Health Care Preferred Provider Program Payor Agreements

Section 2051.280  Health Care Preferred Provider Program Payor Agreements Administrators shall file with the Department a sample copy of all payor agreements. WC PPPs are exempt from the requirements of this Section, but must instead comply with the requirements of Section 2051.285.  These agreements shall contain at a minimum: a)         Terms requiring and specifying all incentives to be provided to the insured or beneficiary to utilize services of a provider that has entered into an agreement with the administrator; b)         Terms stating that, whenever an administrator or a preferred provider finds it medically necessary to refer a beneficiary to a non-preferred provider, the payor shall ensure that the beneficiary so referred shall incur no greater out of pocket liability than had the beneficiary received services from a preferred provider. This subsection does not apply to a beneficiary who willfully chooses to access a non-preferred provider for health care services available through the administrator's panel of participating providers. In these circumstances, the contractual requirements for non-preferred provider reimbursements will apply. This subsection does not apply to administrators offering only a DHCSP; c)         Terms requiring that both the payor's and administrator's name and toll-free telephone numbers be contained on all beneficiaries' identification cards; d)         Terms specifying that only the payor may assume any underwriting risk when that risk is part of the delivery of services.