breach of this contract, shall the provider
bill, charge, collect a deposit from, seek compensation or reimbursement from,
or have any recourse against the enrollee or persons other than the plan acting
on the behalf of the enrollee for services listed in this agreement. This
provision does not prohibit collecting supplemental charges or co-payments in
accordance with the terms of the applicable agreement between the plan and the
enrollee. "
(2)
Language stating that enrollee records shall be kept confidential by the plan
and the health care provider in accordance with section 2131 of the act
(40
P.S §
991.2131) and all applicable State
and Federal laws and regulations, which include:
(i) Language permitting the Department, the
Insurance Department, and, when necessary, the Department of Public Welfare,
access to records for the purpose of quality assurance, investigation of
complaints or grievances, enforcement or other activities related to compliance
with Article XXI, this chapter and other laws of the Commonwealth.
(ii) Language which states that records are
only accessible to Department employees or agents with direct responsibilities
under subparagraph (i).
(3) Language requiring the health care
provider to participate in and abide by the decisions of the plan's quality
assurance, UR and enrollee complaint and grievance systems.
(4) Language addressing any alternative
dispute resolution systems.
(5)
Language requiring the health provider to adhere to State and Federal laws and
regulations.
(6) Language
concerning prompt payment of claims consistent with the requirements of section
2166 of the act (40 P. S. §
991.2166) and
31 Pa. Code §154.18 (relating to prompt payment
of claims).
(7) Language requiring
that if the plan and the health care provider agree to include a termination
without cause provision in the contract, neither party shall be permitted to
terminate the contract without cause upon less than 60 days prior written
notice.
(8) Language requiring the
plan to give at least 30 days prior written notice of any changes to contracts,
policies or procedures affecting health care providers or the provision or
payment of health care services to enrollees, unless the change is required by
law or regulation.
(f) To
be approved by the Department, a health care provider contract shall satisfy
the following:
(1) Include the reimbursement
method being used to reimburse a participating provider under the contract. If
a provider reimbursement is subject to variability due to economic incentives,
including bonus incentive systems, withhold pools or similar systems, the plan
shall describe the systems and the factors being employed by the plan to
determine reimbursement when the contract is submitted to the Department for
review.
(2) Include no incentive
reimbursement system for licensed professional health care providers which
shall weigh utilization performance as a single component more highly than
quality of care, enrollee services and other factors collectively.
(3) Include no financial incentive that
compensates a health care provider for providing less than medically necessary
and appropriate care to an enrollee.
This section cited in 28 Pa. Code §
9.652 (relating to HMO provision
of other than basic health services to enrollees); 28 Pa. Code §
9.723 (relating to IDS); and 28
Pa. Code §
9.724 (relating to plan-IDS
contracts).
