Current through Register Vol. 54, No. 44, November 2, 2024
(a) Managed
care plans shall provide the written information in section 2136(a) of the act
(40
P. S. §
991.2136(a)),
which relates required disclosures, to enrollees and, on written request, to
prospective enrollees and health care providers.
(1) Managed care plans may determine the
format for disclosure of the required information. If the information is
disclosed through materials such as subscriber contracts, schedules of benefits
and enrollee handbooks, the information shall be easily identifiable within the
materials provided.
(2) The written
information to be provided by managed care plans to enrollees, prospective
enrollees and health care providers shall be subject to the filing requirements
under the Accident and Health Filing Reform Act (40 P. S. §§ 3801-3813) and all other applicable statutes
and regulations.
(b) The
information disclosed to enrollees, prospective enrollees and health care
providers shall be easily understandable to the layperson.
(c) The written disclosure of information
shall include:
(1) The information required by
subsection (a).
(2) A list by
specialty of the name, address and telephone number of all participating health
care providers which an enrollee may have access to either directly or through
a referral. The list may be a separate document and may be a regional or county
directory and shall be updated at least annually. If a regional or county
directory is provided, enrollees shall be made aware that other regional or a
full directory is available upon request. If a list of participating providers
for only a specific type of provider or service is provided, it shall include
all participating providers authorized to provide those services.
(3) The information covered under section
2113(d)(2)(ii) of the act (40 P. S. §
991.2113(d)(2)(ii)), which
relates to a medical "gag clause" prohibition.
(4) If applicable, managed care plans shall
disclose in their subscriber contracts, schedule of benefits and other
appropriate material, circumstances under which the managed care plan does not
provide for, reimburse for or cover counseling, referral or other health care
services due to a managed care plan's objections to the provision of the
services on moral or religious grounds.
(d) For the purposes of the specified
disclosure statement required by section 2136(a)(1) of the act, subscriber and
group master contracts and riders, amendments and endorsements, do not
constitute "marketing materials" subject to the specified disclosure statement.
For the purposes of written information distributed to enrollees or potential
enrollees, the term "marketing materials" shall have the meaning given to
written information in the term "advertisement" in §
51.1 (relating to
definitions).
(e) For group
contracts and policies, the managed care plan shall assure that the required
disclosure information is provided to prospective enrollees upon written
request. The managed care plan can either provide the information directly to
prospective enrollees or allow the group policy holder or another entity to
provide the information to prospective enrollees on behalf of the managed care
plan.
(f) For individual contracts
and policies, the managed care plan shall provide the required disclosure
information directly to prospective enrollees upon written request.
(g) The disclosure of information to
enrollees, prospective enrollees and health care providers as required by
section 2136 of the act shall be provided as follows:
(1) During open enrollment periods managed
care plans may disclose summary information to enrollees and prospective
enrollees. If the disclosure of information does not include all the
information required by the act and this chapter, the managed care plan shall
simultaneously provide enrollees and prospective enrollees with a list of other
information which has not been included with the open enrollment information.
The listed information shall be made available to enrollees and prospective
enrollees upon request.
(2)
Following initial enrollment, or upon renewal, if benefits have changed or
networks have substantially changed since the initial enrollment or last
renewal, disclosure information shall be provided to enrollees within 30 days
of the effective date of the contract or policy, renewal date of coverage, if
appropriate, or the date of receipt of the request for the
information.
(3) Disclosure
information requested by prospective enrollees shall be provided to prospective
enrollees within 30 days of the date of the receipt of the written request for
the information.
(4) Disclosure
information requested by health care providers shall be provided to health care
providers within 45 days of the date of the receipt of the written request for
the information.
(h)
Managed care plans shall supply each enrollee, and upon written request, each
prospective enrollee or health care provider, with the following information
which shall be contained and incorporated into subscriber and master group
contracts:
(1) A description of the procedures
for providing emergency services 24 hours a day.
(2) A definition of "emergency services," as
set forth in the act.
(3) Notice
that emergency services are not subject to prior approval.
(4) The enrollee's financial and other
responsibilities regarding emergency services, including the receipt of these
services outside the managed care plan's service area.
(i) Managed care plans, upon written request
by enrollees or prospective enrollees, shall provide written information as
specified in section 2136(b) of the act. This information shall be easily
understandable to the layperson.
This section cited in 28 Pa. Code §9.653 (relating to HMO provision
of limited subnetworks to select enrollees); 28 Pa. Code §9.681 (relating to health care
providers); and 31 Pa. Code §
154.14 (relating to emergency
services).
