| (a) An HCC's contracts with physicians and health care
providers must not impede application of provisions in Insurance Code
Chapters 843 (Health Maintenance Organizations) and 1301 (Preferred
Provider Benefit Plans), and in Chapter 11 of this title (relating
to Health Maintenance Organizations) and Chapter 3, Subchapter X of
this title (relating to Preferred and Exclusive Provider Plans), that
impose requirements concerning relations with physicians or health
care providers.
(b) An HCC is prohibited from using a financial incentive
or making a payment to a physician or health care provider if the
incentive or payment acts directly or indirectly as an inducement
to limit medically necessary services.
(c) If an HCC participant's market share as calculated
under §13.414 of this title (relating to Limited Exemption from
Certain Information Filing Requirements) exceeds 50 percent in a PSA
for any service that no other HCC participant provides to patients
in that PSA, the participant furnishing the service is a dominant
provider for purposes of this subchapter. An HCC with a dominant provider
is prohibited, in the PSA in which the dominant provider furnishes
those services, from:
(1) requiring a private payor to contract exclusively
with the HCC; or
(2) otherwise restricting a private payor's ability
to contract or deal with other HCCs, networks, physicians, or health
care providers.
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