PRINTER'S NO. 1672
No. 1497 Session of 1993
INTRODUCED BY KUKOVICH, RICHARDSON, DeWEESE, STETLER, MIHALICH,
TRELLO, PISTELLA, TRICH, FREEMAN, STEELMAN, BELFANTI, VEON,
ROONEY, SURRA, STABACK, PESCI, JOSEPHS, McCALL, RAYMOND,
DALEY, DeLUCA, COLAIZZO AND MELIO, MAY 3, 1993
REFERRED TO COMMITTEE ON HEALTH AND WELFARE, MAY 3, 1993
AN ACT
1 Providing for equal access to health care; requiring physician
2 referral networks; imposing powers and duties on the
3 Department of Health and the Department of Public Welfare;
4 and providing for penalties.
5 TABLE OF CONTENTS
6 Chapter 1. General Provisions
7 Section 101. Short title.
8 Section 102. Legislative findings and intent.
9 Section 103. Definitions.
10 Chapter 2. Physician Referral Networks
11 Section 201. Physician referral networks for medical assistance
12 recipients.
13 Section 202. Determination of where physician referral networks
14 to be established.
15 Section 203. Administration.
16 Section 204. Evaluation of physician referral networks.
17 Chapter 3. Access to Health Care
18 Section 301. Discrimination prohibited.
1 Section 302. Enforcement.
2 Section 303. Remedy.
3 Chapter 4. Equal Access to Physician Health Care Services
4 Section 401. Purpose.
5 Section 402. Evaluation criteria.
6 Section 403. Criteria for evaluation.
7 Section 404. Evaluation.
8 Section 405. Sanctions for physician nonparticipation in the
9 medical assistance program.
10 Section 406. Enforcement authority.
11 Chapter 5. Miscellaneous Provisions
12 Section 501. Effective date.
13 The General Assembly of the Commonwealth of Pennsylvania
14 hereby enacts as follows:
15 CHAPTER 1
16 GENERAL PROVISIONS
17 Section 101. Short title.
18 This act shall be known and may be cited as the Equal Access
19 to Health Care Act.
20 Section 102. Legislative findings and intent.
21 All citizens of this Commonwealth have a right to
22 nondiscriminatory treatment by health care providers regardless
23 of a citizen's source of payment for health care services, and
24 all citizens of this Commonwealth shall have equal access to
25 physician health care services.
26 Section 103. Definitions.
27 The following words and phrases when used in this act shall
28 have the meanings given to them in this section unless the
29 context clearly indicates otherwise:
30 "District." A portion of this Commonwealth established by
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1 section 202(a).
2 "MAAC." The Medical Assistance Advisory Committee.
3 "Medical assistance." The State program of medical
4 assistance established under the act of June 13, 1967 (P.L.31,
5 No.21), known as the Public Welfare Code.
6 "Medicaid." The Federal medical assistance program
7 established under Title XIX of the Social Security Act (49 Stat.
8 620, 42 U.S.C. § 301 et seq.).
9 "Medicare." The Health Insurance for the Aged Act, Title
10 XVIII of the Social Security Amendments of 1965, as amended.
11 "Physician referral network." Any county or area physician
12 referral network for medical assistance recipients established
13 under section 201.
14 "Primary care physicians." Family and general practitioners,
15 obstetricians, pediatricians, internists and emergency
16 physicians.
17 "Specialty care physicians." All physicians who are not
18 primary care physicians.
19 "Workers' Compensation." The workers' compensation program
20 established under the act of June 2, 1915 (P.L.736, No.338),
21 known as The Pennsylvania Workmen's Compensation Act.
22 CHAPTER 2
23 PHYSICIAN REFERRAL NETWORKS
24 Section 201. Physician referral networks for medical assistance
25 recipients.
26 (a) Establishment.--The Department of Health, in cooperation
27 with the Pennsylvania Medical Society and its local and county
28 medical societies and the Pennsylvania Osteopathic Medical
29 Association, shall establish physician referral networks in all
30 areas of this Commonwealth where access to the services of
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1 primary care and/or specialty care physicians by medial
2 assistance beneficiaries is significantly below that available
3 to the general population.
4 (b) Purpose.--The purpose of these physician referral
5 networks shall be to assure access to primary care and specialty
6 physicians in this Commonwealth by medical assistance
7 beneficiaries.
8 Section 202. Determination of where physician referral networks
9 to be established.
10 (a) Districts.--For purposes of this act, this Commonwealth
11 shall be divided into districts determined by the Department of
12 Health in consultation with the Pennsylvania Medical Society.
13 (b) Physician referral networks.--Physician referral
14 networks shall be established in at least half of the districts
15 established in subsection (a) within one year of the effective
16 date of this act and in all districts within two years of the
17 effective date of this act.
18 (c) Submission of plan.--The Department of Health, in
19 cooperation with the Pennsylvania Medical Society and the
20 Consumer Subcommittee of the MAAC shall, within 180 days of the
21 effective date of this act, submit to the General Assembly a
22 plan prioritizing the order of districts in which physician
23 referral networks will be established.
24 Section 203. Administration.
25 (a) Services.--Each physician referral network shall provide
26 referral assistance to medical assistance beneficiaries in
27 obtaining appropriate primary care and specialty physician
28 services in a timely manner and within reasonable commuting
29 distance. The physician referral network shall place a priority
30 on referring medical assistance beneficiaries to physicians
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1 whose practice is in the beneficiaries' county of residence. In
2 fulfilling this purpose, the physician referral network shall
3 offer physicians on an equitable and rotating basis to medical
4 assistance beneficiaries seeking physician services. Medical
5 assistance beneficiaries shall have the right to request up to
6 three physician referrals.
7 (b) Lists.--Each physician referral network established
8 shall maintain a list of all physicians to be used in referring
9 medical assistance beneficiaries seeking a physician for the
10 county or region of the physician referral network. The State
11 Board of Medicine and the State Board of Osteopathic Medicine
12 shall provide the Department of Health with the names, office
13 addresses and telephone numbers of all physicians for each
14 district where a physician network is established.
15 (c) Outreach program.--The Department of Health, in
16 coordination with the Pennsylvania Medical Society, shall
17 establish an outreach program to promote the use of the
18 physician referral networks by medical assistance recipients and
19 those agencies and organizations who administer programs
20 utilized by medical assistance beneficiaries.
21 (d) Toll-free hotlines.--The Department of Health shall
22 establish a toll-free hotline for use by medical assistance
23 beneficiaries, physicians, county assistance offices, hospitals
24 and the general public to receive and refer calls to the
25 appropriate physician referral network for medical assistance
26 recipients needing a physician. This hotline shall also receive,
27 record and respond to calls concerning complaints about lack of
28 access to physicians for medical assistance beneficiaries and
29 complaints of physicians about medical assistance beneficiaries
30 who do not make scheduled physician appointments. The Department
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1 of Health shall maintain a record of all complaints filed and if
2 any action by the Department of Health or the physician referral
3 network was taken to solve the complaint.
4 (e) Additional information.--When the Department of Public
5 Welfare sends determination or redetermination notices of
6 medical assistance eligibility to medical assistance
7 beneficiaries, the Department of Public Welfare shall include
8 information about the physician referral networks and the toll-
9 free hotline established in subsection (d).
10 Section 204. Evaluation of physician referral networks.
11 (a) Criteria.--Within two years of the effective date of
12 this act, the Department of Health, in consultation with the
13 Pennsylvania Medical Society and the Consumer Subcommittee of
14 the MAAC, shall establish evaluation criteria to be used in
15 determining whether, in those districts where a physician
16 referral network is established, access to physician services by
17 medical assistance beneficiaries is equal to that of the general
18 population.
19 (b) Independent evaluation.--
20 (1) Three years after the effective date of this act,
21 the Department of Health shall have an independent evaluation
22 conducted, using the evaluation criteria in subsection (a) to
23 determine the effectiveness of each physician referral
24 network established under this act. This evaluation shall be
25 completed within 180 days. Based on the independent
26 evaluation, records of all complaints filed with the
27 Department of Health under section 203(d), and any other data
28 and information determined to be relevant to the evaluation,
29 the Department of Health shall determine, for each of the
30 physician referral networks established under this act,
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1 whether the physician referral network has resulted in
2 providing access to physician services by medical assistance
3 beneficiaries that is equal to that of the general
4 population.
5 (2) In its evaluation of each physician referral
6 network, the Department of Health shall allow for the
7 submission by the general public of data or information
8 concerning whether the physician referral network has
9 resulted in providing access to physician services by medical
10 assistance beneficiaries that is equal to that of the general
11 population.
12 (3) In its evaluation of each physician referral
13 network, the Department of Health shall determine whether the
14 ability of each referral network to provide access to
15 physicians for medical assistance beneficiaries that is equal
16 to that in the general population is not attainable due to
17 the inadequacy of payments to physicians under the medical
18 assistance program.
19 (c) Further evaluation.--
20 (1) Three years after the effective date of this act,
21 the Department of Health shall have an independent evaluation
22 conducted, using the evaluation criteria in subsection (a) to
23 determine the effectiveness of the physician referral network
24 program. This evaluation shall be completed within 180 days.
25 Based on the independent evaluation, records of all
26 complaints filed with the Department of Health under section
27 203(d), and any other data and information determined to be
28 relevant to the evaluation, the Department of Health shall
29 determine whether or not the physician referral networks
30 should be continued for another five years.
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1 (2) In its evaluation, the Department of Health shall
2 allow for the submission by the general public of data or
3 information concerning whether, in those counties or regions
4 where physician referral networks were established, access to
5 physician services by medical assistance beneficiaries is
6 equal to that of the general population.
7 (3) In its evaluation, the Department of Health shall
8 determine whether the ability of the physician referral
9 network to provide access to physicians for medical
10 assistance beneficiaries that is equal to that in the general
11 population is not attainable at the existing level of
12 payments to physicians under the medical assistance program.
13 (d) Expiration.--The physician referral network program
14 shall expire five years after the effective date of this act,
15 absent action by the General Assembly.
16 CHAPTER 3
17 ACCESS TO HEALTH CARE
18 Section 301. Discrimination prohibited.
19 (a) Nondiscrimination.--No health care provider in this
20 Commonwealth shall discriminate against any person based on that
21 person's enrollment in or eligibility for medical assistance or
22 otherwise based upon a person's source of payment for health
23 care.
24 (b) Definition.--As used in this section, the term
25 "discriminate" shall include, but not be limited to, the
26 following:
27 (1) The refusal to provide health or medical care or
28 services, diagnosis or treatment which the health care
29 provider is qualified to provide.
30 (2) The segregation of medical assistance, Medicare or
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1 workers' compensation patients from other patients with
2 respect to office or health service facilities.
3 (3) The rendering of inferior medical or health care
4 services.
5 Section 302. Enforcement.
6 The Department of Public Welfare shall exercise all powers
7 necessary and appropriate to enforce this chapter, including,
8 but not limited to, the following powers:
9 (1) To require health care providers to enter into
10 provider agreements with the Department of Public Welfare.
11 (2) To monitor and enforce health care provider
12 participation in the medical assistance program, Medicare
13 program and workers' compensation program.
14 Section 303. Remedy.
15 Any individual alleging discrimination under this chapter may
16 file a civil cause of action in a court of competent
17 jurisdiction against a health care provider alleged to be in
18 violation of this chapter. If the health care provider is found
19 to have violated this chapter, the court may assess attorney
20 fees, costs and penalties against the health care provider in
21 addition to any monetary compensation to the plaintiff. A
22 judgment against a health care provider shall be referred by the
23 court to the appropriate professional licensing authority or
24 regulatory agency.
25 CHAPTER 4
26 EQUAL ACCESS TO PHYSICIAN HEALTH CARE SERVICES
27 Section 401. Purpose.
28 The purpose of this chapter is to assure that access to
29 primary care and specialty care physicians services by medical
30 assistance, Medicare and workers' compensation beneficiaries is
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1 equal to that of the general population. This shall be met by
2 establishing criteria for primary care and specialty care
3 physicians to meet in fulfilling this purpose.
4 Section 402. Evaluation criteria.
5 (a) Establishment of evaluation criteria.--Within 180 days
6 of the effective date of this act, the Department of Health, in
7 consultation with the Pennsylvania Medical Society, the
8 Pennsylvania Osteopathic Medical Association and the Consumer
9 Subcommittee of the MAAC, shall establish evaluation criteria to
10 be used and the data to be collected in determining whether
11 access to physician services by medical assistance, Medicare and
12 workers' compensation beneficiaries is equal to that of the
13 general population.
14 (b) Publication.--Within 12 months of the establishment of
15 the criteria and the data to be collected, and annually
16 thereafter, the Department of Health shall publish the data
17 collected during the preceding period.
18 Section 403. Criteria for evaluation.
19 (a) Criteria.--Criteria for evaluating whether access to
20 physician services by medical assistance, Medicare and workers'
21 compensation beneficiaries is equal to that of the general
22 population shall include:
23 (1) A compilation and comparison of the number of
24 medical assistance beneficiaries who request a physician
25 through a physician referral network established under
26 chapter 2 and who are referred to such physicians.
27 (2) A standard for measuring access to primary care
28 physicians whereby at least 50% of such physicians by county
29 participate and document incrementally by year an appropriate
30 number of claims each year. The number of claims shall be
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1 established for each county.
2 (3) A standard for measuring specialty care physicians,
3 including the number of such physicians participating in the
4 medical assistance program by district established in section
5 202(a), the number of medical assistance claims per physician
6 and the adequacy of reimbursement.
7 (4) Recognition that participation in a physician
8 referral network and acceptance of all referrals made thereby
9 shall constitute active participation.
10 (b) Insufficient base.--Where the absence of sufficient
11 physicians prevents successful referral, access shall be deemed
12 to be no less than that available to the general population.
13 Section 404. Evaluation.
14 (a) Initial evaluation.--Three years after the effective
15 date of this act, the Department of Health shall have an
16 independent evaluation conducted, using the evaluation criteria
17 established under section 402, to determine by county whether
18 access to primary care physician services and by district
19 whether access to specialty care physician services for medical
20 assistance beneficiaries is equal to that of the general
21 population. This evaluation shall be completed within 180 days
22 thereafter.
23 (b) Annual evaluation.--After the initial evaluation under
24 subsection (a), the Department of Health shall conduct an
25 evaluation annually thereafter to determine by county whether
26 access to primary care physician services and by district
27 whether access to specialty care physician services for medical
28 assistance beneficiaries is equal to that of the general
29 population.
30 (c) Publication.--The Department of Health shall annually
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1 publish the data set forth in section 403 and the results of the
2 evaluation conducted under subsections (a) and (b).
3 Section 405. Sanctions for physician nonparticipation in the
4 medical assistance program.
5 (a) Submission.--Based upon its evaluation in section 404,
6 the Department of Health shall submit within 30 days to the
7 Department of Public Welfare the names of those counties for
8 primary care physicians and separately those districts for
9 specialty care physicians where it has determined access to
10 physician services by medical assistance beneficiaries is not
11 equal to that of the general population.
12 (b) Penalty assessment.--Upon receipt of notice from the
13 Department of Health under subsection (a), the Department of
14 Public Welfare shall impose an assessment on all physicians
15 within the designated county or district who do not actively
16 participate in the medical assistance program. The Department of
17 Public Welfare shall use the evaluation criteria set forth in
18 section 403 to determine if a physician is actively
19 participating in the medical assistance program. The Department
20 of Public Welfare shall determine the assessment amount based on
21 the funding necessary to meet the purposes of this chapter and
22 to treat those medical assistance recipients within the
23 designated area without access to physicians by any or all of
24 the following methods: expanding physician staff at an existing
25 health care clinic serving medical assistance beneficiaries,
26 establishing a health care clinic to serve medical assistance
27 beneficiaries and contracting with a specified number of
28 physicians to treat a specified number of medical assistance
29 beneficiaries. Money collected by the Department of Public
30 Welfare under this section shall be placed in a special
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1 restricted receipt account and shall be used only for those
2 measures determined by the Department of Public Welfare under
3 this subsection. Any moneys remaining in this account shall
4 annually be remitted to the Department of Public Welfare for
5 enforcing the provisions of this subsection. Assessments
6 collected under this act shall not be subject to the provisions
7 of 42 Pa.C.S. § 3733 (relating to deposits into account).
8 (c) Review of participation.--In addition to any assessment
9 imposed in subsection (b), the Department of Public Welfare, one
10 year after the initial assessment imposed in subsection (b),
11 shall determine, based on criteria set forth in section 403,
12 whether the physician is still not actively participating in the
13 medical assistance program. If the Department of Public Welfare
14 determines that the physician is not actively participating in
15 the medical assistance program, the Department of Public Welfare
16 shall notify all hospitals licensed in this Commonwealth of this
17 determination. Upon receipt of this notification from the
18 Department of Public Welfare, hospitals that have granted
19 hospital privileges to the physician shall suspend those
20 privileges. The sanction in this subsection shall be withdrawn
21 upon documentation that the physician has met the criteria set
22 forth in section 402. The Department of Public Welfare may
23 suspend the sanction set forth in this subsection for any
24 physician who enters into a written agreement with the
25 Department of Public Welfare setting forth specific actions the
26 physician will immediately take to actively participate in the
27 medical assistance program. Within 60 days following a
28 suspension of the sanction in this subsection, the Department of
29 Public Welfare shall determine whether the physician is in
30 compliance with the agreement. At any time the Department of
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1 Public Welfare determines that a physician is not in compliance
2 with the agreement, the sanctions set forth in this subsection
3 shall be reimposed. If the Department of Public Welfare
4 determines that the physician is not affiliated with a hospital
5 in this Commonwealth, then the assessment imposed in subsection
6 (b) may be increased.
7 (d) Payment or appeal.--Any physician charged under
8 subsection (b) shall have 30 days to pay the assessed penalty in
9 full, or, if the provider wishes to contest either the amount of
10 the penalty or the fact of the violation, the party shall
11 forward the assessed penalty, not to exceed $2,500, to the
12 Secretary of Public Welfare for placement in an escrow account
13 with the State Treasurer. If, after administrative hearing or
14 judicial review of the proposed penalty, it is determined that
15 no violation occurred or that the amount of the penalty shall be
16 reduced, the Secretary of Public Welfare shall, within 30 days,
17 remit the appropriate amount to the physician or hospital with
18 any interest accumulated by the escrow deposit. Failure to
19 forward the payment to the Secretary of Public Welfare within 30
20 days shall result in a waiver of rights to contest the fact of
21 the violation or the amount of the penalty. The amount assessed
22 after administrative hearing or a waiver of the administrative
23 hearing shall be payable to the Commonwealth and shall be
24 collectible in any manner provided by law for the collection of
25 debts. If any provider liable to pay the penalty neglects or
26 refuses to pay the penalty after demand, the failure to pay
27 shall constitute a judgment in favor of the Commonwealth in the
28 amount of the penalty, together with the interest and any costs
29 that may accrue.
30 (e) Appeal.--Any physician charged under subsection (c)
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1 shall have 30 days to contest the suspension of hospital
2 privileges by forwarding $2,500 to the Secretary of Public
3 Welfare for placement in an escrow account with the State
4 Treasurer. If, after administrative hearing or judicial review
5 of the proposed penalty, it is determined that no violation
6 occurred, the Secretary of Public Welfare shall, within 30 days,
7 remit the $2,500 to the physician with any interest accumulated
8 by the escrow deposit. Failure to forward the payment to the
9 Secretary of Public Welfare within 30 days shall result in a
10 waiver of rights to contest the fact of the violation.
11 Section 406. Enforcement authority.
12 The Department of Public Welfare shall have the authority to
13 bring proceedings in Commonwealth Court to enforce the
14 provisions of this chapter.
15 CHAPTER 5
16 MISCELLANEOUS PROVISIONS
17 Section 501. Effective date.
18 This act shall take effect (to be determined).
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