§ 154.15. Continuity of care.
(a) Managed care plans are required to provide the option of continuity of care for enrollees when one of the following applies:
(1) A managed care plan terminates a contract with a participating provider for reasons other than for cause as set forth in section 2117(b) of the act (40 P. S. § 991.2117(b)) and the enrollee is then in an ongoing course of treatment with that provider.
(2) A new enrollee enters a managed care plan and is then in an ongoing course of treatment with a nonparticipating provider which is not otherwise covered by the terminated coverage.
(b) A current enrollee shall be allowed to continue an ongoing course of treatment with a provider whose contract has been terminated by the plan for reasons other than for cause (as set forth in section 2117(b) of the act) for a transitional period of up to 60 days from the date the enrollee was notified by the plan of the termination or pending termination. The managed care plan, in consultation with the enrollee and the health care provider, may extend the transitional period if determined to be clinically appropriate. For an enrollee in the second or third trimester of pregnancy at the time of notice of the termination or pending termination, the transitional period shall be extended through postpartum care related to the delivery.
(c) A new enrollee shall be allowed to continue an ongoing course of treatment with a nonparticipating provider when joining a managed care plan for a transitional period of up to 60 days from the effective date of enrollment in the managed care plan. The managed care plan, in consultation with the enrollee and the health care provider, may extend the transitional period if determined to be clinically appropriate. For an enrollee in the second or third trimester of pregnancy on the effective date of enrollment, the transitional period shall be extended through postpartum care related to the delivery.
(d) Continuity of care is at the option of the enrollee.
(e) Nonparticipating and terminated providers may be required by the plan to agree to the same terms and conditions which are applicable to the managed care plan’s participating providers. If multiple providers are involved in an ongoing course of treatment, one of the following conditions shall be met:
(1) All of the providers involved may be required by the plan to agree to the plan’s terms and conditions.
(2) Those providers who accept the plan’s terms and conditions may be required by the plan to agree to utilize participating providers for the provision of all other health care services to enrollees.
(f) Health care services provided under the continuity of care requirements shall be covered by the managed care plan under the same terms and conditions as applicable for participating health care providers. To be eligible for payment by plans, providers shall agree to the terms and conditions of the managed care plan prior to providing service under the continuity of care provisions.
(g) Managed care plans may require nonparticipating or terminating providers to agree to terms that include:
(1) Accepting the plan’s payment as payment in full for covered services, without balance billing, except for permitted deductibles, copayments or coinsurance.
(2) Agreeing to hold the enrollee harmless for any moneys which may be owed by the managed care plan to the provider.
(3) Complying with the plan’s utilization review and quality assurance requirements.
(4) Agreeing that the provider will provide copies of the enrollee’s medical records to the plan or the enrollee’s participating primary care provider, or both, prior to the conclusion of the ongoing course of previously authorized treatment.
(5) Agreeing to follow the plan’s procedures for precertification or prior approval of specified nonemergency services or procedures.
(h) Managed care plans may not require nonparticipating providers to undergo the full plan’s credentialing process as part of the continuity of care provision.
(i) Written disclosure of the continuity of care benefit requirements imposed under the act and this chapter shall be incorporated into the subscriber and master group contracts and the enrollee handbook (if provided to the enrollee). This information and other information necessary to provide continuity of care services shall also be provided in written form to terminated or terminating and nonparticipating providers within 10 days of notice to the plan that an enrollee is requesting continuity of care benefits.
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