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).

31 Pa. Code § 152.8. Compliance with Health Maintenance Organization Act (40 P. S. § §  1551—1567).

§ 152.8. Compliance with Health Maintenance Organization Act (40 P. S. § §  1551—1567).

 If, in the review of the application of a risk-assuming preferred provider organization, the Secretary determines that the preferred provider organization is in fact engaging or proposing to engage in the business of a health maintenance organization as defined in the Health Maintenance Organization Act, the Secretary will so inform the applicant and the Commissioner and require the preferred provider organization to seek licensure as a health maintenance organization. In determining whether or not a risk-assuming preferred provider organization is doing the business of a health maintenance organization, the Department of Health will evaluate and consider the following:

   (1)  The type and amount of economic risk being assumed by preferred providers.

   (2)  The degree to which the delivery of health care is organized and managed by the preferred provider organization.

   (3)  The degree of freedom of provider choice offered to enrollees.

   (4)  The degree of contractual responsibility assumed by participating primary care physicians for the management of health care of enrollees.

   (5)  The degree to which preferred providers may share in the financial gains or losses arising from preferred provider arrangements.

   (6)  The extent to which the preferred provider organization provides basic health services as defined in the Health Maintenance Organization Act and 28 Pa. Code Chapter 9 (relating to health maintenance organizations).

   (7)  The extent to which the preferred provider organization combines the delivery and financing of health care.

   (8)  The extent to which the preferred provider organization agrees to provide, arrange for the provision of or pay for health services for a fixed pre-paid fee.

Cross References

   This section cited in 31 Pa. Code §  152.103 (relating to HMO and PPO differentiation).



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