PRINTER'S NO. 3331
No. 2550 Session of 1992
INTRODUCED BY ULIANA, FLICK, GRUPPO, BOYES, HANNA, NYCE,
GERLACH, DEMPSEY, KRUSZEWSKI, NOYE, NICKOL, FARGO,
D. W. SNYDER, ARMSTRONG, SEMMEL, TOMLINSON AND DENT,
MARCH 25, 1992
REFERRED TO COMMITTEE ON HEALTH AND WELFARE, MARCH 25, 1992
AN ACT
1 Amending the act of June 13, 1967 (P.L.31, No.21), entitled "An
2 act to consolidate, editorially revise, and codify the public
3 welfare laws of the Commonwealth," requiring the Department
4 of Public Welfare to establish, implement and administer a
5 medical assistance program which provides care and managerial
6 services through primary care providers.
7 The health of 1.1 million Pennsylvanians is adversely
8 affected by the lack of health care insurance coverage and
9 accessibility to primary care providers. The plight of the
10 uninsured causes the use of more expensive health care services
11 at the most serious stage of illness, thereby increasing health
12 care costs to all citizens of this Commonwealth.
13 The provision of a Statewide managed-care system would be
14 beneficial to uninsured Pennsylvanians by altering the way
15 health care is currently accessed, targeting the prevention of
16 disease and reducing the need to use the more expensive health
17 care services.
18 Therefore, it is declared that reforming the current Medicaid
19 system to incorporate a Statewide managed-care system coupled
1 with an aggressive medical cost recovery program would provide
2 the funds necessary to implement a Statewide managed-care system
3 for Pennsylvania's uninsured which would contain health care
4 costs while ensuring a healthier population.
5 The General Assembly of the Commonwealth of Pennsylvania
6 hereby enacts as follows:
7 Section 1. The act of June 13, 1967 (P.L.31, No.21), known
8 as the Public Welfare Code, is amended by adding a section to
9 read:
10 Section 443.7. Pennsylvania Access to Care Program.--(a) It
11 is the intent and direction of the General Assembly that the
12 Department of Public Welfare establish, implement and administer
13 a mandatory Statewide program for the provision of primary
14 medical services to eligible recipients within selected service
15 areas.
16 (b) As used in this section:
17 "Department" means the Department of Public Welfare of the
18 Commonwealth or any successor agency.
19 "Eligible recipient" means any person who receives cash
20 assistance under section 432(1) and (2) and any person who is
21 determined to be chronically needy under section 432(3).
22 "Emergency medical services" means medical services provided
23 after the sudden onset of a medical condition manifesting itself
24 by acute symptoms of sufficient severity, including severe pain,
25 such that the absence of immediate medical attention could
26 reasonably be expected to result in:
27 (1) placing the patient's health in serious jeopardy;
28 (2) serious impairment to bodily functions; or
29 (3) serious dysfunction of any bodily organ or part.
30 "Medical service delivery area" means the geographic area
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1 within which eligible recipients will receive primary medical
2 services from primary medical providers. The geographic area may
3 be equivalent to the area covered by a county board of
4 assistance or such larger or smaller area as may be designated
5 by departmental regulation.
6 "Primary care provider" means a physician, group of
7 physicians, licensed nurse practitioner, community mental health
8 centers, Federally qualified health centers, local health
9 departments or other types of clinics approved by departmental
10 regulation.
11 "Primary medical services" means that level of medical care
12 which addresses an eligible recipient's general health needs,
13 including the coordination of the eligible recipient's health
14 care with the responsibility for the prevention of disease, the
15 promotion and maintenance of good health, the treatment of
16 illness and the referral to other specialists for more intensive
17 care when appropriate. The term specifically excludes any of the
18 services presently excluded from State Medicaid coverage.
19 "Program" means the mandatory Statewide primary care medical
20 services program established in subsection (c).
21 (c) The department shall establish, implement and administer
22 a mandatory Statewide medical assistance program which utilizes
23 primary care providers to supply or manage primary medical
24 services for qualified eligible recipients within established
25 medical service delivery areas.
26 (d) The department shall promulgate regulations to implement
27 and administer the medical assistance program under subsection
28 (c) and which address the following:
29 (1) The establishment of and modification to medical service
30 delivery areas to provide timely and efficient primary medical
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1 services to eligible recipients without overburdening
2 participating primary care providers.
3 (2) The procurement of a sufficient number of primary care
4 providers for the treatment of eligible recipients within
5 medical service delivery areas.
6 (3) The selection of or assignment to primary care providers
7 of eligible recipients, including procedures permitting eligible
8 recipients to request changes of the primary care providers.
9 (4) The review of eligibility criteria to insure that
10 eligible recipients are not qualified for other available forms
11 of medical assistance.
12 (5) The procedures to be followed by primary care providers
13 when referring eligible recipients for specialized care or
14 hospitalization.
15 (6) The establishment of procedures to resolve disputes
16 between the department and primary care providers or between
17 eligible recipients and primary care providers.
18 (7) The decertification of primary care providers for
19 failure to comply with this section or the regulations
20 promulgated hereunder.
21 (8) The establishment of procedures, including the operation
22 of a third party liability program and the coordination of
23 claims review with health care insurers, to prevent or eliminate
24 any duplication of services which may be obtained by an eligible
25 recipient and to obtain payment for services which are covered
26 under other programs.
27 (9) Such other regulations which may be necessary to
28 implement and administer the provisions of this section.
29 (e) Participating primary care providers shall:
30 (1) Provide comprehensive primary medical services to
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1 eligible recipients.
2 (2) Meet all of the requirements in the provider agreement,
3 signed upon enrollment as a primary care provider.
4 (3) Furnish services during a regular schedule of office
5 hours, for at least twenty hours a week on not fewer than three
6 days a week, at any location which accepts participants, with
7 allowances made by the department on a case-by-case basis.
8 (4) Maintain availability of a licensed physician or
9 licensed nurse practitioner by telephone for twenty-four hours a
10 day, seven days a week, through call arrangements or back-up
11 coverage.
12 (5) Maintain a single medical record on each eligible
13 recipient.
14 (6) Designate a single qualified physician or nurse
15 practitioner as the principal rendering provider for an eligible
16 recipient, if the primary care provider is a qualified group
17 practice, clinic or hospital outpatient department.
18 (7) Notify the eligible recipient before submitting a
19 request to the program of any intent to discontinue services to
20 the eligible recipient and then continue to provide services
21 until the eligible recipient has been linked by the program with
22 another primary care provider, not to exceed thirty days from
23 receipt by the department of the request.
24 (8) Ensure that all physicians and nurse practitioners who
25 render services conform with the provider requirements in this
26 section.
27 (9) Have hospital admitting privileges or be able to refer
28 eligible recipients to a primary care provider with hospital
29 admitting privileges.
30 (10) Designate and make known to all eligible recipients
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1 linked with that primary care provider the other participating
2 physician, physicians, nurse practitioner or nurse practitioners
3 who will be available to furnish primary medical services during
4 periods, such as vacation or illness, when the primary care
5 provider does not maintain a regular schedule of office hours.
6 (f) Eligible recipients of primary medical services shall:
7 (1) Enroll or be enrolled in the program in compliance with
8 department regulations.
9 (2) Choose or be assigned by the department to a primary
10 care provider within a health service delivery area.
11 (3) Request permission to change the primary care provider
12 at any time for good cause.
13 (4) Request, only once annually, a change of the primary
14 care provider without cause.
15 (5) Utilize the primary care provider for all primary
16 medical services except emergency medical services.
17 (g) The department may impose sanctions on any primary care
18 provider for any of the following:
19 (1) Failing to meet all of the requirements in this section.
20 (2) Failing to meet all of the requirements in the provider
21 agreement.
22 (3) Making any false statement, report or representation to
23 the program.
24 (4) Providing or authorizing medically unnecessary or
25 inappropriate care for participants.
26 (5) Exhibiting a pattern of substandard or inadequate
27 medical practice.
28 (h) The sanctions which the department may impose against a
29 primary care provider are any or all of the following:
30 (1) Limiting the type of recipients enrolled with the
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1 primary care provider.
2 (2) Limiting the maximum number of recipients enrolled with
3 the primary care provider or the rate of growth in enrollments.
4 (3) Suspending new enrollments of recipients with the
5 primary care provider, except by a recipient's request.
6 (4) Suspending all new enrollments of recipients with the
7 primary care provider.
8 (5) Transferring some or all recipients to other primary
9 care providers.
10 (6) Suspending program payments to the primary care provider
11 and transferring the recipients to other primary care providers.
12 (7) Suspending the provider as a primary care provider for
13 services rendered pursuant to this section.
14 (8) Disenrolling the provider as a primary care provider and
15 transferring recipients to other primary care providers.
16 (i) The annual resulting monetary difference between the
17 projected cost of providing State Medicaid services to qualified
18 individuals and the actual costs incurred in providing the
19 Pennsylvania Access to Care Program may, after legislative
20 approval by the General Assembly and the Governor, be used to
21 expand the coverage of eligible recipients as follows:
22 (1) In year one, expand coverage of eligible recipients from
23 one hundred thirty-three percent of the Federal poverty level to
24 one hundred fifty percent of the Federal poverty level.
25 (2) In year two, expand coverage of eligible recipients from
26 one hundred fifty percent of the Federal poverty level to one
27 hundred sixty-five percent of the Federal poverty level.
28 (3) In year three, expand coverage of eligible recipients
29 from one hundred sixty-five percent of the Federal poverty level
30 to one hundred eighty percent of the Federal poverty level.
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1 (4) In year four, expand coverage of eligible recipients
2 from one hundred eighty percent of the Federal poverty level to
3 two hundred percent of the Federal poverty level.
4 (j) The department shall, prior to implementing this
5 section, obtain all necessary waivers from Federal Medicaid
6 statutes, rules and regulations.
7 Section 2. This act shall take effect July 1, 1992.
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