Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 52 Pa.B. 7348 (November 26, 2022).

28 Pa. Code § 9.651. HMO provision and coverage of basic health services to enrollees.

OPERATIONAL STANDARDS


§ 9.651. HMO provision and coverage of basic health services to enrollees.

 (a)  An HMO shall maintain an adequate network of health care providers through which it provides coverage for basic health services to enrollees as medically necessary and appropriate without unreasonable limitations as to frequency and cost.

 (b)  An HMO may exclude coverage for services, except to the extent that a service is required to be covered by State or Federal law.

 (c)  An HMO shall provide or arrange for the provision of and cover the following basic health services as the HMO determines to be medically necessary and appropriate according to its definition of medical necessity:

   (1)  Emergency services on a 24-hour-per-day, 7-day-per-week basis. The plan may not require an enrollee, or a participating health care provider advising the enrollee regarding the existence of an emergency, to utilize a participating health care provider for emergency services, including ambulance services. See §  9.672 (relating to emergency services).

   (2)  Outpatient services.

   (3)  Inpatient services for general acute care hospitalization for a minimum of 90 days per contract or calendar year.

   (4)  Preventive services.

 (d)  An HMO shall provide other benefits as may be mandated by State and Federal law.

Cross References

   This section cited in 28 Pa. Code §  9.602 (relating to definitions).



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