31 Pa. Code § 152.105 - Delivery system and quality of care oversight

(a) The use of a gatekeeper product by a PPO restricts enrollee freedom of provider choice and is an arrangement which may lead to undertreatment or poor quality care, since enrollee access to specialty and other needed care is restricted. Gatekeeper PPOs, in order to adequately address the issue of potential undertreatment or poor quality care and to protect their enrollees, and in return for the privilege of being permitted use of gatekeepers, shall:

(1) Establish and maintain compliance with the same Department of Health standards regarding quality of care oversight as required of HMOs in 28 Pa. Code §§ 9.74, 9.75 and 9.93 (Reserved).

(2) Establish and maintain compliance with the same Department of Health standards regarding enrollee grievance systems as required of HMOs in 28 Pa. Code § 9.73 (Reserved).

(3) Establish and maintain data systems capable of making quarterly and annual reports to the Departments substantially equivalent to those required of HMOs as found in 28 Pa. Code §§ 9.91 and 9.92 (Reserved).

(4) Submit and receive prior approval from the Department and the Department of Health of advertising, marketing and enrollee literature which adequately explains the role of the primary care gatekeeper and the limitations of coverage.

(5) Submit evidence of compliance with the Department of Health's accessibility and availability standards equal to these established for HMOs, and evidence of sufficient trained and experienced staff to monitor and control the delivery system on an appropriate local or regional basis.

(b) In applying the HMO standards to gatekeeper PPOs, the Department of Health may take into consideration the fact that HMOs are independent entities while PPOs may be product lines of insurers.

Notes

31 Pa. Code § 152.105

The provisions of this § 152.105 adopted September 27, 1991, effective 9/28/1991, 21 Pa.B. 4424.

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