§ 9.679. Access requirements in service areas.
(a) A plan shall only provide coverage to enrollees who work or reside in a service area when the plan has been approved to operate in that service area by the Department.
(b) A plan seeking to expand its service area beyond that which was initially approved shall file with the Department a service area expansion request.
(c) A plan shall report to the Department any probable loss from the network of any general acute care hospital and any primary care provider, whether an individual practice or a group practice, with 2,000 or more assigned enrollees.
(d) Except as otherwise authorized in this section, a plan shall provide for at least 90% of its enrollees in each county in its service area, access to covered services that are within 20 miles or 30 minutes travel from an enrollee’s residence or work in a county designated as a metropolitan statistical area (MSA) by the Federal Census Bureau, and within 45 miles or 60 minutes travel from an enrollee’s residence or work in any other county.
(e) A plan shall at all times assure enrollee access to primary care providers, speciality care providers and other health care facilities and services necessary to provide covered benefits. At a minimum, the following health care services must be available in accordance with the standards in subsection (d):
(1) General acute inpatient hospital services.
(2) Common laboratory and diagnostic services.
(3) Primary care.
(4) General surgery.
(5) Orthopedic surgery.
(6) Obstetrical and gynecological services.
(7) Ophthalmology.
(8) Allergy and immunology.
(9) Anesthesiology.
(10) Otolaryngology.
(11) Physical medicine and rehabilitation.
(12) Psychiatry and neurology.
(13) Neurological surgery.
(14) Urology.
(f) If a plan is unable to meet the travel standards in subsection (d), it shall inform the Department in writing and provide a written description of why it is unable to do so and its alternative arrangements to ensure access to health care providers of these services. The plan shall include in its description a specific explanation of exactly how it intends to provide access to health care services including:
(1) The use of participating or nonparticipating providers.
(2) Applicable payment arrangements.
(3) Measures to secure health care provider cooperation with plan policies and procedures concerning UR, case management, claims payment and access to medical information necessary to authorize payment of covered health care services.
(4) Travel arrangements, if any.
(g) A plan using a health care provider of services delivered in the home need not meet the requirements of subsection (d) or (f) as long as the services can be reliably provided in the enrollee’s home regardless of distance between the home and the provider’s location.
(h) For infrequently utilized health care services, such as transplants, a plan may provide access to nonparticipating health care providers or contract with health care providers outside of the approved service area.
(i) A plan offering coverage for nonbasic health care services, either as part of the basic benefit package or through supplemental coverage, such as prescription drugs, vision, dental, and durable medical equipment, shall ensure that its network of health care providers for these services meets the standards for frequently utilized services in subsections (d)—(g).
(j) If there is a therapeutic reason to arrange for services at a distance greater than the travel standards in subsections (d) and (f), whether for frequently or infrequently utilized health care services, the plan may make arrangements necessary to provide access to quality health care services.
(k) A plan shall cover services provided by a nonparticipating health care provider at no less than the in-network level of benefit when the plan has no available network provider. A plan is not required to have network providers available outside of the approved service area for the purposes of enrollees seeking basic health care services while outside of the service area. A plan is not required to pay a noncontracted provider at the same benefit level as a network provider for basic health care services sought by and provided an enrollee while outside the service area when in-network providers were available.
(l) A plan seeking to expand its service area beyond that which was initially approved shall file with the Department, for the Department’s approval, a service area expansion request that meets the requirements of this section and includes:
(1) Projected enrollment for the first year of operation.
(2) A provider listing of contracted and credentialed health care providers.
(m) A plan shall provide the Department with a description of its provider network in a format specified by the Department, annually, and at other times at the Department’s request to enable the Department to analyze network disruptions or investigate complaints.
Cross References This section cited in 28 Pa. Code § 9.652 (relating to HMO provision of other than basic health services to enrollees); 28 Pa. Code § 9.653 (relating to HMO provision of limited subnetworks to select enrollees).
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