§ 9.685. Standards for approval of point-of-service products.

 (a)  If a plan offers a point-of-service product, it shall submit a formal product filing for the POS product to the Department and the Insurance Department.

 (b)  A plan may offer POS options to groups and enrollees, if the plan:

   (1)  Has a system for tracking, monitoring and reporting enrollee self-referrals for the following purposes:

     (i)   To ensure that self-referral activity is not occurring because of an access problem, a deliberate attempt to force an enrollee to bypass a primary care provider for nonmedical reasons or over restrictive or burdensome plan requirements.

     (ii)   To promptly investigate any PCP practice in which enrollees are utilizing substantially higher levels of non-PCP referred care than average, to ensure that enrollee self-referrals are not a reflection of access or quality problems on the part of the PCP practice, inappropriate patient direction or burdensome plan requirements.

   (2)  Provides clear disclosure to enrollees of out-of-pocket expenses.

   (3)  Does not directly or indirectly encourage enrollees to seek care without a PCP referral or from out-of-network providers due to an inadequate network of participating providers in any given specialty.



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