| (2) Exclusive provider benefit plan notice.
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(g) Untrue or misleading information prohibited. No
insurer, or agent or representative of an insurer, may cause or permit
the use or distribution of information which is untrue or misleading.
(h) Disclosure concerning access to preferred provider
listing. The insurer must provide notice to all insureds at least
annually describing how the insured may access a current listing of
all preferred providers on a cost-free basis. The notice must include,
at a minimum, information concerning how to obtain a nonelectronic
copy of the listing and a telephone number through which insureds
may obtain assistance during regular business hours to find available
preferred providers.
(i) Required updates of available provider listings.
The insurer must ensure that it updates its listing of preferred providers
on its Internet website at least once a month, as required by Insurance
Code §1451.505. The insurer must ensure that it updates all other
electronic or nonelectronic listings of preferred providers made available
to insureds at least every three months.
(j) Annual provision of provider listing required in
certain cases. If no Internet-based preferred provider listing or
other method of identifying current preferred providers is maintained
for use by insureds, the insurer must distribute a current preferred
provider listing to all insureds no less than annually by mail, or
by an alternative method of delivery if an alternative method is agreed
to by the insured, group policyholder on behalf of the group, or certificate
holder.
(k) Reliance on provider listing in certain cases.
A claim for services rendered by a nonpreferred provider must be paid
in the same manner as if no preferred provider had been available
under §3.3708(b) - (d) of this title (relating to Payment of
Certain Basic Benefit Claims and Related Disclosures) and §3.3725(d)
- (f) of this title (relating to Payment of Certain Out-of-Network
Claims), as applicable, if an insured demonstrates that:
(1) in obtaining services, the insured reasonably relied
upon a statement that a physician or provider was a preferred provider
as specified in:
(A) a provider listing; or
(B) provider information on the insurer's website;
(2) the provider listing or website information was
obtained from the insurer, the insurer's website, or the website of
a third party designated by the insurer to provide such information
for use by its insureds;
(3) the provider listing or website information was
obtained not more than 30 days prior to the date of services; and
(4) the provider listing or website information obtained
indicates that the provider is a preferred provider within the insurer's
network.
(l) Additional listing-specific disclosure requirements.
In all preferred provider listings, including any Internet-based postings
by the insurer to insureds about preferred providers, the insurer
must comply with the requirements in paragraphs (1) - (11) of this
subsection.
(1) The provider information must include a method
for insureds to identify those hospitals that have contractually agreed
with the insurer to facilitate the usage of preferred providers as
specified in subparagraphs (A) and (B) of this paragraph.
(A) The hospital will exercise good-faith efforts to
accommodate requests from insureds to utilize preferred providers.
(B) In those instances in which a particular facility-based
physician or physician group is assigned at least 48 hours prior to
services being rendered, the hospital will provide the insured with
information that is:
(i) furnished at least 24 hours prior to services being
rendered; and
(ii) sufficient to enable the insured to identify the
physician or physician group with enough specificity to permit the
insured to determine, along with preferred provider listings made
available by the insurer, whether the assigned facility-based physician
or physician group is a preferred provider.
(2) The provider information must include a method
for insureds to identify, for each preferred provider hospital, the
percentage of the total dollar amount of claims filed with the insurer
by or on behalf of facility-based physicians that are not under contract
with the insurer. The information must be available by class of facility-based
physician, including radiologists, anesthesiologists, pathologists,
emergency department physicians, neonatologists, and assistant surgeons.
(3) In determining the percentages specified in paragraph
(2) of this subsection, an insurer may consider claims filed in a
12-month period designated by the insurer ending not more than 12
months before the date the information specified in paragraph (2)
of this subsection is provided to the insured.
(4) The provider information must indicate whether
each preferred provider is accepting new patients.
(5) The provider information must provide a method
by which insureds may notify the insurer of inaccurate information
in the listing, with specific reference to:
(A) information about the provider's contract status;
and
(B) whether the provider is accepting new patients.
(6) The provider information must provide a method
by which insureds may identify preferred provider facility-based physicians
able to provide services at preferred provider facilities.
(7) The provider information must be provided in at
least 10-point font.
(8) The provider information must specifically identify
those facilities at which the insurer has no contracts with a class
of facility-based provider, specifying the applicable provider class.
(9) The provider information must be dated.
(10) For each health care provider that is a facility
included in the listing, the insurer must:
(A) create separate headings under the facility name
for radiologists, anesthesiologists, pathologists, emergency department
physicians, neonatologists, and assistant surgeons;
(B) under each heading described by subparagraph (A)
of this paragraph, list each preferred facility-based physician practicing
in the specialty corresponding with that heading;
(C) for the facility and each facility-based physician
described by subparagraph (B) of this paragraph, clearly indicate
each health benefit plan issued by the insurer that may provide coverage
for the services provided by that facility, physician, or facility-based
physician group;
(D) for each facility-based physician described by
subparagraph (B) of this paragraph, include the name, street address,
telephone number, and any physician group in which the facility-based
physician practices; and
(E) include the facility in a listing of all facilities
and indicate:
(i) the name of the facility;
(ii) the municipality in which the facility is located
or county in which the facility is located if the facility is in the
unincorporated area of the county; and
(iii) each health benefit plan issued by the insurer
that may provide coverage for the services provided by the facility.
(11) The listing must list each facility-based physician
individually and, if a physician belongs to a physician group, also
as part of the physician group.
(m) Annual policyholder notice concerning use of a
local market access plan. An insurer operating a preferred provider
benefit plan that relies on a local market access plan as specified
in §3.3707 of this title (relating to Waiver Due to Failure to
Contract in Local Markets) must provide notice of this fact to each
individual and group policyholder participating in the plan at policy
issuance and at least 30 days prior to renewal of an existing policy.
The notice must include:
(1) a link to any webpage listing of regions, counties,
or ZIP codes made available pursuant to subsection (e)(2) of this
section;
(2) information on how to obtain or view any local
market access plan or plans the insurer uses; and
(3) a link to the department's website where the department
posts information relevant to the grant of waivers.
(n) Disclosure of substantial decrease in the availability
of certain preferred providers. An insurer is required to provide
notice as specified in this subsection of a substantial decrease in
the availability of preferred facility-based physicians at a preferred
provider facility.
(1) A decrease is substantial if:
(A) the contract between the insurer and any facility-based
physician group that comprises 75% or more of the preferred providers
for that specialty at the facility terminates; or
Cont'd... |
