HOUSE AMENDED PRIOR PRINTER'S NOS. 1488, 1491, 1510, PRINTER'S NO. 1827 1621
No. 1137 Session of 2007
INTRODUCED BY D. WHITE, RAFFERTY, PILEGGI, ORIE, SCARNATI, ROBBINS, ERICKSON, GORDNER, C. WILLIAMS, FONTANA, MADIGAN, ARMSTRONG, PIPPY, FERLO, WONDERLING, WAUGH, BAKER, REGOLA, BROWNE AND BOSCOLA, OCTOBER 23, 2007
AS AMENDED ON SECOND CONSIDERATION, HOUSE OF REPRESENTATIVES, MARCH 12, 2008
AN ACT 1 Amending the act of March 20, 2002 (P.L.154, No.13), entitled 2 "An act reforming the law on medical professional liability; 3 providing for patient safety and reporting; establishing the 4 Patient Safety Authority and the Patient Safety Trust Fund; 5 abrogating regulations; providing for medical professional 6 liability informed consent, damages, expert qualifications, 7 limitations of actions and medical records; establishing the 8 Interbranch Commission on Venue; providing for medical 9 professional liability insurance; establishing the Medical 10 Care Availability and Reduction of Error Fund; providing for 11 medical professional liability claims; establishing the Joint 12 Underwriting Association; regulating medical professional 13 liability insurance; providing for medical licensure 14 regulation; providing for administration; imposing penalties; 15 and making repeals," further providing for medical <-- 16 professional liability insurance, for the Medical Care 17 Availability and Reduction of Error Fund and for actuarial 18 data; providing for the Medical Care Availability and <-- 19 Reduction of Error (Mcare) FOR PENNSYLVANIANS (MCAP) Reserve <-- 20 Fund; and further providing for abatement program, for the <-- 21 Health Care Provider Retention Account and for expiration; <-- 22 AND PROVIDING FOR EXPIRATION OF CERTAIN SECTIONS. FURTHER <-- 23 PROVIDING FOR MEDICAL PROFESSIONAL LIABILITY INSURANCE, FOR 24 THE MEDICAL CARE AVAILABILITY AND REDUCTION OF ERROR FUND AND 25 FOR ACTUARIAL DATA; ESTABLISHING THE PENNSYLVANIA ACCESS TO 26 BASIC CARE (PA ABC) PROGRAM FUND AND THE CONTINUING ACCESS 27 WITH RELIEF FOR EMPLOYERS (CARE) FUND; FURTHER DEFINING 28 "HEALTH CARE PROVIDER"; FURTHER PROVIDING FOR THE HEALTH CARE 29 PROVIDER RETENTION PROGRAM; ESTABLISHING THE SUPPLEMENTAL
1 ASSISTANCE AND FUNDING ACCOUNT; FURTHER PROVIDING FOR 2 EXPIRATION OF THE HEALTH CARE PROVIDER RETENTION PROGRAM; 3 ESTABLISHING THE PENNSYLVANIA ACCESS TO BASIC CARE (PA ABC) 4 PROGRAM; PROVIDING FOR CONTINUING ACCESS WITH RELIEF FOR 5 EMPLOYERS (CARE) GRANTS, FOR HEALTH CARE COVERAGE FOR CERTAIN 6 ADULTS, INDIVIDUALS, EMPLOYEES AND EMPLOYERS AND FOR 7 EXPIRATION OF CERTAIN SECTIONS; AND REPEALING PROVISIONS OF 8 THE TOBACCO SETTLEMENT ACT. 9 The General Assembly of the Commonwealth of Pennsylvania 10 hereby enacts as follows: 11 Section 1. Sections 711, 712 and 745 of the act of March 20, <-- 12 2002 (P.L.154, No.13), known as the Medical Care Availability 13 and Reduction of Error (Mcare) Act, are amended to read: 14 Section 711. Medical professional liability insurance. 15 (a) Requirement.--A health care provider providing health 16 care services in this Commonwealth shall: 17 (1) purchase medical professional liability insurance 18 from an insurer which is licensed or approved by the 19 department; or 20 (2) provide self-insurance. 21 (b) Proof of insurance.--A health care provider required by 22 subsection (a) to purchase medical professional liability 23 insurance or provide self-insurance shall submit proof of 24 insurance or self-insurance to the department within 60 days of 25 the policy being issued. 26 (c) Failure to provide proof of insurance.--If a health care 27 provider fails to submit the proof of insurance or self- 28 insurance required by subsection (b), the department shall, 29 after providing the health care provider with notice, notify the 30 health care provider's licensing authority. A health care 31 provider's license shall be suspended or revoked by its 32 licensure board or agency if the health care provider fails to 33 comply with any of the provisions of this chapter. 20070S1137B1827 - 2 -
1 (d) Basic coverage limits.--A health care provider shall 2 insure or self-insure medical professional liability in 3 accordance with the following: 4 (1) For policies issued or renewed in the calendar year 5 2002, the basic insurance coverage shall be: 6 (i) $500,000 per occurrence or claim and $1,500,000 7 per annual aggregate for a health care provider who 8 conducts more than 50% of its health care business or 9 practice within this Commonwealth and that is not a 10 hospital. 11 (ii) $500,000 per occurrence or claim and $1,500,000 12 per annual aggregate for a health care provider who 13 conducts 50% or less of its health care business or 14 practice within this Commonwealth. 15 (iii) $500,000 per occurrence or claim and 16 $2,500,000 per annual aggregate for a hospital. 17 (2) For policies issued or renewed in the calendar years 18 2003, 2004 and 2005, the basic insurance coverage shall be: 19 (i) $500,000 per occurrence or claim and $1,500,000 20 per annual aggregate for a participating health care 21 provider that is not a hospital. 22 (ii) $1,000,000 per occurrence or claim and 23 $3,000,000 per annual aggregate for a nonparticipating 24 health care provider. 25 (iii) $500,000 per occurrence or claim and 26 $2,500,000 per annual aggregate for a hospital. 27 (3) Unless the commissioner finds pursuant to section 28 745(a) that additional basic insurance coverage capacity is 29 not available, for policies issued or renewed in calendar 30 year 2006 and each year thereafter subject to paragraph (4), 20070S1137B1827 - 3 -
1 the basic insurance coverage shall be: 2 (i) Up to $750,000 per occurrence or claim and 3 $2,250,000 per annual aggregate for a participating 4 health care provider that is not a hospital. 5 (ii) Up to $1,000,000 per occurrence or claim and 6 $3,000,000 per annual aggregate for a nonparticipating 7 health care provider. 8 (iii) Up to $750,000 per occurrence or claim and 9 $3,750,000 per annual aggregate for a hospital. 10 If the commissioner finds pursuant to section 745(a) that 11 additional basic insurance coverage capacity is not 12 available, the basic insurance coverage requirements shall 13 remain at the level required by paragraph (2); and the 14 commissioner shall conduct a study every [two years] year 15 until the commissioner finds that additional basic insurance 16 coverage capacity is available, at which time the 17 commissioner shall increase the required basic insurance 18 coverage in accordance with this paragraph. 19 (4) Unless the commissioner finds pursuant to section 20 745(b) that additional basic insurance coverage capacity is 21 not available, for policies issued or renewed [three] two 22 years after the increase in coverage limits required by 23 paragraph (3) and for each year thereafter, the basic 24 insurance coverage shall be: 25 (i) Up to $1,000,000 per occurrence or claim and 26 $3,000,000 per annual aggregate for a participating 27 health care provider that is not a hospital. 28 (ii) Up to $1,000,000 per occurrence or claim and 29 $3,000,000 per annual aggregate for a nonparticipating 30 health care provider. 20070S1137B1827 - 4 -
1 (iii) Up to $1,000,000 per occurrence or claim and 2 $4,500,000 per annual aggregate for a hospital. 3 If the commissioner finds pursuant to section 745(b) that 4 additional basic insurance coverage capacity is not 5 available, the basic insurance coverage requirements shall 6 remain at the level required by paragraph (3); and the 7 commissioner shall conduct a study every [two years] year 8 until the commissioner finds that additional basic insurance 9 coverage capacity is available, at which time the 10 commissioner shall increase the required basic insurance 11 coverage in accordance with this paragraph. 12 (5) The amount of basic insurance coverage per 13 occurrence or claim under paragraphs (3) and (4) shall be no 14 less than $500,000 and shall be set in $50,000 increments. 15 (6) In no event shall the total coverage for basic 16 primary insurance and the fund, per occurrence or claim, be 17 less than $1,000,000 or less than $3,000,000 per annual 18 aggregate for a participating or nonparticipating health care 19 provider, except hospitals which have total coverage limits 20 of not less than $1,000,000 per occurrence or less than 21 $4,500,000 per annual aggregate. 22 (e) Fund participation.--A participating health care 23 provider shall be required to participate in the fund. 24 (f) Self-insurance.-- 25 (1) If a health care provider self-insures its medical 26 professional liability, the health care provider shall submit 27 its self-insurance plan, such additional information as the 28 department may require and the examination fee to the 29 department for approval. 30 (2) The department shall approve the plan if it 20070S1137B1827 - 5 -
1 determines that the plan constitutes protection equivalent to 2 the insurance required of a health care provider under 3 subsection (d). 4 (g) Basic insurance liability.-- 5 (1) An insurer providing medical professional liability 6 insurance shall not be liable for payment of a claim against 7 a health care provider for any loss or damages awarded in a 8 medical professional liability action in excess of the basic 9 insurance coverage required by subsection (d) unless the 10 health care provider's medical professional liability 11 insurance policy or self-insurance plan provides for a higher 12 limit. 13 (2) If a claim exceeds the limits of a participating 14 health care provider's basic insurance coverage or self- 15 insurance plan, the fund shall be responsible for payment of 16 the claim against the participating health care provider up 17 to the fund liability limits. 18 (h) Excess insurance.-- 19 (1) No insurer providing medical professional liability 20 insurance with liability limits in excess of the fund's 21 liability limits to a participating health care provider 22 shall be liable for payment of a claim against the 23 participating health care provider for a loss or damages in a 24 medical professional liability action except the losses and 25 damages in excess of the fund coverage limits. 26 (2) No insurer providing medical professional liability 27 insurance with liability limits in excess of the fund's 28 liability limits to a participating health care provider 29 shall be liable for any loss resulting from the insolvency or 30 dissolution of the fund. 20070S1137B1827 - 6 -
1 (i) Governmental entities.--A governmental entity may 2 satisfy its obligations under this chapter, as well as the 3 obligations of its employees to the extent of their employment, 4 by either purchasing medical professional liability insurance or 5 assuming an obligation as a self-insurer, and paying the 6 assessments under this chapter. 7 (j) Exemptions.--The following participating health care 8 providers shall be exempt from this chapter: 9 (1) A physician who exclusively practices the specialty 10 of forensic pathology. 11 (2) A participating health care provider who is a member 12 of the Pennsylvania military forces while in the performance 13 of the member's assigned duty in the Pennsylvania military 14 forces under orders. 15 (3) A retired licensed participating health care 16 provider who provides care only to the provider or the 17 provider's immediate family members. 18 Section 712. Medical Care Availability and Reduction of Error 19 Fund. 20 (a) Establishment.--There is hereby established within the 21 State Treasury a special fund to be known as the Medical Care 22 Availability and Reduction of Error Fund. Money in the fund 23 shall be used to pay claims against participating health care 24 providers for losses or damages awarded in medical professional 25 liability actions against them in excess of the basic insurance 26 coverage required by section 711(d), liabilities transferred in 27 accordance with subsection (b) and for the administration of the 28 fund. 29 (b) Transfer of assets and liabilities.-- 30 (1) (i) The money in the Medical Professional Liability 20070S1137B1827 - 7 -
1 Catastrophe Loss Fund established under section 701(d) of 2 the former act of October 15, 1975 (P.L.390, No.111), 3 known as the Health Care Services Malpractice Act, is 4 transferred to the fund. 5 (ii) The rights of the Medical Professional 6 Liability Catastrophe Loss Fund established under section 7 701(d) of the former Health Care Services Malpractice Act 8 are transferred to and assumed by the fund. 9 (2) The liabilities and obligations of the Medical 10 Professional Liability Catastrophe Loss Fund established 11 under section 701(d) of the former Health Care Services 12 Malpractice Act are transferred to and assumed by the fund. 13 (c) Fund liability limits.-- 14 (1) For calendar year 2002, the limit of liability of 15 the fund created in section 701(d) of the former Health Care 16 Services Malpractice Act for each health care provider that 17 conducts more than 50% of its health care business or 18 practice within this Commonwealth and for each hospital shall 19 be $700,000 for each occurrence and $2,100,000 per annual 20 aggregate. 21 (2) The limit of liability of the fund for each 22 participating health care provider shall be as follows: 23 (i) For calendar year 2003 and each year thereafter, 24 the limit of liability of the fund shall be $500,000 for 25 each occurrence and $1,500,000 per annual aggregate. 26 (ii) If the basic insurance coverage requirement is 27 increased in accordance with section 711(d)(3) or (4) 28 and, notwithstanding subparagraph (i), for each calendar 29 year following the increase in the basic insurance 30 coverage requirement, the limit of liability of the fund 20070S1137B1827 - 8 -
1 shall be [$250,000 for each occurrence and $750,000 per 2 annual aggregate. 3 (iii) If the basic insurance coverage requirement is 4 increased in accordance with section 711(d)(4) and, 5 notwithstanding subparagraphs (i) and (ii), for each 6 calendar year following the increase in the basic 7 insurance coverage requirement, the limit of liability of 8 the fund shall be zero] $1,000,000 per occurrence and 9 $3,000,000 per annual aggregate, except hospitals which 10 shall be $1,000,000 per occurrence and $4,500,000 per 11 annual aggregate, minus the amount the commissioner 12 determines for basic insurance coverage under section 13 711(d)(3) and (4). 14 (d) Assessments.-- 15 (1) For calendar year 2003 and for each year thereafter, 16 the fund shall be funded by an assessment on each 17 participating health care provider. Assessments shall be 18 levied by the department on or after January 1 of each year. 19 The assessment shall be based on the prevailing primary 20 premium for each participating health care provider and 21 shall, in the aggregate, produce an amount sufficient to do 22 all of the following: 23 (i) Reimburse the fund for the payment of reported 24 claims which became final during the preceding claims 25 period. 26 (ii) Pay expenses of the fund incurred during the 27 preceding claims period. 28 (iii) Pay principal and interest on moneys 29 transferred into the fund in accordance with section 30 713(c). 20070S1137B1827 - 9 -
1 (iv) Provide a reserve that shall be 10% of the sum 2 of subparagraphs (i), (ii) and (iii). 3 (2) The department shall notify all basic insurance 4 coverage insurers and self-insured participating health care 5 providers of the assessment by November 1 for the succeeding 6 calendar year. Beginning January 1, 2008, the department 7 shall bill and collect the assessment from all participating 8 health care providers. 9 (3) Any appeal of the assessment shall be filed with the 10 department. 11 (4) FOR CALENDAR YEAR BEGINNING JANUARY 1, 2008, THE <-- 12 DEPARTMENT MAY DELAY OR SUSPEND THE COLLECTION OF ASSESSMENTS 13 UNTIL THE REQUIREMENTS UNDER SECTION 752(B) ARE MET. 14 (e) Discount on surcharges and assessments.-- 15 (1) For calendar year 2002, the department shall 16 discount the aggregate surcharge imposed under section 17 701(e)(1) of the Health Care Services Malpractice Act by 5% 18 of the aggregate surcharge imposed under that section for 19 calendar year 2001 in accordance with the following: 20 (i) Fifty percent of the aggregate discount shall be 21 granted equally to hospitals and to participating health 22 care providers that were surcharged as members of one of 23 the four highest rate classes of the prevailing primary 24 premium. 25 (ii) Notwithstanding subparagraph (i), 50% of the 26 aggregate discount shall be granted equally to all 27 participating health care providers. 28 (iii) The department shall issue a credit to a 29 participating health care provider who, prior to the 30 effective date of this section, has paid the surcharge 20070S1137B1827 - 10 -
1 imposed under section 701(e)(1) of the former Health Care 2 Services Malpractice Act for calendar year 2002 prior to 3 the effective date of this section. 4 (2) For calendar years 2003 and 2004, the department 5 shall discount the aggregate assessment imposed under 6 subsection (d) for each calendar year by 10% of the aggregate 7 surcharge imposed under section 701(e)(1) of the former 8 Health Care Services Malpractice Act for calendar year 2001 9 in accordance with the following: 10 (i) Fifty percent of the aggregate discount shall be 11 granted equally to hospitals and to participating health 12 care providers that were assessed as members of one of 13 the four highest rate classes of the prevailing primary 14 premium. 15 (ii) Notwithstanding subparagraph (i), 50% of the 16 aggregate discount shall be granted equally to all 17 participating health care providers. 18 (3) For calendar years 2005 and thereafter, if the basic 19 insurance coverage requirement is increased in accordance 20 with section 711(d)(3) or (4), the department may discount 21 the aggregate assessment imposed under subsection (d) by an 22 amount not to exceed the aggregate sum to be deposited in the 23 fund in accordance with subsection (m). 24 (f) Updated rates.--The joint underwriting association shall 25 file updated rates for all health care providers with the 26 commissioner by May 1 of each year. The department shall review 27 and may adjust the prevailing primary premium in line with any 28 applicable changes which have been approved by the commissioner. 29 (g) Additional adjustments of the prevailing primary 30 premium.--The department shall adjust the applicable prevailing 20070S1137B1827 - 11 -
1 primary premium of each participating health care provider in 2 accordance with the following: 3 (1) The applicable prevailing primary premium of a 4 participating health care provider which is not a hospital 5 may be adjusted through an increase in the individual 6 participating health care provider's prevailing primary 7 premium not to exceed 20%. Any adjustment shall be based upon 8 the frequency of claims paid by the fund on behalf of the 9 individual participating health care provider during the past 10 five most recent claims periods and shall be in accordance 11 with the following: 12 (i) If three claims have been paid during the past 13 five most recent claims periods by the fund, a 10% 14 increase shall be charged. 15 (ii) If four or more claims have been paid during 16 the past five most recent claims periods by the fund, a 17 20% increase shall be charged. 18 (2) The applicable prevailing primary premium of a 19 participating health care provider which is not a hospital 20 and which has not had an adjustment under paragraph (1) may 21 be adjusted through an increase in the individual 22 participating health care provider's prevailing primary 23 premium not to exceed 20%. Any adjustment shall be based upon 24 the severity of at least two claims paid by the fund on 25 behalf of the individual participating health care provider 26 during the past five most recent claims periods. 27 (3) The applicable prevailing primary premium of a 28 participating health care provider not engaged in direct 29 clinical practice on a full-time basis may be adjusted 30 through a decrease in the individual participating health 20070S1137B1827 - 12 -
1 care provider's prevailing primary premium not to exceed 10%. 2 Any adjustment shall be based upon the lower risk associated 3 with the less-than-full-time direct clinical practice. 4 (4) The applicable prevailing primary premium of a 5 hospital may be adjusted through an increase or decrease in 6 the individual hospital's prevailing primary premium not to 7 exceed 20%. Any adjustment shall be based upon the frequency 8 and severity of claims paid by the fund on behalf of other 9 hospitals of similar class, size, risk and kind within the 10 same defined region during the past five most recent claims 11 periods. 12 (h) Self-insured health care providers.--A participating 13 health care provider that has an approved self-insurance plan 14 shall be assessed an amount equal to the assessment imposed on a 15 participating health care provider of like class, size, risk and 16 kind as determined by the department. 17 (i) Change in basic insurance coverage.--If a participating 18 health care provider changes the term of its medical 19 professional liability insurance coverage, the assessment shall 20 be calculated on an annual basis and shall reflect the 21 assessment percentages in effect for the period over which the 22 policies are in effect. 23 (j) Payment of claims.--Claims which became final during the 24 preceding claims period shall be paid on or before December 31 25 following the August 31 on which they became final. 26 (k) Termination.--Upon satisfaction of all liabilities of 27 the fund, the fund shall terminate. Any balance remaining in the 28 fund upon such termination shall be returned by the department 29 to the participating health care providers who participated in 30 the fund in proportion to their assessments in the preceding 20070S1137B1827 - 13 -
1 calendar year. 2 (l) Sole and exclusive source of funding.--Except as 3 provided in subsection (m), the surcharges imposed under section 4 701(e)(1) of the Health Care Services Malpractice Act and 5 assessments on participating health care providers and any 6 income realized by investment or reinvestment shall constitute 7 the sole and exclusive sources of funding for the fund. Nothing 8 in this subsection shall prohibit the fund from accepting 9 contributions from nongovernmental sources. A claim against or a 10 liability of the fund shall not be deemed to constitute a debt 11 or liability of the Commonwealth or a charge against the General 12 Fund. 13 (m) Supplemental funding.--Notwithstanding the provisions of 14 75 Pa.C.S. § 6506(b) (relating to surcharge) to the contrary, 15 beginning January 1, 2004, and for a period of nine calendar 16 years thereafter, all surcharges levied and collected under 75 17 Pa.C.S. § 6506(a) by any division of the unified judicial system 18 shall be remitted to the Commonwealth for deposit in the Medical 19 Care Availability and Restriction of Error Fund. These funds 20 shall be used to reduce surcharges and assessments in accordance 21 with subsection (e). Beginning January 1, 2014, and each year 22 thereafter, the surcharges levied and collected under 75 Pa.C.S. 23 § 6506(a) shall be deposited into the General Fund. 24 (n) Waiver of right to consent to settlement.--A 25 participating health care provider may maintain the right to 26 consent to a settlement in a basic insurance coverage policy for 27 medical professional liability insurance upon the payment of an 28 additional premium amount. 29 Section 745. Actuarial data. 30 (a) Initial study.--The following shall apply: 20070S1137B1827 - 14 -
1 (1) No later than April 1, 2005, each insurer providing 2 medical professional liability insurance in this Commonwealth 3 shall file loss data as required by the commissioner. For 4 failure to comply, the commissioner shall impose an 5 administrative penalty of $1,000 for every day that this data 6 is not provided in accordance with this paragraph. 7 (2) By July 1, 2005, the commissioner shall conduct a 8 study regarding the availability of additional basic 9 insurance coverage capacity. The study shall include an 10 estimate of the total change in medical professional 11 liability insurance loss-cost resulting from implementation 12 of this act prepared by an independent actuary. The fee for 13 the independent actuary shall be borne by the fund. In 14 developing the estimate, the independent actuary shall 15 consider all of the following: 16 (i) The most recent accident year and ratemaking 17 data available. 18 (ii) Any other relevant factors within or outside 19 this Commonwealth in accordance with sound actuarial 20 principles. 21 (b) Additional study.--The following shall apply: 22 (1) Three years following the increase of the basic 23 insurance coverage requirement in accordance with section 24 711(d)(3), each insurer providing medical professional 25 liability insurance in this Commonwealth shall file loss data 26 with the commissioner upon request. For failure to comply, 27 the commissioner shall impose an administrative penalty of 28 $1,000 for every day that this data is not provided in 29 accordance with this paragraph. 30 (2) Three months following the request made under 20070S1137B1827 - 15 -
1 paragraph (1), the commissioner shall conduct a study 2 regarding the availability of additional basic insurance 3 coverage capacity. The study shall include an estimate of the 4 total change in medical professional liability insurance 5 loss-cost resulting from implementation of this act prepared 6 by an independent actuary. The fee for the independent 7 actuary shall be borne by the fund. In developing the 8 estimate, the independent actuary shall consider all of the 9 following: 10 (i) The most recent accident year and ratemaking 11 data available. 12 (ii) Any other relevant factors including economic 13 considerations within or outside this Commonwealth in 14 accordance with sound actuarial principles. 15 Section 2. Chapter 7 of the act is amended by adding 16 subchapters A SUBCHAPTER to read: <-- 17 SUBCHAPTER E <-- 18 MEDICAL CARE AVAILABILITY AND REDUCTION OF ERROR 19 (MCARE) RESERVE FUND 20 Section 751. Establishment. 21 There is established within the State Treasury a special fund 22 to be known as the Medical Care Availability and Reduction of 23 Error (Mcare) Reserve Fund. 24 Section 752. Allocation. 25 Money in the Medical Care Availability and Reduction of Error 26 (Mcare) Reserve Fund shall be allocated annually as follows: 27 (1) Fifty percent of the total amount in the Medical 28 Care Availability and Reduction of Error (Mcare) Reserve Fund 29 shall remain in the Medical Care Availability and Reduction 30 of Error (Mcare) Reserve Fund for the sole purpose of 20070S1137B1827 - 16 -
1 reducing the unfunded liability of the fund. 2 (2) Twenty-five percent of the total amount in the 3 Medical Care Availability and Reduction of Error (Mcare) 4 Reserve Fund shall be transferred to the Patient Safety Trust 5 Fund for use by the Department of Public Welfare for 6 implementing section 407. 7 (3) Twenty-five percent of the total amount in the 8 Medical Care Availability and Reduction of Error (Mcare) 9 Reserve Fund shall be transferred to the Medical Safety 10 Automation Fund. 11 SUBCHAPTER F 12 MEDICAL SAFETY AUTOMATION FUND 13 Section 762. Medical Safety Automation Fund established. 14 There is established within the State Treasury a special fund 15 to be known as the Medical Safety Automation Fund. No money in 16 the Medical Safety Automation Fund shall be used until 17 legislation is enacted for the purpose of providing medical 18 safety automation system grants to health care providers under 19 the act of July 19, 1979 (P.L.130, No.48), known as the Health 20 Care Facilities Act, a group practice or a community-based 21 health care provider. 22 SUBCHAPTER E <-- 23 MEDICAL CARE AVAILABILITY FOR PENNSYLVANIANS 24 (MCAP) RESERVE FUND 25 SECTION 751. ESTABLISHMENT. 26 THERE IS ESTABLISHED WITHIN THE STATE TREASURY A SPECIAL FUND 27 TO BE KNOWN AS THE MEDICAL CARE AVAILABILITY FOR PENNSYLVANIANS 28 (MCAP) RESERVE FUND. 29 SECTION 752. ALLOCATION. 30 (A) ANNUAL ALLOCATION.--MONEY IN THE MEDICAL CARE 20070S1137B1827 - 17 -
1 AVAILABILITY FOR PENNSYLVANIANS (MCAP) RESERVE FUND SHALL BE 2 ALLOCATED ANNUALLY AS FOLLOWS: 3 (1) FIFTY PERCENT OF THE TOTAL AMOUNT IN THE MEDICAL 4 CARE AVAILABILITY FOR PENNSYLVANIANS (MCAP) RESERVE FUND 5 SHALL REMAIN IN THE MEDICAL CARE AVAILABILITY FOR 6 PENNSYLVANIANS (MCAP) RESERVE FUND FOR THE SOLE PURPOSE OF 7 REDUCING THE UNFUNDED LIABILITY OF THE FUND. 8 (2) FIFTY PERCENT OF THE TOTAL AMOUNT IN THE MEDICAL 9 CARE AVAILABILITY FOR PENNSYLVANIANS (MCAP) RESERVE FUND 10 SHALL BE DEDICATED TO FUNDING THE PROGRAM ESTABLISHED UNDER 11 SUBSECTION (B). 12 (B) ENACTMENT OF LEGISLATION.--NO MONEY IN THE MEDICAL CARE 13 AVAILABILITY FOR PENNSYLVANIANS (MCAP) RESERVE FUND SHALL BE 14 USED UNTIL LEGISLATION IS ENACTED THAT PROVIDES BOTH ASSISTANCE 15 TO CERTAIN SMALL BUSINESS EMPLOYERS IN COVERING THEIR LOW WAGE 16 UNINSURED AND ACCESS TO AFFORDABLE HEALTH INSURANCE COVERAGE FOR 17 UNINSURED LOW-INCOME ADULT PENNSYLVANIANS. 18 Section 3. Section 1102 of the act, amended October 27, 2006 19 (P.L.1198, No.128), is amended to read: 20 Section 1102. Abatement program. 21 (a) Establishment.--There is hereby established within the 22 Insurance Department a program to be known as the Health Care 23 Provider Retention Program. The Insurance Department, in 24 conjunction with the Department of Public Welfare, shall 25 administer the program. The program shall provide assistance in 26 the form of assessment abatements to health care providers for 27 calendar years 2003, 2004, 2005, 2006 [and], 2007 and 2008 AND <-- 28 2007, except that licensed podiatrists shall not be eligible for 29 calendar years 2003 and 2004, and nursing homes shall not be 30 eligible for calendar years 2003, 2004 and 2005. 20070S1137B1827 - 18 -
1 (b) Other [abatement.--] abatements.-- 2 (1) Emergency physicians not employed full time by a 3 trauma center or working under an exclusive contract with a 4 trauma center shall retain eligibility for an abatement 5 pursuant to section 1104(b)(2) for calendar years 2003, 2004, 6 2005 and 2006. Commencing in calendar year 2007, these 7 emergency physicians shall be eligible for an abatement 8 pursuant to section 1104(b)(1). 9 (2) Birth centers shall retain eligibility for abatement 10 pursuant to section 1104(b)(2) for calendar years 2003, 2004, 11 2005, 2006 and 2007. Commencing in calendar year 2008, birth 12 centers shall be eligible for an abatement pursuant to 13 section 1104(b)(1). 14 Section 4. Section 1112 of the act, added December 22, 2005 15 (P.L.458, No.88), is amended to read: 16 Section 1112. Health Care Provider Retention Account. 17 (a) Fund established.--There is established within the 18 General Fund a special account to be known as the Health Care 19 Provider Retention Account. Funds in the account shall be 20 subject to an annual appropriation by the General Assembly to 21 the Department of Public Welfare. The Department of Public 22 Welfare shall administer funds appropriated under this section 23 consistent with its duties under section 201(1) of the act of 24 June 13, 1967 (P.L.31, No.21), known as the Public Welfare Code. 25 (b) Transfers from Mcare Fund.--By December 31 of each year, 26 the Secretary of the Budget may transfer from the Medical Care 27 Availability and Reduction of Error (Mcare) Fund established in 28 section 712(a) to the account an amount equal to the difference 29 between the amount deposited under section 712(m) and the amount 30 granted as discounts under section 712(e)(2) for that calendar 20070S1137B1827 - 19 -
1 year. 2 (c) Transfers from account.--The Secretary of the Budget may 3 annually transfer from the account to the Medical Care 4 Availability and Reduction of Error (MCARE) Fund an amount up to 5 the aggregate amount of abatements granted by the Insurance 6 Department under section 1104(b). 7 (c.1) Transfers to the Medical Care Availability and <-- 8 Reduction of Error (Mcare) Reserve Fund.--If the Secretary of 9 the Budget makes a transfer from the account under subsection 10 (c), the remaining funds in the account shall be transferred to 11 the Medical Care Availability and Reduction of Error (Mcare) 12 Reserve Fund. If the Secretary of the Budget does not make a 13 transfer from the account under subsection (c), all of the funds 14 in the account shall be transferred to the Medical Care 15 Availability and Reduction of Error (Mcare) Reserve Fund. 16 (C.1) TRANSFERS TO THE MEDICAL CARE AVAILABILITY FOR <-- 17 PENNSYLVANIANS (MCAP) RESERVE FUND.--IF THE SECRETARY OF THE 18 BUDGET MAKES A TRANSFER FROM THE ACCOUNT UNDER SUBSECTION (C), 19 THE REMAINING FUNDS IN THE ACCOUNT SHALL BE TRANSFERRED TO THE 20 MEDICAL CARE AVAILABILITY FOR PENNSYLVANIANS (MCAP) RESERVE 21 FUND. IF THE SECRETARY OF THE BUDGET DOES NOT MAKE A TRANSFER 22 FROM THE ACCOUNT UNDER SUBSECTION (C), ALL OF THE FUNDS IN THE 23 ACCOUNT SHALL BE TRANSFERRED TO THE MEDICAL CARE AVAILABILITY 24 FOR PENNSYLVANIANS (MCAP) RESERVE FUND. 25 (d) Other deposits.--The Department of Public Welfare may 26 deposit any other funds received by the department which it 27 deems appropriate in the account. 28 (e) Administration assistance.--The Insurance Department 29 shall provide assistance to the Department of Public Welfare in 30 administering the account. 20070S1137B1827 - 20 -
1 Section 5. Section 1115 of the act, amended October 27, 2006 2 (P.L.1198, No.128), is amended to read: 3 Section 1115. Expiration. 4 The Health Care Provider Retention Program established under 5 this chapter shall expire December 31, [2008] 2009 2011. <-- 6 Section 6. Section 5106 of the act is amended to read: 7 Section 5106. Expiration. 8 Section 312 shall expire on December 31, [2007] 2008. 9 SECTION 7. IF THE REQUIREMENTS OF SECTION 752(B) OF THE ACT <-- 10 ARE NOT SATISFIED WITHIN 90 DAYS AFTER ENACTMENT, SECTIONS 711, 11 712(D), (E), (G), (H) AND (I) OF THE ACT SHALL EXPIRE JUNE 30, 12 2008. IF THESE SECTIONS EXPIRE ON JUNE 30, 2008, THE FUND SHALL 13 CONTINUE TO BE RESPONSIBLE FOR PAYMENT OF CLAIMS AGAINST 14 PARTICIPATING HEALTH CARE PROVIDERS AS OF JUNE 30, 2008, UP TO 15 THE FUND LIABILITY LIMITS AS OF JUNE 30, 2008, TO THE EXTENT THE 16 FUND WOULD HAVE BEEN RESPONSIBLE FOR PAYMENT OF SUCH CLAIMS IF 17 SECTIONS 711, 712(D), (E), (G), (H) AND (I) OF THE ACT DID NOT 18 EXPIRE JUNE 30, 2008. 19 Section 7 8. This act shall take effect immediately. <-- 20 SECTION 1. SECTION 711(D) AND (G) OF THE ACT OF MARCH 20, <-- 21 2002 (P.L.154, NO.13), KNOWN AS THE MEDICAL CARE AVAILABILITY 22 AND REDUCTION OF ERROR (MCARE) ACT, ARE AMENDED TO READ: 23 SECTION 711. MEDICAL PROFESSIONAL LIABILITY INSURANCE. 24 * * * 25 (D) BASIC COVERAGE LIMITS.--A HEALTH CARE PROVIDER SHALL 26 INSURE OR SELF-INSURE MEDICAL PROFESSIONAL LIABILITY IN 27 ACCORDANCE WITH THE FOLLOWING: 28 (1) FOR POLICIES ISSUED OR RENEWED IN THE CALENDAR YEAR 29 2002, THE BASIC INSURANCE COVERAGE SHALL BE: 30 (I) $500,000 PER OCCURRENCE OR CLAIM AND $1,500,000 20070S1137B1827 - 21 -
1 PER ANNUAL AGGREGATE FOR A HEALTH CARE PROVIDER WHO
2 CONDUCTS MORE THAN 50% OF ITS HEALTH CARE BUSINESS OR
3 PRACTICE WITHIN THIS COMMONWEALTH AND THAT IS NOT A
4 HOSPITAL.
5 (II) $500,000 PER OCCURRENCE OR CLAIM AND $1,500,000
6 PER ANNUAL AGGREGATE FOR A HEALTH CARE PROVIDER WHO
7 CONDUCTS 50% OR LESS OF ITS HEALTH CARE BUSINESS OR
8 PRACTICE WITHIN THIS COMMONWEALTH.
9 (III) $500,000 PER OCCURRENCE OR CLAIM AND
10 $2,500,000 PER ANNUAL AGGREGATE FOR A HOSPITAL.
11 (2) FOR POLICIES ISSUED OR RENEWED IN THE CALENDAR YEARS
12 2003[, 2004 AND 2005] THROUGH 2008, THE BASIC INSURANCE
13 COVERAGE SHALL BE:
14 (I) $500,000 PER OCCURRENCE OR CLAIM AND $1,500,000
15 PER ANNUAL AGGREGATE FOR A PARTICIPATING HEALTH CARE
16 PROVIDER THAT IS NOT A HOSPITAL.
17 (II) $1,000,000 PER OCCURRENCE OR CLAIM AND
18 $3,000,000 PER ANNUAL AGGREGATE FOR A NONPARTICIPATING
19 HEALTH CARE PROVIDER.
20 (III) $500,000 PER OCCURRENCE OR CLAIM AND
21 $2,500,000 PER ANNUAL AGGREGATE FOR A HOSPITAL.
22 [(3) UNLESS THE COMMISSIONER FINDS PURSUANT TO SECTION
23 745(A) THAT ADDITIONAL BASIC INSURANCE COVERAGE CAPACITY IS
24 NOT AVAILABLE, FOR POLICIES ISSUED OR RENEWED IN CALENDAR
25 YEAR 2006 AND EACH YEAR THEREAFTER SUBJECT TO PARAGRAPH (4),
26 THE BASIC INSURANCE COVERAGE SHALL BE:
27 (I) $750,000 PER OCCURRENCE OR CLAIM AND $2,250,000
28 PER ANNUAL AGGREGATE FOR A PARTICIPATING HEALTH CARE
29 PROVIDER THAT IS NOT A HOSPITAL.
30 (II) $1,000,000 PER OCCURRENCE OR CLAIM AND
20070S1137B1827 - 22 -
1 $3,000,000 PER ANNUAL AGGREGATE FOR A NONPARTICIPATING 2 HEALTH CARE PROVIDER. 3 (III) $750,000 PER OCCURRENCE OR CLAIM AND 4 $3,750,000 PER ANNUAL AGGREGATE FOR A HOSPITAL. 5 IF THE COMMISSIONER FINDS PURSUANT TO SECTION 745(A) THAT 6 ADDITIONAL BASIC INSURANCE COVERAGE CAPACITY IS NOT 7 AVAILABLE, THE BASIC INSURANCE COVERAGE REQUIREMENTS SHALL 8 REMAIN AT THE LEVEL REQUIRED BY PARAGRAPH (2); AND THE 9 COMMISSIONER SHALL CONDUCT A STUDY EVERY TWO YEARS UNTIL THE 10 COMMISSIONER FINDS THAT ADDITIONAL BASIC INSURANCE COVERAGE 11 CAPACITY IS AVAILABLE, AT WHICH TIME THE COMMISSIONER SHALL 12 INCREASE THE REQUIRED BASIC INSURANCE COVERAGE IN ACCORDANCE 13 WITH THIS PARAGRAPH. 14 (4) UNLESS THE COMMISSIONER FINDS PURSUANT TO SECTION 15 745(B) THAT ADDITIONAL BASIC INSURANCE COVERAGE CAPACITY IS 16 NOT AVAILABLE, FOR POLICIES ISSUED OR RENEWED THREE YEARS 17 AFTER THE INCREASE IN COVERAGE LIMITS REQUIRED BY PARAGRAPH 18 (3) AND FOR EACH YEAR THEREAFTER, THE BASIC INSURANCE 19 COVERAGE SHALL BE: 20 (I) $1,000,000 PER OCCURRENCE OR CLAIM AND 21 $3,000,000 PER ANNUAL AGGREGATE FOR A PARTICIPATING 22 HEALTH CARE PROVIDER THAT IS NOT A HOSPITAL. 23 (II) $1,000,000 PER OCCURRENCE OR CLAIM AND 24 $3,000,000 PER ANNUAL AGGREGATE FOR A NONPARTICIPATING 25 HEALTH CARE PROVIDER. 26 (III) $1,000,000 PER OCCURRENCE OR CLAIM AND 27 $4,500,000 PER ANNUAL AGGREGATE FOR A HOSPITAL. 28 IF THE COMMISSIONER FINDS PURSUANT TO SECTION 745(B) THAT 29 ADDITIONAL BASIC INSURANCE COVERAGE CAPACITY IS NOT 30 AVAILABLE, THE BASIC INSURANCE COVERAGE REQUIREMENTS SHALL 20070S1137B1827 - 23 -
1 REMAIN AT THE LEVEL REQUIRED BY PARAGRAPH (3); AND THE 2 COMMISSIONER SHALL CONDUCT A STUDY EVERY TWO YEARS UNTIL THE 3 COMMISSIONER FINDS THAT ADDITIONAL BASIC INSURANCE COVERAGE 4 CAPACITY IS AVAILABLE, AT WHICH TIME THE COMMISSIONER SHALL 5 INCREASE THE REQUIRED BASIC INSURANCE COVERAGE IN ACCORDANCE 6 WITH THIS PARAGRAPH.] 7 (5) FOR POLICIES ISSUED OR RENEWED IN CALENDAR YEAR 8 2009, THE BASIC INSURANCE COVERAGE SHALL BE: 9 (I) $550,000 PER OCCURRENCE OR CLAIM AND $1,650,000 10 PER ANNUAL AGGREGATE FOR A PARTICIPATING HEALTH CARE 11 PROVIDER THAT IS NOT A HOSPITAL. 12 (II) $1,000,000 PER OCCURRENCE OR CLAIM AND 13 $3,000,000 PER ANNUAL AGGREGATE FOR A NONPARTICIPATING 14 HEALTH CARE PROVIDER. 15 (III) $550,000 PER OCCURRENCE OR CLAIM AND 16 $2,700,000 PER ANNUAL AGGREGATE FOR A HOSPITAL. 17 (6) FOR POLICIES ISSUED OR RENEWED IN CALENDAR YEARS 18 2010 AND THEREAFTER: 19 (I) THE BASIC INSURANCE COVERAGE FOR A PARTICIPATING 20 HEALTH CARE PROVIDER THAT IS NOT A HOSPITAL SHALL 21 INCREASE BY $50,000 PER OCCURRENCE OR CLAIM AND $150,000 22 PER ANNUAL AGGREGATE PER YEAR UNTIL SUCH TIME AS THE 23 BASIC INSURANCE COVERAGE REQUIRED SHALL BE $1,000,000 PER 24 OCCURRENCE OR CLAIM AND $3,000,000 PER ANNUAL AGGREGATE. 25 (II) THE BASIC INSURANCE COVERAGE FOR A 26 NONPARTICIPATING HEALTH CARE PROVIDER SHALL BE $1,000,000 27 PER OCCURRENCE OR CLAIM AND $3,000,000 PER ANNUAL 28 AGGREGATE. 29 (III) THE BASIC INSURANCE COVERAGE FOR A HOSPITAL 30 SHALL INCREASE BY $50,000 PER OCCURRENCE OR CLAIM AND 20070S1137B1827 - 24 -
1 $200,000 PER ANNUAL AGGREGATE UNTIL SUCH TIME AS THE 2 BASIC INSURANCE COVERAGE REQUIREMENT SHALL BE $1,000,000 3 PER OCCURRENCE OR CLAIM AND $4,500,000 PER ANNUAL 4 AGGREGATE PER YEAR. 5 (7) BASIC INSURANCE COVERAGE AMOUNTS SHALL BE EXCLUSIVE 6 OF A DEDUCTIBLE OR ANY OTHER CONTRIBUTION FROM THE HEALTH 7 CARE PROVIDER. 8 * * * 9 (G) BASIC INSURANCE LIABILITY.-- 10 (1) AN INSURER PROVIDING MEDICAL PROFESSIONAL LIABILITY 11 INSURANCE SHALL NOT BE LIABLE FOR PAYMENT OF A CLAIM AGAINST 12 A HEALTH CARE PROVIDER FOR ANY LOSS OR DAMAGES AWARDED IN A 13 MEDICAL PROFESSIONAL LIABILITY ACTION IN EXCESS OF THE BASIC 14 INSURANCE COVERAGE REQUIRED BY SUBSECTION (D) UNLESS THE 15 HEALTH CARE PROVIDER'S MEDICAL PROFESSIONAL LIABILITY 16 INSURANCE POLICY OR SELF-INSURANCE PLAN PROVIDES FOR A HIGHER 17 LIMIT. 18 (2) IF A CLAIM EXCEEDS THE LIMITS OF A PARTICIPATING 19 HEALTH CARE PROVIDER'S BASIC INSURANCE COVERAGE OR SELF- 20 INSURANCE PLAN, THE FUND SHALL BE RESPONSIBLE FOR PAYMENT OF 21 THE CLAIM AGAINST THE PARTICIPATING HEALTH CARE PROVIDER UP 22 TO THE FUND LIABILITY LIMITS. THE FUND SHALL NOT BE 23 RESPONSIBLE IF A CLAIMANT HAS WAIVED COLLECTION OF ANY 24 PORTION OF THE APPLICABLE BASIC INSURANCE COVERAGE LIMIT. 25 (3) IF THE HEALTH CARE PROVIDER HAS MORE THAN ONE BASIC 26 INSURANCE COVERAGE POLICY WITH MORE THAN ONE INSURER 27 APPLICABLE TO A CLAIM, THE FUND SHALL BE LIABLE WHEN THE 28 POLICY WITH THE HIGHEST LIMIT HAS BEEN TENDERED TO THE FUND. 29 * * * 30 SECTION 2. SECTION 712(C), (D), (E), (I), (J) AND (M) OF THE 20070S1137B1827 - 25 -
1 ACT ARE AMENDED AND THE SECTION IS AMENDED BY ADDING A
2 SUBSECTION TO READ:
3 SECTION 712. MEDICAL CARE AVAILABILITY AND REDUCTION OF ERROR
4 FUND.
5 * * *
6 (C) FUND LIABILITY LIMITS.--
7 (1) FOR CALENDAR YEAR 2002, THE LIMIT OF LIABILITY OF
8 THE FUND CREATED IN SECTION 701(D) OF THE FORMER HEALTH CARE
9 SERVICES MALPRACTICE ACT FOR EACH HEALTH CARE PROVIDER THAT
10 CONDUCTS MORE THAN 50% OF ITS HEALTH CARE BUSINESS OR
11 PRACTICE WITHIN THIS COMMONWEALTH AND FOR EACH HOSPITAL SHALL
12 BE $700,000 FOR EACH OCCURRENCE AND $2,100,000 PER ANNUAL
13 AGGREGATE.
14 (2) THE LIMIT OF LIABILITY OF THE FUND FOR EACH
15 PARTICIPATING HEALTH CARE PROVIDER SHALL BE [AS FOLLOWS:
16 (I) FOR] FOR CALENDAR YEAR 2003 AND EACH YEAR
17 THEREAFTER, THE LIMIT OF LIABILITY OF THE FUND SHALL BE
18 $500,000 FOR EACH OCCURRENCE AND $1,500,000 PER ANNUAL
19 AGGREGATE.
20 [(II) IF THE BASIC INSURANCE COVERAGE REQUIREMENT IS
21 INCREASED IN ACCORDANCE WITH SECTION 711(D)(3) AND,
22 NOTWITHSTANDING SUBPARAGRAPH (I), FOR EACH CALENDAR YEAR
23 FOLLOWING THE INCREASE IN THE BASIC INSURANCE COVERAGE
24 REQUIREMENT, THE LIMIT OF LIABILITY OF THE FUND SHALL BE
25 $250,000 FOR EACH OCCURRENCE AND $750,000 PER ANNUAL
26 AGGREGATE.
27 (III) IF THE BASIC INSURANCE COVERAGE REQUIREMENT IS
28 INCREASED IN ACCORDANCE WITH SECTION 711(D)(4) AND,
29 NOTWITHSTANDING SUBPARAGRAPHS (I) AND (II), FOR EACH
30 CALENDAR YEAR FOLLOWING THE INCREASE IN THE BASIC
20070S1137B1827 - 26 -
1 INSURANCE COVERAGE REQUIREMENT, THE LIMIT OF LIABILITY OF 2 THE FUND SHALL BE ZERO.] 3 (3) THE LIMIT OF LIABILITY OF THE FUND FOR EACH 4 PARTICIPATING HEALTH CARE PROVIDER SHALL BE: 5 (I) FOR CALENDAR YEARS 2003 THROUGH 2008, $500,000 6 FOR EACH OCCURRENCE AND $1,500,000 PER ANNUAL AGGREGATE. 7 (II) FOR CALENDAR YEAR 2009, $450,000 PER OCCURRENCE 8 OR CLAIM AND $1,350,000 PER ANNUAL AGGREGATE. 9 (III) FOR CALENDAR YEARS 2010 AND THEREAFTER, THE 10 LIMIT OF LIABILITY SHALL DECREASE BY $50,000 PER 11 OCCURRENCE OR CLAIM AND $150,000 PER ANNUAL AGGREGATE PER 12 YEAR UNTIL SUCH TIME AS THE FUND LIMIT OF LIABILITY SHALL 13 BE ZERO DOLLARS PER OCCURRENCE OR CLAIM AND ZERO DOLLARS 14 PER ANNUAL AGGREGATE. 15 (D) ASSESSMENTS.-- 16 (1) FOR CALENDAR [YEAR 2003 AND FOR EACH YEAR 17 THEREAFTER,] YEARS 2003 THROUGH 2017, THE FUND SHALL BE 18 FUNDED BY AN ASSESSMENT ON EACH PARTICIPATING HEALTH CARE 19 PROVIDER. ASSESSMENTS SHALL BE LEVIED BY THE DEPARTMENT ON OR 20 AFTER JANUARY 1 OF EACH YEAR. THE ASSESSMENT SHALL BE BASED 21 ON THE PREVAILING PRIMARY PREMIUM FOR EACH PARTICIPATING 22 HEALTH CARE PROVIDER AND SHALL, IN THE AGGREGATE, PRODUCE AN 23 AMOUNT SUFFICIENT TO DO ALL OF THE FOLLOWING: 24 (I) REIMBURSE THE FUND FOR THE PAYMENT OF REPORTED 25 CLAIMS WHICH BECAME FINAL DURING THE PRECEDING CLAIMS 26 PERIOD. 27 (II) PAY EXPENSES OF THE FUND INCURRED DURING THE 28 PRECEDING CLAIMS PERIOD. 29 (III) PAY PRINCIPAL AND INTEREST ON MONEYS 30 TRANSFERRED INTO THE FUND IN ACCORDANCE WITH SECTION 20070S1137B1827 - 27 -
1 713(C). 2 (IV) PROVIDE A RESERVE THAT SHALL BE 10% OF THE SUM 3 OF SUBPARAGRAPHS (I), (II) AND (III). 4 (2) THE DEPARTMENT SHALL NOTIFY ALL BASIC INSURANCE 5 COVERAGE INSURERS AND SELF-INSURED PARTICIPATING HEALTH CARE 6 PROVIDERS OF THE ASSESSMENT BY NOVEMBER 1 FOR THE SUCCEEDING 7 CALENDAR YEAR. 8 (3) ANY APPEAL OF THE ASSESSMENT SHALL BE FILED WITH THE 9 DEPARTMENT. 10 [(E) DISCOUNT ON SURCHARGES AND ASSESSMENTS.-- 11 (1) FOR CALENDAR YEAR 2002, THE DEPARTMENT SHALL 12 DISCOUNT THE AGGREGATE SURCHARGE IMPOSED UNDER SECTION 13 701(E)(1) OF THE HEALTH CARE SERVICES MALPRACTICE ACT BY 5% 14 OF THE AGGREGATE SURCHARGE IMPOSED UNDER THAT SECTION FOR 15 CALENDAR YEAR 2001 IN ACCORDANCE WITH THE FOLLOWING: 16 (I) FIFTY PERCENT OF THE AGGREGATE DISCOUNT SHALL BE 17 GRANTED EQUALLY TO HOSPITALS AND TO PARTICIPATING HEALTH 18 CARE PROVIDERS THAT WERE SURCHARGED AS MEMBERS OF ONE OF 19 THE FOUR HIGHEST RATE CLASSES OF THE PREVAILING PRIMARY 20 PREMIUM. 21 (II) NOTWITHSTANDING SUBPARAGRAPH (I), 50% OF THE 22 AGGREGATE DISCOUNT SHALL BE GRANTED EQUALLY TO ALL 23 PARTICIPATING HEALTH CARE PROVIDERS. 24 (III) THE DEPARTMENT SHALL ISSUE A CREDIT TO A 25 PARTICIPATING HEALTH CARE PROVIDER WHO, PRIOR TO THE 26 EFFECTIVE DATE OF THIS SECTION, HAS PAID THE SURCHARGE 27 IMPOSED UNDER SECTION 701(E)(1) OF THE FORMER HEALTH CARE 28 SERVICES MALPRACTICE ACT FOR CALENDAR YEAR 2002 PRIOR TO 29 THE EFFECTIVE DATE OF THIS SECTION. 30 (2) FOR CALENDAR YEARS 2003 AND 2004, THE DEPARTMENT 20070S1137B1827 - 28 -
1 SHALL DISCOUNT THE AGGREGATE ASSESSMENT IMPOSED UNDER 2 SUBSECTION (D) FOR EACH CALENDAR YEAR BY 10% OF THE AGGREGATE 3 SURCHARGE IMPOSED UNDER SECTION 701(E)(1) OF THE FORMER 4 HEALTH CARE SERVICES MALPRACTICE ACT FOR CALENDAR YEAR 2001 5 IN ACCORDANCE WITH THE FOLLOWING: 6 (I) FIFTY PERCENT OF THE AGGREGATE DISCOUNT SHALL BE 7 GRANTED EQUALLY TO HOSPITALS AND TO PARTICIPATING HEALTH 8 CARE PROVIDERS THAT WERE ASSESSED AS MEMBERS OF ONE OF 9 THE FOUR HIGHEST RATE CLASSES OF THE PREVAILING PRIMARY 10 PREMIUM. 11 (II) NOTWITHSTANDING SUBPARAGRAPH (I), 50% OF THE 12 AGGREGATE DISCOUNT SHALL BE GRANTED EQUALLY TO ALL 13 PARTICIPATING HEALTH CARE PROVIDERS. 14 (3) FOR CALENDAR YEARS 2005 AND THEREAFTER, IF THE BASIC 15 INSURANCE COVERAGE REQUIREMENT IS INCREASED IN ACCORDANCE 16 WITH SECTION 711(D)(3) OR (4), THE DEPARTMENT MAY DISCOUNT 17 THE AGGREGATE ASSESSMENT IMPOSED UNDER SUBSECTION (D) BY AN 18 AMOUNT NOT TO EXCEED THE AGGREGATE SUM TO BE DEPOSITED IN THE 19 FUND IN ACCORDANCE WITH SUBSECTION (M).] 20 * * * 21 (I) CHANGE IN BASIC INSURANCE COVERAGE.--IF A PARTICIPATING 22 HEALTH CARE PROVIDER CHANGES THE TERM OF ITS MEDICAL 23 PROFESSIONAL LIABILITY INSURANCE COVERAGE, THE ASSESSMENT SHALL 24 BE CALCULATED ON AN ANNUAL BASIS AND SHALL REFLECT THE 25 ASSESSMENT PERCENTAGES IN EFFECT FOR THE PERIOD OVER WHICH THE 26 POLICIES ARE IN EFFECT. A POLICY PERIOD LESS THAN 12 MONTHS MAY 27 RESULT IN A PRORATED REDUCTION IN THE MCARE ANNUAL AGGREGATE 28 LIMIT. 29 (J) PAYMENT OF CLAIMS.--CLAIMS WHICH BECAME FINAL DURING THE 30 PRECEDING CLAIMS PERIOD SHALL BE PAID ON [OR BEFORE] DECEMBER 31 20070S1137B1827 - 29 -
1 OR THE LAST BUSINESS DAY OF THE YEAR FOLLOWING THE AUGUST 31 ON 2 WHICH THEY BECAME FINAL. 3 * * * 4 (M) SUPPLEMENTAL FUNDING.--NOTWITHSTANDING THE PROVISIONS OF 5 75 PA.C.S. § 6506(B) (RELATING TO SURCHARGE) TO THE CONTRARY, 6 BEGINNING JANUARY 1, 2004, [AND FOR A PERIOD OF NINE CALENDAR 7 YEARS THEREAFTER,] THROUGH JUNE 30, 2018, ALL SURCHARGES LEVIED 8 AND COLLECTED UNDER 75 PA.C.S. § 6506(A) BY ANY DIVISION OF THE 9 UNIFIED JUDICIAL SYSTEM SHALL BE REMITTED TO THE COMMONWEALTH 10 FOR DEPOSIT IN THE MEDICAL CARE AVAILABILITY AND [RESTRICTION] 11 REDUCTION OF ERROR FUND. THESE FUNDS SHALL BE USED TO REDUCE 12 SURCHARGES AND ASSESSMENTS IN ACCORDANCE WITH SUBSECTION (E). 13 BEGINNING [JANUARY 1, 2014] JULY 1, 2018, AND EACH YEAR 14 THEREAFTER, THE SURCHARGES LEVIED AND COLLECTED UNDER 75 PA.C.S. 15 § 6506(A) SHALL BE DEPOSITED INTO THE [GENERAL FUND.] HEALTH 16 CARE PROVIDER RETENTION ACCOUNT. 17 * * * 18 (O) COVERAGE OF CLAIMS IN RELATION TO PAYMENT OF CERTAIN 19 LATE ASSESSMENTS.-- 20 (1) ALL BASIC INSURANCE COVERAGE INSURERS, SELF-INSURED 21 PARTICIPATING HEALTH CARE PROVIDERS AND RISK RETENTION GROUPS 22 SHALL BILL, COLLECT AND REMIT THE ASSESSMENT TO THE 23 DEPARTMENT WITHIN 60 DAYS OF THE INCEPTION OR RENEWAL DATE OF 24 THE PRIMARY PROFESSIONAL LIABILITY POLICY. 25 (2) ALL BASIC INSURANCE COVERAGE INSURERS, SELF-INSURED 26 PARTICIPATING HEALTH CARE PROVIDERS AND RISK RETENTION GROUPS 27 SHALL BE SUBJECT TO THE FOLLOWING: 28 (I) FOR ASSESSMENTS REMITTED TO THE DEPARTMENT IN 29 EXCESS OF 60 DAYS AFTER THE INCEPTION OR RENEWAL DATE OF 30 THE PRIMARY POLICY, THE BASIC INSURANCE COVERAGE INSURER, 20070S1137B1827 - 30 -
1 SELF-INSURED PARTICIPATING HEALTH CARE PROVIDER OR RISK 2 RETENTION GROUP SHALL PAY TO THE DEPARTMENT A PENALTY 3 EQUAL TO 10% PER ANNUM OF EACH UNTIMELY ASSESSMENT 4 ACCRUING FROM THE 61ST DAY AFTER THE INCEPTION OR RENEWAL 5 DATE OF THE PRIMARY POLICY UNTIL THE REMITTANCE IS 6 RECEIVED BY THE DEPARTMENT. 7 (II) IN ADDITION TO THE PROVISIONS OF SUBPARAGRAPH 8 (I), IF THE DEPARTMENT FINDS THAT THERE HAS BEEN A 9 PATTERN OR PRACTICE OF NOT COMPLYING WITH THIS SECTION, 10 THE BASIC INSURANCE COVERAGE INSURER, SELF-INSURED 11 PARTICIPATING HEALTH CARE PROVIDER OR RISK RETENTION 12 GROUP SHALL BE SUBJECT TO THE PENALTIES AND PROCESS SET 13 FORTH IN THE ACT OF JULY 22, 1974 (P.L.589, NO.205), 14 KNOWN AS THE UNFAIR INSURANCE PRACTICES ACT. 15 (III) IF THE BASIC INSURANCE COVERAGE INSURER, SELF- 16 INSURER OR RISK RETENTION GROUP RECEIVES THE ASSESSMENT 17 FROM A HEALTH CARE PROVIDER, PROFESSIONAL CORPORATION OR 18 PROFESSIONAL ASSOCIATION WITH LESS THAN 30 DAYS TO MAKE 19 THE REMITTANCE TIMELY AS PROVIDED UNDER THIS SUBSECTION, 20 THE BASIC INSURANCE COVERAGE INSURER, SELF-INSURER OR 21 RISK RETENTION GROUP REMITTANCE PERIOD SHALL BE EXTENDED 22 BY 30 DAYS FROM THE DATE OF RECEIPT UPON PROVIDING 23 REASONABLE EVIDENCE TO THE DEPARTMENT REGARDING THE DATE 24 OF RECEIPT AND SHALL NOT BE SUBJECT TO THE PENALTIES 25 PROVIDED FOR UNDER THIS SECTION. 26 (IV) IF THE BASIC INSURANCE COVERAGE INSURER, SELF- 27 INSURER OR RISK RETENTION GROUP RECEIVES AN ASSESSMENT 28 AFTER 60 DAYS OF THE INCEPTION OR RENEWAL DATE OF THE 29 PRIMARY PROFESSIONAL LIABILITY POLICY AND REMITS THE 30 ASSESSMENT WITHIN 30 DAYS FROM THE DATE OF RECEIPT, THE 20070S1137B1827 - 31 -
1 BASIC INSURANCE COVERAGE INSURER, SELF-INSURER OR RISK 2 RETENTION GROUP SHALL NOT BE SUBJECT TO THE PENALTIES 3 PROVIDED FOR UNDER THIS SECTION. REMITTANCES TO THE 4 DEPARTMENT BEYOND THE 30-DAY PERIOD SHALL BE SUBJECT TO 5 THE PENALTIES PROVIDED FOR UNDER THIS SECTION. 6 (V) (A) A HEALTH CARE PROVIDER OR PROFESSIONAL 7 CORPORATION, PROFESSIONAL ASSOCIATION OR PARTNERSHIP 8 SHALL BE PROVIDED COVERAGE FROM THE INCEPTION OR 9 RENEWAL DATE OF THE PRIMARY PROFESSIONAL LIABILITY 10 POLICY IF THE BILLED ASSESSMENT IS PAID TO THE BASIC 11 INSURANCE COVERAGE INSURER, SELF-INSURER OR RISK 12 RETENTION GROUP WITHIN 60 DAYS OF THE INCEPTION OR 13 RENEWAL DATE OF THE PRIMARY PROFESSIONAL LIABILITY 14 POLICY. 15 (B) A HEALTH CARE PROVIDER OR PROFESSIONAL 16 CORPORATION, PROFESSIONAL ASSOCIATION OR PARTNERSHIP 17 THAT FAILS TO PAY THE BILLED ASSESSMENT TO ITS BASIC 18 INSURANCE COVERAGE INSURER, SELF-INSURER OR RISK 19 RETENTION GROUP WITHIN 60 DAYS OF POLICY INCEPTION OR 20 RENEWAL AND BEFORE RECEIVING NOTICE OF A CLAIM SHALL 21 NOT HAVE COVERAGE FOR THAT CLAIM. 22 (C) IF A HEALTH CARE PROVIDER OR PROFESSIONAL 23 CORPORATION, PROFESSIONAL ASSOCIATION OR PARTNERSHIP 24 IS BILLED BY THE BASIC INSURANCE COVERAGE INSURER, 25 SELF-INSURER OR RISK RETENTION GROUP LATER THAN 30 26 DAYS AFTER THE POLICY INCEPTION OR RENEWAL DATE AND 27 THE HEALTH CARE PROVIDER OR PROFESSIONAL CORPORATION, 28 PROFESSIONAL ASSOCIATION OR PARTNERSHIP PAYS THE 29 BASIC INSURANCE COVERAGE INSURER, SELF-INSURER OR 30 RISK RETENTION GROUP WITHIN 30 DAYS FROM THE DATE OF 20070S1137B1827 - 32 -
1 RECEIPT OF THE BILL AND THE BASIC INSURANCE COVERAGE 2 INSURER, SELF-INSURER OR RISK RETENTION GROUP CARRIER 3 REMITS THE ASSESSMENT TO THE DEPARTMENT WITHIN 30 4 DAYS FROM THE DATE OF RECEIPT, THE HEALTH CARE 5 PROVIDER SHALL BE PROVIDED COVERAGE AS OF THE 6 INCEPTION OR RENEWAL DATE OF THE PRIMARY POLICY. 7 COVERAGE SHALL ALSO BE PROVIDED TO THE HEALTH CARE 8 PROVIDER OR PROFESSIONAL CORPORATION, PROFESSIONAL 9 ASSOCIATION OR PARTNERSHIP FOR ALL PROFESSIONAL 10 LIABILITY CLAIMS MADE AFTER PAYMENT OF THE 11 ASSESSMENT. 12 (VI) EXCEPT AS TO PROVISIONS IN CONFLICT WITH THIS 13 SECTION, NOTHING IN THIS SECTION SHALL BE CONSTRUED TO 14 AFFECT EXISTING REGULATIONS SAVED BY SECTION 5107(A), AND 15 ALL EXISTING REGULATIONS SHALL REMAIN IN FULL FORCE AND 16 EFFECT. 17 SECTION 3. SECTION 745 OF THE ACT IS REPEALED: 18 [SECTION 745. ACTUARIAL DATA. 19 (A) INITIAL STUDY.--THE FOLLOWING SHALL APPLY: 20 (1) NO LATER THAN APRIL 1, 2005, EACH INSURER PROVIDING 21 MEDICAL PROFESSIONAL LIABILITY INSURANCE IN THIS COMMONWEALTH 22 SHALL FILE LOSS DATA AS REQUIRED BY THE COMMISSIONER. FOR 23 FAILURE TO COMPLY, THE COMMISSIONER SHALL IMPOSE AN 24 ADMINISTRATIVE PENALTY OF $1,000 FOR EVERY DAY THAT THIS DATA 25 IS NOT PROVIDED IN ACCORDANCE WITH THIS PARAGRAPH. 26 (2) BY JULY 1, 2005, THE COMMISSIONER SHALL CONDUCT A 27 STUDY REGARDING THE AVAILABILITY OF ADDITIONAL BASIC 28 INSURANCE COVERAGE CAPACITY. THE STUDY SHALL INCLUDE AN 29 ESTIMATE OF THE TOTAL CHANGE IN MEDICAL PROFESSIONAL 30 LIABILITY INSURANCE LOSS-COST RESULTING FROM IMPLEMENTATION 20070S1137B1827 - 33 -
1 OF THIS ACT PREPARED BY AN INDEPENDENT ACTUARY. THE FEE FOR 2 THE INDEPENDENT ACTUARY SHALL BE BORNE BY THE FUND. IN 3 DEVELOPING THE ESTIMATE, THE INDEPENDENT ACTUARY SHALL 4 CONSIDER ALL OF THE FOLLOWING: 5 (I) THE MOST RECENT ACCIDENT YEAR AND RATEMAKING 6 DATA AVAILABLE. 7 (II) ANY OTHER RELEVANT FACTORS WITHIN OR OUTSIDE 8 THIS COMMONWEALTH IN ACCORDANCE WITH SOUND ACTUARIAL 9 PRINCIPLES. 10 (B) ADDITIONAL STUDY.--THE FOLLOWING SHALL APPLY: 11 (1) THREE YEARS FOLLOWING THE INCREASE OF THE BASIC 12 INSURANCE COVERAGE REQUIREMENT IN ACCORDANCE WITH SECTION 13 711(D)(3), EACH INSURER PROVIDING MEDICAL PROFESSIONAL 14 LIABILITY INSURANCE IN THIS COMMONWEALTH SHALL FILE LOSS DATA 15 WITH THE COMMISSIONER UPON REQUEST. FOR FAILURE TO COMPLY, 16 THE COMMISSIONER SHALL IMPOSE AN ADMINISTRATIVE PENALTY OF 17 $1,000 FOR EVERY DAY THAT THIS DATA IS NOT PROVIDED IN 18 ACCORDANCE WITH THIS PARAGRAPH. 19 (2) THREE MONTHS FOLLOWING THE REQUEST MADE UNDER 20 PARAGRAPH (1), THE COMMISSIONER SHALL CONDUCT A STUDY 21 REGARDING THE AVAILABILITY OF ADDITIONAL BASIC INSURANCE 22 COVERAGE CAPACITY. THE STUDY SHALL INCLUDE AN ESTIMATE OF THE 23 TOTAL CHANGE IN MEDICAL PROFESSIONAL LIABILITY INSURANCE 24 LOSS-COST RESULTING FROM IMPLEMENTATION OF THIS ACT PREPARED 25 BY AN INDEPENDENT ACTUARY. THE FEE FOR THE INDEPENDENT 26 ACTUARY SHALL BE BORNE BY THE FUND. IN DEVELOPING THE 27 ESTIMATE, THE INDEPENDENT ACTUARY SHALL CONSIDER ALL OF THE 28 FOLLOWING: 29 (I) THE MOST RECENT ACCIDENT YEAR AND RATEMAKING 30 DATA AVAILABLE. 20070S1137B1827 - 34 -
1 (II) ANY OTHER RELEVANT FACTORS WITHIN OR OUTSIDE 2 THIS COMMONWEALTH IN ACCORDANCE WITH SOUND ACTUARIAL 3 PRINCIPLES.] 4 SECTION 4. CHAPTER 7 OF THE ACT IS AMENDED BY ADDING 5 SUBCHAPTERS TO READ: 6 SUBCHAPTER E 7 PENNSYLVANIA ACCESS TO BASIC CARE 8 (PA ABC) PROGRAM FUND 9 SECTION 751. ESTABLISHMENT. 10 THERE IS ESTABLISHED WITHIN THE STATE TREASURY A SPECIAL FUND 11 TO BE KNOWN AS THE PENNSYLVANIA ACCESS TO BASIC CARE (PA ABC) 12 PROGRAM FUND. 13 SECTION 752. ALLOCATION. 14 MONEY IN THE PENNSYLVANIA ACCESS TO BASIC CARE (PA ABC) 15 PROGRAM FUND IS HEREBY APPROPRIATED UPON APPROVAL OF THE 16 GOVERNOR FOR HEALTH CARE COVERAGE AND SERVICES UNDER CHAPTER 13. 17 SUBCHAPTER F 18 CONTINUING ACCESS WITH RELIEF FOR 19 EMPLOYERS (CARE) FUND 20 SECTION 761. ESTABLISHMENT. 21 THERE IS ESTABLISHED WITHIN THE STATE TREASURY A SPECIAL FUND 22 TO BE KNOWN AS THE CONTINUING ACCESS WITH RELIEF FOR EMPLOYERS 23 (CARE) FUND. 24 SECTION 762. ALLOCATION. 25 MONEY IN THE CONTINUING ACCESS WITH RELIEF FOR EMPLOYERS 26 (CARE) FUND IS HEREBY APPROPRIATED ON A CONTINUING BASIS TO THE 27 DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT AND SHALL BE 28 DEDICATED TO ASSISTING CERTAIN EMPLOYERS THAT CURRENTLY OFFER 29 AND MAINTAIN HEALTH CARE COVERAGE FOR THEIR EMPLOYEES IN 30 COMPLIANCE WITH THE REQUIREMENTS UNDER SECTION 1308. 20070S1137B1827 - 35 -
1 SECTION 5. THE DEFINITION OF "HEALTH CARE PROVIDER" IN 2 SECTION 1101 OF THE ACT, ADDED DECEMBER 22, 2005 (P.L.458, 3 NO.88), IS AMENDED TO READ: 4 SECTION 1101. DEFINITIONS. 5 THE FOLLOWING WORDS AND PHRASES WHEN USED IN THIS CHAPTER 6 SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SECTION UNLESS THE 7 CONTEXT CLEARLY INDICATES OTHERWISE: 8 * * * 9 "HEALTH CARE PROVIDER." [AN INDIVIDUAL WHO IS ALL OF THE 10 FOLLOWING: 11 (1) A PHYSICIAN, LICENSED PODIATRIST, CERTIFIED NURSE 12 MIDWIFE OR NURSING HOME. 13 (2) A PARTICIPATING HEALTH CARE PROVIDER AS DEFINED IN 14 SECTION 702.] ANY OF THE FOLLOWING: 15 (1) A NURSING HOME OR BIRTH CENTER THAT IS A 16 PARTICIPATING HEALTH CARE PROVIDER AS DEFINED IN SECTION 702. 17 (2) AN INDIVIDUAL WHO IS A PHYSICIAN, LICENSED 18 PODIATRIST OR CERTIFIED NURSE MIDWIFE. 19 * * * 20 SECTION 6. SECTION 1102 OF THE ACT, AMENDED OCTOBER 27, 2006 21 (P.L.1198, NO.128), IS AMENDED TO READ: 22 SECTION 1102. ABATEMENT PROGRAM. 23 (A) ESTABLISHMENT.--THERE IS HEREBY ESTABLISHED WITHIN THE 24 INSURANCE DEPARTMENT A PROGRAM TO BE KNOWN AS THE HEALTH CARE 25 PROVIDER RETENTION PROGRAM. THE INSURANCE DEPARTMENT, IN 26 CONJUNCTION WITH THE DEPARTMENT OF PUBLIC WELFARE, SHALL 27 ADMINISTER THE PROGRAM. THE PROGRAM SHALL PROVIDE ASSISTANCE IN 28 THE FORM OF ASSESSMENT ABATEMENTS TO HEALTH CARE PROVIDERS FOR 29 CALENDAR YEARS [2003, 2004, 2005, 2006 AND 2007] BEGINNING 2003 30 AND ENDING 2017, EXCEPT THAT LICENSED PODIATRISTS SHALL NOT BE 20070S1137B1827 - 36 -
1 ELIGIBLE FOR CALENDAR YEARS 2003 AND 2004, AND NURSING HOMES 2 SHALL NOT BE ELIGIBLE FOR CALENDAR YEARS 2003, 2004 AND 2005. 3 (B) OTHER [ABATEMENT.--] ABATEMENTS.-- 4 (1) EMERGENCY PHYSICIANS NOT EMPLOYED FULL TIME BY A 5 TRAUMA CENTER OR WORKING UNDER AN EXCLUSIVE CONTRACT WITH A 6 TRAUMA CENTER SHALL RETAIN ELIGIBILITY FOR AN ABATEMENT 7 PURSUANT TO SECTION 1104(B)(2) FOR CALENDAR YEARS 2003, 2004, 8 2005 AND 2006. COMMENCING IN CALENDAR YEAR 2007, THESE 9 EMERGENCY PHYSICIANS SHALL BE ELIGIBLE FOR AN ABATEMENT 10 PURSUANT TO SECTION 1104(B)(1). 11 (2) BIRTH CENTERS SHALL RETAIN ELIGIBILITY FOR ABATEMENT 12 PURSUANT TO SECTION 1104(B)(2) FOR CALENDAR YEARS 2003, 2004, 13 2005, 2006 AND 2007. COMMENCING IN CALENDAR YEAR 2008, BIRTH 14 CENTERS SHALL BE ELIGIBLE FOR ABATEMENT PURSUANT TO SECTION 15 1104(B)(1). 16 SECTION 7. SECTION 1103 OF THE ACT, ADDED DECEMBER 22, 2005 17 (P.L.458, NO.88), IS AMENDED BY ADDING PARAGRAPHS TO READ: 18 SECTION 1103. ELIGIBILITY. 19 A HEALTH CARE PROVIDER SHALL NOT BE ELIGIBLE FOR [ASSESSMENT] 20 ABATEMENT UNDER THE PROGRAM IF ANY OF THE FOLLOWING APPLY: 21 * * * 22 (6) THE HEALTH CARE PROVIDER HAS REFUSED TO BE AN ACTIVE 23 PROVIDER IN THE PENNSYLVANIA ACCESS TO BASIC CARE (PA ABC) 24 PROGRAM IN THE HEALTH CARE PROVIDER'S SERVICE AREA. 25 (7) THE ACTIVE HEALTH CARE PROVIDER IS AN ACTIVE 26 PROVIDER IN THE PENNSYLVANIA ACCESS TO BASIC CARE (PA ABC) 27 PROGRAM AND PLACES RESTRICTIONS ON BENEFITS FOR PATIENTS 28 ENROLLED IN THAT PROGRAM. 29 (8) THE HEALTH CARE PROVIDER HAS REFUSED TO BE AN ACTIVE 30 PROVIDER IN THE CHILDREN'S HEALTH INSURANCE PROGRAM 20070S1137B1827 - 37 -
1 ESTABLISHED UNDER ARTICLE XXIII OF THE ACT OF MAY 17, 1921 2 (P.L.682, NO.284), KNOWN AS THE INSURANCE COMPANY LAW OF 3 1921. 4 (9) THE ACTIVE HEALTH CARE PROVIDER IS AN ACTIVE 5 PROVIDER IN THE CHILDREN'S HEALTH INSURANCE PROGRAM AND 6 PLACES RESTRICTIONS ON BENEFITS FOR PATIENTS ENROLLED IN THE 7 CHILDREN'S HEALTH INSURANCE PROGRAM. 8 (10) THE DEPARTMENT OF REVENUE HAS DETERMINED THAT THE 9 HEALTH CARE PROVIDER HAS NOT FILED ALL REQUIRED STATE TAX 10 REPORTS AND RETURNS FOR ALL APPLICABLE TAXABLE YEARS OR HAS 11 NOT PAID ANY BALANCE OF STATE TAX DUE AS DETERMINED AT 12 SETTLEMENT, ASSESSMENT OR DETERMINATION BY THE DEPARTMENT OF 13 REVENUE THAT ARE NOT SUBJECT TO A TIMELY PERFECTED 14 ADMINISTRATIVE OR JUDICIAL APPEAL OR SUBJECT TO A DULY 15 AUTHORIZED DEFERRED PAYMENT PLAN AS OF THE DATE OF 16 APPLICATION. NOTWITHSTANDING THE PROVISIONS OF SECTION 353(F) 17 OF THE ACT OF MARCH 4, 1971 (P.L.6, NO.2), KNOWN AS THE TAX 18 REFORM CODE OF 1971, THE DEPARTMENT OF REVENUE SHALL SUPPLY 19 THE INSURANCE DEPARTMENT WITH INFORMATION CONCERNING THE 20 STATUS OF DELINQUENT TAXES OWED BY A HEALTH CARE PROVIDER FOR 21 PURPOSES OF THIS PARAGRAPH. 22 (11) (I) THE HEALTH CARE PROVIDER HAS NOT ATTENDED AT 23 LEAST ONE COMMONWEALTH-SPONSORED INDEPENDENT DRUG 24 INFORMATION SERVICE SESSION, EITHER IN PERSON OR BY 25 VIDEOCONFERENCE. 26 (II) THIS PARAGRAPH DOES NOT APPLY IF THE 27 COMMONWEALTH HAS NOT MADE A COMMONWEALTH-SPONSORED 28 INDEPENDENT DRUG INFORMATION SERVICE SESSION AVAILABLE TO 29 THE HEALTH CARE PROVIDER PRIOR TO THE DATE THAT THE 30 HEALTH CARE PROVIDER'S APPLICATION IS SUBMITTED UNDER 20070S1137B1827 - 38 -
1 SECTION 1104. 2 SECTION 8. SECTION 1104(B) OF THE ACT, AMENDED DECEMBER 22, 3 2005 (P.L.458, NO.88), IS AMENDED TO READ: 4 SECTION 1104. PROCEDURE. 5 * * * 6 (B) REVIEW.--UPON RECEIPT OF A COMPLETED APPLICATION, THE 7 INSURANCE DEPARTMENT SHALL REVIEW THE APPLICANT'S INFORMATION 8 AND GRANT THE APPLICABLE ABATEMENT OF THE ASSESSMENT FOR THE 9 PREVIOUS CALENDAR YEAR SPECIFIED ON THE APPLICATION IN 10 ACCORDANCE WITH ALL OF THE FOLLOWING: 11 (1) THE INSURANCE DEPARTMENT SHALL NOTIFY THE DEPARTMENT 12 OF PUBLIC WELFARE THAT THE APPLICANT HAS SELF-CERTIFIED AS 13 ELIGIBLE AND WAS NOT DISQUALIFIED FOR AN ABATEMENT UNDER 14 SECTION 1103(6), (7), (8), (9), (10) AND (11) FOR A 100% 15 ABATEMENT OF THE IMPOSED ASSESSMENT IF THE HEALTH CARE 16 PROVIDER WAS ASSESSED UNDER SECTION 712(D) AS: 17 (I) A PHYSICIAN WHO IS ASSESSED AS A MEMBER OF ONE 18 OF THE FOUR HIGHEST RATE CLASSES OF THE PREVAILING 19 PRIMARY PREMIUM; 20 (II) AN EMERGENCY PHYSICIAN; 21 (III) A PHYSICIAN WHO ROUTINELY PROVIDES OBSTETRICAL 22 SERVICES IN RURAL AREAS AS DESIGNATED BY THE INSURANCE 23 DEPARTMENT; [OR] 24 (IV) A CERTIFIED NURSE MIDWIFE[.]; OR 25 (V) A BIRTH CENTER. 26 (2) THE INSURANCE DEPARTMENT SHALL NOTIFY THE DEPARTMENT 27 OF PUBLIC WELFARE THAT THE APPLICANT HAS SELF-CERTIFIED AS 28 ELIGIBLE AND WAS NOT DISQUALIFIED FOR AN ABATEMENT UNDER 29 SECTION 1103(6), (7), (8), (9), (10) AND (11) FOR A 50% 30 ABATEMENT OF THE IMPOSED ASSESSMENT IN CALENDAR YEARS 2008 20070S1137B1827 - 39 -
1 THROUGH 2012, A 56.5% ABATEMENT IN CALENDAR YEAR 2013, A 2 63.5% ABATEMENT IN CALENDAR YEAR 2014, A 70% ABATEMENT IN 3 CALENDAR YEAR 2015, A 78% ABATEMENT IN CALENDAR YEAR 2016, AN 4 88% ABATEMENT IN CALENDAR YEAR 2017 AND A 100% ABATEMENT IN 5 CALENDAR YEAR 2018 IF THE HEALTH CARE PROVIDER WAS ASSESSED 6 UNDER SECTION 712(D) AS: 7 (I) A PHYSICIAN BUT IS A PHYSICIAN WHO DOES NOT 8 QUALIFY FOR ABATEMENT UNDER PARAGRAPH (1); 9 (II) A LICENSED PODIATRIST; [OR] 10 (III) A NURSING HOME[.]; OR 11 (IV) A BIRTH CENTER. 12 * * * 13 SECTION 9. SECTION 1112(C) AND (E) OF THE ACT, ADDED 14 DECEMBER 22, 2005 (P.L.458, NO.88), ARE AMENDED AND THE SECTION 15 IS AMENDED BY ADDING SUBSECTIONS TO READ: 16 SECTION 1112. HEALTH CARE PROVIDER RETENTION ACCOUNT. 17 * * * 18 (A.1) SUPPLEMENTAL ASSISTANCE AND FUNDING ACCOUNT.--THERE IS 19 ESTABLISHED WITHIN THE HEALTH CARE PROVIDER RETENTION ACCOUNT A 20 SPECIAL ACCOUNT TO BE KNOWN AS THE SUPPLEMENTAL ASSISTANCE AND 21 FUNDING ACCOUNT. FUNDS IN THIS ACCOUNT SHALL BE USED ANNUALLY TO 22 SUPPLEMENT THE FUNDING OF THE PENNSYLVANIA ACCESS TO BASIC CARE 23 (PA ABC) PROGRAM. 24 * * * 25 (C) TRANSFERS FROM ACCOUNT.-- 26 (1) THE SECRETARY OF THE BUDGET MAY ANNUALLY TRANSFER 27 FROM THE ACCOUNT TO THE MEDICAL CARE AVAILABILITY AND 28 REDUCTION OF ERROR (MCARE) FUND AN AMOUNT UP TO THE AGGREGATE 29 AMOUNT OF ABATEMENTS GRANTED BY THE INSURANCE DEPARTMENT 30 UNDER SECTION 1104(B). 20070S1137B1827 - 40 -
1 (2) IN ADDITION TO THE TRANSFERS SPECIFIED IN PARAGRAPH 2 (1), THE SECRETARY OF THE BUDGET MAY ALSO TRANSFER FUNDS FROM 3 THE ACCOUNT TO THE MEDICAL CARE AVAILABILITY AND REDUCTION OF 4 ERROR (MCARE) FUND FOR THE PURPOSE OF PAYING CLAIMS AND 5 OPERATING EXPENSES COMING DUE AFTER JANUARY 1, 2018. 6 (3) THE SECRETARY OF THE BUDGET MAY TRANSFER FUNDS FROM 7 THE ACCOUNT TO THE PENNSYLVANIA ACCESS TO BASIC CARE (PA ABC) 8 PROGRAM FUND. 9 (4) THE SECRETARY OF THE BUDGET SHALL ANNUALLY TRANSFER 10 FROM THE ACCOUNT TO THE CONTINUING ACCESS RELIEF FOR 11 EMPLOYERS (CARE) FUND AN AMOUNT AT LEAST EQUAL TO THE AMOUNT 12 DEPOSITED UNDER SECTION 712(M). 13 (C.1) TRANSFERS FROM THE SUPPLEMENTAL ASSISTANCE AND FUNDING 14 ACCOUNT.--THE SECRETARY OF THE BUDGET SHALL ANNUALLY TRANSFER 15 FUNDS FROM THE SUPPLEMENTAL ASSISTANCE AND FUNDING ACCOUNT 16 ESTABLISHED UNDER SUBSECTION (A.1) TO THE PENNSYLVANIA ACCESS TO 17 BASIC CARE (PA ABC) PROGRAM FUND. 18 * * * 19 [(E) ADMINISTRATION ASSISTANCE.--THE INSURANCE DEPARTMENT 20 SHALL PROVIDE ASSISTANCE TO THE DEPARTMENT OF PUBLIC WELFARE IN 21 ADMINISTERING THE ACCOUNT.] 22 SECTION 10. SECTION 1115 OF THE ACT, AMENDED OCTOBER 27, 23 2006 (P.L.1198, NO.128), IS AMENDED TO READ: 24 SECTION 1115. EXPIRATION. 25 THE HEALTH CARE PROVIDER RETENTION PROGRAM ESTABLISHED UNDER 26 THIS CHAPTER SHALL EXPIRE DECEMBER 31, [2008] 2018. 27 SECTION 11. THE ACT IS AMENDED BY ADDING A CHAPTER TO READ: 28 CHAPTER 13 29 PENNSYLVANIA ACCESS TO BASIC CARE (PA ABC) PROGRAM 30 SECTION 1301. SCOPE. 20070S1137B1827 - 41 -
1 THIS CHAPTER RELATES TO OFFERING HEALTH CARE COVERAGE TO 2 ELIGIBLE ADULTS, INDIVIDUALS, EMPLOYEES AND EMPLOYERS. 3 SECTION 1302. DEFINITIONS. 4 THE FOLLOWING WORDS AND PHRASES WHEN USED IN THIS CHAPTER 5 SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SECTION UNLESS THE 6 CONTEXT CLEARLY INDICATES OTHERWISE: 7 "ADULTBASIC PROGRAM." THE ADULT BASIC COVERAGE INSURANCE 8 PROGRAM ESTABLISHED UNDER SECTION 1303 OF THE ACT OF JUNE 26, 9 2001 (P.L.755, NO.77), KNOWN AS THE TOBACCO SETTLEMENT ACT. 10 "AVERAGE ANNUAL WAGE." THE TOTAL ANNUAL WAGES PAID BY AN 11 EMPLOYER DIVIDED BY THE NUMBER OF THE EMPLOYER'S FULL-TIME 12 EQUIVALENT EMPLOYEES. 13 "BEHAVIORAL HEALTH SERVICES." MENTAL HEALTH OR SUBSTANCE 14 ABUSE SERVICES. 15 "CHILDREN'S HEALTH INSURANCE PROGRAM." THE CHILDREN'S HEALTH 16 CARE PROGRAM ESTABLISHED UNDER ARTICLE XXIII OF THE ACT OF MAY 17 17, 1921 (P.L.682, NO.284), KNOWN AS THE INSURANCE COMPANY LAW 18 OF 1921. 19 "CHRONIC DISEASE MANAGEMENT PROGRAM." A PROGRAM THAT ALLOWS 20 A PATIENT, WITH THE SUPPORT OF A HEALTH CARE TEAM, TO PLAY AN 21 ACTIVE ROLE IN THE PATIENT'S CARE AND ASSURES THAT THERE IS AN 22 INFRASTRUCTURE TO ENSURE COMPLIANCE WITH ESTABLISHED PRACTICE 23 GUIDELINES. 24 "COMMUNITY HEALTH REINVESTMENT AGREEMENT." THE AGREEMENT ON 25 COMMUNITY HEALTH REINVESTMENT ENTERED INTO FEBRUARY 2, 2005, BY 26 THE INSURANCE DEPARTMENT AND CAPITAL BLUE CROSS, HIGHMARK INC., 27 HOSPITAL SERVICE ASSOCIATION OF NORTHEASTERN PENNSYLVANIA AND 28 INDEPENDENCE BLUE CROSS AND PUBLISHED IN THE PENNSYLVANIA 29 BULLETIN AT 35 PA.B. 4155. 30 "CONTRACTOR." AN INSURER AWARDED A CONTRACT TO PROVIDE 20070S1137B1827 - 42 -
1 HEALTH CARE SERVICES UNDER THIS CHAPTER. THE TERM INCLUDES AN 2 ENTITY AND ITS SUBSIDIARY WHICH IS ESTABLISHED UNDER 40 PA.C.S. 3 CH. 61 (RELATING TO HOSPITAL PLAN CORPORATIONS) OR 63 (RELATING 4 TO PROFESSIONAL HEALTH SERVICES PLAN CORPORATIONS), THE ACT OF 5 MAY 17, 1921 (P.L.682, NO.284), KNOWN AS THE INSURANCE COMPANY 6 LAW OF 1921, OR THE ACT OF DECEMBER 29, 1972 (P.L.1701, NO.364), 7 KNOWN AS THE HEALTH MAINTENANCE ORGANIZATION ACT. 8 "DEPARTMENT." THE INSURANCE DEPARTMENT OF THE COMMONWEALTH. 9 "ELIGIBLE ADULT." AN INDIVIDUAL WHO MEETS ALL OF THE 10 FOLLOWING: 11 (1) IS AT LEAST 19 YEARS OF AGE BUT NOT MORE THAN 64 12 YEARS OF AGE. 13 (2) LEGALLY RESIDES WITHIN THE UNITED STATES. 14 (3) HAS BEEN DOMICILED IN THIS COMMONWEALTH FOR AT LEAST 15 90 DAYS PRIOR TO APPLICATION TO THE PROGRAM. 16 (4) IS INELIGIBLE TO RECEIVE CONTINUOUS ELIGIBILITY 17 COVERAGE UNDER TITLE XIX OR XXI OF THE SOCIAL SECURITY ACT 18 (49 STAT. 620, 42 U.S.C. § 301 ET SEQ.), EXCEPT FOR BENEFITS 19 AUTHORIZED UNDER A WAIVER GRANTED BY THE UNITED STATES 20 DEPARTMENT OF HEALTH AND HUMAN SERVICES TO IMPLEMENT THE 21 PENNSYLVANIA ACCESS TO BASIC CARE (PA ABC) PROGRAM. 22 (5) IS INELIGIBLE FOR MEDICAL ASSISTANCE OR MEDICARE. 23 (6) MAY CURRENTLY BE ENROLLED IN THE ADULTBASIC PROGRAM 24 OR IS ON THE WAITING LIST FOR THAT PROGRAM ON THE EFFECTIVE 25 DATE OF THIS SECTION. 26 (7) SUBJECT TO THE PROVISIONS OF SECTION 1305, HAS A 27 HOUSEHOLD INCOME THAT IS NO GREATER THAN 300% OF THE FEDERAL 28 POVERTY LEVEL AT THE TIME OF APPLICATION. 29 (8) HAS NOT BEEN COVERED BY ANY HEALTH INSURANCE PLAN OR 30 PROGRAM FOR AT LEAST 180 DAYS IMMEDIATELY PRECEDING THE DATE 20070S1137B1827 - 43 -
1 OF APPLICATION, EXCEPT THAT THE 180-DAY PERIOD SHALL NOT 2 APPLY TO AN ELIGIBLE ADULT WHO MEETS ONE OF THE FOLLOWING: 3 (I) IS ELIGIBLE TO RECEIVE BENEFITS UNDER THE ACT OF 4 DECEMBER 5, 1936 (2ND SP.SESS., 1937 P.L.2897, NO.1), 5 KNOWN AS THE UNEMPLOYMENT COMPENSATION LAW; 6 (II) WAS COVERED UNDER A HEALTH INSURANCE PLAN OR 7 PROGRAM PROVIDED BY AN EMPLOYER, BUT AT THE TIME OF 8 APPLICATION IS NO LONGER COVERED BECAUSE OF A CHANGE IN 9 THE INDIVIDUAL'S EMPLOYMENT STATUS AND IS INELIGIBLE TO 10 RECEIVE BENEFITS UNDER THE UNEMPLOYMENT COMPENSATION LAW; 11 (III) LOST COVERAGE AS A RESULT OF DIVORCE OR 12 SEPARATION FROM A COVERED INDIVIDUAL, THE DEATH OF A 13 COVERED INDIVIDUAL OR A CHANGE IN EMPLOYMENT STATUS OF A 14 COVERED INDIVIDUAL; OR 15 (IV) IS TRANSFERRING FROM ANOTHER GOVERNMENT- 16 SUBSIDIZED HEALTH INSURANCE PROGRAM, INCLUDING A TRANSFER 17 THAT OCCURS AS A RESULT OF FAILURE TO MEET INCOME 18 ELIGIBILITY REQUIREMENTS. 19 "ELIGIBLE EMPLOYEE." AN ELIGIBLE ADULT OR AN EMPLOYEE WHO 20 MEETS ALL THE REQUIREMENTS OF AN ELIGIBLE ADULT OR EMPLOYEE AT 21 THE TIME THE ELIGIBLE EMPLOYER MAKES APPLICATION TO THE PROGRAM. 22 "ELIGIBLE EMPLOYER." AN EMPLOYER THAT MEETS ALL OF THE 23 FOLLOWING: 24 (1) HAS AT LEAST TWO BUT NOT MORE THAN 50 FULL-TIME 25 EQUIVALENT EMPLOYEES. 26 (2) HAS NOT OFFERED HEALTH CARE COVERAGE THROUGH ANY 27 PLAN OR PROGRAM DURING THE 180 DAYS IMMEDIATELY PRECEDING THE 28 DATE OF APPLICATION FOR PARTICIPATION IN THE PENNSYLVANIA 29 ACCESS TO BASIC CARE (PA ABC) PROGRAM. 30 (3) HAS NOT PROVIDED REMUNERATION IN ANY FORM TO AN 20070S1137B1827 - 44 -
1 EMPLOYEE ON PAYROLL FOR THE PURCHASE OF HEALTH CARE COVERAGE 2 DURING THE 180 DAYS IMMEDIATELY PRECEDING THE DATE ON WHICH 3 THE EMPLOYER APPLIES FOR PARTICIPATION IN THE PROGRAM. 4 (4) PAYS AN AVERAGE ANNUAL WAGE THAT IS LESS THAN 300% 5 OF THE FEDERAL POVERTY LEVEL FOR AN INDIVIDUAL. 6 "EMPLOYEE." AN INDIVIDUAL WHO IS EMPLOYED FOR MORE THAN 20 7 HOURS IN A SINGLE WEEK AND FROM WHOSE WAGES AN EMPLOYER IS 8 REQUIRED UNDER THE INTERNAL REVENUE CODE OF 1986 (PUBLIC LAW 99- 9 514, 26 U.S.C. § 1 ET SEQ.) TO WITHHOLD FEDERAL INCOME TAX. 10 "EMPLOYER." THE TERM SHALL INCLUDE: 11 (1) ANY OF THE FOLLOWING WHO OR WHICH EMPLOYS TWO BUT 12 NOT MORE THAN 50 EMPLOYEES TO PERFORM SERVICES FOR 13 REMUNERATION: 14 (I) AN INDIVIDUAL, PARTNERSHIP, ASSOCIATION, 15 DOMESTIC OR FOREIGN CORPORATION OR OTHER ENTITY; 16 (II) THE LEGAL REPRESENTATIVE, TRUSTEE IN 17 BANKRUPTCY, RECEIVER OR TRUSTEE OF ANY INDIVIDUAL, 18 PARTNERSHIP, ASSOCIATION OR CORPORATION OR OTHER ENTITY; 19 OR 20 (III) THE LEGAL REPRESENTATIVE OF A DECEASED 21 INDIVIDUAL. 22 (2) AN INDIVIDUAL WHO IS SELF-EMPLOYED. 23 (3) THE EXECUTIVE, LEGISLATIVE AND JUDICIAL BRANCHES OF 24 THE COMMONWEALTH AND ANY ONE OF ITS POLITICAL SUBDIVISIONS. 25 "FUND." THE PENNSYLVANIA ACCESS TO BASIC CARE (PA ABC) 26 PROGRAM FUND. 27 "HEALTH BENEFIT PLAN." AN INSURANCE COVERAGE PLAN THAT 28 PROVIDES THE BENEFITS SET FORTH UNDER SECTION 1313. THE TERM 29 DOES NOT INCLUDE ANY OF THE FOLLOWING: 30 (1) AN ACCIDENT-ONLY POLICY. 20070S1137B1827 - 45 -
1 (2) A CREDIT-ONLY POLICY. 2 (3) A LONG-TERM OR DISABILITY INCOME POLICY. 3 (4) A SPECIFIED DISEASE POLICY. 4 (5) A MEDICARE SUPPLEMENT POLICY. 5 (6) A CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE 6 UNIFORMED SERVICES (CHAMPUS) SUPPLEMENT POLICY. 7 (7) A FIXED INDEMNITY POLICY. 8 (8) A DENTAL-ONLY POLICY. 9 (9) A VISION-ONLY POLICY. 10 (10) A WORKERS' COMPENSATION POLICY. 11 (11) AN AUTOMOBILE MEDICAL PAYMENT POLICY PURSUANT TO 75 12 PA.C.S. (RELATING TO VEHICLES). 13 (12) SUCH OTHER SIMILAR POLICIES PROVIDING FOR LIMITED 14 BENEFITS. 15 "HEALTH CARE COVERAGE." A HEALTH BENEFIT PLAN OR OTHER FORM 16 OF HEALTH CARE COVERAGE THAT IS APPROVED BY THE DEPARTMENT OF 17 COMMUNITY AND ECONOMIC DEVELOPMENT IN CONSULTATION WITH THE 18 INSURANCE DEPARTMENT. THE TERM DOES NOT INCLUDE COVERAGE UNDER 19 THE PA ABC PROGRAM. 20 "HEALTH MAINTENANCE ORGANIZATION" OR "HMO." AN ENTITY 21 ORGANIZED AND REGULATED UNDER THE ACT OF DECEMBER 29, 1972 22 (P.L.1701, NO.364), KNOWN AS THE HEALTH MAINTENANCE ORGANIZATION 23 ACT. 24 "HEALTH SAVINGS ACCOUNT." AN ACCOUNT ESTABLISHED BY AN 25 EMPLOYER UNDER SECTION 1307 ON BEHALF OF AN EMPLOYEE WHOSE 26 INCOME IS GREATER THAN 200% OF THE FEDERAL POVERTY LEVEL. 27 "HOSPITAL." AN INSTITUTION THAT HAS AN ORGANIZED MEDICAL 28 STAFF ENGAGED PRIMARILY IN PROVIDING TO INPATIENTS, BY OR UNDER 29 THE SUPERVISION OF PHYSICIANS, DIAGNOSTIC AND THERAPEUTIC 30 SERVICES FOR THE CARE OF INJURED, DISABLED, PREGNANT, DISEASED 20070S1137B1827 - 46 -
1 OR SICK OR MENTALLY ILL PERSONS. THE TERM INCLUDES A FACILITY 2 FOR THE DIAGNOSIS AND TREATMENT OF DISORDERS WITHIN THE SCOPE OF 3 SPECIFIC MEDICAL SPECIALTIES. THE TERM DOES NOT INCLUDE A 4 FACILITY THAT CARES EXCLUSIVELY FOR THE MENTALLY ILL. 5 "HOSPITAL PLAN CORPORATION." A HOSPITAL PLAN CORPORATION AS 6 DEFINED IN 40 PA.C.S. § 6101 (RELATING TO DEFINITIONS). 7 "INDIVIDUAL." A PERSON WHO MEETS ALL THE REQUIREMENTS OF AN 8 ELIGIBLE ADULT BUT WHOSE HOUSEHOLD INCOME IS GREATER THAN 300% 9 OF THE FEDERAL POVERTY LEVEL. 10 "INSURER." A COMPANY OR HEALTH INSURANCE ENTITY LICENSED IN 11 THIS COMMONWEALTH TO ISSUE AN INDIVIDUAL OR GROUP HEALTH, 12 SICKNESS OR ACCIDENT POLICY OR SUBSCRIBER CONTRACT OR 13 CERTIFICATE OR PLAN THAT PROVIDES MEDICAL OR HEALTH CARE 14 COVERAGE BY A HEALTH CARE FACILITY OR LICENSED HEALTH CARE 15 PROVIDER AND THAT IS OFFERED OR GOVERNED UNDER THIS ACT OR ANY 16 OF THE FOLLOWING: 17 (1) THE ACT OF MAY 17, 1921 (P.L.682, NO.284), KNOWN AS 18 THE INSURANCE COMPANY LAW OF 1921. 19 (2) THE ACT OF DECEMBER 29, 1972 (P.L.1701, NO.364), 20 KNOWN AS THE HEALTH MAINTENANCE ORGANIZATION ACT. 21 (3) THE ACT OF MAY 18, 1976 (P.L.123, NO.54), KNOWN AS 22 THE INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM 23 STANDARDS ACT. 24 (4) 40 PA.C.S. CH. 61 (RELATING TO HOSPITAL PLAN 25 CORPORATIONS) OR 63 (RELATING TO PROFESSIONAL HEALTH SERVICES 26 PLAN CORPORATIONS). 27 "MEDICAL ASSISTANCE." THE STATE PROGRAM OF MEDICAL 28 ASSISTANCE ESTABLISHED UNDER THE ACT OF JUNE 13, 1967 (P.L.31, 29 NO.21), KNOWN AS THE PUBLIC WELFARE CODE. 30 "MEDICAL LOSS RATIO." THE RATIO OF PAID MEDICAL CLAIM COSTS 20070S1137B1827 - 47 -
1 TO EARNED PREMIUMS. 2 "MEDICARE." THE FEDERAL PROGRAM ESTABLISHED UNDER TITLE 3 XVIII OF THE SOCIAL SECURITY ACT (49 STAT. 620, 42 U.S.C. § 1395 4 ET SEQ.). 5 "OFFEROR." AN INSURER THAT SUBMITS A BID OR PROPOSAL UNDER 6 SECTION 1311 IN RESPONSE TO THE DEPARTMENT'S PROCUREMENT 7 SOLICITATION. 8 "PREEXISTING CONDITION." A DISEASE OR PHYSICAL CONDITION FOR 9 WHICH MEDICAL ADVICE OR TREATMENT HAS BEEN RECEIVED PRIOR TO THE 10 EFFECTIVE DATE OF COVERAGE. 11 "PRESCRIPTION DRUG." A CONTROLLED SUBSTANCE, OTHER DRUG OR 12 DEVICE FOR MEDICATION DISPENSED BY ORDER OF AN APPROPRIATELY 13 LICENSED MEDICAL PROFESSIONAL. 14 "PROFESSIONAL HEALTH SERVICES PLAN CORPORATION." A NOT-FOR- 15 PROFIT CORPORATION OPERATING UNDER THE PROVISIONS OF 40 PA.C.S. 16 CH. 63 (RELATING TO PROFESSIONAL HEALTH SERVICES PLAN 17 CORPORATIONS). 18 "PROGRAM." THE PENNSYLVANIA ACCESS TO BASIC CARE (PA ABC) 19 PROGRAM ESTABLISHED UNDER THIS CHAPTER. 20 "QUALIFYING HEALTH CARE COVERAGE." A HEALTH BENEFIT PLAN OR 21 OTHER FORM OF HEALTH CARE COVERAGE ACTUARIALLY EQUIVALENT TO THE 22 BENEFITS IN SECTION 1313 AND APPROVED BY THE INSURANCE 23 DEPARTMENT. 24 "TERMINATE." THE TERM INCLUDES CANCELLATION, NONRENEWAL AND 25 RESCISSION. 26 "UNEMPLOYMENT COMPENSATION LAW." THE ACT OF DECEMBER 5, 1936 27 (2ND SP.SESS., 1937 P.L.2897, NO.1), KNOWN AS THE UNEMPLOYMENT 28 COMPENSATION LAW. 29 "UNINSURED PERIOD." A CONTINUOUS PERIOD OF TIME OF NOT LESS 30 THAN 180 CONSECUTIVE DAYS IMMEDIATELY PRECEDING ENROLLMENT 20070S1137B1827 - 48 -
1 APPLICATION DURING WHICH AN ADULT HAS BEEN WITHOUT HEALTH CARE 2 COVERAGE IN ACCORDANCE WITH THE REQUIREMENTS OF THIS CHAPTER. 3 SECTION 1303. ESTABLISHMENT OF PROGRAM. 4 THE PENNSYLVANIA ACCESS TO BASIC CARE (PA ABC) PROGRAM IS 5 ESTABLISHED IN THE DEPARTMENT. 6 SECTION 1304. FUNDING. 7 (A) SOURCES.--THE FOLLOWING ARE THE SOURCES OF MONEY FOR THE 8 PROGRAM: 9 (1) MONEY RECEIVED FROM THE SUPPLEMENTAL ASSISTANCE AND 10 FUNDING ACCOUNT ESTABLISHED UNDER SECTION 1112(A.1). 11 (2) MONEY RECEIVED FROM THE FEDERAL GOVERNMENT OR OTHER 12 SOURCES. 13 (3) MONEY REQUIRED TO BE DEPOSITED PURSUANT TO OTHER 14 PROVISIONS OF THIS CHAPTER OR ANY OTHER LAW OF THIS 15 COMMONWEALTH. 16 (4) UPON IMPLEMENTATION OF THE PROGRAM: 17 (I) ONLY THOSE FUNDS APPROPRIATED FOR HEALTH 18 INVESTMENT INSURANCE UNDER SECTION 306(B)(1)(VI) OF THE 19 ACT OF JUNE 26, 2001 (P.L.755, NO.77), KNOWN AS THE 20 TOBACCO SETTLEMENT ACT, AND DESIGNATED FOR THE ADULTBASIC 21 PROGRAM. 22 (II) MONEY CURRENTLY REQUIRED TO BE DEDICATED TO THE 23 ADULTBASIC PROGRAM OR ANY ALTERNATIVE PROGRAM TO BENEFIT 24 PERSONS OF LOW INCOME UNDER THE COMMUNITY HEALTH 25 REINVESTMENT AGREEMENT WITHIN THE RESPECTIVE SERVICE 26 AREAS FOR EACH PARTY TO THAT AGREEMENT. MONEY UNDER THIS 27 SUBPARAGRAPH SHALL BE USED ONLY TO DEFRAY THE COST OF THE 28 PROGRAM AND SUBSIDIES APPROVED UNDER SECTIONS 1305 AND 29 1306. 30 (5) ANY MONEYS DERIVED FROM WHATEVER SOURCES AND 20070S1137B1827 - 49 -
1 DESIGNATED SPECIFICALLY TO FUND THE PROGRAM. 2 (6) RETURN ON INVESTMENTS IN THE FUND. 3 SECTION 1305. PURCHASE BY ELIGIBLE ADULTS AND INDIVIDUALS. 4 (A) ELIGIBLE ADULTS.--AN ELIGIBLE ADULT WHO SEEKS TO 5 PURCHASE COVERAGE UNDER THE PROGRAM MUST: 6 (1) SUBMIT AN APPLICATION TO THE DEPARTMENT OR ITS 7 CONTRACTOR. 8 (2) PAY TO THE DEPARTMENT OR ITS CONTRACTOR THE AMOUNT 9 OF THE PREMIUM SPECIFIED. 10 (3) BE RESPONSIBLE FOR ANY REQUIRED COPAYMENTS FOR 11 HEALTH CARE SERVICES RENDERED UNDER THE HEALTH BENEFIT PLAN 12 IN SECTION 1313 SUBJECT TO FEDERAL WAIVER REQUIREMENTS. 13 (4) NOTIFY THE DEPARTMENT OR ITS CONTRACTOR OF ANY 14 CHANGE IN THE ELIGIBLE ADULT'S OR INDIVIDUAL'S HOUSEHOLD 15 INCOME. 16 (B) MONTHLY PREMIUMS.--EXCEPT TO THE EXTENT THAT CHANGES MAY 17 BE NECESSARY TO MEET FEDERAL REQUIREMENTS UNDER SECTION 1317 OR 18 TO ENCOURAGE ELIGIBLE EMPLOYER PARTICIPATION, SUBSIDIES FOR THE 19 2008-2009 FISCAL YEAR AND EACH FISCAL YEAR THEREAFTER SHALL 20 RESULT IN THE FOLLOWING PREMIUM AMOUNT BASED ON HOUSEHOLD INCOME 21 FOR A HEALTH BENEFIT PLAN: 22 (1) FOR AN ELIGIBLE ADULT WHOSE HOUSEHOLD INCOME IS NOT 23 GREATER THAN 150% OF THE FEDERAL POVERTY LEVEL, NO MONTHLY 24 PREMIUM. 25 (2) FOR AN ELIGIBLE ADULT WHOSE HOUSEHOLD INCOME IS 26 GREATER THAN 150% BUT NOT GREATER THAN 175% OF THE FEDERAL 27 POVERTY LEVEL, A MONTHLY PREMIUM OF $40. 28 (3) FOR AN ELIGIBLE ADULT WHOSE HOUSEHOLD INCOME IS 29 GREATER THAN 175% BUT NOT GREATER THAN 200% OF THE FEDERAL 30 POVERTY LEVEL, A MONTHLY PREMIUM OF $50. 20070S1137B1827 - 50 -
1 (4) FOR AN ELIGIBLE ADULT WHOSE HOUSEHOLD INCOME IS 2 GREATER THAN 200%, A MONTHLY PREMIUM MAY BE ESTABLISHED BASED 3 UPON FEDERAL REQUIREMENTS AND IN ACCORDANCE WITH FEDERAL 4 WAIVERS, IF APPLICABLE, BY THE COMMISSIONER. 5 (C) OTHER ELIGIBLE ADULTS.--AN ELIGIBLE ADULT WHOSE 6 HOUSEHOLD INCOME IS GREATER THAN 200% OF THE FEDERAL POVERTY 7 LEVEL MAY PURCHASE UNDER THE PROGRAM EITHER THE BENEFIT PACKAGE 8 UNDER SECTION 1313 OR OTHER QUALIFYING HEALTH CARE COVERAGE AT 9 THE PER-MEMBER, PER-MONTH PREMIUM COST. 10 (D) INDIVIDUALS.--FOR AN INDIVIDUAL WHOSE HOUSEHOLD INCOME 11 IS GREATER THAN 300% OF THE FEDERAL POVERTY LEVEL, AN INDIVIDUAL 12 MAY PURCHASE THE BENEFIT PACKAGE UNDER SECTION 1313 AT THE PER- 13 MEMBER, PER-MONTH PREMIUM COST AS LONG AS THE INDIVIDUAL 14 DEMONSTRATES, ON AN ANNUAL BASIS AND IN A MANNER DETERMINED BY 15 THE DEPARTMENT, EITHER ONE OF THE FOLLOWING: 16 (1) THE INDIVIDUAL IS UNABLE TO AFFORD INDIVIDUAL OR 17 GROUP COVERAGE BECAUSE THAT COVERAGE WOULD EXCEED 10% OF THE 18 INDIVIDUAL'S HOUSEHOLD INCOME OR BECAUSE THE TOTAL COST OF 19 COVERAGE FOR THE INDIVIDUAL IS 150% OF THE PREMIUM COST 20 ESTABLISHED UNDER THIS SECTION FOR THAT SERVICE AREA. 21 (2) THE INDIVIDUAL HAS BEEN REFUSED COVERAGE BY AN 22 INSURER BECAUSE THE INDIVIDUAL OR A MEMBER OF THAT 23 INDIVIDUAL'S IMMEDIATE FAMILY HAS A PREEXISTING CONDITION AND 24 COVERAGE IS NOT AVAILABLE TO THE INDIVIDUAL. 25 (E) ESTABLISHING PREMIUMS.--FOR EACH FISCAL YEAR BEGINNING 26 AFTER JUNE 30, 2009, THE DEPARTMENT MAY ADJUST THE PREMIUM 27 AMOUNTS UNDER SUBSECTION (B) TO REFLECT CHANGES IN THE COST OF 28 MEDICAL SERVICES AND SHALL FORWARD NOTICE OF THE NEW PREMIUM 29 AMOUNTS TO THE LEGISLATIVE REFERENCE BUREAU FOR PUBLICATION AS A 30 NOTICE IN THE PENNSYLVANIA BULLETIN. 20070S1137B1827 - 51 -
1 (F) PURCHASE OF HEALTH BENEFIT PLAN.--AN ELIGIBLE ADULT'S OR 2 INDIVIDUAL'S PAYMENT TO THE DEPARTMENT OR ITS CONTRACTOR UNDER 3 SUBSECTION (B) SHALL BE USED TO PURCHASE THE BENEFIT HEALTH PLAN 4 ESTABLISHED UNDER SECTION 1313 AND MUST BE REMITTED IN A TIMELY 5 MANNER. 6 (G) SUBSIDY.--FUNDING FOR THE PROGRAM SHALL BE USED BY THE 7 DEPARTMENT TO PAY THE DIFFERENCE BETWEEN THE TOTAL MONTHLY COST 8 OF THE HEALTH BENEFIT PLAN AND THE ELIGIBLE ADULT'S PREMIUM. 9 SUBSIDIZATION OF THE HEALTH BENEFIT PLAN IS CONTINGENT UPON THE 10 AMOUNT OF THE FUNDING FOR THE PROGRAM AND IS LIMITED TO ELIGIBLE 11 ADULTS IN COMPLIANCE WITH THIS SECTION. 12 SECTION 1306. PARTICIPATION BY ELIGIBLE EMPLOYERS AND ELIGIBLE 13 EMPLOYEES. 14 (A) ELIGIBLE EMPLOYERS.--AN ELIGIBLE EMPLOYER THAT SEEKS TO 15 PARTICIPATE IN THE PROGRAM SHALL: 16 (1) OFFER TO ALL ELIGIBLE EMPLOYEES THE OPPORTUNITY TO 17 PARTICIPATE IN THE PROGRAM AND ENROLL AT LEAST ONE-HALF OF 18 THE ELIGIBLE EMPLOYEES. 19 (2) COMPLY WITH THE APPLICATION PROCESS ESTABLISHED BY 20 THE DEPARTMENT OR ITS CONTRACTOR. 21 (3) REMIT TO THE DEPARTMENT OR ITS CONTRACTOR ANY 22 PREMIUM AMOUNTS REQUIRED UNDER SUBSECTIONS (C) AND (D). 23 (4) ALLOW HEALTH INSURANCE PREMIUMS TO BE PAID BY 24 ELIGIBLE EMPLOYEES ON A PRETAX BASIS AND INFORM ITS EMPLOYEES 25 OF THE AVAILABILITY OF SUCH PROGRAM. 26 (5) NOTIFY THE DEPARTMENT OR ITS CONTRACTOR OF ANY 27 CHANGE IN THE ELIGIBLE EMPLOYEE'S INCOME. 28 (B) ELIGIBLE EMPLOYEES.--AN ELIGIBLE EMPLOYEE WHO SEEKS TO 29 PARTICIPATE WITH AN ELIGIBLE EMPLOYER UNDER THE PROGRAM MUST: 30 (1) SUBMIT AN APPLICATION WITH THE ELIGIBLE EMPLOYER TO 20070S1137B1827 - 52 -
1 THE DEPARTMENT OR ITS CONTRACTOR. 2 (2) BE RESPONSIBLE FOR ANY REQUIRED COPAYMENTS FOR 3 HEALTH CARE SERVICES RENDERED UNDER THE HEALTH BENEFIT PLAN 4 IN SECTION 1313. 5 (C) PREMIUMS FOR EMPLOYERS.-- 6 (1) IN ADDITION TO REMITTING THE ELIGIBLE EMPLOYEE 7 PORTION UNDER SUBSECTIONS (A) AND (D), AN ELIGIBLE EMPLOYER 8 SHALL PAY THE EMPLOYER SHARE OF THE TOTAL MONTHLY COST FOR 9 EACH PARTICIPATING EMPLOYEE TO THE DEPARTMENT OR ITS 10 CONTRACTOR EACH MONTH. 11 (2) IN ADDITION TO REMITTING THE ELIGIBLE EMPLOYEE 12 PORTION UNDER PARAGRAPH (1), AN ELIGIBLE EMPLOYER'S PREMIUM 13 PAYMENT TO THE DEPARTMENT OR ITS CONTRACTOR SHALL BE AT LEAST 14 50% OF THE TOTAL MONTHLY COST FOR EACH ELIGIBLE EMPLOYEE BUT 15 NOT LESS THAN $150. 16 (D) PREMIUMS FOR ELIGIBLE EMPLOYEES.--THE PREMIUM FOR 17 ELIGIBLE EMPLOYEES SHALL BE THE SAME AS THE PREMIUM REQUIRED TO 18 BE PAID BY ELIGIBLE ADULTS UNDER SECTION 1305(B). 19 (E) PURCHASE BY CERTAIN ELIGIBLE EMPLOYEES.--AN ELIGIBLE 20 EMPLOYEE WHOSE HOUSEHOLD INCOME IS GREATER THAN 200% OF THE 21 FEDERAL POVERTY LEVEL MAY PURCHASE EITHER THE BENEFIT PACKAGE 22 UNDER SECTION 1313 OR OTHER QUALIFYING HEALTH CARE COVERAGE 23 UNDER SECTION 1307 AT THE PER-MEMBER, PER-MONTH PREMIUM COST 24 MINUS ANY AMOUNT REMITTED BY THE EMPLOYER UNDER SUBSECTION (C). 25 (F) PUBLISHING PREMIUM AMOUNTS.--FOR EACH FISCAL YEAR 26 BEGINNING AFTER JUNE 30, 2009, THE DEPARTMENT MAY ESTABLISH 27 DIFFERENT PREMIUM AMOUNTS FOR ELIGIBLE EMPLOYEES AND ELIGIBLE 28 EMPLOYERS AS REQUIRED UNDER THIS SECTION AND SHALL FORWARD 29 NOTICE OF THE NEW PREMIUM AMOUNTS TO THE LEGISLATIVE REFERENCE 30 BUREAU FOR PUBLICATION AS A NOTICE IN THE PENNSYLVANIA BULLETIN. 20070S1137B1827 - 53 -
1 (G) PURCHASE OF COVERAGE.--A PREMIUM PAYMENT MADE BY AN 2 ELIGIBLE EMPLOYER TO THE DEPARTMENT OR ITS CONTRACTOR SHALL BE 3 USED TO PURCHASE THE HEALTH BENEFIT PLAN AND MUST BE REMITTED IN 4 A TIMELY MANNER. 5 (H) ALTERNATIVE COVERAGE.-- 6 (1) NOTWITHSTANDING ANY OTHER PROVISION OF LAW TO THE 7 CONTRARY, EMPLOYER-BASED COVERAGE MAY, IN THE COMMISSIONER'S 8 SOLE DISCRETION, BE PURCHASED IN PLACE OF PARTICIPATION IN 9 THE PROGRAM OR MAY BE PURCHASED IN CONJUNCTION WITH ANY 10 PORTION OF THE PROGRAM PROVIDED OUTSIDE THE SCOPE OF THE 11 PROGRAM CONTRACTS BY THE COMMONWEALTH PAYING THE EMPLOYEE'S 12 SHARE OF THE PREMIUM TO THE EMPLOYER IF IT IS MORE COST 13 EFFECTIVE FOR THE COMMONWEALTH TO PURCHASE HEALTH CARE 14 COVERAGE FROM AN EMPLOYEE'S EMPLOYER-BASED PROGRAM THAN TO 15 PAY THE COMMONWEALTH'S SHARE OF A SUBSIDIZED PREMIUM. 16 (2) THIS SECTION SHALL APPLY TO ANY EMPLOYER-BASED 17 PROGRAM, WHETHER INDIVIDUAL OR FAMILY, SUCH THAT IF THE 18 COMMONWEALTH'S SHARE FOR THE EMPLOYEE PLUS ITS SHARE FOR ANY 19 SPOUSE UNDER THE PROGRAM OR CHILDREN UNDER THE CHILDREN'S 20 HEALTH INSURANCE PROGRAM IS GREATER THAN THE EMPLOYEE'S 21 PREMIUM SHARE FOR FAMILY COVERAGE UNDER THE EMPLOYER-BASED 22 PROGRAM, THE COMMONWEALTH MAY CHOOSE TO PAY THE LATTER ALONE 23 OR IN COMBINATION WITH PROVIDING ANY BENEFIT THE COMMONWEALTH 24 DOES NOT PROVIDE THROUGH ITS PROGRAM CONTRACTS. 25 (I) TERMINATION OF EMPLOYMENT.--AN ELIGIBLE EMPLOYEE WHO IS 26 TERMINATED FROM EMPLOYMENT SHALL BE ELIGIBLE TO CONTINUE 27 PARTICIPATING IN THE PROGRAM IF THE ELIGIBLE EMPLOYEE CONTINUES 28 TO MEET THE REQUIREMENTS AS AN ELIGIBLE ADULT AND PAYS ANY 29 INCREASED PREMIUM REQUIRED. 30 SECTION 1307. HEALTH SAVINGS ACCOUNTS. 20070S1137B1827 - 54 -
1 THE DEPARTMENT SHALL PERMIT THE ESTABLISHMENT OF HEALTH 2 SAVINGS ACCOUNTS THAT ARE ACTUARIALLY EQUIVALENT TO THE BENEFITS 3 IN SECTION 1313 FOR EMPLOYEES WHO ENROLL IN THE PROGRAM. HEALTH 4 SAVINGS ACCOUNTS ESTABLISHED UNDER THE PROGRAM SHALL MEET THE 5 REQUIREMENTS AS DEFINED IN SECTION 223(D) OF THE INTERNAL 6 REVENUE CODE OF 1986 (PUBLIC LAW 99-514, 26 U.S.C. § 223(D)). 7 SECTION 1308. CONTINUING ACCESS WITH RELIEF FOR EMPLOYERS 8 (CARE) GRANTS. 9 (A) GENERAL RULE.--A CONTINUING ACCESS WITH RELIEF FOR 10 EMPLOYERS (CARE) GRANT SHALL BE PROVIDED TO EMPLOYERS THAT MEET 11 THE REQUIREMENTS OF THIS SECTION. 12 (B) ELIGIBILITY.--AN EMPLOYER IS ELIGIBLE TO RECEIVE A CARE 13 GRANT IF THAT EMPLOYER MEETS THE FOLLOWING: 14 (1) HAS MAINTAINED COVERAGE FOR AT LEAST 12 CONSECUTIVE 15 MONTHS PRIOR TO THE EFFECTIVE DATE OF THIS ACT; OR 16 (2) (I) HAS MAINTAINED COVERAGE FOR AT LEAST 12 17 CONSECUTIVE MONTHS PRIOR TO APPLYING FOR THE CARE GRANT; 18 (II) HAS INCURRED A HEALTH CARE EXPENSE IN THIS 19 COMMONWEALTH; AND 20 (III) HAS A TAX LIABILITY FOR THE YEAR IN WHICH 21 APPLICATION IS MADE FOR THE CARE GRANT. 22 (C) APPLICATION.--BEGINNING JULY 1, 2009, AND FOR EACH YEAR 23 THEREAFTER, AN EMPLOYER SEEKING TO RECEIVE A CARE GRANT SHALL 24 SUBMIT AN APPLICATION TO THE DEPARTMENT CONTAINING, AT A 25 MINIMUM, THE FOLLOWING INFORMATION: 26 (1) A STATEMENT OF THE AGGREGATE HEALTH CARE EXPENSE 27 MADE BY THE EMPLOYER TO PROVIDE COVERAGE DURING THE PREVIOUS 28 12 CONSECUTIVE MONTHS TO EMPLOYEES. 29 (2) THE NAMES, ADDRESSES AND SOCIAL SECURITY NUMBERS OF 30 THE EMPLOYEES PROVIDED HEALTH CARE COVERAGE UNDER PARAGRAPH 20070S1137B1827 - 55 -
1 (1) AND WHETHER THAT HEALTH CARE COVERAGE IS FOR THE EMPLOYEE 2 OR THE EMPLOYEE AND THE EMPLOYEE'S SPOUSE AND/OR DEPENDENTS. 3 (3) THE NAMES AND ADDRESSES OF THE INSURANCE CARRIERS OR 4 UNDERWRITERS THAT RECEIVED PAYMENT FROM THE EMPLOYER FOR THE 5 HEALTH CARE COVERAGE PROVIDED UNDER PARAGRAPH (2). 6 (D) COMPUTATION.--AN EMPLOYER WHO QUALIFIES UNDER SUBSECTION 7 (B) SHALL RECEIVE A GRANT LIMITED TO ACTUAL EMPLOYER HEALTH CARE 8 EXPENSES PAID FOR THE PREVIOUS 12 CONSECUTIVE MONTHS IN 9 ACCORDANCE WITH THE FOLLOWING: 10 (1) NO GREATER THAN 25% OF THE EMPLOYER'S HEALTH CARE 11 EXPENSE TO MAINTAIN HEALTH CARE COVERAGE FOR THE EMPLOYEE. 12 (2) NO GREATER THAN 50% OF THE EMPLOYER'S HEALTH CARE 13 EXPENSE TO MAINTAIN HEALTH CARE COVERAGE FOR THE EMPLOYEE, 14 THE EMPLOYEE'S SPOUSE AND/OR DEPENDENTS. 15 (3) THE TOTAL AMOUNT OF PARAGRAPHS (1) AND (2) SHALL NOT 16 EXCEED THE TAX LIABILITY OWED BY THE EMPLOYER FOR THE YEAR 17 APPLICATION IS MADE FOR THE CARE GRANT. 18 (4) IF NO TAX LIABILITY IS OWED BY THE EMPLOYER THEN THE 19 EMPLOYER MAY NOT APPLY FOR A CARE GRANT. 20 (E) DUTIES OF DEPARTMENT.--THE DEPARTMENT HAS THE FOLLOWING 21 DUTIES: 22 (1) ADMINISTER THE PROGRAM. 23 (2) IN CONSULTATION WITH OTHER APPROPRIATE COMMONWEALTH 24 AGENCIES: 25 (I) DEVELOP AN APPLICATION FOR THE COLLECTION OF 26 INFORMATION THAT IS CONSISTENT WITH THE REQUIREMENTS OF 27 THIS SECTION AND THAT CONTAINS ANY OTHER INFORMATION THAT 28 MAY BE NECESSARY TO AWARD CARE GRANTS. 29 (II) DEVELOP A PROCESS TO DETERMINE THE VALIDITY OF 30 INFORMATION COLLECTED BY THE DEPARTMENT FROM THE 20070S1137B1827 - 56 -
1 APPLICATION WITH INFORMATION FILED BY THE EMPLOYER, THE 2 EMPLOYEE OR INSURERS WITH ANY OTHER AGENCY. THIS PROCESS 3 SHALL INCLUDE GUARANTEEING CONFIDENTIALITY OF EMPLOYER 4 AND EMPLOYEE INFORMATION THAT IS CONSISTENT WITH FEDERAL 5 AND STATE LAWS. 6 (F) COORDINATION.--THE DEPARTMENT SHALL COORDINATE WITH 7 OTHER DEPARTMENTS IN THE IMPLEMENTATION OF THIS SECTION. 8 (G) LIMITATION ON GRANTS.--THE TOTAL AMOUNT OF GRANTS 9 APPROVED BY THE DEPARTMENT SHALL NOT EXCEED THE AMOUNT OF 10 FUNDING DESIGNATED UNDER SECTION 762. ANY APPLICATION FILED BY 11 AN EMPLOYER WHEN FUNDING IS NOT AVAILABLE SHALL NOT BE 12 CONSIDERED AND CANNOT BE CARRIED FORWARD FOR CONSIDERATION IN 13 ANY SUCCEEDING FISCAL YEAR. 14 (H) LAPSE.--FUNDS NOT USED BY THE DEPARTMENT FOR CARE GRANTS 15 AT THE END OF THE FISCAL YEAR SHALL LAPSE BACK TO THE HEALTH 16 CARE PROVIDER RETENTION ACCOUNT AND BE DESIGNATED TO THE PA ABC 17 PROGRAM. 18 (I) REPORT TO GENERAL ASSEMBLY.--THE DEPARTMENT SHALL SUBMIT 19 AN ANNUAL REPORT TO THE GENERAL ASSEMBLY INDICATING THE 20 EFFECTIVENESS OF THE PROGRAM PROVIDED UNDER THIS SECTION NO 21 LATER THAN MARCH 15, 2010. THE REPORT SHALL INCLUDE THE NAMES OF 22 ALL THE EMPLOYERS THAT RECEIVED A CARE GRANT AS OF THE DATE OF 23 THE REPORT AND THE AMOUNT OF EACH CARE GRANT APPROVED. THE 24 REPORT MAY ALSO INCLUDE ANY RECOMMENDATIONS FOR CHANGES IN THE 25 CALCULATION OR ADMINISTRATION OF THE CARE GRANT. 26 (J) SUNSET.--THIS SECTION SHALL SUNSET JANUARY 1, 2018. 27 (K) DEFINITIONS.--AS USED IN THIS SECTION, THE FOLLOWING 28 WORDS AND PHRASES SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS 29 SUBSECTION: 30 "CARE GRANT." A CONTINUING ACCESS WITH RELIEF FOR EMPLOYERS 20070S1137B1827 - 57 -
1 (CARE) GRANT PROVIDED BY THE DEPARTMENT OF COMMUNITY AND 2 ECONOMIC DEVELOPMENT. 3 "COVERAGE." HEALTH CARE COVERAGE THAT IS MAINTAINED BY AN 4 EMPLOYER FOR AN EMPLOYEE, THE EMPLOYEE'S SPOUSE AND/OR 5 DEPENDENTS FOR 12 CONSECUTIVE MONTHS. 6 "DEPARTMENT." THE DEPARTMENT OF COMMUNITY AND ECONOMIC 7 DEVELOPMENT OF THE COMMONWEALTH. 8 "EMPLOYEE." AN INDIVIDUAL WHO MEETS THE FOLLOWING: 9 (1) IS EMPLOYED FOR MORE THAN 20 HOURS IN A SINGLE WEEK 10 AND FROM WHOSE WAGES AN EMPLOYER IS REQUIRED UNDER THE 11 INTERNAL REVENUE CODE OF 1986 (PUBLIC LAW 99-514, 26 U.S.C. 12 §1 ET SEQ.) TO WITHHOLD FEDERAL INCOME TAX. 13 (2) IS AT LEAST 19 YEARS OF AGE BUT NO OLDER THAN 64 14 YEARS OF AGE. 15 (3) LEGALLY RESIDES WITHIN THE UNITED STATES. 16 (4) HAS BEEN DOMICILED IN THIS COMMONWEALTH FOR AT LEAST 17 90 DAYS PRIOR TO ENROLLMENT. 18 (5) HAS A HOUSEHOLD INCOME THAT IS NO GREATER THAN 300% 19 OF THE FEDERAL POVERTY LEVEL AT THE TIME OF APPLICATION. 20 "EMPLOYER." AN EMPLOYER THAT MEETS ALL OF THE FOLLOWING: 21 (1) HAS AT LEAST TWO, BUT NOT MORE THAN 50 FULL-TIME 22 EQUIVALENT EMPLOYEES. 23 (2) PAYS AN AVERAGE ANNUAL WAGE THAT IS NOT GREATER THAN 24 300% OF THE FEDERAL POVERTY LIMIT FOR AN INDIVIDUAL. 25 "HEALTH CARE COVERAGE." A HEALTH BENEFIT PLAN OR OTHER FORM 26 OF HEALTH CARE COVERAGE THAT IS APPROVED BY THE DEPARTMENT OF 27 COMMUNITY AND ECONOMIC DEVELOPMENT IN CONSULTATION WITH THE 28 INSURANCE DEPARTMENT. THE TERM DOES NOT INCLUDE COVERAGE UNDER 29 THE PA ABC PROGRAM. 30 "HEALTH CARE EXPENSE." A PAYMENT MADE BY AN EMPLOYER TO 20070S1137B1827 - 58 -
1 MAINTAIN HEALTH CARE COVERAGE FOR AN EMPLOYEE, THE EMPLOYEE'S 2 SPOUSE AND/OR DEPENDENTS. 3 "PROGRAM." THE CONTINUING ACCESS WITH RELIEF FOR EMPLOYERS 4 (CARE) GRANT PROGRAM ESTABLISHED UNDER THIS SECTION. 5 "TAX LIABILITY." LIABILITY UNDER ARTICLE III, IV OR VI OF 6 THE ACT OF MARCH 4, 1971 (P.L.6, NO.2), KNOWN AS THE TAX REFORM 7 CODE OF 1971. 8 SECTION 1309. PROGRAM REQUIREMENTS. 9 (A) RATES.--RATES FOR THE PROGRAM SHALL BE APPROVED ANNUALLY 10 BY THE DEPARTMENT AND MAY VARY BY REGION AND CONTRACTOR. RATES 11 SHALL BE BASED ON AN ACTUARIALLY SOUND AND ADEQUATE REVIEW. 12 (B) ANNUAL PREMIUMS REVIEW.--PREMIUMS FOR THE PROGRAM SHALL 13 BE ESTABLISHED ANNUALLY BY THE DEPARTMENT. 14 (C) USE OF FUNDING.--FUNDING SHALL BE USED BY THE DEPARTMENT 15 TO PAY THE DIFFERENCE BETWEEN THE TOTAL MONTHLY COST OF THE 16 HEALTH BENEFIT PLAN AND THE PREMIUM PAYMENTS BY THE ELIGIBLE 17 EMPLOYEE, THE ELIGIBLE EMPLOYER OR THE ELIGIBLE ADULT. 18 (D) MONTHLY INCREASES.--WITH RESPECT TO A CONTINUOUS PERIOD 19 OF ELIGIBILITY FOR AN ELIGIBLE EMPLOYER TO APPLY FOR 20 PARTICIPATION IN THE PROGRAM AND IN ADDITION TO THE REQUIREMENTS 21 OF SECTION 1306(D), AN ELIGIBLE EMPLOYER SHALL BE SUBJECT TO A 22 1% INCREASE IN THE BASE PREMIUM FOR EACH MONTH AFTER THE LATTER 23 OF THE FOLLOWING: 24 (1) TWELVE MONTHS FROM THE DATE OF THE EFFECTIVE DATE OF 25 THIS SECTION; OR 26 (2) TWELVE MONTHS FROM THE DATE THE ELIGIBLE EMPLOYER 27 FILES FOR A FEDERAL OR STATE TAX IDENTIFICATION NUMBER. 28 (E) FUNDING CONTINGENCY FOR SUBSIDIZATION.--SUBSIDIZATION OF 29 PREMIUMS PAID UNDER SECTIONS 1305 AND 1306 IS CONTINGENT UPON 30 THE AMOUNT OF THE FUNDING AVAILABLE TO THE PROGRAM, THE FEDERAL 20070S1137B1827 - 59 -
1 POVERTY LEVELS APPROVED BY THE FEDERAL WAIVER OR STATE PLAN 2 AMENDMENTS GRANTED UNDER SECTION 1317 AND IS LIMITED TO ELIGIBLE 3 ADULTS AND ELIGIBLE EMPLOYEES WHO ARE IN COMPLIANCE WITH THE 4 REQUIREMENTS UNDER THIS CHAPTER. 5 (F) LIMIT ON SUBSIDY.--AT NO TIME SHALL THE SUBSIDY PAID BY 6 THE COMMONWEALTH FROM FUNDS OTHER THAN FEDERAL MONEYS FOR THE 7 PREMIUM OF ELIGIBLE EMPLOYEES BE MORE THAN 40% OF THE TOTAL COST 8 OF THE HEALTH BENEFIT PLAN PURCHASED IN EACH REGION OR WITH EACH 9 CONTRACTOR. 10 SECTION 1310. DUTIES OF DEPARTMENT. 11 THE DEPARTMENT HAS THE FOLLOWING DUTIES: 12 (1) ADMINISTER THE PROGRAM ON A STATEWIDE BASIS. 13 (2) SOLICIT BIDS OR PROPOSALS AND AWARD CONTRACTS AS 14 FOLLOWS: 15 (I) THE DEPARTMENT SHALL SOLICIT BIDS OR PROPOSALS 16 AND AWARD CONTRACTS FOR THE BASIC BENEFIT PACKAGE UNDER 17 SECTION 1313 THROUGH A COMPETITIVE PROCUREMENT PROCESS IN 18 ACCORDANCE WITH 62 PA.C.S. (RELATING TO PROCUREMENT) AND 19 SECTION 1311. THE DEPARTMENT MAY AWARD CONTRACTS ON A 20 MULTIPLE-AWARD BASIS AS DESCRIBED IN 62 PA.C.S. § 517 21 (RELATING TO MULTIPLE AWARDS). 22 (II) (A) IN ORDER TO EFFECTUATE THE PROGRAM 23 PROMPTLY UPON RECEIPT OF ALL APPLICABLE WAIVERS AND 24 APPROVALS FROM THE FEDERAL GOVERNMENT, THE DEPARTMENT 25 MAY AMEND SUCH CONTRACTS AS CURRENTLY EXIST TO 26 PROVIDE BENEFITS UNDER EITHER THE ADULTBASIC PROGRAM 27 OR THE PUBLIC WELFARE CODE, OR MAY OTHERWISE PROCURE 28 SERVICES OUTSIDE OF THE COMPETITIVE PROCUREMENT 29 PROCESS OF 62 PA.C.S. 30 (B) THIS SUBPARAGRAPH SHALL EXPIRE AT SUCH TIME 20070S1137B1827 - 60 -
1 AS THERE ARE EFFECTIVE CONTRACTS AWARDED UNDER THIS 2 SECTION IN EVERY COUNTY OF THIS COMMONWEALTH, BUT NOT 3 LATER THAN 18 MONTHS AFTER THE EFFECTIVE DATE OF THIS 4 SECTION. 5 (3) SUBJECT TO FEDERAL REQUIREMENTS, IMPOSE REASONABLE 6 COST-SHARING ARRANGEMENTS AND ENCOURAGE APPROPRIATE USE BY 7 CONTRACTORS OF COST-EFFECTIVE HEALTH CARE PROVIDERS WHO WILL 8 PROVIDE QUALITY HEALTH CARE BY ESTABLISHING AND ADJUSTING 9 COPAYMENTS TO BE INCORPORATED INTO THE PROGRAM BY 10 CONTRACTORS. THE DEPARTMENT SHALL FORWARD CHANGES OF 11 COPAYMENTS TO THE LEGISLATIVE REFERENCE BUREAU FOR 12 PUBLICATION AS NOTICES IN THE PENNSYLVANIA BULLETIN. THE 13 CHANGES SHALL BE IMPLEMENTED BY CONTRACTORS AS SOON AS 14 PRACTICABLE FOLLOWING PUBLICATION, BUT IN NO EVENT MORE THAN 15 120 DAYS FOLLOWING PUBLICATION. 16 (4) IN CONSULTATION WITH OTHER APPROPRIATE COMMONWEALTH 17 AGENCIES, CONDUCT MONITORING AND OVERSIGHT OF CONTRACTS 18 ENTERED INTO WITH CONTRACTORS. 19 (5) IN CONSULTATION WITH OTHER APPROPRIATE COMMONWEALTH 20 AGENCIES, MONITOR, REVIEW AND EVALUATE THE ADEQUACY, 21 ACCESSIBILITY AND AVAILABILITY OF SERVICES DELIVERED TO 22 ELIGIBLE ADULTS OR ELIGIBLE EMPLOYEES. 23 (6) IN CONSULTATION WITH OTHER APPROPRIATE COMMONWEALTH 24 AGENCIES, ESTABLISH AND COORDINATE THE DEVELOPMENT, 25 IMPLEMENTATION AND SUPERVISION OF AN OUTREACH PLAN TO ENSURE 26 THAT ALL THOSE WHO MAY BE ELIGIBLE ARE AWARE OF THE PROGRAM. 27 THE OUTREACH PLAN SHALL INCLUDE PROVISIONS FOR: 28 (I) REACHING SPECIAL POPULATIONS, INCLUDING NONWHITE 29 AND NON-ENGLISH SPEAKING INDIVIDUALS AND INDIVIDUALS WITH 30 DISABILITIES. 20070S1137B1827 - 61 -
1 (II) REACHING DIFFERENT GEOGRAPHIC AREAS, INCLUDING 2 RURAL AND INNER-CITY AREAS. 3 (III) ASSURING THAT SPECIAL EFFORTS ARE COORDINATED 4 WITHIN THE OVERALL OUTREACH ACTIVITIES THROUGHOUT THIS 5 COMMONWEALTH. 6 (7) AT THE REQUEST OF AN ELIGIBLE ADULT, ELIGIBLE 7 EMPLOYEE OR ELIGIBLE EMPLOYER, FACILITATE THE PAYMENT ON A 8 PRETAX BASIS OF PREMIUMS: 9 (I) FOR THE PROGRAM AND DEPENDENTS COVERED UNDER THE 10 PROGRAM; OR 11 (II) IF APPLICABLE, FOR THE CHILDREN'S HEALTH 12 INSURANCE PROGRAM. 13 (8) ESTABLISH PENALTIES FOR ELIGIBLE ADULTS, ELIGIBLE 14 EMPLOYEES OR ELIGIBLE EMPLOYERS WHO ENROLL IN THE PROGRAM, 15 DROP ENROLLMENT AND SUBSEQUENTLY RE-ENROLL FOR THE PURPOSE OF 16 AVOIDING THE ONGOING PAYMENT OF PREMIUMS. THE COMMISSIONER 17 SHALL FORWARD NOTICE OF THESE PENALTIES TO THE LEGISLATIVE 18 REFERENCE BUREAU FOR PUBLICATION AS A NOTICE IN THE 19 PENNSYLVANIA BULLETIN. 20 (9) COORDINATE WITH THE DEPARTMENT OF PUBLIC WELFARE IN 21 THE IMPLEMENTATION OF THIS CHAPTER AND MAY DESIGNATE THE 22 DEPARTMENT OF PUBLIC WELFARE TO PERFORM ANY DUTIES THAT ARE 23 APPROPRIATE UNDER THIS CHAPTER. 24 SECTION 1311. SUBMISSION OF PROPOSALS AND AWARD OF CONTRACTS. 25 (A) CORPORATIONS REQUIRED TO SUBMIT.--EACH PROFESSIONAL 26 HEALTH SERVICES PLAN CORPORATION AND HOSPITAL PLAN CORPORATION 27 AND THEIR SUBSIDIARIES AND AFFILIATES DOING BUSINESS IN THIS 28 COMMONWEALTH SHALL SUBMIT A BID OR PROPOSAL TO THE DEPARTMENT TO 29 CARRY OUT THE PURPOSES OF THIS SECTION IN THE GEOGRAPHIC AREA 30 SERVICED BY THE CORPORATION. ALL OTHER INSURERS MAY SUBMIT A BID 20070S1137B1827 - 62 -
1 OR PROPOSAL TO THE DEPARTMENT TO CARRY OUT THE PURPOSES OF THIS 2 SECTION. 3 (B) REVIEW AND SCORING OF BIDS OR PROPOSALS.--THE 4 DEPARTMENT SHALL REVIEW AND SCORE THE BIDS OR PROPOSALS ON THE 5 BASIS OF ALL THE REQUIREMENTS FOR THE PROGRAM. THE DEPARTMENT 6 MAY INCLUDE OTHER CRITERIA IN THE SOLICITATION AND IN THE 7 SCORING AND SELECTION OF THE BIDS OR PROPOSALS THAT THE 8 DEPARTMENT, IN THE EXERCISE OF ITS DUTIES UNDER SECTION 1310, 9 DEEMS NECESSARY. THE DEPARTMENT SHALL DO ALL OF THE FOLLOWING: 10 (1) SELECT, TO THE GREATEST EXTENT PRACTICABLE, OFFERORS 11 THAT CONTRACT WITH HEALTH CARE PROVIDERS TO PROVIDE HEALTH 12 CARE SERVICES ON A COST-EFFECTIVE BASIS. THE DEPARTMENT SHALL 13 SELECT OFFERORS THAT USE APPROPRIATE COST-MANAGEMENT METHODS, 14 INCLUDING THE CHRONIC CARE AND PREVENTION MEASURES, WHICH 15 WILL ENABLE THE PROGRAM TO PROVIDE COVERAGE TO THE MAXIMUM 16 NUMBER OF ENROLLEES. 17 (2) SELECT, TO THE GREATEST EXTENT PRACTICABLE, ONLY 18 OFFERORS THAT COMPLY WITH ALL PROCEDURES RELATING TO 19 COORDINATION OF BENEFITS AS REQUIRED BY THE DEPARTMENT AND 20 THE DEPARTMENT OF PUBLIC WELFARE. 21 (C) CONTRACT TERMS.--CONTRACTS MAY BE FOR AN INITIAL TERM OF 22 UP TO FIVE YEARS, WITH OPTIONS TO EXTEND FOR FIVE ONE-YEAR 23 PERIODS. 24 (D) DUTIES OF CONTRACTORS.--A CONTRACTOR THAT CONTRACTS WITH 25 THE DEPARTMENT TO PROVIDE A HEALTH BENEFIT PLAN TO ELIGIBLE 26 ADULTS OR ELIGIBLE EMPLOYEES: 27 (1) SHALL PROCESS CLAIMS FOR THE COVERAGE. 28 (2) MAY NOT DENY COVERAGE TO AN ELIGIBLE ADULT OR 29 ELIGIBLE EMPLOYEE WHO HAS BEEN APPROVED BY THE DEPARTMENT TO 30 PARTICIPATE IN THE PROGRAM. 20070S1137B1827 - 63 -
1 SECTION 1312. RATES AND CHARGES. 2 (A) MEDICAL LOSS RATIO.--THE MEDICAL LOSS RATIO FOR A 3 CONTRACT SHALL BE NOT LESS THAN 85%. 4 (B) LIMITATION ON FEES.--NO ELIGIBLE ADULT OR ELIGIBLE 5 EMPLOYEE SHALL BE CHARGED A FEE, OTHER THAN THOSE SPECIFIED IN 6 THIS CHAPTER, AS A REQUIREMENT FOR PARTICIPATING IN THE PROGRAM. 7 SECTION 1313. HEALTH BENEFIT PLAN. 8 (A) BENEFITS.--THE HEALTH BENEFIT PLAN TO BE OFFERED UNDER 9 THE PROGRAM SHALL BE OF THE SCOPE AND DURATION AS THE DEPARTMENT 10 DETERMINES AND SHALL PROVIDE FOR ALL OF THE FOLLOWING, WHICH MAY 11 BE AS LIMITED OR UNLIMITED AS THE DEPARTMENT MAY DETERMINE: 12 (1) PRELIMINARY AND ANNUAL HEALTH ASSESSMENTS. 13 (2) EMERGENCY CARE. 14 (3) INPATIENT AND OUTPATIENT CARE. 15 (4) PRESCRIPTION DRUGS, MEDICAL SUPPLIES AND EQUIPMENT. 16 (5) EMERGENCY DENTAL CARE. 17 (6) MATERNITY CARE. 18 (7) SKILLED NURSING. 19 (8) HOME HEALTH AND HOSPICE CARE. 20 (9) CHRONIC DISEASE MANAGEMENT. 21 (10) PREVENTIVE AND WELLNESS CARE. 22 (11) INPATIENT AND OUTPATIENT BEHAVIORAL HEALTH 23 SERVICES. 24 (B) COMMONWEALTH ELECTION.--THE COMMONWEALTH MAY ELECT TO 25 PROVIDE ANY BENEFIT INDEPENDENTLY AND OUTSIDE THE SCOPE OF THE 26 PROGRAM CONTRACTS. 27 (C) ENROLLMENT.--ENROLLMENT IN THE PROGRAM MAY NOT BE 28 PROHIBITED BASED UPON A PREEXISTING CONDITION, NOR MAY A PROGRAM 29 HEALTH BENEFIT PLAN EXCLUDE A DIAGNOSIS OR TREATMENT FOR A 30 CONDITION BASED UPON ITS PREEXISTENCE. 20070S1137B1827 - 64 -
1 (D) COPAYMENTS.--THE DEPARTMENT MAY ESTABLISH A COPAYMENT 2 FOR ANY OF THE SERVICES PROVIDED IN THE HEALTH BENEFIT PLAN AS 3 LONG AS THE COPAYMENT MEETS ANY FEDERAL REQUIREMENTS UNDER 4 SECTION 1317. THE DEPARTMENT SHALL FORWARD NOTICE OF THE 5 COPAYMENT AMOUNTS TO THE LEGISLATIVE REFERENCE BUREAU FOR 6 PUBLICATION AS A NOTICE IN THE PENNSYLVANIA BULLETIN. 7 SECTION 1314. DATA MATCHING. 8 (A) COVERED INDIVIDUALS.--ALL ENTITIES PROVIDING HEALTH 9 INSURANCE OR HEALTH CARE COVERAGE WITHIN THIS COMMONWEALTH 10 SHALL, NOT LESS FREQUENTLY THAN ONCE EVERY MONTH, PROVIDE THE 11 NAMES, IDENTIFYING INFORMATION AND ANY ADDITIONAL INFORMATION ON 12 COVERAGE AND BENEFITS AS THE DEPARTMENT MAY SPECIFY FOR ALL 13 INDIVIDUALS FOR WHOM THE ENTITIES PROVIDE INSURANCE OR COVERAGE. 14 (B) USE OF INFORMATION.-- 15 (1) THE DEPARTMENT SHALL USE INFORMATION OBTAINED IN 16 SUBSECTION (A) TO DETERMINE WHETHER ANY PORTION OF AN 17 ELIGIBLE ADULT'S, ELIGIBLE EMPLOYEE'S OR ELIGIBLE EMPLOYER'S 18 PREMIUM IS BEING PAID FROM ANY OTHER SOURCE AND TO DETERMINE 19 WHETHER ANOTHER ENTITY HAS PRIMARY LIABILITY FOR ANY HEALTH 20 CARE CLAIMS PAID UNDER ANY PROGRAM ADMINISTERED BY THE 21 DEPARTMENT. 22 (2) IF A DETERMINATION IS MADE THAT AN ELIGIBLE ADULT'S, 23 ELIGIBLE EMPLOYEE'S OR ELIGIBLE EMPLOYER'S PREMIUM IS BEING 24 PAID FROM ANOTHER SOURCE, THE DEPARTMENT MAY NOT MAKE ANY 25 ADDITIONAL PAYMENTS TO THE INSURER FOR THE ELIGIBLE ADULT, 26 ELIGIBLE EMPLOYEE OR ELIGIBLE EMPLOYER. 27 (C) EXCESS PAYMENT.--IF A PAYMENT HAS BEEN MADE TO AN 28 INSURER BY THE DEPARTMENT FOR AN ELIGIBLE ADULT, ELIGIBLE 29 EMPLOYEE OR ELIGIBLE EMPLOYER FOR WHOM ANY PORTION OF THE 30 PREMIUM PAID BY THE DEPARTMENT IS BEING PAID FROM ANOTHER 20070S1137B1827 - 65 -
1 SOURCE, THE INSURER SHALL REIMBURSE THE DEPARTMENT THE AMOUNT OF 2 ANY EXCESS PAYMENT OR PAYMENTS. 3 (D) REIMBURSEMENT.--THE DEPARTMENT MAY SEEK REIMBURSEMENT 4 FROM AN ENTITY THAT PROVIDES HEALTH INSURANCE OR HEALTH CARE 5 COVERAGE THAT IS PRIMARY TO THE COVERAGE PROVIDED UNDER ANY 6 PROGRAM ADMINISTERED BY THE DEPARTMENT. 7 (E) TIMELINESS.--TO THE MAXIMUM EXTENT PERMITTED BY LAW AND 8 NOTWITHSTANDING ANY POLICY OR PLAN PROVISION TO THE CONTRARY, A 9 CLAIM BY THE DEPARTMENT FOR REIMBURSEMENT UNDER SUBSECTION (C) 10 OR (D) SHALL BE DEEMED TIMELY FILED IF IT IS FILED WITH THE 11 INSURER OR ENTITY WITHIN THREE YEARS FOLLOWING THE DATE OF 12 PAYMENT. 13 (F) AGREEMENTS.--THE DEPARTMENT MAY ENTER INTO AGREEMENTS 14 WITH ENTITIES THAT PROVIDE HEALTH INSURANCE AND HEALTH CARE 15 COVERAGE FOR THE PURPOSE OF CARRYING OUT THE PROVISIONS OF THIS 16 SECTION. THE AGREEMENTS SHALL PROVIDE FOR THE ELECTRONIC 17 EXCHANGE OF DATA BETWEEN THE PARTIES AT A MUTUALLY AGREED UPON 18 FREQUENCY, BUT NOT LESS THAN MONTHLY, AND MAY ALSO ALLOW FOR 19 PAYMENT OF A FEE BY THE DEPARTMENT TO THE ENTITY PROVIDING 20 HEALTH INSURANCE OR HEALTH CARE COVERAGE. 21 (G) OTHER COVERAGE.-- 22 (1) THE DEPARTMENT SHALL DETERMINE WHETHER ANY OTHER 23 HEALTH CARE COVERAGE IS AVAILABLE TO AN ELIGIBLE ADULT, 24 ELIGIBLE EMPLOYEE OR ELIGIBLE EMPLOYER THROUGH AN ALIMONY 25 AGREEMENT OR AN EMPLOYMENT-RELATED OR OTHER GROUP BASIS. 26 (2) IF OTHER HEALTH CARE COVERAGE IS AVAILABLE, THE 27 DEPARTMENT SHALL REEVALUATE THE ENROLLEE'S ELIGIBILITY UNDER 28 THIS CHAPTER. 29 (H) PENALTY.-- 30 (1) THE DEPARTMENT MAY IMPOSE A PENALTY OF UP TO $1,000 20070S1137B1827 - 66 -
1 PER VIOLATION ON ANY INSURER THAT FAILS TO COMPLY WITH THE 2 OBLIGATIONS IMPOSED BY THIS CHAPTER. 3 (2) ALL MONEYS COLLECTED UNDER THIS SUBSECTION SHALL BE 4 DEPOSITED INTO THE FUND. 5 SECTION 1315. ENTITLEMENTS AND CLAIMS. 6 NOTHING IN THIS CHAPTER SHALL BE CONSTRUED AS AN ENTITLEMENT 7 DERIVED FROM THE COMMONWEALTH OR A CLAIM ON ANY FUNDS OF THE 8 COMMONWEALTH. THE DEPARTMENT OF PUBLIC WELFARE, IN CONJUNCTION 9 WITH THE DEPARTMENT, SHALL ESTABLISH A WAITING LIST AND STATE 10 PLAN AMENDMENTS AND REVISIONS TO FEDERAL WAIVERS AS ARE 11 NECESSARY TO ENSURE THAT EXPENDITURES IN THE PROGRAM DO NOT 12 EXCEED AVAILABLE FUNDING. 13 SECTION 1316. REGULATIONS. 14 THE DEPARTMENT MAY PROMULGATE REGULATIONS FOR THE 15 IMPLEMENTATION AND ADMINISTRATION OF THIS CHAPTER. 16 SECTION 1317. FEDERAL WAIVERS. 17 (1) THE DEPARTMENT OF PUBLIC WELFARE, IN COOPERATION 18 WITH THE DEPARTMENT, SHALL APPLY FOR ALL APPLICABLE WAIVERS 19 FROM THE FEDERAL GOVERNMENT AND SHALL SEEK APPROVAL TO AMEND 20 THE STATE PLAN AS NECESSARY TO CARRY OUT THE PROVISIONS OF 21 THIS CHAPTER. 22 (2) IF THE DEPARTMENT OF PUBLIC WELFARE RECEIVES 23 APPROVAL OF A WAIVER OR APPROVAL OF A STATE PLAN AMENDMENT AS 24 REQUIRED BY THIS SECTION, IT SHALL NOTIFY THE DEPARTMENT AND 25 TRANSMIT NOTICE OF THE WAIVER OR STATE PLAN AMENDMENT 26 APPROVALS TO THE LEGISLATIVE REFERENCE BUREAU FOR PUBLICATION 27 AS A NOTICE IN THE PENNSYLVANIA BULLETIN. 28 (3) THE DEPARTMENT MAY CHANGE THE BENEFITS UNDER SECTION 29 1313 AND THE PREMIUM AND COPAYMENT AMOUNTS PAYABLE UNDER 30 SECTIONS 1305 AND 1306 AND ELIGIBILITY REQUIREMENTS IN ORDER 20070S1137B1827 - 67 -
1 FOR THE PROGRAM TO MEET FEDERAL REQUIREMENTS. 2 SECTION 1318. FEDERAL FUNDS. 3 NOTWITHSTANDING ANY OTHER PROVISION OF LAW, THE DEPARTMENT OF 4 PUBLIC WELFARE, IN COOPERATION WITH THE DEPARTMENT, SHALL TAKE 5 ANY ACTION NECESSARY TO DO ALL OF THE FOLLOWING: 6 (1) ENSURE THE RECEIPT OF FEDERAL FINANCIAL 7 PARTICIPATION UNDER TITLE XIX OF THE SOCIAL SECURITY ACT (49 8 STAT. 620, 42 U.S.C. § 1396 ET SEQ.) FOR COVERAGE AND FOR 9 SERVICES PROVIDED UNDER THIS CHAPTER. 10 (2) QUALIFY FOR AVAILABLE FEDERAL FINANCIAL 11 PARTICIPATION UNDER TITLE XIX OF THE SOCIAL SECURITY ACT. 12 SECTION 12. THE INSURANCE DEPARTMENT SHALL PUBLISH A NOTICE 13 IN THE PENNSYLVANIA BULLETIN WHEN A LAW IS ENACTED THAT PROVIDES 14 FOR OR DESIGNATES AT LEAST $120,000,000 FOR THE SUPPLEMENTAL 15 ASSISTANCE AND FUNDING ACCOUNT. 16 SECTION 13. REPEALS ARE AS FOLLOWS: 17 (1) THE GENERAL ASSEMBLY DECLARES THAT THE REPEAL UNDER 18 PARAGRAPH (2) IS NECESSARY TO EFFECTUATE THIS ACT. 19 (2) CHAPTER 13 OF THE ACT OF JUNE 26, 2001 (P.L.755, 20 NO.77), KNOWN AS THE TOBACCO SETTLEMENT ACT, IS REPEALED. 21 (3) ALL OTHER ACTS AND PARTS OF ACTS ARE REPEALED 22 INSOFAR AS THEY ARE INCONSISTENT WITH THIS ACT. 23 SECTION 14. THE AMENDMENT OF SECTION 712(E) OF THE ACT SHALL 24 APPLY RETROACTIVELY TO DECEMBER 31, 2007. 25 SECTION 15. THIS ACT SHALL TAKE EFFECT AS FOLLOWS: 26 (1) THE FOLLOWING PROVISIONS SHALL TAKE EFFECT JULY 1, 27 2008, OR IMMEDIATELY, WHICHEVER IS LATER: 28 (I) THE AMENDMENT OF SECTION 712(E) AND (M) OF THE 29 ACT. 30 (II) THE AMENDMENT OF THE DEFINITION OF "HEALTH CARE 20070S1137B1827 - 68 -
1 PROVIDER" IN SECTION 1101 OF THE ACT. 2 (III) THE AMENDMENT OF SECTION 1112 OF THE ACT. 3 (IV) SECTION 12 OF THIS ACT. 4 (2) THE REMAINDER OF THIS ACT SHALL TAKE EFFECT UPON 5 PUBLICATION OF THE NOTICE SPECIFIED UNDER SECTION 12 OF THIS 6 ACT. J23L40MSP/20070S1137B1827 - 69 -