Current through Register Vol. 54, No. 12, March 23, 2024
(a) A plan may
contract with an IDS for the provision of care by IDS participating health care
providers to plan enrollees. The contract between the plan and the IDS shall be
in compliance with the requirements of this subchapter.
(b) The plan shall provide a copy of the IDS
contract to the Department for review and approval. An IDS contract not based
on an approved standard contract shall be submitted to the Department for
review and approval. An IDS contract shall be reviewed by the Department in
accordance with §
9.722(a)
(relating to plan and health care provider contracts). If the IDS contract is
based on a standard form contract, the plan shall provide the Department with
notice of the contract, including the name, address and description of the IDS,
before the effective date of the contract.
(c) The plan shall submit the IDS's standard
provider contract to the Department for review and approval before the
effective date of the IDS contract. If an IDS's providers have executed
plan-provider contracts instead of IDS-provider contracts, the plan shall
provide the Department with written notice of those contracts before the
effective date of the IDS contract.
(d) For the Department to approve a contract
between the plan and the IDS, the contract must meet the following standards:
(1) An IDS, assuming financial risk from a
plan, is not required to obtain its own license to assume the risk, provided
that the ultimate responsibility for benefits and services to enrollees, as set
forth in the enrollee contract, remains the responsibility of the
plan.
(2) If a person or entity is
delivering prepaid basic health care services to enrollees, but not soliciting
or enrolling members in a plan, that person or entity is not required to obtain
a certificate of authority. If the person or entity is delivering prepaid basic
health care services and performing administrative services or other similar
functions, but not soliciting or enrolling plan members, that person or entity
is not required to obtain a certificate of authority.
(3) The IDS shall acknowledge and agree that
under no circumstance shall provision of covered services to enrollees be
delayed, reduced, denied or otherwise hindered because of the financial or
contractual relationship between the plan and the IDS or between the IDS and
the participating health care providers.
(4) The IDS shall acknowledge and agree that
only those IDS participating health care providers who meet the plan's
credentialing and provider contracting standards may participate and provide
services to enrollees and that the ultimate authority to approve or terminate
IDS health care providers is retained by the plan.
(5) The IDS shall acknowledge and agree that
the plan is required to establish, operate and maintain a health care services
delivery system, quality assurance system, provider credentialing system,
enrollee complaint and grievance system, and other systems meeting Department
standards and that the plan is directly accountable to the Department for
compliance with the standards and for provision of quality, cost-effective care
to plan enrollees. Nothing in the plan-IDS contract may limit the plan's
authority or responsibility to meet standards or to take prompt corrective
action to address a quality of care problem, resolve an enrollee complaint or
grievance, or to comply with a regulatory requirement of the
Department.
(6) The IDS shall agree
to provide the plan and the Department with access to medical and other records
concerning the provision of services to enrollees by the IDS through its
participating health care providers. The IDS shall agree to permit and
cooperate with onsite reviews by the Department for purposes of monitoring the
effectiveness of the IDS performance of any plan-delegated functions.
(7) The IDS shall agree that any delegation
of authority or responsibility, in part or in full, for provider credentialing
and relations, quality assessment, UR and other plan functions to the IDS shall
be subject to performance monitoring by the plan and Department, and is subject
to independent validation by the plan, the Department, or an independent
quality review organization or CRE approved by the Department.
(8) The IDS shall agree to collect and
provide the plan with utilization, financial and other data for the purposes of
monitoring and comparative performance analysis.
(9) The IDS shall agree to comply with data
reporting requirements, including encounter, utilization and reimbursement
methodology required by the Department.
(10) The IDS shall obtain and maintain
Department certification as a CRE if performing UR activities in Subchapter K
(relating to CREs) and sections 2151 and 2152 of the act (40 P. S. §§
991.2151 and
2152).
(11) The IDS contract shall contain enrollee
financial hold-harmless provisions acceptable to the Department which prevent
the IDS and IDS participating health care providers from billing plan enrollees
for covered services (other than authorized co-payments, co-insurance, or
deductibles) under any circumstances including insolvency of the plan or the
IDS.
(12) The IDS contract shall
safeguard patient access to care and avoid significant disruption of service
delivery by adequately providing for continuation of services by IDS
participating health care providers to plan enrollees if the IDS contractual
agreement is in any way jeopardized, suspended, terminated or unexpectedly not
renewed. In the event of termination, the plan shall ensure continuity of care
for those affected enrollees, under Act 68 and §
9.684 (relating to continuity of
care).
(13) If the plan and IDS
agree to include a termination without cause provision in the contract between
the plan and the IDS, neither party shall be permitted to terminate the
contract without cause upon less than 60 days prior written notice.
(14) Any delegation of medical management
shall meet the requirements of §
9.675 (relating to delegation of
medical management).