Pennsylvania Code & Bulletin
COMMONWEALTH OF PENNSYLVANIA

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31 Pa. Code § 152.102. Definitions.

§ 152.102. Definitions.

 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

   ERISA-exempt PPO—A PPO which, in accordance with §  152.3(d) (relating to content of an application for approval), has submitted and received joint Department and Department of Health approval of an ERISA-exemption certificate.

   Gatekeeper product—A product offered by a PPO which requires an enrollee to preselect a particular primary care physician from among a list of participating primary care physicians, and to receive from the physician, as a condition for receipt of a higher level of benefits or reimbursement level, or both, referrals for nonemergency specialty, hospital and other services.

   HMO—Health maintenance organization.

   PPO—Preferred provider organization.

   Passive gatekeeper product—A product offered by a PPO which does not require an enrollee to preselect a particular primary care physician, but requires, as a condition for receipt of a higher level of benefits or reimbursement level, or both, that an enrollee receive care from or a referral from a participating preferred primary care physician. The products are permissible if their restrictions are adequately disclosed to enrollees and receive appropriate approval of the Department. However, since they do not lock enrollees into use of a particular primary care physician, they are not subject to § §  152.101, 152.103—152.105 and this section (relating to primary care gatekeeper PPO products—statement of policy).

Source

   The provisions of this §  152.102 adopted September 27, 1991, effective September 28, 1991, 21 Pa.B. 4424.

Cross References

   This section cited in 28 Pa. Code §  9.502 (relating to definitions).



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