PRINTER'S NO. 2755
No. 2113 Session of 1999
INTRODUCED BY COSTA, DeWEESE, VEON, DeLUCA, BELARDI, READSHAW,
WALKO, TRELLO, VAN HORNE, MICHLOVIC, FRANKEL, GRUCELA,
SOLOBAY, YUDICHAK, FREEMAN, CURRY, DALEY, MANN, STURLA,
STABACK, GEORGE, HALUSKA, HARHAI, HORSEY, JOSEPHS, LAUGHLIN,
MELIO, MYERS, ROONEY, SHANER, STEELMAN, TANGRETTI, THOMAS,
TRAVAGLIO, YOUNGBLOOD AND BROWNE, DECEMBER 7, 1999
REFERRED TO COMMITTEE ON INSURANCE, DECEMBER 7, 1999
AN ACT
1 Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
2 act relating to insurance; amending, revising, and
3 consolidating the law providing for the incorporation of
4 insurance companies, and the regulation, supervision, and
5 protection of home and foreign insurance companies, Lloyds
6 associations, reciprocal and inter-insurance exchanges, and
7 fire insurance rating bureaus, and the regulation and
8 supervision of insurance carried by such companies,
9 associations, and exchanges, including insurance carried by
10 the State Workmen's Insurance Fund; providing penalties; and
11 repealing existing laws," further defining "managed care
12 plan"; further providing for responsibilities of managed care
13 plans; providing for transfer of liability prohibition; and
14 further providing for emergency services, for
15 confidentiality, for required disclosure and for preemption.
16 The General Assembly of the Commonwealth of Pennsylvania
17 hereby enacts as follows:
18 Section 1. The definition of "managed care plan" in section
19 2102 of the act of May 17, 1921 (P.L.682, No.284), known as The
20 Insurance Company Law of 1921, added June 17, 1998 (P.L.464,
21 No.68), is amended to read:
22 Section 2102. Definitions.--As used in this article, the
1 following words and phrases shall have the meanings given to
2 them in this section:
3 * * *
4 "Managed care plan." A health care plan that uses a
5 gatekeeper to manage the utilization of health care services,
6 integrates the financing and delivery of health care services to
7 enrollees by arrangements with health care providers selected to
8 participate on the basis of specific standards [and] or provides
9 financial incentives for enrollees to use the participating
10 health care providers in accordance with procedures established
11 by the plan. A managed care plan includes health care arranged
12 through an entity operating under any of the following:
13 (1) Section 630.
14 (2) The act of December 29, 1972 (P.L.1701, No.364), known
15 as the "Health Maintenance Organization Act."
16 (3) The act of December 14, 1992 (P.L.835, No.134), known as
17 the "Fraternal Benefit Societies Code."
18 (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan
19 corporations).
20 (5) 40 Pa.C.S. Ch. 63 (relating to professional health
21 services plan corporations).
22 The term includes an entity, including a municipality, whether
23 licensed or unlicensed, that contracts with or functions as a
24 managed care plan to provide health care services to enrollees.
25 The term does not include ancillary service plans or an
26 indemnity arrangement which is primarily fee for service.
27 * * *
28 Section 2. Sections 2111, 2112, 2116 and 2131(a) of the act,
29 added June 17, 1998 (P.L.464, No.68), are amended to read:
30 Section 2111. Responsibilities of Managed Care Plans.--A
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1 managed care plan shall do all of the following:
2 (1) Assure availability and accessibility of adequate health
3 care providers in a timely manner, which enables enrollees to
4 have access to quality care and continuity of health care
5 services.
6 (2) Consult with health care providers in active clinical
7 practice regarding professional qualifications and necessary
8 specialists to be included in the plan.
9 (3) Adopt and maintain a definition of medical necessity
10 used by the plan in determining health care services.
11 (4) Ensure that emergency services are provided twenty-four
12 (24) hours a day, seven (7) days a week and provide reasonable
13 payment or reimbursement for emergency services.
14 (5) Adopt and maintain procedures by which an enrollee can
15 obtain health care services outside the plan's service area.
16 (6) Adopt and maintain procedures by which an enrollee with
17 a life-threatening, degenerative or disabling disease or
18 condition shall, upon request, receive an evaluation and, if the
19 plan's established standards are met, be permitted to receive:
20 (i) a standing referral to a specialist with clinical
21 expertise in treating the disease or condition; or
22 (ii) the designation of a specialist to provide and
23 coordinate the enrollee's primary and specialty care.
24 The referral to or designation of a specialist shall be pursuant
25 to a treatment plan approved by the managed care plan in
26 consultation with the primary care provider, the enrollee and,
27 as appropriate, the specialist. When possible, the specialist
28 must be a health care provider participating in the plan.
29 (7) Provide direct access to obstetrical and gynecological
30 services by permitting an enrollee to select a health care
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1 provider participating in the plan to obtain maternity and
2 gynecological care, including medically necessary and
3 appropriate follow-up care and referrals for diagnostic testing
4 related to maternity and gynecological care, without prior
5 approval from a primary care provider. The health care services
6 shall be within the scope of practice of the selected health
7 care provider. The selected health care provider shall inform
8 the enrollee's primary care provider of all health care services
9 provided.
10 (8) Adopt and maintain a complaint process as set forth in
11 subdivision (g).
12 (9) Adopt and maintain a grievance process as set forth in
13 subdivision (i).
14 (10) Adopt and maintain credentialing standards for health
15 care providers as set forth in subdivision (d).
16 (11) Ensure that there are participating health care
17 providers that are physically accessible to people with
18 disabilities and can communicate with individuals with sensory
19 disabilities in accordance with Title III of the Americans with
20 Disabilities Act of 1990 (Public Law 101-336, 42 U.S.C. § 12181
21 et seq.).
22 (12) Provide a list of health care providers participating
23 in the plan to the department every two (2) years or as may
24 otherwise be required by the department. The list shall include
25 the extent to which health care providers in the plan are
26 accepting new enrollees.
27 (13) Report to the department and the Insurance Department
28 in accordance with the requirements of this article. Such
29 information shall include the number, type and disposition of
30 all complaints and grievances filed with the plan.
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1 (14) Offer every member the opportunity to seek treatment
2 outside of the managed care plan network. The managed care plan
3 may cover the reasonable and appropriate costs of such an option
4 by raising the premium charged for the member or implementing a
5 requirement that the member bear some percentage of the cost
6 associated with receiving treatment outside of the plan's
7 network.
8 Section 2112. Financial Incentives and Transfer of Liability
9 Prohibition.--No managed care plan shall use any financial
10 incentive that compensates a health care provider for providing
11 less than medically necessary and appropriate care to an
12 enrollee. A managed care plan shall not include any provision in
13 a contract with a health care provider that holds the plan
14 harmless from liability for treatment or payment of services or
15 includes an indemnification clause that transfers responsibility
16 for indemnification or otherwise transfers financial or medical
17 liability relating to the activities or omissions of the plan
18 from the plan to the provider. Nothing in this section shall be
19 deemed to prohibit a managed care plan from using a capitated
20 payment arrangement or other risk-sharing arrangement.
21 Section 2116. Emergency Services.--If an enrollee seeks
22 emergency services and the emergency health care provider
23 determines that emergency services are necessary, the emergency
24 health care provider shall initiate necessary intervention to
25 evaluate and, if necessary, stabilize the condition of the
26 enrollee without seeking or receiving authorization from the
27 managed care plan. The managed care plan shall pay all
28 reasonably necessary costs associated with the emergency
29 services provided during the period of the emergency, including
30 the costs of any medical assessment or test to determine if
19990H2113B2755 - 5 -
1 urgent care is required. When processing a reimbursement claim
2 for emergency services, a managed care plan shall consider both
3 the presenting symptoms and the services provided. The emergency
4 health care provider shall notify the enrollee's managed care
5 plan of the provision of emergency services and the condition of
6 the enrollee. If an enrollee's condition has stabilized and the
7 enrollee can be transported without suffering detrimental
8 consequences or aggravating the enrollee's condition, the
9 enrollee may be relocated to another facility to receive
10 continued care and treatment as necessary.
11 Section 2131. Confidentiality.--(a) (1) A managed care
12 plan and a utilization review entity shall adopt and maintain
13 procedures to ensure that all identifiable information regarding
14 enrollee health, diagnosis and treatment is adequately protected
15 and remains confidential in compliance with all applicable
16 Federal and State laws and regulations and professional ethical
17 standards.
18 (2) A managed care plan may not sell or transfer for
19 financial consideration the names or any patient-identifying
20 information. A managed care plan may not release any patient
21 specific genetic information without the written consent of the
22 patient or the patient's legal representative or legal guardian.
23 * * *
24 Section 3. Section 2136(a) of the act is amended by adding a
25 paragraph to read:
26 Section 2136. Required Disclosure.--(a) A managed care plan
27 shall supply each enrollee and, upon written request, each
28 prospective enrollee or health care provider with the following
29 written information. Such information shall be easily
30 understandable by the layperson and shall include, but not be
19990H2113B2755 - 6 -
1 limited to:
2 * * *
3 (16) Each enrolled member and each prospective member shall
4 be informed in writing that the member has the right to:
5 (i) obtain, without paying any financial penalty, specific
6 prescription drugs that are not included in the managed care
7 plan's drug formulary if the patient is allergic to the
8 formulary medication, if the formulary medication may interact
9 with other medications the patient is taking or if the patient
10 has an intolerance for the formulary medication;
11 (ii) be informed about alternative treatment options and the
12 consequences of each option;
13 (iii) receive basic comparative information about the plan
14 in which the member is enrolled or potentially could enroll;
15 (iv) participate in and be covered for clinical trials and
16 experimental treatment as long as there is a meaningful
17 potential for a significant clinical benefit from the trial or
18 treatment;
19 (v) receive a clear statement as to the charges and payments
20 for which the member is or may be liable and to the limitations
21 or other conditions that affect that member's ability to access
22 health care services;
23 (vi) file a grievance, authorize a provider to file a
24 grievance on the member's behalf, and file a complaint and
25 receive a timely response;
26 (vii) to be informed about any special provider payment
27 procedures that could potentially impact on the member's ability
28 to access care;
29 (viii) obtain a referral out of network when the network is
30 insufficient to provide treatment required by the patient;
19990H2113B2755 - 7 -
1 (ix) to designate the member's own care coordinator or
2 gatekeeper from among the network of providers participating in
3 the plan;
4 (x) select a specialist as the member's primary care
5 provider if the member has been diagnosed and is in treatment
6 for a chronic illness or disability; and
7 (xi) seek treatment from a provider not in the plan provider
8 network with a clear statement as to the additional cost to the
9 member for the service.
10 * * *
11 Section 4. Section 2193 of the act, added June 17, 1998
12 (P.L.464, No.68), is amended to read:
13 [Section 2193. Preemption.--Nothing in this article shall
14 regulate or authorize regulation which would be ineffective by
15 reason of the State law preemption provisions of the Employee
16 Retirement Income Security Act of 1974 (Public Law 93-406, 88
17 Stat. 829).]
18 Section 5. This act shall take effect immediately.
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