See the bold text below:

(a) An insurer or MA or CHIP managed care plan shall supply each covered person or enrollee and, upon written request, each prospective covered person or enrollee or health care provider with the following written information. Such information shall be easily understandable by the layperson and shall include, but not be limited to:

(1) A description of coverage, benefits and benefit maximums, including benefit limitations and exclusions of coverage, health care services and the definition of medical necessity used by the insurer or MA or CHIP managed care plan in determining whether these benefits will be covered. The following statement or substantially similar statement shall be included in all marketing materials in boldface type:

For Insurers: This health insurance policy may not cover all your health care expenses. Read your contract or member handbook carefully to determine which health care services are covered.

For MA or CHIP managed care plans: Your managed care plan may not cover all your health care expenses. Read your member handbook carefully to determine which health care services are covered.

The notice shall be followed by a telephone number to contact the insurer or MA or CHIP managed care plan.

(2) A description of all necessary prior authorizations or other requirements for nonemergency health care services as required by section 2155.

(3) An explanation of a covered person’s or enrollee’s financial responsibility for payment of premiums, coinsurance, copayments, deductibles and other charges, annual limits on a covered person’s or enrollee’s financial responsibility and caps on payments for health care services provided under the health insurance policy or an agreement with the Department of Human Services.

(4) An explanation of a covered person’s or enrollee’s financial responsibility for payment when a health care service is provided by a nonparticipating health care provider, when a health care service is provided by any health care provider without required authorization or when the care rendered is not covered under the health insurance policy or by an agreement with the Department of Human Services.

(5) A description of how the insurer or MA or CHIP managed care plan addresses the needs of non-English-speaking covered persons or enrollees.

(6) A notice of mailing addresses and telephone numbers necessary to enable a covered person or enrollee to obtain approval or authorization of a health care service or other information regarding the health insurance policy or services covered by the MA or CHIP managed care plan.

(7) A summary of the insurer’s or MA or CHIP managed care plan’s utilization review policies and procedures.

(8) A summary of all complaint, grievance or adverse benefit determination procedures used to resolve disputes between the insurer or MA or CHIP managed care plan and a covered person or enrollee or a health care provider, including:

(i) The procedure to file a complaint, grievance or adverse benefit determination appeal as set forth in this article, including a toll-free telephone number to obtain information regarding the filing and status of a complaint, grievance or adverse benefit determination.

(ii) The right to appeal a decision relating to a complaint, grievance or adverse benefit determination.

(iii) The covered person’s or enrollee’s right to designate a representative to participate in the complaint, grievance or adverse benefit determination process as set forth in this article.

(iv) A notice that all decisions involving denial of payment for a health care service will be made by qualified personnel with experience in the same or similar scope of practice and that all notices of decisions will include information regarding the basis for the determination.

(9) A description of the procedure for providing emergency services twenty-four (24) hours a day. The description shall include:

(i) A definition of emergency services as set forth in this article.

(ii) Notice that emergency services are not subject to prior approval.

(iii) The covered person’s or enrollee’s financial and other responsibilities regarding emergency services, including the receipt of these services outside the insurer’s or MA or CHIP managed care plan’s service area.

(10) A description of the procedures for covered persons or enrollees to select a participating health care provider, including how to determine whether a participating health care provider is accepting new patients.

(11) A description of the procedures for changing primary care providers and specialists.

(12) A description of the procedures by which a covered person or enrollee may obtain a referral to a health care provider outside the health insurance policy’s or MA or CHIP managed care plan’s provider network when that provider network does not include a health care provider with appropriate training and experience to meet the health care service needs of a covered person or enrollee.

(13) A description of the procedures that a covered person or enrollee with a life-threatening, degenerative or disabling disease or condition shall follow and satisfy to be eligible for either of the following:

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

(ii) The designation of a specialist to provide and coordinate the covered person’s or enrollee’s primary and specialty care.

(14) A list by specialty of the name, address and telephone number of all health care providers participating in the provider network for the health insurance policy or MA or CHIP managed care plan. The list may be a separate document and shall be updated at least once every 90 days or more frequently as may be required by Federal or State law, including section 2799A-5 of the Public Health Service Act (58 Stat. 682, 42 U.S.C. § 201 et seq.).

(15) A list of the information available to covered persons or enrollees or prospective covered persons or enrollees, upon written request, under subsection (b).

(b) Each insurer or MA or CHIP managed care plan shall, upon written request of a covered person or enrollee or prospective covered person or enrollee, provide the following written information:

(1) A list of the names, business addresses and official positions of the membership of the board of directors or officers of the insurer or MA or CHIP managed care plan.

(2) The procedures adopted to protect the confidentiality of medical records and other covered person or enrollee information.

(3) A description of the credentialing process for health care providers.

(4) A list of the participating health care providers affiliated with participating hospitals.

(5) Whether a specifically identified drug is included or excluded from coverage.

(6) A description of the process by which a health care provider can prescribe specific drugs, drugs used for an off-label purpose, biologicals and medications not included in the drug formulary for prescription drugs when the formulary’s equivalent has been ineffective in the treatment of the covered person’s or enrollee’s disease or if the drug causes or is reasonably expected to cause adverse or harmful reactions to the covered person or enrollee.

(7) A description of the procedures followed by the insurer or MA or CHIP managed care plan to make decisions about the experimental nature of individual drugs, medical devices or treatments.

(8) A summary of the methodologies used by the insurer or MA or CHIP managed care plan to reimburse for health care services. Nothing in this paragraph shall be construed to require disclosure of individual contracts or the specific details of any financial arrangement between an insurer or MA or CHIP managed care plan and a health care provider.

(9) A description of the procedures used in the insurer’s or MA or CHIP managed care plan’s quality assurance program.

(10) Other information as may be required by the department or the Insurance Department.

(c)(1) An insurer shall include a description of the insurer’s external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage the insurer provides to covered persons.

(2) The disclosure required by paragraph (1) shall be in a format as prescribed by the department.

(3) The description of procedures required under paragraph (1) shall include:

(i) A statement that informs the covered person of the right to file a request for external review of an adverse benefit determination or final adverse benefit determination, including a request regarding whether the insurer has complied with the surprise billing and cost-sharing protections under the No Surprises Act (Public Law 116-260, Div. BB, Title I, 134 Stat. 2758).

(ii) The telephone number and address of the department.

(iii) A statement that, when filing a request for an external review, the covered benefit is required to authorize the release of medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.

(iv) An explanation that external review is available when the adverse benefit determination or final adverse benefit determination involves an issue of medical necessity, appropriateness, health care setting, level of care or effectiveness.

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.