28 Pa. Code § 9.684 – Continuity of care.

(a) Provider terminations initiated by the plan shall be governed as follows:
1. (1) Except as noted in subsections (i) and (j), an enrollee may continue an ongoing course of treatment, at the option of the enrollee, for up to 60 days from the date the enrollee is notified by the plan of the termination or pending termination of a participating health care provider.
2. (2) If the provider who is terminated is a primary care provider, the plan shall provide written notice of the termination to each enrollee assigned to that primary care provider and shall request and facilitate the enrollee’s transfer to another primary care provider.
3. (3) If the provider who is terminated is not a primary care provider, the plan shall notify all affected enrollees identified through referral and claims data.
4. (4) Written notice from the plan shall include instructions as to how to exercise the continuity of care option, including qualifying criteria, the procedure for notifying the plan of the enrollee’s intention and how the enrollee will be notified that a continuing care arrangement has been agreed to by the provider and the plan.
(b) A new enrollee seeking to continue care with a nonparticipating provider shall notify the plan of the enrollee’s request to continue an ongoing course of treatment for the transitional period.
(c) The transitional period for an enrollee who is a woman in the second or third trimester of pregnancy as of the effective date of coverage, if she is a new enrollee, or as of the date the notice of termination or pending termination was provided by the plan, shall extend through the completion of postpartum care.
(d) The transitional period may be extended by the plan if extension is determined to be clinically appropriate. The plan shall consult with the enrollee and the health care provider in making this determination.
(e) A plan shall cover health care services provided under this section under the same terms and conditions as applicable for services provided by participating health care providers.
(f) A plan may require nonparticipating health care providers to meet the same terms and conditions as participating health care providers with the exception that a plan may not require nonparticipating health care providers to undergo full credentialing.
(g) A plan shall provide the nonparticipating or terminated health care provider with written notice of the terms and conditions to be met at either the earliest possible opportunity following notice of termination to the provider, or immediately upon request from an enrollee to continue services with a nonparticipating health care provider.
(h) To be eligible for payment by a plan, a nonparticipating or terminated provider shall agree to the terms and conditions of the plan prior to providing service under the continuity of care provisions. If the health care provider does not agree to the terms and conditions of the plan prior to providing the service, the provider shall notify the enrollee of that fact.
(i) This section does not require a plan to provide health care services that are not covered under the terms and conditions of the plan.
(j) If the plan terminates a participating health care provider for cause, as described in section 2117(b) of the act (40 P. S. § 991.2117(b)) the plan will not be responsible for the health care services provided by the terminated provider to the enrollee following the date of termination.