Insurers would need provider agreement for mid-contract changes

An insurer or its administrator would be barred from changing, amending, or reinterpreting a covered contract term on its own during the contract period. The rule would cover insurers offering, issuing, or renewing covered health insurance policies in Pennsylvania and their contracts with licensed health care providers. The restriction would cover important contract terms such as payment methods, covered services, prior approval, medical necessity, quality, credentialing, and billing requirements. The insurer and provider could change a term through mutual written agreement during the contract period. An insurer or administrator could make a change expressly required by federal or state law. A change not required by law could take effect at renewal only after written notice at least 90 days before renewal. The restriction would apply during the contract period; the act would take effect 60 days after enactment.

The Insurance Department could impose a civil penalty of up to $1,000 and other legally authorized penalties for a violation. The penalties would apply to an insurer or administrator that violates the proposed contract-change rules. A violation would also count as a violation of Pennsylvania’s Unfair Trade Practices and Consumer Protection Law and Unfair Insurance Practices Act. The department could issue regulations needed to carry out the proposed chapter. The rules would not apply to self-funded employer plans governed by federal law, employers acting as plan sponsors, or health benefit arrangements outside department regulation. The rules would not stop an insurer from adding coverage for a health care service during a policy term. The provisions would take effect 60 days after enactment.