Section 991.2136 - Required disclosure(a) A managed care plan shall supply each enrollee and, upon written request, each prospective enrollee or health care provider with the following written information. Such information shall be easily understandable by the layperson and shall include, but not be limited to:(1) a description of coverage, benefits and benefit maximums, including benefit limitations and exclusions of coverage, health care services and the definition of medical necessity used by the plan in determining whether these benefits will be covered. The following statement shall be included in all marketing materials in boldface type: This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered.
The notice shall be followed by a telephone number to contact the plan.
(2) A description of all necessary prior authorizations or other requirements for nonemergency health care services.(3) An explanation of an enrollee's financial responsibility for payment of premiums, coinsurance, copayments, deductibles and other charges, annual limits on an enrollee's financial responsibility and caps on payments for health care services provided under the plan.(4) An explanation of an enrollee's financial responsibility for payment when a health care service is provided by a nonparticipating health care provider, when a health care service is provided by any health care provider without required authorization or when the care rendered is not covered by the plan.(5) A description of how the managed care plan addresses the needs of non-English-speaking enrollees.(6) A notice of mailing addresses and telephone numbers necessary to enable an enrollee to obtain approval or authorization of a health care service or other information regarding the plan.(7) A summary of the plan's utilization review policies and procedures.(8) A summary of all complaint and grievance procedures used to resolve disputes between the managed care plan and an enrollee or a health care provider, including: (i) The procedure to file a complaint or grievance as set forth in this article, including a toll-free telephone number to obtain information regarding the filing and status of a complaint or grievance.(ii) The right to appeal a decision relating to a complaint or grievance.(iii) The enrollee's right to designate a representative to participate in the complaint or grievance process as set forth in this article.(iv) A notice that all disputes involving denial of payment for a health care service will be made by qualified personnel with experience in the same or similar scope of practice and that all notices of decisions will include information regarding the basis for the determination.(9) A description of the procedure for providing emergency services twenty-four (24) hours a day. The description shall include:(i) A definition of emergency services as set forth in this article.(ii) Notice that emergency services are not subject to prior approval.(iii) The enrollee's financial and other responsibilities regarding emergency services, including the receipt of these services outside the managed care plan's service area.(10) A description of the procedures for enrollees to select a participating health care provider, including how to determine whether a participating health care provider is accepting new enrollees.(11) A description of the procedures for changing primary care providers and specialists.(12) A description of the procedures by which an enrollee may obtain a referral to a health care provider outside the provider network when that provider network does not include a health care provider with appropriate training and experience to meet the health care service needs of an enrollee.(13) A description of the procedures that an enrollee with a life-threatening, degenerative or disabling disease or condition shall follow and satisfy to be eligible for:(i) a standing referral to a specialist with clinical expertise in treating the disease or condition; or(ii) the designation of a specialist to provide and coordinate the enrollee's primary and specialty care.(14) A list by specialty of the name, address and telephone number of all participating health care providers. The list may be a separate document and shall be updated at least annually.(15) A list of the information available to enrollees or prospective enrollees, upon written request, under subsection (b).(b) Each managed care plan shall, upon written request of an enrollee or prospective enrollee, provide the following written information:(1) A list of the names, business addresses and official positions of the membership of the board of directors or officers of the managed care plan.(2) The procedures adopted to protect the confidentiality of medical records and other enrollee information.(3) A description of the credentialing process for health care providers.(4) A list of the participating health care providers affiliated with participating hospitals.(5) Whether a specifically identified drug is included or excluded from coverage.(6) A description of the process by which a health care provider can prescribe specific drugs, drugs used for an off-label purpose, biologicals and medications not included in the drug formulary for prescription drugs or biologicals when the formulary's equivalent has been ineffective in the treatment of the enrollee's disease or if the drug causes or is reasonably expected to cause adverse or harmful reactions to the enrollee.(7) A description of the procedures followed by the managed care plan to make decisions about the experimental nature of individual drugs, medical devices or treatments.(8) A summary of the methodologies used by the managed care plan to reimburse for health care services. Nothing in this paragraph shall be construed to require disclosure of individual contracts or the specific details of any financial arrangement between a managed care plan and a health care provider.(9) A description of the procedures used in the managed care plan's quality assurance program.(10) Other information as may be required by the department or the Insurance Department.1921, May 17, P.L. 682, No. 284, § 2136, added 1998, June 17, P.L. 464, No. 68, § 1, effective 1/1/1999.