PRIOR PRINTER'S NO. 1448 PRINTER'S NO. 2237
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 AND K SMITH, APRIL 30, 2007
AS REPORTED FROM COMMITTEE ON INSURANCE, HOUSE OF
REPRESENTATIVES, AS AMENDED, JULY 5, 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 a
3 section to read:
4 Section 635.2. Autism Spectrum Disorders Coverage.--(a) A
5 health insurance policy delivered, issued, executed or renewed
6 in this Commonwealth on or after the effective date of this
7 section shall provide coverage for autism spectrum disorders and
8 include coverage for the following care and services:
9 (1) Habilitation care.
10 (2) Psychiatric care.
11 (3) Psychological care.
12 (4) Rehabilitation care.
13 (5) Respite care.
14 (6) Therapeutic care.
15 (7) Medications prescribed by a physician or certified nurse
16 practitioner to address symptoms of autism spectrum disorders.
17 (b) Coverage provided under this section shall be subject to
18 a maximum benefit of three thousand dollars per month for the
19 covered individual, adjusted annually by the average percentage
20 increase or decrease of private medical insurance premiums each
21 year. The limit shall not apply to coverage of the other health
22 conditions of the individual not related to the treatment of
23 autism spectrum disorders.
24 (c) Coverage under this section shall be subject to
25 copayment, deductible and coinsurance provisions of a health
26 insurance policy to the extent that other medical services
27 covered by the policy are subject to these provisions.
28 (d) This section shall not be construed as limiting benefits
29 which are otherwise available to an individual under a health
30 insurance policy.
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1 (e) This section shall not apply to the following types of
2 policies:
3 (1) Accident only.
4 (2) Limited benefit.
5 (3) Credit.
6 (4) Dental.
7 (5) Vision.
8 (6) Specified disease.
9 (7) Medicare supplement.
10 (8) CHAMPUS (Civilian Health and Medical Program of the
11 Uniformed Services) supplement.
12 (9) Long-term care or disability income.
13 (10) Workers' compensation.
14 (11) Automobile medical payment.
15 (12) Hospital indemnity.
16 (f) This section shall not apply to the Commonwealth's
17 medical assistance program nor to medical assistance managed
18 care contractors under the medical assistance program.
19 (g) As used in this section:
20 (1) "Autism spectrum disorders" means any of the pervasive
21 developmental disorders as defined by the most recent edition of
22 the Diagnostic and Statistical Manual of Mental Disorders (DSM),
23 including autistic disorder, Asperger's disorder and pervasive
24 developmental disorder not otherwise specified.
25 (2) "Habilitation care" means care designed to assist
26 individuals in acquiring, retaining and improving the self-help,
27 socialization and adaptive skills necessary to reside
28 successfully in home or community-based settings. Habilitation
29 care may be provided for up to twenty-four hours a day based on
30 the needs of the individual receiving the care and includes
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1 health, social or home or community-based services or other
2 services needed to insure the optimal functioning of an
3 individual in the individual's home or community-based setting;
4 behavioral interventions based on the principles of applied
5 behavioral analysis; and related structured behavioral programs
6 for up to forty hours a week.
7 (3) "Health insurance policy" means any group health,
8 sickness or accident policy or subscriber contract or
9 certificate issued by an insurance entity subject to one of the
10 following:
11 (i) This act.
12 (ii) The act of December 29, 1972 (P.L.1701, No.364), known
13 as the "Health Maintenance Organization Act."
14 (iii) The act of May 18, 1976 (P.L.123, No.54), known as the
15 "Individual Accident and Sickness Insurance Minimum Standards
16 Act."
17 (iv) 40 Pa.C.S. Ch. 61 (relating to hospital plan
18 corporations) or 63 (relating to professional health services
19 plan corporations).
20 (4) "Psychiatric care" means direct or consultative services
21 provided by a psychiatrist licensed in the state in which the
22 psychiatrist practices.
23 (5) "Psychological care" means direct or consultative
24 services provided by a licensed psychologist in the state in
25 which the psychiatrist practices.
26 (6) "Rehabilitative care" means professional, counseling and
27 guidance services and treatment programs which are necessary to
28 develop, maintain and restore, to the maximum extent
29 practicable, the functioning of an individual.
30 (7) "Respite care" means care furnished in relief of the
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1 primary caregiver on an intermittent basis for a limited period
2 to an individual who resides primarily in a private residence
3 when such care will help the individual to continue residing in
4 the private residence. The term includes nursing care or private
5 nursing care provided on a respite basis.
6 (8) "Therapeutic care" means services provided by licensed
7 or certified speech therapists, occupational therapists,
8 physical therapists or behavioral health specialists.
9 Section 2. This act shall take effect in 60 days.
10 SECTION 1. THE ACT OF MAY 17, 1921 (P.L.682, NO.284), KNOWN <--
11 AS THE INSURANCE COMPANY LAW OF 1921, IS AMENDED BY ADDING
12 SECTIONS TO READ:
13 SECTION 635.2. AUTISM SPECTRUM DISORDERS COVERAGE.--(A) A
14 HEALTH INSURANCE POLICY OR GOVERNMENT PROGRAM SHALL PROVIDE TO
15 COVERED INDIVIDUALS OR RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE
16 COVERAGE FOR THE DIAGNOSIS OF AUTISM SPECTRUM DISORDERS AND FOR
17 THE TREATMENT OF AUTISM SPECTRUM DISORDERS.
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). THE COMMISSIONER SHALL SUBMIT THE ADJUSTED MAXIMUM
30 BENEFIT TO THE LEGISLATIVE REFERENCE BUREAU FOR PUBLICATION
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1 ANNUALLY IN THE PENNSYLVANIA BULLETIN NO LATER THAN APRIL 1 OF
2 EACH CALENDAR YEAR, AND THE PUBLISHED ADJUSTED MAXIMUM BENEFIT
3 SHALL BE APPLICABLE IN THE FOLLOWING CALENDAR YEAR TO HEALTH
4 INSURANCE POLICIES AND GOVERNMENT PROGRAMS SUBJECT TO THIS ACT.
5 PAYMENTS MADE BY AN INSURER ON BEHALF OF A COVERED INDIVIDUAL
6 FOR ANY CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM, THE
7 PROVISION OF WHICH WAS FOR THE TREATMENT OF A HEALTH CONDITION
8 UNRELATED TO THE COVERED INDIVIDUAL'S AUTISM SPECTRUM DISORDER,
9 SHALL NOT BE APPLIED TOWARD ANY MAXIMUM BENEFIT ESTABLISHED
10 UNDER THIS SUBSECTION.
11 (C) COVERAGE UNDER THIS SECTION SHALL BE SUBJECT TO
12 COPAYMENT, DEDUCTIBLE AND COINSURANCE PROVISIONS OF A HEALTH
13 INSURANCE POLICY OR GOVERNMENT PROGRAM TO THE EXTENT THAT OTHER
14 MEDICAL SERVICES COVERED BY THE POLICY OR GOVERNMENT PROGRAM ARE
15 SUBJECT TO THESE PROVISIONS.
16 (D) THIS SECTION SHALL NOT BE CONSTRUED AS LIMITING BENEFITS
17 WHICH ARE OTHERWISE AVAILABLE TO AN INDIVIDUAL UNDER A HEALTH
18 INSURANCE POLICY.
19 (E) THIS SECTION SHALL NOT APPLY TO THE FOLLOWING TYPES OF
20 POLICIES:
21 (1) ACCIDENT ONLY.
22 (2) LIMITED BENEFIT.
23 (3) CREDIT.
24 (4) DENTAL.
25 (5) VISION.
26 (6) SPECIFIED DISEASE.
27 (7) MEDICARE SUPPLEMENT.
28 (8) CHAMPUS (CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE
29 UNIFORMED SERVICES) SUPPLEMENT.
30 (9) LONG-TERM CARE OR DISABILITY INCOME.
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1 (10) WORKERS' COMPENSATION.
2 (11) AUTOMOBILE MEDICAL PAYMENT.
3 (12) HOSPITAL INDEMNITY.
4 (F) AS USED IN THIS SECTION:
5 (1) "APPLIED BEHAVIORAL ANALYSIS" MEANS THE DESIGN,
6 IMPLEMENTATION AND EVALUATION OF ENVIRONMENTAL MODIFICATIONS,
7 USING BEHAVIORAL STIMULI AND CONSEQUENCES, TO PRODUCE SOCIALLY
8 SIGNIFICANT IMPROVEMENT IN HUMAN BEHAVIOR, INCLUDING THE USE OF
9 DIRECT OBSERVATION, MEASUREMENT AND FUNCTIONAL ANALYSIS OF THE
10 RELATIONS BETWEEN ENVIRONMENT AND BEHAVIOR.
11 (2) "AUTISM SERVICE PROVIDER" MEANS ANY PERSON, ENTITY OR
12 GROUP THAT PROVIDES TREATMENT OF AUTISM SPECTRUM DISORDERS.
13 (3) "AUTISM SPECTRUM DISORDERS" MEANS ANY OF THE PERVASIVE
14 DEVELOPMENTAL DISORDERS AS DEFINED BY THE MOST RECENT EDITION OF
15 THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM),
16 INCLUDING AUTISTIC DISORDER, ASPERGER'S DISORDER AND PERVASIVE
17 DEVELOPMENTAL DISORDER NOT OTHERWISE SPECIFIED.
18 (4) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS MEDICALLY
19 NECESSARY ASSESSMENTS, EVALUATIONS OR TESTS IN ORDER TO DIAGNOSE
20 WHETHER AN INDIVIDUAL HAS AN AUTISM SPECTRUM DISORDER.
21 (5) "EVIDENCED-BASED RESEARCH" MEANS RESEARCH THAT APPLIES
22 RIGOROUS, SYSTEMATIC AND OBJECTIVE PROCEDURES TO OBTAIN VALID
23 KNOWLEDGE RELEVANT TO AUTISM SPECTRUM DISORDERS.
24 (6) "GOVERNMENT PROGRAM" MEANS ANY OF THE FOLLOWING:
25 (I) THE COMMONWEALTH'S MEDICAL ASSISTANCE PROGRAM
26 ESTABLISHED UNDER THE ACT OF JUNE 13, 1967 (P.L.31, NO.21),
27 KNOWN AS THE "PUBLIC WELFARE CODE."
28 (II) THE ADULT BASIC COVERAGE INSURANCE PROGRAM ESTABLISHED
29 UNDER CHAPTER 13 OF THE ACT OF JUNE 26, 2001 (P.L.755, NO.77),
30 KNOWN AS THE "TOBACCO SETTLEMENT ACT."
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1 (III) THE CHILDREN'S HEALTH CARE PROGRAM ESTABLISHED UNDER
2 THIS ACT.
3 (7) "HEALTH INSURANCE POLICY" MEANS ANY GROUP HEALTH,
4 SICKNESS OR ACCIDENT POLICY OR SUBSCRIBER CONTRACT OR
5 CERTIFICATE ISSUED BY AN INSURANCE ENTITY SUBJECT TO ONE OF THE
6 FOLLOWING:
7 (I) THIS ACT.
8 (II) THE ACT OF DECEMBER 29, 1972 (P.L.1701, NO.364), KNOWN
9 AS THE "HEALTH MAINTENANCE ORGANIZATION ACT."
10 (III) THE ACT OF MAY 18, 1976 (P.L.123, NO.54), KNOWN AS THE
11 "INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS
12 ACT."
13 (IV) 40 PA.C.S. CH. 61 (RELATING TO HOSPITAL PLAN
14 CORPORATIONS) OR 63 (RELATING TO PROFESSIONAL HEALTH SERVICES
15 PLAN CORPORATIONS).
16 (8) "MEDICALLY NECESSARY" MEANS ANY CARE, TREATMENT,
17 INTERVENTION, SERVICE OR ITEM WHICH IS PRESCRIBED, PROVIDED OR
18 ORDERED BY A LICENSED PHYSICIAN, LICENSED PSYCHOLOGIST OR
19 CERTIFIED REGISTERED NURSE PRACTITIONER IN ACCORDANCE WITH
20 ACCEPTED STANDARDS OF PRACTICE AND WHICH WILL, OR IS REASONABLY
21 EXPECTED TO, DO ANY OF THE FOLLOWING:
22 (I) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY OR
23 DISABILITY.
24 (II) REDUCE OR AMELIORATE THE PHYSICAL, MENTAL OR
25 DEVELOPMENTAL EFFECTS OF AN ILLNESS, CONDITION, INJURY OR
26 DISABILITY.
27 (III) ASSIST TO ACHIEVE OR MAINTAIN MAXIMUM FUNCTIONAL
28 CAPACITY IN PERFORMING DAILY ACTIVITIES, TAKING INTO ACCOUNT
29 BOTH THE FUNCTIONAL CAPACITY OF THE RECIPIENT AND THOSE
30 FUNCTIONAL CAPACITIES THAT ARE APPROPRIATE OF RECIPIENTS OF THE
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1 SAME AGE.
2 (9) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A
3 LICENSED PHYSICIAN OR CERTIFIED REGISTERED NURSE PRACTITIONER
4 AND ANY HEALTH-RELATED SERVICES DEEMED MEDICALLY NECESSARY TO
5 DETERMINE THE NEED OR EFFECTIVENESS OF THE MEDICATIONS.
6 (10) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE
7 SERVICES PROVIDED BY A PSYCHIATRIST LICENSED IN THE STATE IN
8 WHICH THE PSYCHIATRIST PRACTICES.
9 (11) "PSYCHOLOGICAL CARE" MEANS DIRECT OR CONSULTATIVE
10 SERVICES PROVIDED BY A LICENSED PSYCHOLOGIST IN THE STATE IN
11 WHICH THE PSYCHOLOGIST PRACTICES.
12 (12) "REHABILITATIVE CARE" MEANS PROFESSIONAL, COUNSELING
13 AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING APPLIED
14 BEHAVIORAL ANALYSIS, WHICH ARE NECESSARY TO DEVELOP, MAINTAIN
15 AND RESTORE, TO THE MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING
16 OF AN INDIVIDUAL.
17 (13) "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED
18 OR CERTIFIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS OR
19 PHYSICAL THERAPISTS.
20 (14) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" SHALL INCLUDE
21 THE FOLLOWING CARE PRESCRIBED, PROVIDED OR ORDERED FOR AN
22 INDIVIDUAL DIAGNOSED WITH AN AUTISM SPECTRUM DISORDER BY A
23 LICENSED PHYSICIAN, LICENSED PSYCHOLOGIST OR CERTIFIED
24 REGISTERED NURSE PRACTITIONER IF THE CARE IS DETERMINED TO BE
25 MEDICALLY NECESSARY:
26 (I) PSYCHIATRIC CARE.
27 (II) PSYCHOLOGICAL CARE.
28 (III) REHABILITATIVE CARE.
29 (IV) THERAPEUTIC CARE.
30 (V) PHARMACY CARE.
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1 (VI) ANY CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM FOR
2 INDIVIDUALS WITH AN AUTISM SPECTRUM DISORDER WHICH IS DETERMINED
3 BY THE DEPARTMENT OF PUBLIC WELFARE, BASED UPON ITS REVIEW OF
4 BEST PRACTICES OR EVIDENCED-BASED RESEARCH, TO BE MEDICALLY
5 NECESSARY AND WHICH IS PUBLISHED IN THE PENNSYLVANIA BULLETIN.
6 ANY SUCH CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM WHICH
7 WAS NOT PREVIOUSLY COVERED SHALL BE INCLUDED IN ANY HEALTH
8 INSURANCE POLICY OR CONTRACT UNDER A GOVERNMENT PROGRAM
9 DELIVERED, ISSUED, EXECUTED OR RENEWED ON OR AFTER 120 DAYS
10 FOLLOWING THE DATE OF ITS PUBLICATION IN THE PENNSYLVANIA
11 BULLETIN.
12 (G) THE DEPARTMENT OF PUBLIC WELFARE SHALL PROMULGATE
13 REGULATIONS ESTABLISHING STANDARDS FOR QUALIFIED AUTISM SERVICE
14 PROVIDERS. FOR PURPOSES OF IMPLEMENTING THIS SECTION, AND
15 NOTWITHSTANDING ANY OTHER PROVISION OF LAW, SECRETARY OF PUBLIC
16 WELFARE SHALL PROMULGATE REGULATIONS PURSUANT TO SECTION
17 204(1)(IV) OF THE ACT OF JULY 31, 1968 (P.L.769, NO.240),
18 REFERRED TO AS THE COMMONWEALTH DOCUMENTS LAW, WHICH SHALL, FOR
19 120 DAYS FROM THE EFFECTIVE DATE OF THIS ACT, BE EXEMPT FROM ALL
20 THE FOLLOWING ACTS:
21 (1) SECTION 205 OF THE COMMONWEALTH DOCUMENTS LAW.
22 (2) SECTION 204(B) OF THE ACT OF OCTOBER 15, 1980 (P.L.950,
23 NO.164), KNOWN AS THE "COMMONWEALTH ATTORNEYS ACT."
24 (3) THE ACT OF JUNE 25, 1982 (P.L.633, NO.181), KNOWN AS THE
25 "REGULATORY REVIEW ACT."
26 ONCE THE REGULATIONS ARE PROMULGATED, PAYMENT FOR THE TREATMENT
27 OF AUTISM SPECTRUM DISORDERS COVERED UNDER THIS SECTION SHALL
28 ONLY BE MADE TO AUTISM SERVICE PROVIDERS WHO MEET THE STANDARDS.
29 (H) TO THE EXTENT THAT THE DIAGNOSIS AND TREATMENT OF AUTISM
30 SPECTRUM DISORDERS ARE NOT ALREADY COVERED BY THE HEALTH
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1 INSURANCE POLICY OR GOVERNMENT PROGRAM, COVERAGE UNDER THIS
2 SECTION SHALL BE INCLUDED IN HEALTH INSURANCE POLICIES AND
3 CONTRACTS UNDER A GOVERNMENT PROGRAM WHICH ARE DELIVERED,
4 EXECUTED, ISSUED, AMENDED, ADJUSTED OR RENEWED ON OR AFTER ONE
5 HUNDRED TWENTY DAYS FROM THE EFFECTIVE DATE OF THIS SECTION,
6 EXCEPT THAT THE APPLICABILITY OF THIS SECTION TO GOVERNMENT
7 PROGRAMS SHALL BE CONTINGENT UPON FEDERAL APPROVAL IF NECESSARY.
8 SECTION 2116.1. TREATMENT OF AUTISM SPECTRUM DISORDERS.--(A)
9 EXCEPT FOR GOVERNMENT PROGRAMS, IF AN ENROLLEE HAS OBTAINED A
10 REFERRAL OR OTHER AUTHORIZATION THROUGH UTILIZATION REVIEW FROM
11 A MANAGED CARE PLAN OR A LICENSED INSURER TO RECEIVE ANY CARE,
12 TREATMENT, INTERVENTION, SERVICE OR ITEM FOR AN AUTISM SPECTRUM
13 DISORDER FROM A HEALTH CARE PROVIDER OR SPECIALIST, THE REFERRAL
14 OR OTHER AUTHORIZATION SHALL CONSTITUTE A STANDING REFERRAL FOR
15 ANY SUBSEQUENT CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM
16 PROVIDED BY ANY HEALTH CARE PROVIDER OR SPECIALIST UNTIL THE
17 CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM FOR WHICH THE
18 REFERRAL OR AUTHORIZATION WAS APPROVED HAS REACHED ITS
19 CONCLUSION.
20 (B) IF A HEALTH CARE PROVIDER PROVIDES CARE, TREATMENTS,
21 INTERVENTIONS, SERVICES OR ITEMS TO AN ENROLLEE, THE COVERAGE OF
22 WHICH IS REQUIRED UNDER SECTION 635.2 AND THE PROVIDER IS
23 ENROLLED IN THE COMMONWEALTH'S MEDICAL ASSISTANCE PROGRAM BUT IS
24 NOT A NETWORK PROVIDER WITH THE ENROLLEE'S PRIVATE INSURANCE
25 PLAN, THE PROVIDER SHALL BE REIMBURSED UNDER THE TERMS AND
26 CONDITIONS APPLICABLE TO THE PLAN'S PARTICIPATING PROVIDERS.
27 THIS REQUIREMENT SHALL NOT BE SUBJECT TO ANY TIME LIMITATION OR
28 TRANSITION PERIOD, BUT SHALL OTHERWISE BE IN ACCORD WITH ALL
29 TERMS APPLICABLE TO NONPARTICIPATING PROVIDERS UNDER THE MANAGED
30 CARE CONTINUITY OF CARE PROVISIONS THEN IN EFFECT.
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1 SECTION 2. SECTION 2121 OF THE ACT, ADDED JUNE 17, 1998
2 (P.L.464, NO.68), IS AMENDED TO READ:
3 SECTION 2121. PROCEDURES.--(A) A MANAGED CARE PLAN SHALL
4 ESTABLISH A CREDENTIALING PROCESS TO ENROLL QUALIFIED HEALTH
5 CARE PROVIDERS AND CREATE AN ADEQUATE PROVIDER NETWORK. THE
6 PROCESS SHALL BE APPROVED BY THE DEPARTMENT AND SHALL INCLUDE
7 WRITTEN CRITERIA AND PROCEDURES FOR INITIAL ENROLLMENT, RENEWAL,
8 RESTRICTIONS AND TERMINATION OF CREDENTIALS FOR HEALTH CARE
9 PROVIDERS.
10 (B) [THE] EXCEPT AS PROVIDED UNDER SUBSECTION (B.1), THE
11 DEPARTMENT SHALL ESTABLISH CREDENTIALING STANDARDS FOR MANAGED
12 CARE PLANS. THE DEPARTMENT MAY ADOPT NATIONALLY RECOGNIZED
13 ACCREDITING STANDARDS TO ESTABLISH THE CREDENTIALING STANDARDS
14 FOR MANAGED CARE PLANS.
15 (B.1) PURSUANT TO SECTION 635.2(G), THE DEPARTMENT OF PUBLIC
16 WELFARE SHALL ESTABLISH STANDARDS TO BE UTILIZED BY MANAGED CARE
17 PLANS FOR THE CREDENTIALING OF HEALTH CARE PROVIDERS PROVIDING
18 CARE, TREATMENTS, INTERVENTIONS, SERVICES OR ITEMS TO ENROLLEES
19 FOR AN AUTISM SPECTRUM DISORDER AS DEFINED UNDER SECTION 635.2.
20 IN ADDITION, THE DEPARTMENT MAY REQUIRE THAT A MANAGED CARE PLAN
21 GRANT CREDENTIALS TO ANY HEALTH CARE PROVIDER WHOM THE
22 DEPARTMENT OF PUBLIC WELFARE DETERMINES MEETS OR EXCEEDS THE
23 DEPARTMENT OF PUBLIC WELFARE'S CREDENTIALING STANDARDS.
24 (B.2) WITH RESPECT TO AUTISM SERVICE PROVIDERS, A MANAGED
25 CARE PLAN OR LICENSED INSURER SHALL INFORM CREDENTIALING
26 APPLICANTS OF A DECISION WITHIN NINETY DAYS AFTER THE COMPLETE
27 APPLICATION HAS BEEN SUBMITTED TO THE MANAGED CARE PLAN OR
28 INSURER. A MANAGED CARE PLAN OR INSURER SHALL NOT REQUIRE A
29 HEALTH CARE PROVIDER TO SUBMIT AN APPLICATION FOR CREDENTIALING
30 AS A RESULT OF A CHANGE OF EMPLOYERS IF THE PROVIDER'S NEW
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1 EMPLOYER IS IN THE MANAGED CARE PLAN'S SERVICE AREA OR NETWORK.
2 (C) A MANAGED CARE PLAN SHALL SUBMIT A REPORT TO THE
3 DEPARTMENT REGARDING ITS CREDENTIALING PROCESS AT LEAST EVERY
4 TWO (2) YEARS OR AS MAY OTHERWISE BE REQUIRED BY THE DEPARTMENT.
5 (D) A MANAGED CARE PLAN SHALL DISCLOSE RELEVANT
6 CREDENTIALING CRITERIA AND PROCEDURES TO HEALTH CARE PROVIDERS
7 THAT APPLY TO PARTICIPATE OR THAT ARE PARTICIPATING IN THE
8 PLAN'S PROVIDER NETWORK. A MANAGED CARE PLAN SHALL ALSO DISCLOSE
9 RELEVANT CREDENTIALING CRITERIA AND PROCEDURES PURSUANT TO A
10 COURT ORDER OR RULE. ANY INDIVIDUAL PROVIDING INFORMATION DURING
11 THE CREDENTIALING PROCESS OF A MANAGED CARE PLAN SHALL HAVE THE
12 PROTECTIONS SET FORTH IN THE ACT OF JULY 20, 1974 (P.L.564,
13 NO.193), KNOWN AS THE "PEER REVIEW PROTECTION ACT."
14 (E) NO MANAGED CARE PLAN SHALL EXCLUDE OR TERMINATE A HEALTH
15 CARE PROVIDER FROM PARTICIPATION IN THE PLAN DUE TO ANY OF THE
16 FOLLOWING:
17 (1) THE HEALTH CARE PROVIDER ENGAGED IN ANY OF THE
18 ACTIVITIES SET FORTH IN SECTION 2113(C).
19 (2) THE HEALTH CARE PROVIDER HAS A PRACTICE THAT INCLUDES A
20 SUBSTANTIAL NUMBER OF PATIENTS WITH EXPENSIVE MEDICAL
21 CONDITIONS.
22 (3) THE HEALTH CARE PROVIDER OBJECTS TO THE PROVISION OF OR
23 REFUSES TO PROVIDE A HEALTH CARE SERVICE ON MORAL OR RELIGIOUS
24 GROUNDS.
25 (F) IF A MANAGED CARE PLAN DENIES ENROLLMENT OR RENEWAL OF
26 CREDENTIALS TO A HEALTH CARE PROVIDER, THE MANAGED CARE PLAN
27 SHALL PROVIDE THE HEALTH CARE PROVIDER WITH WRITTEN NOTICE OF
28 THE DECISION. THE NOTICE SHALL INCLUDE A CLEAR RATIONALE FOR THE
29 DECISION.
30 SECTION 3. THIS ACT SHALL TAKE EFFECT IN 180 DAYS.
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