28 Pa. Code § 9.653. HMO provision of limited subnetworks to select enrollees.

§ 9.653. HMO provision of limited subnetworks to select enrollees.

(a)  An HMO that wants to offer benefit plans based on limited subnetworks, that is, networks which include only selected participating health care providers, shall request approval from the Department to do so.
(b)  The Department will approve a request to offer limited subnetworks if the proposal meets the following requirements:
   (1)  There is adequate disclosure to potential enrollees and any current enrollees who would be affected by a change to a limited subnetwork benefit package of the economic penalties that apply when enrollees do not obtain health care services through the limited subnetwork. Disclosure of the limitations in the number of the HMO’s participating providers must be consistent with the act and the requirements of 31 Pa. Code §  154.16 (relating to disclosure of information).
   (2)  If a covered service is not available within the limited subnetwork, the HMO shall provide or arrange for the provision of the service at no additional out-of-pocket cost to the enrollee, other than the routine copayments which would have been applicable if the service had been provided within the limited subnetwork.
   (3)  The limited subnetwork meets the minimum healthcare provider standards in §  9.679 (relating to access requirements in service areas) and has an adequate number and distribution of network providers to provide care which is available and accessible to enrollees within a defined area.
   (4)  Enrollment is limited to enrollees within a reasonable traveling distance to the limited participating subnetwork providers.
   (5)  The limited subnetwork meets the standards for adequate networks and accessibility in §  9.679.

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