State Law

The Insurance Company Law of 1921 (P.L.682, No.284)

08/22/2023 Pennsylvania Section 2111

Responsibilities of insurers and MA and CHIP managed care plans

Directories

See the bold text below:

An insurer or MA or CHIP managed care plan shall do all of the following:

(1) Assure availability and accessibility of adequate health care providers in a timely manner, which enables covered persons or enrollees to have access to quality care and continuity of health care services.

(2) Consult with health care providers in active clinical practice regarding professional qualifications and necessary specialists to be included in. The provider network under a health insurance policy or an agreement with the department of human services.

(3) Adopt and maintain a definition of medical necessity used by an insurer or MA or CHIP managed care plan in determining authorization of health care services.

(4) Ensure that emergency services are provided twenty-four (24) hours a day, seven (7) days a week and provide reasonable payment or reimbursement for emergency services.

(5) Adopt and maintain procedures by which a covered person or enrollee can obtain health care services outside the health insurance policy’s or MA or CHIP managed care plan’s service area.

(6) Adopt and maintain procedures by which a covered person or enrollee with a life-threatening, degenerative or disabling disease or condition shall, upon request, receive an evaluation and, if the health insurance policy’s established standards are met or the standards established by an agreement with the department of human services, be permitted to receive:

(i) A standing referral to a specialist with clinical expertise in treating the disease or condition; or

(ii) The designation of a specialist to provide and coordinate the covered person’s or enrollee’s primary and specialty care. The referral to or designation of a specialist shall be pursuant to a treatment plan approved by the insurer or MA or CHIP managed care plan in consultation with the primary care provider, the covered person or enrollee and, as appropriate, the specialist. When possible, the specialist must be a health care provider participating in the health insurance policy or MA or CHIP managed care plan’s provider network.

(7) Provide direct access to obstetrical and gynecological services by permitting a covered person or enrollee to select a health care provider participating in the health insurance policy or MA or CHIP managed care plan’s provider network to obtain maternity and gynecological care, including medically necessary and appropriate follow-up care and referrals for diagnostic testing related to maternity and gynecological care, without prior approval from a primary care provider. The health care services shall be within the scope of practice of the selected health care provider. The selected health care provider shall inform the covered person’s or enrollee’s primary care provider of all health care services provided.

(8) Adopt and maintain a complaint process as set forth in subdivision (g).

(9) Adopt and maintain a grievance process as set forth in subdivision (i).

(10) Adopt and maintain credentialing standards for health care providers as set forth in subdivision (d).

(11) Ensure that there are participating health care providers that are physically accessible to people with disabilities and can communicate with individuals with sensory disabilities in accordance with title III of the Americans with Disabilities Act of 1990 (public law 101-336, 42 U.S.C. § 12181 et seq.).

Directories

(12) Provide a list of health care providers participating in the health insurance policy or MA or CHIP managed care plan’s provider network to the department every two (2) years or as may otherwise be required by the department. The list shall include the extent to which health care providers in the health insurance policy or MA or CHIP managed care plan’s provider network are accepting new enrollees.

(13) Report to the department in accordance with the requirements of this article. Such information shall include the number, type and disposition of all complaints, grievances and adverse benefit determinations filed with the insurer under a health insurance policy or with the MA or CHIP managed care plan, as applicable.

This section is codified at https://www.legis.state.pa.us/cfdocs/Legis/LI/uconsCheck.cfm?txtType=HTM&yr=1921&sessInd=0&smthLwInd=0&act=0284.