Current through Register Vol. 55, No. 1, January 4, 2025
Section 301.204 - Group specific community rating for HMOs(a) HMOs will be permitted by the Department to use group specific community rating subject to the methodology in the proposed regulations published by the Health Care Financing Administration in Federal Register, Vol. 56, Number 133 at page 31597, July 11, 1991 (to be codified at 42 CFR 417.104(b)(2)(ii)) or in a final adopted regulation if there is a change in this section.(b) In addition to the Federal standards, an HMO shall also meet the following conditions to use group specific community rating in this Commonwealth: (1) The HMO shall demonstrate that it has the capability to capture claims data on a group specific basis.(2) Group specific community rating will only be applicable to groups that have an enrollment in the HMO of at least 250 employes for the most current 12-month period. An HMO may set the minimum size requirement at a higher level than 250 enrolled employes. The minimum size requirement applies to each HMO product sold to the group.(3) Once an HMO elects to use group specific community rating, it shall use the method for all groups that meet the minimum size requirement established by that HMO and approved by the Department.(4) The HMO shall have covered the group for at least 36 consecutive months.The provisions of this § 301.203 adopted September 27, 1991, effective 9/28/1991, 21 Pa.B. 4424.