PRIOR PRINTER'S NOS. 1448, 2237 PRINTER'S NO. 2326
No. 1150 Session of 2007
INTRODUCED BY D. O'BRIEN, DeWEESE, PALLONE, PHILLIPS, RAPP,
SCAVELLO, STURLA, BAKER, BASTIAN, BOYD, BROOKS, CALTAGIRONE,
CARROLL, CLYMER, COHEN, CONKLIN, DALEY, DALLY, DeLUCA,
DePASQUALE, DONATUCCI, EVERETT, FREEMAN, GEIST, GEORGE,
GIBBONS, GINGRICH, GOODMAN, GRUCELA, HALUSKA, HARKINS,
HENNESSEY, HERSHEY, JAMES, JOSEPHS, KAUFFMAN, W. KELLER,
KENNEY, KIRKLAND, KOTIK, KULA, LEACH, LENTZ, MAHONEY,
MANDERINO, MANN, MARKOSEK, MARSHALL, McILHATTAN, MOYER, MURT,
MUSTIO, McGEEHAN, MYERS, NAILOR, M. O'BRIEN, PASHINSKI,
PAYNE, PETRONE, PRESTON, READSHAW, REICHLEY, ROSS, SCHRODER,
SEIP, SHAPIRO, SHIMKUS, M. SMITH, SOLOBAY, SONNEY, STABACK,
STEIL, SURRA, TANGRETTI, TRUE, VEREB, WATSON, J. WHITE,
WOJNAROSKI, YUDICHAK, MACKERETH, MANTZ, BARRAR, HORNAMAN,
CAUSER, WALKO, HELM, MELIO, DENLINGER, BRENNAN, RAMALEY,
DiGIROLAMO, GERGELY, M. KELLER, FRANKEL, FABRIZIO,
YOUNGBLOOD, REED, ROAE, CURRY, K SMITH, GALLOWAY, SIPTROTH
AND RUBLEY APRIL 30, 2007
AS AMENDED ON SECOND CONSIDERATION, HOUSE OF REPRESENTATIVES,
JULY 13, 2007
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," providing, in health and accident
12 insurance, for autism spectrum disorders coverage and for
13 treatment of autism spectrum disorders; and further providing
14 for quality health care procedures.
15 The General Assembly of the Commonwealth of Pennsylvania
16 hereby enacts as follows:
1 Section 1. The act of May 17, 1921 (P.L.682, No.284), known
2 as The Insurance Company Law of 1921, is amended by adding
3 sections to read:
4 Section 635.2. Autism Spectrum Disorders Coverage.--(a) A
5 health insurance policy or government program shall provide to
6 covered individuals or recipients under twenty-one years of age
7 coverage for the diagnosis of autism spectrum disorders and for
8 the treatment of autism spectrum disorders. TO THE EXTENT THAT <--
9 THE DIAGNOSIS AND TREATMENT OF AUTISM SPECTRUM DISORDERS ARE NOT
10 ALREADY COVERED BY THE HEALTH INSURANCE POLICY OR GOVERNMENT
11 PROGRAM, COVERAGE UNDER THIS SECTION SHALL BE INCLUDED IN HEALTH
12 INSURANCE POLICIES AND CONTRACTS UNDER A GOVERNMENT PROGRAM
13 WHICH ARE DELIVERED, EXECUTED, ISSUED, AMENDED, ADJUSTED OR
14 RENEWED ON OR AFTER ONE HUNDRED EIGHTY DAYS FROM THE EFFECTIVE
15 DATE OF THIS SECTION, EXCEPT THAT THE APPLICABILITY OF THIS
16 SECTION TO GOVERNMENT PROGRAMS SHALL BE CONTINGENT UPON FEDERAL
17 APPROVAL IF NECESSARY.
18 (b) Except for the Commonwealth's medical assistance program
19 established under the act of June 13, 1967 (P.L.31, No.21),
20 known as the "Public Welfare Code," and except for the
21 Children's Health Care Program established under this act,
22 coverage provided under this section shall be subject to a
23 maximum benefit of thirty-six thousand dollars ($36,000) per
24 year but shall not be subject to any limits on the number of
25 visits to an autism service provider. After December 30, 2009,
26 the Insurance Commissioner shall, on an annual basis, adjust the
27 maximum benefit for inflation using the Medical Price Index <--
28 (MPI) component of the Department of Labor Consumer Price Index
29 (CPI). CARE COMPONENT OF THE UNITED STATES DEPARTMENT OF LABOR <--
30 CONSUMER PRICE INDEX FOR ALL URBAN CONSUMERS (CPI-U). The
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1 commissioner shall submit the adjusted maximum benefit to the
2 Legislative Reference Bureau for publication annually in the
3 Pennsylvania Bulletin no later than April 1 of each calendar
4 year, and the published adjusted maximum benefit shall be
5 applicable in the following calendar year to health insurance
6 policies and government programs subject to this act. Payments
7 made by an insurer on behalf of a covered individual for any
8 care, treatment, intervention, service or item, the provision of
9 which was for the treatment of a health condition unrelated to
10 the covered individual's autism spectrum disorder, shall not be
11 applied toward any maximum benefit established under this
12 subsection.
13 (c) Coverage under this section shall be subject to
14 copayment, deductible and coinsurance provisions of a health
15 insurance policy or government program to the extent that other
16 medical services covered by the policy or government program are
17 subject to these provisions.
18 (d) This section shall not be construed as limiting benefits
19 which are otherwise available to an individual under a health
20 insurance policy.
21 (e) This section shall not apply to the following types of
22 policies:
23 (1) Accident only.
24 (2) Limited benefit.
25 (3) Credit.
26 (4) Dental.
27 (5) Vision.
28 (6) Specified disease.
29 (7) Medicare supplement.
30 (8) CHAMPUS (Civilian Health and Medical Program of the
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1 Uniformed Services) supplement.
2 (9) Long-term care or disability income.
3 (10) Workers' compensation.
4 (11) Automobile medical payment.
5 (12) Hospital indemnity.
6 (f) As used in this section:
7 (1) "Applied behavioral analysis" means the design,
8 implementation and evaluation of environmental modifications,
9 using behavioral stimuli and consequences, to produce socially
10 significant improvement in human behavior, including the use of
11 direct observation, measurement and functional analysis of the
12 relations between environment and behavior.
13 (2) "Autism service provider" means any person, entity or
14 group that provides treatment of autism spectrum disorders.
15 (3) "Autism spectrum disorders" means any of the pervasive
16 developmental disorders as defined by the most recent edition of
17 the Diagnostic and Statistical Manual of Mental Disorders (DSM),
18 including autistic disorder, Asperger's disorder and pervasive
19 developmental disorder not otherwise specified.
20 (4) "Diagnosis of autism spectrum disorders" means medically
21 necessary assessments, evaluations or tests in order to diagnose
22 whether an individual has an autism spectrum disorder.
23 (5) "Evidenced-based research" means research that applies
24 rigorous, systematic and objective procedures to obtain valid
25 knowledge relevant to autism spectrum disorders.
26 (6) "Government program" means any of the following:
27 (i) The Commonwealth's medical assistance program
28 established under the act of June 13, 1967 (P.L.31, No.21),
29 known as the "Public Welfare Code."
30 (ii) The adult basic coverage insurance program established
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1 under Chapter 13 of the act of June 26, 2001 (P.L.755, No.77),
2 known as the "Tobacco Settlement Act."
3 (iii) The Children's Health Care Program established under
4 this act.
5 (7) "Health insurance policy" means any group health,
6 sickness or accident policy or subscriber contract or
7 certificate issued by an insurance entity subject to one of the
8 following:
9 (i) This act.
10 (ii) The act of December 29, 1972 (P.L.1701, No.364), known
11 as the "Health Maintenance Organization Act."
12 (iii) The act of May 18, 1976 (P.L.123, No.54), known as the
13 "Individual Accident and Sickness Insurance Minimum Standards
14 Act."
15 (iv) 40 Pa.C.S. Ch. 61 (relating to hospital plan
16 corporations) or 63 (relating to professional health services
17 plan corporations).
18 (8) "Medically necessary" means any care, treatment,
19 intervention, service or item which is prescribed, provided or
20 ordered by a licensed physician, licensed psychologist or
21 certified registered nurse practitioner in accordance with
22 accepted standards of practice and which will, or is reasonably
23 expected to, do any of the following:
24 (i) Prevent the onset of an illness, condition, injury or
25 disability.
26 (ii) Reduce or ameliorate the physical, mental or
27 developmental effects of an illness, condition, injury or
28 disability.
29 (iii) Assist to achieve or maintain maximum functional
30 capacity in performing daily activities, taking into account
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1 both the functional capacity of the recipient and those
2 functional capacities that are appropriate of recipients of the
3 same age.
4 (9) "Pharmacy care" means medications prescribed by a
5 licensed physician or certified registered nurse practitioner
6 and any health-related services deemed medically necessary to
7 determine the need or effectiveness of the medications.
8 (10) "Psychiatric care" means direct or consultative
9 services provided by a psychiatrist licensed in the state in
10 which the psychiatrist practices.
11 (11) "Psychological care" means direct or consultative
12 services provided by a licensed psychologist PSYCHOLOGIST <--
13 LICENSED in the state in which the psychologist practices.
14 (12) "Rehabilitative care" means professional, counseling
15 and guidance services and treatment programs, including applied
16 behavioral analysis, which are necessary to develop, maintain
17 and restore, to the maximum extent practicable, the functioning
18 of an individual.
19 (13) "Therapeutic care" means services provided by licensed
20 or certified speech therapists, occupational therapists or
21 physical therapists.
22 (14) "Treatment for autism spectrum disorders" shall include
23 the following care prescribed, provided or ordered for an
24 individual diagnosed with an autism spectrum disorder by a
25 licensed physician, licensed psychologist or certified
26 registered nurse practitioner if the care is determined to be
27 medically necessary:
28 (i) Psychiatric care.
29 (ii) Psychological care.
30 (iii) Rehabilitative care.
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1 (iv) Therapeutic care.
2 (v) Pharmacy care.
3 (vi) Any care, treatment, intervention, service or item for
4 individuals with an autism spectrum disorder which is determined
5 by the Department of Public Welfare, based upon its review of
6 best practices or evidenced-based research, to be medically
7 necessary and which is published in the Pennsylvania Bulletin.
8 Any such care, treatment, intervention, service or item which
9 was not previously covered shall be included in any health
10 insurance policy or contract under a government program
11 delivered, issued, executed or renewed on or after 120 days
12 following the date of its publication in the Pennsylvania
13 Bulletin.
14 (g) The Department of Public Welfare shall promulgate
15 regulations establishing standards for qualified autism service
16 providers. For purposes of implementing this section, and
17 notwithstanding any other provision of law, THE Secretary of <--
18 Public Welfare shall promulgate regulations pursuant to section
19 204(1)(iv) of the act of July 31, 1968 (P.L.769, No.240),
20 referred to as the Commonwealth Documents Law, which shall, for
21 120 days from the effective date of this act, be exempt from all
22 OF the following acts: <--
23 (1) Section 205 of the Commonwealth Documents Law.
24 (2) Section 204(b) of the act of October 15, 1980 (P.L.950,
25 No.164), known as the "Commonwealth Attorneys Act."
26 (3) The act of June 25, 1982 (P.L.633, No.181), known as the
27 "Regulatory Review Act."
28 Once the regulations are promulgated, payment for the treatment
29 of autism spectrum disorders covered under this section shall
30 only be made to autism service providers who meet the standards.
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1 (h) To the extent that the diagnosis and treatment of autism <--
2 spectrum disorders are not already covered by the health
3 insurance policy or government program, coverage under this
4 section shall be included in health insurance policies and
5 contracts under a government program which are delivered,
6 executed, issued, amended, adjusted or renewed on or after one
7 hundred twenty days from the effective date of this section,
8 except that the applicability of this section to government
9 programs shall be contingent upon Federal approval if necessary.
10 Section 2116.1. Treatment of Autism Spectrum Disorders.--(a)
11 Except for government programs, if an enrollee has obtained a
12 referral or other authorization through utilization review from
13 a managed care plan or a licensed insurer to receive any care,
14 treatment, intervention, service or item for an autism spectrum
15 disorder from a health care provider or specialist, the referral
16 or other authorization shall constitute a standing referral for
17 any subsequent care, treatment, intervention, service or item
18 provided by any health care provider or specialist until the
19 care, treatment, intervention, service or item for which the
20 referral or authorization was approved has reached its
21 conclusion.
22 SECTION 2116.1. TREATMENT OF AUTISM SPECTRUM DISORDERS.--(A) <--
23 EXCEPT FOR INPATIENT SERVICES, IF AN ENROLLEE HAS OBTAINED
24 AUTHORIZATION THROUGH UTILIZATION REVIEW FROM A MANAGED CARE
25 PLAN, GOVERNMENT PROGRAM OR A LICENSED INSURER TO RECEIVE ANY
26 CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM FOR AN AUTISM
27 SPECTRUM DISORDER, THE AUTHORIZATION SHALL BE VALID FOR TWELVE
28 MONTHS, UNLESS THE ENROLLEE'S PRIMARY CARE PROVIDER DETERMINES
29 THAT AN EARLIER RE-EVALUATION IS NECESSARY IN ORDER TO
30 ADEQUATELY ADDRESS THE CLINICAL NEEDS OF THE ENROLLEE.
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1 (A.1) IN APPLYING SUBSECTION (A), IF WITHIN THE TWELVE-MONTH
2 PERIOD FOLLOWING THE EFFECTIVE DATE OF THIS SECTION A HEALTH
3 INSURANCE POLICY IS DELIVERED, ISSUED, EXECUTED OR RENEWED AND
4 AT THE TIME OF SUCH DELIVERY, ISSUANCE, EXECUTION OR RENEWAL AN
5 ENROLLEE IS RECEIVING ANY INPATIENT OR OUTPATIENT CARE,
6 TREATMENT, INTERVENTION, SERVICE OR ITEM FOR AN AUTISM SPECTRUM
7 DISORDER PURSUANT TO AN AUTHORIZATION OBTAINED FROM A GOVERNMENT
8 PROGRAM, AND THE CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM
9 IS COVERED UNDER THE HEALTH INSURANCE POLICY BEING DELIVERED,
10 ISSUED, EXECUTED OR RENEWED, THE AUTHORIZATION FROM THE
11 GOVERNMENT PROGRAM SHALL REMAIN VALID FOR THE REMAINDER OF THE
12 EXISTING AUTHORIZATION PERIOD AS TO ANY MANAGED CARE PLAN OR
13 PRIVATE INSURER AND SUCH AUTHORIZATION SHALL BE HONORED BY ANY
14 MANAGED CARE PLAN OR PRIVATE INSURER PROVIDING COVERAGE TO THE
15 ENROLLEE.
16 (b) If a health care provider provides care, treatments,
17 interventions, services or items to an enrollee, the coverage of
18 which is required under section 635.2 and the provider is
19 enrolled in the Commonwealth's medical assistance program but is
20 not a network provider with the enrollee's private insurance
21 plan, the provider shall be reimbursed under the terms and
22 conditions applicable to the plan's participating providers.
23 This requirement shall not be subject to any time limitation or
24 transition period, but shall otherwise be in accord with all
25 terms applicable to nonparticipating providers under the managed
26 care continuity of care provisions then in effect.
27 Section 2. Section 2121 of the act, added June 17, 1998
28 (P.L.464, No.68), is amended to read:
29 Section 2121. Procedures.--(a) A managed care plan shall
30 establish a credentialing process to enroll qualified health
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1 care providers and create an adequate provider network. The
2 process shall be approved by the department and shall include
3 written criteria and procedures for initial enrollment, renewal,
4 restrictions and termination of credentials for health care
5 providers.
6 (b) [The] Except as provided under subsection (b.1), the
7 department shall establish credentialing standards for managed
8 care plans. The department may adopt nationally recognized
9 accrediting standards to establish the credentialing standards
10 for managed care plans.
11 (b.1) Pursuant to section 635.2(g), the Department of Public
12 Welfare shall establish standards to be utilized by managed care
13 plans for the credentialing of health care providers providing
14 care, treatments, interventions, services or items to enrollees
15 for an autism spectrum disorder as defined under section 635.2.
16 In addition, the department may require that a managed care plan
17 grant credentials to any health care provider whom the
18 Department of Public Welfare determines meets or exceeds the
19 Department of Public Welfare's credentialing standards.
20 (b.2) With respect to autism service providers, a managed <--
21 care plan or licensed insurer shall inform credentialing
22 applicants of a decision within ninety days after the complete
23 application has been submitted to the managed care plan or
24 insurer. A managed care plan or insurer shall not require a
25 health care provider to submit an application for credentialing
26 as a result of a change of employers if the provider's new
27 employer is in the managed care plan's service area or network.
28 (c) A managed care plan shall submit a report to the
29 department regarding its credentialing process at least every
30 two (2) years or as may otherwise be required by the department.
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1 (d) A managed care plan shall disclose relevant
2 credentialing criteria and procedures to health care providers
3 that apply to participate or that are participating in the
4 plan's provider network. A managed care plan shall also disclose
5 relevant credentialing criteria and procedures pursuant to a
6 court order or rule. Any individual providing information during
7 the credentialing process of a managed care plan shall have the
8 protections set forth in the act of July 20, 1974 (P.L.564,
9 No.193), known as the "Peer Review Protection Act."
10 (e) No managed care plan shall exclude or terminate a health
11 care provider from participation in the plan due to any of the
12 following:
13 (1) The health care provider engaged in any of the
14 activities set forth in section 2113(c).
15 (2) The health care provider has a practice that includes a
16 substantial number of patients with expensive medical
17 conditions.
18 (3) The health care provider objects to the provision of or
19 refuses to provide a health care service on moral or religious
20 grounds.
21 (f) If a managed care plan denies enrollment or renewal of
22 credentials to a health care provider, the managed care plan
23 shall provide the health care provider with written notice of
24 the decision. The notice shall include a clear rationale for the
25 decision.
26 Section 3. This act shall take effect in 180 days. <--
27 SECTION 3. THIS ACT SHALL TAKE EFFECT AS FOLLOWS: <--
28 (1) THE FOLLOWING PROVISIONS SHALL TAKE EFFECT IN 90
29 DAYS:
30 (I) THE ADDITION OF SECTION 635.2(F) AND (G) OF THE
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1 ACT.
2 (II) THE AMENDMENT OF SECTION 2121 OF THE ACT.
3 (III) THIS SECTION.
4 (2) THE REMAINDER OF THIS ACT SHALL TAKE EFFECT IN 210
5 DAYS.
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