Section 154.16. Information for enrollees

(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.

Notation

Cross References

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).