31 Pa. Code § 152.103 - HMO and PPO differentiation

(a) General. Under the time provisions of § 152.8 (relating to compliance with Health Maintenance Organization Act (40 P. S. §§ 1551-1567)), the Secretary of Health will determine when a PPO is engaging in the business of an HMO and required to seek licensure as such. The use of a primary care gatekeeper is a feature associated with HMOs, and is a required feature, under Department of Health HMO regulations at 28 Pa. Code Chapter 9 (relating to health maintenance organizations) of licensed HMOs. A PPO using a primary care gatekeeper feature, otherwise meeting the standards of this chapter, will not be considered an HMO by the Secretary or be required to obtain an HMO certificate of authority prior to commencement of operations if it meets the following standards:

(1) Preferred primary care physicians are reimbursed solely on a fee-for-service basis.

(2) Preferred primary care physicians are not at financial risk for the provision for health service utilization to enrollees through use of risk incentive withhold pools or other means of financial reward for utilization control.

(3) The PPO is not an exclusive provider organization.

(b) Exception. A PPO will be permitted to utilize primary care gatekeepers which are capitated or at financial risk, or both, if the primary care gatekeeper services are being offered under a subcontract between the PPO and an affiliated licensed HMO, if:

(1) The provisions of the subcontract are acceptable to the Departments and the Department of Health.

(2) The HMO's quality assurance systems, and similar consumer protection measures are extended to the PPO enrollees in a manner found acceptable by the Department of Health.

Notes

31 Pa. Code § 152.103

The provisions of this § 152.103 adopted September 27, 1991, effective 9/28/1991, 21 Pa.B. 4424.

This section cited in 31 Pa. Code § 152.102 (relating to definitions).