PRINTER'S NO. 1039
No. 877 Session of 2007
INTRODUCED BY EARLL, ERICKSON, SCARNATI, PILEGGI, BROWNE, CORMAN, COSTA, BOSCOLA, FOLMER, MUSTO, ORIE, RAFFERTY, REGOLA, ROBBINS, M. WHITE, DINNIMAN, WONDERLING, BAKER, MELLOW, WAUGH, MADIGAN, VANCE, D. WHITE AND PICCOLA, MAY 21, 2007
REFERRED TO PUBLIC HEALTH AND WELFARE, MAY 21, 2007
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," in public assistance, 4 adding definitions; and further providing for prepayment for 5 contracted medical services and for established drug 6 regimens. 7 The General Assembly of the Commonwealth of Pennsylvania 8 hereby enacts as follows: 9 Section 1. Section 402 of the act of June 13, 1967 (P.L.31, 10 No.21), known as the Public Welfare Code, is amended by adding 11 definitions to read: 12 Section 402. Definitions.--As used in this article, unless 13 the content clearly indicates otherwise: 14 * * * 15 "Behavioral health care services." Services provided to 16 recipients in inpatient or outpatient settings to diagnose, 17 treat or otherwise manage mental health or substance abuse 18 diagnoses and disorders.
1 * * * 2 "Managed care contractor." A managed care organization 3 providing managed care services relating to physical health care 4 to recipients under one or more contracts with the Department of 5 Public Welfare for the provision of mandatory managed care or 6 voluntary managed care. 7 "Managed care organization." A public or private 8 organization that is a federally qualified health maintenance 9 organization or meets the State plan's definition of a health 10 maintenance organization or otherwise qualifies as a managed 11 care plan as defined in Article XXI of the act of May 17, 1921 12 (P.L.682, No.284), known as "The Insurance Company Law of 1921." 13 "Mandatory managed care." The Commonwealth's HealthChoices 14 Program, which provides mandatory managed health care to 15 recipients in specified areas of this Commonwealth through 16 contracts with managed care organizations. 17 "Medicaid." The program authorized by Subchapter XIX of the 18 Social Security Act (49 Stat. 620, 42 U.S.C. § 1396 et seq.), 19 and subject to regulations promulgated under that act. 20 "Medical assistance." The Commonwealth program authorized by 21 Subchapter XIX of the Social Security Act (49 Stat. 620, 42 22 U.S.C. § 1396 et seq.), and authorized in this Commonwealth 23 under this act and subject to regulations promulgated under 24 Subchapter XIX of the Social Security Act and this act. The term 25 includes any successor program implemented by either the Federal 26 Government or the Commonwealth, to the extent a contractor 27 provides services with respect to the program. 28 * * * 29 "Physical health care services." Services provided to 30 recipients by contractors including, but not limited to, primary 20070S0877B1039 - 2 -
1 care, preventive health, specialty physician, outpatient, 2 inpatient and pharmacy services. The term does not include 3 behavioral health care services. 4 * * * 5 "Recipient." An individual eligible to receive health care 6 or health-related services under the medical assistance program. 7 * * * 8 "State plan." The document prepared by the Commonwealth in 9 the manner required by section 1396a(a) of the Social Security 10 Act (49 Stat. 620, 42 U.S.C. § 1396a(a)), as approved by the 11 Centers for Medicare and Medicaid Services, that describes the 12 nature, scope and operation of the medical assistance program 13 and gives assurances that the Commonwealth will administer the 14 program in compliance with Federal requirements. The term shall 15 include waivers granted by the Centers for Medicare and Medicaid 16 Services not otherwise included in the plan submitted by the 17 Commonwealth for Centers for Medicare and Medicaid Services 18 approval. 19 * * * 20 "Voluntary managed care." The Commonwealth's program, which 21 provides voluntary managed care to recipients in specified areas 22 of the Commonwealth through contracts with managed care 23 organizations. 24 "Waiver." A determination made by the Centers for Medicare 25 and Medicaid Services under Subchapter XIX of the Social 26 Security Act (49 Stat. 620, 42 U.S.C. § 1396 et seq.), and 27 regulations promulgated under that act, which allows the 28 Commonwealth to make modifications in its operation of the 29 medical assistance program. 30 * * * 20070S0877B1039 - 3 -
1 Section 2. Section 443.5 of the act, added July 15, 1976 2 (P.L.993, No.202), is amended to read: 3 Section 443.5. Prepayment for Contracted Medical Services.-- 4 (a) For categorically needy or medically needy persons eligible 5 for medical assistance, prepaid capitation payments or insurance 6 premiums for services under the medical assistance State plan 7 may be made on behalf of eligible persons through competitive 8 bidding with profit or non-profit contractors, insurers, or 9 health maintenance organizations. Profit and non-profit insurers 10 must be approved under applicable State laws. Prepaid capitation 11 or premium payments made under such contracts shall not exceed 12 payments made to other third party payers for comparable 13 services and similar benefit conditions. Capitation payments 14 charged for anticipated medical assistance eligible persons 15 under a contract may be prepaid by the Commonwealth subject to 16 monthly, quarterly, and annual adjustment by the department 17 based on actual enrollment and fixed capitation rates. 18 (b) The department shall administer a program of mandatory 19 managed care for physical health care services in this 20 Commonwealth in geographic areas that include: 21 (1) The Southeast. 22 (2) The Southwest. 23 (3) The Lehigh and Capital areas. 24 (c) (1) The department shall also administer a program of 25 voluntary managed care for recipients residing outside the 26 geographic areas described in subsection (b). The department 27 shall contract with no more than five managed care 28 organizations to serve each county covered by the voluntary 29 managed care program if managed care contractors are willing 30 to participate and meet departmental criteria. 20070S0877B1039 - 4 -
1 (2) Managed care contractors participating in the 2 voluntary managed care program shall provide substantially 3 the same physical health care benefits as are made available 4 to recipients under the mandatory managed care program. 5 (3) The department shall allow recipients to voluntarily 6 participate in a managed care plan and notify the recipients 7 of their choices among contractors or fee-for-service 8 Medicaid. 9 (d) The delivery of medical assistance services through a 10 system of mandatory managed care or voluntary managed care as 11 provided in subsections (b) and (c) shall be maintained by the 12 department, unless termination of either of these programs of 13 services is approved by the General Assembly. 14 (e) The chairman and minority chairman of the Public Health 15 and Welfare Committee of the Senate and the chairman and 16 minority chairman of the Health and Human Services Committee of 17 the House of Representatives shall be notified and provided a 18 copy of any State plan amendment and any waiver request along 19 with any supporting documents, no later than forty-eight hours 20 prior to submission of the Commonwealth's State plan amendment 21 or waiver request to the Centers for Medicare and Medicaid 22 Services. 23 Section 3. Section 459 of the act, added July 7, 2005 24 (P.L.177, No.42), is amended to read: 25 Section 459. Established Drug Regimens.--(a) When 26 determining prior authorization criteria for a preferred drug 27 class, the department shall consider the potential destabilizing 28 effect on the recipient's health by any change in the 29 recipient's established drug regimen, including, but not limited 30 to, prescription drugs for human immunodeficiency virus (HIV), 20070S0877B1039 - 5 -
1 acquired immune deficiency syndrome (AIDS), behavioral health, 2 hemophilia, hepatitis C, biologic drugs, immunosuppressants and 3 anticonvulsants. 4 (b) The department shall consider pharmaceutical services a 5 covered benefit under both mandatory managed care and voluntary 6 managed care which shall be provided and continued under 7 contracts with managed care contractors. 8 Section 4. This act shall take effect immediately. E21L67BIL/20070S0877B1039 - 6 -