SENATE AMENDED
PRIOR PRINTER'S NO. 1046
PRINTER'S NO. 2631
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
857
Session of
2015
INTRODUCED BY PICKETT, QUINN, DeLUCA, LONGIETTI, SCHLOSSBERG,
DRISCOLL, SAMUELSON, BISHOP, TOEPEL, KILLION, HICKERNELL,
MACKENZIE, SAINATO, SCHREIBER, KOTIK, CONKLIN, JAMES,
SCHWEYER, BAKER, MILLARD, MOUL, STEPHENS, READSHAW, HELM,
FABRIZIO, SCHLEGEL CULVER, HEFFLEY, GODSHALL, MALONEY,
McNEILL, IRVIN, D. COSTA, ENGLISH, A. HARRIS, FARINA,
V. BROWN, KAUFFMAN, GRELL, RAPP, ACOSTA, DONATUCCI, COHEN,
HAHN, MARSHALL, GINGRICH, SAYLOR, MURT, WATSON, GABLER,
McCARTER, GIBBONS, KORTZ, RADER, BARBIN, JOZWIAK, DAVIS,
BROWNLEE AND MILNE, MARCH 31, 2015
AS AMENDED ON THIRD CONSIDERATION, IN SENATE, DECEMBER 8, 2015
AN ACT
Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
act relating to insurance; amending, revising, and
consolidating the law providing for the incorporation of
insurance companies, and the regulation, supervision, and
protection of home and foreign insurance companies, Lloyds
associations, reciprocal and inter-insurance exchanges, and
fire insurance rating bureaus, and the regulation and
supervision of insurance carried by such companies,
associations, and exchanges, including insurance carried by
the State Workmen's Insurance Fund; providing penalties; and
repealing existing laws," IN CASUALTY INSURANCE, PROVIDING
FOR EMERGENCY SERVICE SYSTEM BILLING; IN AUTOMOBILE INSURANCE
ISSUANCE, RENEWAL, CANCELLATION AND REFUSAL, PROVIDING FOR
COVERAGE OBLIGATIONS OF LOANER VEHICLES; AND, in children's
health care, further providing for expiration.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Section 2362 of the act of May 17, 1921 (P.L.682,
No.284), known as The Insurance Company Law of 1921, amended
October 16, 2013 (P.L.634, No.74), is amended to read:
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Section 2362. Expiration.--This article shall expire
December 31, [2015] 2017.
Section 2. This act shall take effect immediately.
SECTION 1. THE ACT OF MAY 17, 1921 (P.L.682, NO.284), KNOWN
AS THE INSURANCE COMPANY LAW OF 1921, IS AMENDED BY ADDING
SECTIONS TO READ:
SECTION 635.7. BILLING.--(A) WHEN AN EMS AGENCY IS
DISPATCHED BY A PUBLIC SAFETY ANSWERING POINT AS DEFINED IN 35
PA.C.S. ยง 5302 (RELATING TO DEFINITIONS) OR AN EMS AGENCY
DISPATCH CENTER UNDER 35 PA.C.S. ยง 8129(I) (RELATING TO
EMERGENCY MEDICAL SERVICES AGENCIES) FOR AN EMERGENCY AND
PROVIDES MEDICALLY NECESSARY EMERGENCY MEDICAL SERVICES, A
PAYMENT MADE BY AN INSURER FOR A CLAIM COVERED UNDER AND IN
ACCORDANCE WITH A HEALTH INSURANCE POLICY FOR AN EMERGENCY
MEDICAL SERVICE PERFORMED BY THE EMS AGENCY DURING THE CALL
SHALL BE PAID DIRECTLY TO THE EMS AGENCY.
(B) AN INSURER MUST REIMBURSE A NONNETWORK EMS AGENCY UNDER
THE FOLLOWING:
(1) THE EMS AGENCY HAS SUBMITTED A COMPLETED STANDARDIZED
FORM TO THE DEPARTMENT REQUESTING NONNETWORK DIRECT
REIMBURSEMENT FROM AN INSURER AN EMS AGENCY HAS IDENTIFIED. THE
FORM MUST BE SUBMITTED TO THE DEPARTMENT ANNUALLY BY OCTOBER 15.
THE FORM SHALL DECLARE THE EMS AGENCY'S INTENTION TO RECEIVE
DIRECT PAYMENT FROM AN INSURER IDENTIFIED ON THE FORM FOR THE
NEXT CALENDAR YEAR. THE DEPARTMENT SHALL DEVELOP A STANDARDIZED
FORM, USING AN EMS AGENCY'S ASSIGNED LICENSE NUMBER, TO BE USED
BY AN EMS AGENCY THAT MEETS THE CONDITIONS ESTABLISHED UNDER
THIS SECTION. THE DEPARTMENT SHALL DEVELOP AND MAINTAIN A
PUBLICLY ACCESSIBLE ELECTRONIC REGISTRY THAT INDICATES WHICH EMS
AGENCY HAS REQUESTED NONNETWORK DIRECT REIMBURSEMENT FROM AN
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INSURER IDENTIFIED ON THE FORM.
(2) AN EMS AGENCY HAS PROVIDED NOTIFICATION TO THE INSURER
UPON SUBMITTING A CLAIM FOR REIMBURSEMENT THAT THE EMS AGENCY IS
REGISTERED WITH THE DEPARTMENT TO RECEIVE DIRECT REIMBURSEMENT
AS PROVIDED FOR UNDER THIS SECTION.
(C) AN EMS AGENCY MAY BE SUBJECT TO PERIODIC AUDITS BY AN
INSURER TO EXAMINE CLAIMS FOR DIRECT REIMBURSEMENT UNDER THIS
SECTION. IF, THROUGH THE AUDIT, THE INSURER IDENTIFIES AN
IMPROPER PAYMENT, THE INSURER MAY DEDUCT THE IMPROPER PAYMENT
FROM FUTURE REIMBURSEMENTS.
(D) WHERE AN INSURER HAS REIMBURSED A NONNETWORK EMS AGENCY
AT THE SAME RATE IT HAS ESTABLISHED FOR A NETWORK EMS AGENCY,
THE EMS AGENCY MAY NOT BILL THE INSURED DIRECTLY OR INDIRECTLY
OR OTHERWISE ATTEMPT TO COLLECT FROM THE INSURED FOR THE SERVICE
PROVIDED, EXCEPT FOR A BILLING TO RECOVER A COPAYMENT,
COINSURANCE OR DEDUCTIBLE AS SPECIFIED IN THE HEALTH INSURANCE
POLICY.
(E) AN EMS AGENCY THAT SUBMITS A FORM UNDER THIS SECTION MAY
SOLICIT DONATIONS, MEMBERSHIPS OR CONDUCT FUNDRAISING, EXCEPT
THAT AN EMS AGENCY MAY NOT PROMISE, SUGGEST OR INFER TO DONORS
THAT A DONATION WILL RESULT IN THE DONOR NOT BEING BILLED
DIRECTLY FOR ANY PAYMENT AS PROVIDED UNDER THIS SECTION.
NOTWITHSTANDING THIS PARAGRAPH, AN EMS AGENCY MAY BILL IN
ACCORDANCE WITH SUBSECTION (D). A VIOLATION OF THIS SECTION
SHALL BE CONSIDERED A VIOLATION OF THE ACT OF DECEMBER 17, 1968
(P.L.1224, NO.387), KNOWN AS THE "UNFAIR TRADE PRACTICES AND
CONSUMER PROTECTION LAW."
(F) CLAIMS PAID UNDER THIS SECTION SHALL BE SUBJECT TO
SECTION 2166.
(G) THIS SECTION SHALL APPLY ONLY TO AN EMS AGENCY THAT IS A
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NONNETWORK PROVIDER AND PROVIDES EMERGENCY MEDICAL SERVICES,
UNLESS PREEMPTED BY FEDERAL LAW.
(H) THE FOLLOWING WORDS AND PHRASES WHEN USED IN THIS
SECTION SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SUBSECTION
UNLESS THE CONTEXT CLEARLY INDICATES OTHERWISE:
"DEPARTMENT." DEPARTMENT OF HEALTH OF THE COMMONWEALTH.
"EMS AGENCY." AS DEFINED IN 35 PA.C.S. ยง 8103 (RELATING TO
DEFINITIONS).
"EMERGENCY MEDICAL SERVICES." AS DEFINED IN 35 PA.C.S. ยง
8103 (RELATING TO DEFINITIONS).
"INSURER." AS FOLLOWS:
(1) AN ENTITY THAT IS RESPONSIBLE FOR PROVIDING OR PAYING
FOR ALL OR PART OF THE COST OF EMERGENCY MEDICAL SERVICES
COVERED BY AN INSURANCE POLICY, CONTRACT OR PLAN. THE TERM
INCLUDES AN ENTITY SUBJECT TO:
(I) SECTION 630, ARTICLE XXIV OR ANY OTHER PROVISION OF THIS
ACT;
(II) THE ACT OF DECEMBER 29, 1972 (P.L.1701, NO.364), KNOWN
AS THE HEALTH MAINTENANCE ORGANIZATION ACT; OR
(III) 40 PA.C.S. CH. 61 (RELATING TO HOSPITAL PLAN
CORPORATIONS) OR 63 (RELATING TO PROFESSIONAL HEALTH SERVICES
PLAN CORPORATIONS).
(2) THE TERM DOES NOT INCLUDE AN ENTITY THAT IS RESPONSIBLE
FOR PROVIDING OR PAYING UNDER AN INSURANCE POLICY, CONTRACT OR
PLAN WHICH MEETS ANY OF THE FOLLOWING:
(I) IS A HOMEOWNER'S INSURANCE POLICY.
(II) PROVIDES ANY OF THE FOLLOWING TYPES OF INSURANCE:
(A) ACCIDENT ONLY.
(B) FIXED INDEMNITY.
(C) LIMITED BENEFIT.
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(D) CREDIT.
(E) DENTAL.
(F) VISION.
(G) SPECIFIED DISEASE.
(H) MEDICARE SUPPLEMENT.
(I) CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED
SERVICES (CHAMPUS) SUPPLEMENT.
(J) LONG-TERM CARE.
(K) DISABILITY INCOME.
(L) WORKERS' COMPENSATION.
(M) AUTOMOBILE MEDICAL PAYMENT INSURANCE.
SECTION 2007.1. COVERAGE OBLIGATIONS OF LOANER VEHICLES.--
(A) AN INSURANCE COMPANY AUTHORIZED TO WRITE PRIVATE PASSENGER
AUTOMOBILE INSURANCE WITHIN THIS COMMONWEALTH SHALL PROVIDE,
WHERE PURCHASED AND WITHIN THE LIMITS OF THE INSURED'S POLICY,
PRIMARY LIABILITY COVERAGE FOR THIRD-PARTY BODILY INJURY AND
PRIMARY FIRST-PARTY PHYSICAL DAMAGE COVERAGE FOR A MOTOR VEHICLE
PROVIDED BY A MOTOR VEHICLE DEALER, WHEN AN INSURED HAS CUSTODY
OF OR IS OPERATING THAT MOTOR VEHICLE, WHILE A MOTOR VEHICLE
SPECIFICALLY LISTED OR COVERED UNDER THE INSURED'S MOTOR VEHICLE
INSURANCE POLICY IS BEING TRANSPORTED, SERVICED, REPAIRED OR
INSPECTED BY THE MOTOR VEHICLE DEALER.
(B) AN INSURANCE COMPANY AUTHORIZED TO DO BUSINESS IN THIS
COMMONWEALTH SHALL PROVIDE TO A MOTOR VEHICLE DEALER OR AN AGENT
THEREOF WITH CUSTODY OF OR OPERATING A CUSTOMER'S MOTOR VEHICLE
FOR THE PURPOSE OF TRANSPORTING, SERVICING, REPAIRING OR
INSPECTING THE VEHICLE, PRIMARY LIABILITY COVERAGE FOR THIRD-
PARTY BODILY INJURY AND PRIMARY FIRST-PARTY PHYSICAL DAMAGE
COVERAGE IN THE AMOUNTS SET FORTH IN THE CUSTOMER'S PRIVATE
PASSENGER AUTOMOBILE INSURANCE POLICY.
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(C) THIS SECTION SHALL APPLY ONLY TO THE LOAN OF A MOTOR
VEHICLE BY A MOTOR VEHICLE DEALER THAT OCCURS WITHOUT FINANCIAL
REMUNERATION IN THE FORM OF A FEE, RENTAL OR LEASE CHARGE PAID
DIRECTLY BY THE INSURED OPERATING THE MOTOR VEHICLE. PAYMENTS
MADE BY A THIRD PARTY TO A MOTOR VEHICLE DEALER OR SIMILAR
REIMBURSEMENTS SHALL NOT BE CONSIDERED PAYMENTS DIRECTLY FROM
THE INSURED OPERATING THE MOTOR VEHICLE.
(D) A CHANGE IN THE COVERAGE OF A PRIVATE PASSENGER
AUTOMOBILE INSURANCE POLICY RESULTING FROM THIS SECTION SHALL
NOT IMPACT THE VALIDITY OF A WAIVER, SELECTION OF BENEFITS OR
AMOUNT OF BENEFITS IN THAT POLICY, BEYOND THE COVERAGE CHANGE AS
A RESULT OF THIS SECTION. AN INSURER SHALL FILE WITH THE
INSURANCE DEPARTMENT ANY FORMS OR RATES REVISED AS A RESULT OF
THIS SECTION, ALONG WITH CERTIFICATION THAT THE REVISIONS ARE
LIMITED TO THE COMPLIANCE WITH THIS SECTION. THE REVISIONS SHALL
BE EFFECTIVE 10 DAYS AFTER FILING.
(E) AS USED IN THIS SECTION, THE TERM "MOTOR VEHICLE DEALER"
SHALL HAVE THE SAME MEANING AS "DEALER" AS DEFINED IN SECTION 2
OF THE ACT OF DECEMBER 22, 1983 (P.L.306, NO.84), KNOWN AS THE
"BOARD OF VEHICLES ACT."
SECTION 2. ARTICLE XXIII OF THE ACT IS REPEALED:
[ARTICLE XXIII.
CHILDREN'S HEALTH CARE.
(A) GENERAL PROVISIONS.
SECTION 2301. SHORT TITLE.--THIS ARTICLE SHALL BE KNOWN AND
MAY BE CITED AS THE "CHILDREN'S HEALTH CARE ACT."
SECTION 2302. LEGISLATIVE FINDINGS AND INTENT.--THE GENERAL
ASSEMBLY FINDS AND DECLARES AS FOLLOWS:
(1) CITIZENS OF THIS COMMONWEALTH SHOULD HAVE ACCESS TO
AFFORDABLE AND REASONABLY PRICED HEALTH CARE AND TO
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NONDISCRIMINATORY TREATMENT BY HEALTH INSURERS AND PROVIDERS.
(2) THE UNINSURED HEALTH CARE POPULATION OF THIS
COMMONWEALTH IS ESTIMATED TO BE APPROXIMATELY ONE MILLION
PERSONS AND MANY THOUSANDS MORE LACK ADEQUATE INSURANCE
COVERAGE. IT IS ALSO ESTIMATED THAT APPROXIMATELY TWO-THIRDS OF
THE UNINSURED ARE EMPLOYED OR DEPENDENTS OF EMPLOYED PERSONS.
(3) APPROXIMATELY FIFTEEN PER CENTUM (15%) OF THE UNINSURED
HEALTH CARE POPULATION ARE CHILDREN. UNINSURED CHILDREN ARE OF
PARTICULAR CONCERN BECAUSE OF THEIR NEED FOR ONGOING PREVENTIVE
AND PRIMARY CARE. MEASURES NOT TAKEN TO CARE FOR SUCH CHILDREN
NOW WILL RESULT IN HIGHER HUMAN AND FINANCIAL COSTS LATER.
(4) UNINSURED CHILDREN LACK ACCESS TO TIMELY AND APPROPRIATE
PRIMARY AND PREVENTIVE CARE. AS A RESULT, HEALTH CARE IS OFTEN
DELAYED OR FORGONE, RESULTING IN INCREASED RISK OF DEVELOPING
MORE SEVERE CONDITIONS WHICH IN TURN ARE MORE EXPENSIVE TO
TREAT. THIS TENDENCY TO DELAY CARE AND TO SEEK AMBULATORY CARE
IN HOSPITAL-BASED SETTINGS ALSO CAUSES INEFFICIENCIES IN THE
HEALTH CARE SYSTEM.
(5) HEALTH CARE MARKETS HAVE BEEN DISTORTED THROUGH COST
SHIFTS FOR THE UNCOMPENSATED HEALTH CARE COSTS OF UNINSURED
CITIZENS OF THIS COMMONWEALTH WHICH HAS CAUSED DECREASED
COMPETITIVE CAPACITY ON THE PART OF THOSE HEALTH CARE PROVIDERS
WHO SERVE THE POOR AND INCREASED COSTS OF OTHER HEALTH CARE
PAYORS.
(6) NO ONE SECTOR CAN ABSORB THE COST OF PROVIDING HEALTH
CARE TO CITIZENS OF THIS COMMONWEALTH WHO CANNOT AFFORD HEALTH
CARE ON THEIR OWN. THE COST IS TOO LARGE FOR THE PUBLIC SECTOR
ALONE TO BEAR AND INSTEAD REQUIRES THE ESTABLISHMENT OF A PUBLIC
AND PRIVATE PARTNERSHIP TO SHARE THE COSTS IN A MANNER
ECONOMICALLY FEASIBLE FOR ALL INTERESTS. THE MAGNITUDE OF THIS
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NEED ALSO REQUIRES THAT IT BE DONE ON A TIME-PHASED, COST-
MANAGED AND PLANNED BASIS.
(7) ELIGIBLE UNINSURED CHILDREN IN THIS COMMONWEALTH SHOULD
HAVE ACCESS TO COST-EFFECTIVE, COMPREHENSIVE PRIMARY HEALTH
COVERAGE IF THEY ARE UNABLE TO AFFORD COVERAGE OR OBTAIN IT.
(8) CARE SHOULD BE PROVIDED IN APPROPRIATE SETTINGS BY
EFFICIENT PROVIDERS, CONSISTENT WITH HIGH QUALITY CARE AND AT AN
APPROPRIATE STAGE, SOON ENOUGH TO AVERT THE NEED FOR OVERLY
EXPENSIVE TREATMENT.
(9) EQUITY SHOULD BE ASSURED AMONG HEALTH PROVIDERS AND
PAYORS BY PROVIDING A MECHANISM FOR PROVIDERS, EMPLOYERS, THE
PUBLIC SECTOR AND PATIENTS TO SHARE IN FINANCING INDIGENT
CHILDREN'S HEALTH CARE.
SECTION 2303. DEFINITIONS.--AS USED IN THIS ARTICLE, THE
FOLLOWING WORDS AND PHRASES SHALL HAVE THE MEANINGS GIVEN TO
THEM IN THIS SECTION:
"CHILD." A PERSON UNDER NINETEEN (19) YEARS OF AGE.
"CONTRACTOR." AN INSURER AWARDED A CONTRACT UNDER
SUBDIVISION (B) TO PROVIDE HEALTH CARE SERVICES UNDER THIS
ARTICLE. THE TERM INCLUDES AN ENTITY AND ITS SUBSIDIARY WHICH IS
ESTABLISHED UNDER 40 PA.C.S. CH. 61 (RELATING TO HOSPITAL PLAN
CORPORATIONS) OR 63 (RELATING TO PROFESSIONAL HEALTH SERVICES
PLAN CORPORATIONS); THIS ACT; OR THE ACT OF DECEMBER 29, 1972
(P.L.1701, NO.364), KNOWN AS THE "HEALTH MAINTENANCE
ORGANIZATION ACT."
"COUNCIL." THE CHILDREN'S HEALTH ADVISORY COUNCIL
ESTABLISHED IN SECTION 2311(I).
"DEPARTMENT." THE INSURANCE DEPARTMENT OF THE COMMONWEALTH.
"EPSDT." EARLY AND PERIODIC SCREENING, DIAGNOSIS AND
TREATMENT.
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"FUND." THE CHILDREN'S HEALTH FUND FOR HEALTH CARE FOR
INDIGENT CHILDREN ESTABLISHED BY SECTION 1296 OF THE ACT OF
MARCH 4, 1971 (P.L.6, NO.2), KNOWN AS THE "TAX REFORM CODE OF
1971."
"GROUP." A GROUP FOR WHICH A HEALTH INSURANCE POLICY IS
WRITTEN IN THIS COMMONWEALTH.
"HEALTH MAINTENANCE ORGANIZATION" OR "HMO." AN ENTITY
ORGANIZED AND REGULATED UNDER THE ACT OF DECEMBER 29, 1972
(P.L.1701, NO.364), KNOWN AS THE "HEALTH MAINTENANCE
ORGANIZATION ACT."
"HEALTH SERVICE CORPORATION." A PROFESSIONAL HEALTH SERVICE
CORPORATION AS DEFINED IN 40 PA.C.S. ยง 6302 (RELATING TO
DEFINITIONS).
"HEALTHY BEGINNINGS PROGRAM." MEDICAL ASSISTANCE COVERAGE
FOR SERVICES TO CHILDREN AS REQUIRED UNDER TITLE XIX OF THE
SOCIAL SECURITY ACT (49 STAT. 620, 42 U.S.C. ยง 301 ET SEQ.) FOR
THE FOLLOWING:
(1) CHILDREN FROM BIRTH TO AGE ONE (1) WHOSE FAMILY INCOME
IS NO GREATER THAN ONE HUNDRED EIGHTY-FIVE PER CENTUM (185%) OF
THE FEDERAL POVERTY LEVEL;
(2) CHILDREN ONE (1) THROUGH FIVE (5) YEARS OF AGE WHOSE
FAMILY INCOME IS NO GREATER THAN ONE HUNDRED THIRTY-THREE PER
CENTUM (133%) OF THE FEDERAL POVERTY LEVEL; AND
(3) CHILDREN SIX (6) THROUGH EIGHTEEN (18) YEARS OF AGE
WHOSE FAMILY INCOME IS NO GREATER THAN ONE HUNDRED PER CENTUM
(100%) OF THE FEDERAL POVERTY LEVEL.
"HOSPITAL." AN INSTITUTION HAVING AN ORGANIZED MEDICAL STAFF
WHICH IS ENGAGED PRIMARILY IN PROVIDING TO INPATIENTS, BY OR
UNDER THE SUPERVISION OF PHYSICIANS, DIAGNOSTIC AND THERAPEUTIC
SERVICES FOR THE CARE OF INJURED, DISABLED, PREGNANT, DISEASED
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OR SICK OR MENTALLY ILL PERSONS. THE TERM INCLUDES FACILITIES
FOR THE DIAGNOSIS AND TREATMENT OF DISORDERS WITHIN THE SCOPE OF
SPECIFIC MEDICAL SPECIALTIES. THE TERM DOES NOT INCLUDE
FACILITIES CARING EXCLUSIVELY FOR THE MENTALLY ILL.
"HOSPITAL PLAN CORPORATION." A HOSPITAL PLAN CORPORATION AS
DEFINED IN 40 PA.C.S. ยง 6101 (RELATING TO DEFINITIONS).
"INSURER." A HEALTH INSURANCE ENTITY LICENSED IN THIS
COMMONWEALTH TO ISSUE ANY INDIVIDUAL OR GROUP HEALTH, SICKNESS
OR ACCIDENT POLICY OR SUBSCRIBER CONTRACT OR CERTIFICATE THAT
PROVIDES MEDICAL OR HEALTH CARE COVERAGE BY A HEALTH CARE
FACILITY OR LICENSED HEALTH CARE PROVIDER THAT IS OFFERED OR
GOVERNED UNDER THIS ACT OR ANY OF THE FOLLOWING:
(1) THE ACT OF DECEMBER 29, 1972 (P.L.1701, NO.364),
KNOWN AS THE "HEALTH MAINTENANCE ORGANIZATION ACT."
(2) THE ACT OF MAY 18, 1976 (P.L.123, NO.54), KNOWN AS
THE "INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM
STANDARDS ACT."
(3) 40 PA.C.S. CH. 61 (RELATING TO HOSPITAL PLAN
CORPORATIONS) OR 63 (RELATING TO PROFESSIONAL HEALTH SERVICES
PLAN CORPORATIONS).
(4) ARTICLE XXIV.
"MAAC." THE MEDICAL ASSISTANCE ADVISORY COMMITTEE.
"MANAGED CARE ORGANIZATION." HEALTH MAINTENANCE ORGANIZATION
ORGANIZED AND REGULATED UNDER THE ACT OF DECEMBER 29, 1972
(P.L.1701, NO.364), KNOWN AS THE "HEALTH MAINTENANCE
ORGANIZATION ACT," OR A RISK-ASSUMING PREFERRED PROVIDER
ORGANIZATION OR EXCLUSIVE PROVIDER ORGANIZATION, ORGANIZED AND
REGULATED UNDER THIS ACT.
"MCH." MATERNAL AND CHILD HEALTH.
"MEDICAID." THE FEDERAL MEDICAL ASSISTANCE PROGRAM
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ESTABLISHED UNDER TITLE XIX OF THE SOCIAL SECURITY ACT (49 STAT.
620, 42 U.S.C. ยง 1396 ET SEQ.).
"MEDICAL ASSISTANCE." THE STATE PROGRAM OF MEDICAL
ASSISTANCE ESTABLISHED UNDER THE ACT OF JUNE 13, 1967 (P.L.31,
NO.21), KNOWN AS THE "PUBLIC WELFARE CODE."
"MID-LEVEL HEALTH PROFESSIONAL." A PHYSICIAN ASSISTANT,
CERTIFIED REGISTERED NURSE PRACTITIONER, NURSE PRACTITIONER OR A
CERTIFIED NURSE MIDWIFE.
"PARENT." A NATURAL PARENT, STEPPARENT, ADOPTIVE PARENT,
GUARDIAN OR CUSTODIAN OF A CHILD.
"PPO." A PREFERRED PROVIDER ORGANIZATION SUBJECT TO THE
PROVISIONS OF SECTION 630.
"PREEXISTING CONDITION." A DISEASE OR PHYSICAL CONDITION FOR
WHICH MEDICAL ADVICE OR TREATMENT HAS BEEN RECEIVED PRIOR TO THE
EFFECTIVE DATE OF COVERAGE.
"PREMIUM ASSISTANCE PROGRAM." A COMPONENT OF A SEPARATE
CHILD HEALTH PROGRAM, APPROVED UNDER THE STATE PLAN, UNDER WHICH
THE COMMONWEALTH PAYS PART OR ALL OF THE PREMIUM FOR AN ENROLLEE
OR ENROLLEE'S GROUP HEALTH INSURANCE COVERAGE OR COVERAGE UNDER
A GROUP HEALTH PLAN.
"PRESCRIPTION DRUG." A CONTROLLED SUBSTANCE, OTHER DRUG OR
DEVICE FOR MEDICATION DISPENSED BY ORDER OF AN APPROPRIATELY
LICENSED MEDICAL PROFESSIONAL.
"SUBGROUP." AN EMPLOYER COVERED UNDER A CONTRACT ISSUED TO A
MULTIPLE EMPLOYER TRUST OR TO AN ASSOCIATION.
"TERMINATE." INCLUDES CANCELLATION, NONRENEWAL AND
RESCISSION.
"WAITING PERIOD." A PERIOD OF TIME AFTER THE EFFECTIVE DATE
OF ENROLLMENT DURING WHICH AN INSURER EXCLUDES COVERAGE FOR THE
DIAGNOSIS OR TREATMENT OF ONE OR MORE MEDICAL CONDITIONS.
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"WIC." THE FEDERAL SUPPLEMENTAL FOOD PROGRAM FOR WOMEN,
INFANTS AND CHILDREN.
(B) PRIMARY HEALTH CARE PROGRAMS.
SECTION 2311. CHILDREN'S HEALTH CARE.--(A) NOTWITHSTANDING
ANY OTHER PROVISION OF LAW, THE DEPARTMENT SHALL TAKE SUCH
ACTIONS AS MAY BE NECESSARY TO ENSURE THE RECEIPT OF FEDERAL
FINANCIAL PARTICIPATION UNDER TITLE XXI OF THE SOCIAL SECURITY
ACT (49 STAT. 620, 42 U.S.C. ยง 1397AA ET SEQ.) FOR SERVICES
PROVIDED UNDER THIS ACT AND TO QUALIFY THE BENEFIT EXPANSION
PROVIDED BY SUBSECTION (C)(1.1) FOR AVAILABLE FEDERAL FINANCIAL
PARTICIPATION.
(B) (1) THE FUND SHALL BE DEDICATED EXCLUSIVELY FOR
DISTRIBUTION BY THE DEPARTMENT THROUGH CONTRACTS IN ORDER TO
PROVIDE FREE AND SUBSIDIZED HEALTH CARE SERVICES UNDER THIS
SECTION, BASED ON AN ACTUARIALLY SOUND AND ADEQUATE REVIEW, AND
TO DEVELOP AND IMPLEMENT OUTREACH ACTIVITIES REQUIRED UNDER
SECTION 2312.
(2) THE FUND, ALONG WITH FEDERAL, STATE AND OTHER MONEY
AVAILABLE FOR THE PROGRAM, SHALL BE USED FOR HEALTH CARE
COVERAGE FOR CHILDREN AS SPECIFIED IN THIS SECTION. THE
DEPARTMENT SHALL ASSURE THAT THE PROGRAM IS IMPLEMENTED
STATEWIDE. ALL CONTRACTS AWARDED UNDER THIS SECTION SHALL BE
AWARDED THROUGH A COMPETITIVE PROCUREMENT PROCESS. THE
DEPARTMENT AND THE DEPARTMENT OF PUBLIC WELFARE SHALL USE THEIR
BEST EFFORTS TO ENSURE THAT ELIGIBLE CHILDREN ACROSS THIS
COMMONWEALTH HAVE ACCESS TO HEALTH CARE SERVICES TO BE PROVIDED
UNDER THIS ARTICLE.
(3) NO MORE THAN TEN PER CENTUM (10%) OF THE AMOUNT OF THE
CONTRACT MAY BE USED FOR ADMINISTRATIVE EXPENSES OF THE
CONTRACTOR. IF ANY CONTRACTOR PRESENTS DOCUMENTED EVIDENCE THAT
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ADMINISTRATIVE EXPENSES FOR PURPOSES OF EXPANDED OUTREACH AND
SYSTEMS AND OPERATIONAL CHANGES ARE IN EXCESS OF TEN PER CENTUM
(10%) OF THE AMOUNT OF THE CONTRACT, THE DEPARTMENT SHALL MAKE
AN ADDITIONAL ALLOTMENT OF FUNDS, NOT TO EXCEED TWO PER CENTUM
(2%) OF THE AMOUNT OF THE CONTRACT, TO THE CONTRACTOR TO THE
EXTENT THAT THE DEPARTMENT FINDS THE EXPENSES REASONABLE AND
NECESSARY.
(4) NO LESS THAN EIGHTY-FOUR PER CENTUM (84%) OF THE
CONTRACT SHALL BE USED TO PROVIDE THE HEALTH CARE SERVICES
PROVIDED UNDER THIS ARTICLE FOR CHILDREN ELIGIBLE FOR CARE UNDER
THIS ARTICLE.
(5) TO ENSURE THAT INPATIENT HOSPITAL CARE IS PROVIDED TO
ELIGIBLE CHILDREN, EACH PRIMARY CARE PROVIDER FURNISHING PRIMARY
CARE SERVICES SHALL MAKE NECESSARY ARRANGEMENTS FOR ADMISSION TO
THE HOSPITAL AND FOR NECESSARY SPECIALTY CARE.
(C) (1) ANY INSURER RECEIVING FUNDS FROM THE DEPARTMENT TO
PROVIDE COVERAGE OF HEALTH CARE SERVICES SHALL ENROLL, TO THE
EXTENT THAT FUNDS ARE AVAILABLE, ANY CHILD WHO MEETS ALL OF THE
FOLLOWING:
(I) IS A RESIDENT OF THIS COMMONWEALTH.
(II) IS NOT COVERED BY A HEALTH INSURANCE PLAN, A SELF-
INSURANCE PLAN OR A SELF-FUNDED PLAN OR IS NOT ELIGIBLE FOR OR
COVERED BY MEDICAL ASSISTANCE, INCLUDING THE HEALTHY BEGINNINGS
PROGRAM.
(III) IS QUALIFIED BASED ON INCOME UNDER SUBSECTION (D) OR
(E).
(IV) MEETS THE CITIZENSHIP REQUIREMENTS OF TITLE XXI OF THE
SOCIAL SECURITY ACT (49 STAT. 620, 42 U.S.C. ยง 1397AA ET SEQ.).
(1.1) BEGINNING JANUARY 1, 2007, AND SUBJECT TO THE
PROVISIONS OF SECTION 2314, ANY INSURER RECEIVING FUNDS FROM THE
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DEPARTMENT TO PROVIDE COVERAGE OF HEALTH CARE SERVICES UNDER
THIS SECTION SHALL ENROLL, TO THE EXTENT THAT FUNDS ARE
AVAILABLE, ANY CHILD WHO MEETS ALL OF THE FOLLOWING:
(I) IS A RESIDENT OF THIS COMMONWEALTH.
(II) IS NOT COVERED BY A HEALTH INSURANCE PLAN, A SELF-
INSURANCE PLAN OR A SELF-FUNDED PLAN, OR IS NOT PROVIDED ACCESS
TO HEALTH CARE COVERAGE BY COURT ORDER, OR IS NOT ELIGIBLE FOR
OR COVERED BY A MEDICAL ASSISTANCE PROGRAM ADMINISTERED BY THE
DEPARTMENT OF PUBLIC WELFARE, INCLUDING THE HEALTHY BEGINNINGS
PROGRAM.
(III) IS QUALIFIED BASED ON INCOME UNDER SUBSECTION (D),
(E.1), (E.2), (E.3) OR (E.4).
(IV) MEETS THE CITIZENSHIP REQUIREMENTS OF TITLE XXI OF THE
SOCIAL SECURITY ACT.
(2) ENROLLMENT MAY NOT BE DENIED ON THE BASIS OF A
PREEXISTING CONDITION, NOR MAY DIAGNOSIS OR TREATMENT FOR THE
CONDITION BE EXCLUDED BASED ON THE CONDITION'S PREEXISTENCE.
(D) THE PROVISION OF HEALTH CARE INSURANCE FOR ELIGIBLE
CHILDREN SHALL BE FREE TO A CHILD WHOSE FAMILY INCOME IS NO
GREATER THAN TWO HUNDRED PER CENTUM (200%) OF THE FEDERAL
POVERTY LEVEL.
(E.1) THE PROVISION OF HEALTH CARE INSURANCE FOR AN ELIGIBLE
CHILD WHOSE FAMILY INCOME IS GREATER THAN TWO HUNDRED PER CENTUM
(200%) OF THE FEDERAL POVERTY LEVEL BUT NO GREATER THAN TWO
HUNDRED FIFTY PER CENTUM (250%) OF THE FEDERAL POVERTY LEVEL MAY
BE SUBSIDIZED BY THE FUND AT A RATE NOT TO EXCEED SEVENTY-FIVE
PER CENTUM (75%) OF THE PER MEMBER PER MONTH PREMIUM COST.
(E.2) THE PROVISION OF HEALTH CARE INSURANCE FOR AN ELIGIBLE
CHILD WHOSE FAMILY INCOME IS GREATER THAN TWO HUNDRED FIFTY PER
CENTUM (250%) OF THE FEDERAL POVERTY LEVEL BUT NO GREATER THAN
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TWO HUNDRED SEVENTY-FIVE PER CENTUM (275%) OF THE FEDERAL
POVERTY LEVEL MAY BE SUBSIDIZED BY THE FUND AT A RATE NOT TO
EXCEED SIXTY-FIVE PER CENTUM (65%) OF THE PER MEMBER PER MONTH
PREMIUM COST.
(E.3) THE PROVISION OF HEALTH CARE INSURANCE FOR AN ELIGIBLE
CHILD WHOSE FAMILY INCOME IS GREATER THAN TWO HUNDRED SEVENTY-
FIVE PER CENTUM (275%) OF THE FEDERAL POVERTY LEVEL BUT NO
GREATER THAN THREE HUNDRED PER CENTUM (300%) OF THE FEDERAL
POVERTY LEVEL MAY BE SUBSIDIZED BY THE FUND AT A RATE NOT TO
EXCEED SIXTY PER CENTUM (60%) OF THE PER MEMBER PER MONTH
PREMIUM COST.
(E.4) THE FOLLOWING APPLY:
(1) FOR AN ELIGIBLE CHILD WHOSE FAMILY INCOME IS GREATER
THAN THE MAXIMUM LEVEL ESTABLISHED UNDER SUBSECTION (O), THE
FAMILY MAY PURCHASE THE MINIMUM BENEFIT PACKAGE SET FORTH IN
SUBSECTION (L)(6) FOR THAT CHILD AT THE PER MONTH PER MEMBER
PREMIUM COST, WHICH COST SHALL BE DERIVED SEPARATELY FROM THE
OTHER ELIGIBILITY CATEGORIES IN THE PROGRAM, AS LONG AS THE
FAMILY DEMONSTRATES ON AN ANNUAL BASIS AND IN A MANNER
DETERMINED BY THE DEPARTMENT EITHER ONE OF THE FOLLOWING:
(I) THE FAMILY IS UNABLE TO AFFORD INDIVIDUAL OR GROUP
COVERAGE BECAUSE THAT COVERAGE WOULD EXCEED TEN PER CENTUM (10%)
OF THE FAMILY INCOME OR BECAUSE THE TOTAL COST OF COVERAGE FOR
THE CHILD IS ONE HUNDRED FIFTY PER CENTUM (150%) OF THE GREATER
OF:
(A) THE PREMIUM COST ESTABLISHED UNDER THIS SUBSECTION FOR
THAT SERVICE AREA; OR
(B) THE PREMIUM COST ESTABLISHED UNDER THE PROGRAM FOR THAT
SERVICE AREA.
(II) THE FAMILY HAS BEEN REFUSED COVERAGE BY AN INSURER DUE
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TO THE CHILD OR A MEMBER OF THAT CHILD'S IMMEDIATE FAMILY HAVING
A PREEXISTING CONDITION AND COVERAGE IS NOT AVAILABLE TO THE
CHILD.
(2) FOR PURPOSES OF THIS SUBSECTION, "COVERAGE" SHALL NOT
INCLUDE COVERAGE OFFERED THROUGH ACCIDENT ONLY, FIXED INDEMNITY,
LIMITED BENEFIT, CREDIT, DENTAL, VISION, SPECIFIED DISEASE,
MEDICARE SUPPLEMENT, CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE
UNIFORMED SERVICES (CHAMPUS) SUPPLEMENT, LONG-TERM CARE OR
DISABILITY INCOME, WORKERS' COMPENSATION OR AUTOMOBILE MEDICAL
PAYMENT INSURANCE.
(F.1) (RESERVED).
(F.2) FOR ENROLLEES UNDER SUBSECTIONS (E.1), (E.2), (E.3)
AND (E.4), THE FOLLOWING APPLY:
(1) THE DEPARTMENT SHALL HAVE THE AUTHORITY TO IMPOSE
COPAYMENTS FOR THE FOLLOWING SERVICES, EXCEPT AS OTHERWISE
PROHIBITED BY LAW:
(I) OUTPATIENT VISITS.
(II) EMERGENCY ROOM VISITS.
(III) PRESCRIPTION MEDICATIONS.
(IV) ANY OTHER SERVICE DEFINED BY THE DEPARTMENT.
(2) THE DEPARTMENT SHALL HAVE THE AUTHORITY TO ESTABLISH AND
ADJUST THE LEVELS OF THESE COPAYMENTS IN ORDER TO IMPOSE
REASONABLE COST SHARING AND TO ENCOURAGE APPROPRIATE UTILIZATION
OF THESE SERVICES. IN NO EVENT SHALL THE PREMIUMS AND COPAYMENTS
FOR ENROLLEES UNDER SUBSECTIONS (E.1), (E.2) AND (E.3) AMOUNT TO
MORE THAN THE PER CENTUM OF TOTAL HOUSEHOLD INCOME WHICH IS IN
ACCORD WITH THE REQUIREMENTS OF THE CENTERS FOR MEDICARE AND
MEDICAID SERVICES.
(G) THE DEPARTMENT SHALL:
(1) ADMINISTER THE CHILDREN'S HEALTH CARE PROGRAM PURSUANT
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TO THIS ARTICLE.
(2) REVIEW ALL BIDS AND APPROVE AND EXECUTE ALL CONTRACTS
FOR THE PURPOSE OF EXPANDING ACCESS TO HEALTH CARE SERVICES FOR
ELIGIBLE CHILDREN AS PROVIDED FOR IN THIS SUBDIVISION.
(3) CONDUCT MONITORING AND OVERSIGHT OF CONTRACTS ENTERED
INTO.
(4) ISSUE AN ANNUAL REPORT TO THE GOVERNOR, THE GENERAL
ASSEMBLY AND THE PUBLIC FOR EACH CALENDAR YEAR NO LATER THAN
MARCH 1 OUTLINING PRIMARY HEALTH SERVICES FUNDED FOR THE YEAR,
DETAILING THE OUTREACH AND ENROLLMENT EFFORTS AND REPORTING BY
NUMBER OF CHILDREN BY COUNTY AND BY PER CENTUM OF THE FEDERAL
POVERTY LEVEL, THE NUMBER OF CHILDREN RECEIVING HEALTH CARE
SERVICES; BY COUNTY AND BY PER CENTUM OF THE FEDERAL POVERTY
LEVEL, THE PROJECTED NUMBER OF ELIGIBLE CHILDREN; AND THE NUMBER
OF ELIGIBLE CHILDREN ON WAITING LISTS FOR ENROLLMENT IN THE
HEALTH INSURANCE PROGRAM ESTABLISHED UNDER THIS ACT BY COUNTY
AND BY PER CENTUM OF THE FEDERAL POVERTY LEVEL.
(5) IN CONSULTATION WITH APPROPRIATE COMMONWEALTH AGENCIES,
COORDINATE THE DEVELOPMENT AND SUPERVISION OF THE OUTREACH PLAN
REQUIRED UNDER SECTION 2312.
(6) IN CONSULTATION WITH APPROPRIATE COMMONWEALTH AGENCIES,
MONITOR, REVIEW AND EVALUATE THE ADEQUACY, ACCESSIBILITY AND
AVAILABILITY OF SERVICES DELIVERED TO CHILDREN WHO ARE ENROLLED
IN THE HEALTH INSURANCE PROGRAM ESTABLISHED UNDER THIS
SUBDIVISION.
(H) THE DEPARTMENT MAY PROMULGATE REGULATIONS NECESSARY FOR
THE IMPLEMENTATION AND ADMINISTRATION OF THIS SUBDIVISION.
(I) THE CHILDREN'S HEALTH ADVISORY COUNCIL IS ESTABLISHED
WITHIN THE DEPARTMENT AS AN ADVISORY COUNCIL. THE FOLLOWING
SHALL APPLY:
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(1) THE COUNCIL SHALL CONSIST OF FOURTEEN VOTING MEMBERS.
MEMBERS PROVIDED FOR IN SUBPARAGRAPHS (IV), (V), (VI), (VII),
(VIII), (X) AND (XI) SHALL BE APPOINTED BY THE INSURANCE
COMMISSIONER. THE COUNCIL SHALL BE GEOGRAPHICALLY BALANCED ON A
STATEWIDE BASIS AND SHALL INCLUDE:
(I) THE SECRETARY OF HEALTH EX OFFICIO OR A DESIGNEE.
(II) THE INSURANCE COMMISSIONER EX OFFICIO OR A DESIGNEE.
(III) THE SECRETARY OF PUBLIC WELFARE EX OFFICIO OR A
DESIGNEE.
(IV) A REPRESENTATIVE WITH EXPERIENCE IN CHILDREN'S HEALTH
FROM A SCHOOL OF PUBLIC HEALTH LOCATED IN THIS COMMONWEALTH.
(V) A PHYSICIAN WITH EXPERIENCE IN CHILDREN'S HEALTH
APPOINTED FROM A LIST OF THREE QUALIFIED PERSONS RECOMMENDED BY
THE PENNSYLVANIA MEDICAL SOCIETY.
(VI) A REPRESENTATIVE OF A CHILDREN'S HOSPITAL OR A HOSPITAL
WITH A PEDIATRIC OUTPATIENT CLINIC APPOINTED FROM A LIST OF
THREE PERSONS SUBMITTED BY THE HOSPITAL ASSOCIATION OF
PENNSYLVANIA.
(VII) A PARENT OF A CHILD WHO RECEIVES PRIMARY HEALTH CARE
COVERAGE FROM THE FUND.
(VIII) A MID-LEVEL PROFESSIONAL APPOINTED FROM LISTS OF
NAMES RECOMMENDED BY STATEWIDE ASSOCIATIONS REPRESENTING MID-
LEVEL HEALTH PROFESSIONALS.
(IX) A SENATOR APPOINTED BY THE PRESIDENT PRO TEMPORE OF THE
SENATE, A SENATOR APPOINTED BY THE MINORITY LEADER OF THE
SENATE, A REPRESENTATIVE APPOINTED BY THE SPEAKER OF THE HOUSE
OF REPRESENTATIVES AND A REPRESENTATIVE APPOINTED BY THE
MINORITY LEADER OF THE HOUSE OF REPRESENTATIVES.
(X) A REPRESENTATIVE FROM A PRIVATE NONPROFIT FOUNDATION.
(XI) A REPRESENTATIVE OF BUSINESS WHO IS NOT A CONTRACTOR OR
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PROVIDER OF PRIMARY HEALTH CARE INSURANCE UNDER THIS
SUBDIVISION.
(2) IF ANY SPECIFIED ORGANIZATION SHOULD CEASE TO EXIST OR
FAIL TO MAKE A RECOMMENDATION WITHIN NINETY (90) DAYS OF A
REQUEST TO DO SO, THE COUNCIL SHALL SPECIFY A NEW EQUIVALENT
ORGANIZATION TO FULFILL THE RESPONSIBILITIES OF THIS SECTION.
(3) THE INSURANCE COMMISSIONER SHALL CHAIR THE COUNCIL. THE
MEMBERS OF THE COUNCIL SHALL ANNUALLY ELECT, BY A MAJORITY VOTE
OF THE MEMBERS, A VICE CHAIRPERSON FROM AMONG THE MEMBERS OF THE
COUNCIL.
(4) THE PRESENCE OF EIGHT MEMBERS SHALL CONSTITUTE A QUORUM
FOR THE TRANSACTING OF ANY BUSINESS. ANY ACT BY A MAJORITY OF
THE MEMBERS PRESENT AT ANY MEETING AT WHICH THERE IS A QUORUM
SHALL BE DEEMED TO BE THAT OF THE COUNCIL.
(5) ALL MEETINGS OF THE COUNCIL SHALL BE CONDUCTED PURSUANT
TO 65 PA.C.S. CH. 7 (RELATING TO OPEN MEETINGS) UNLESS OTHERWISE
PROVIDED IN THIS SECTION. THE COUNCIL SHALL MEET AT LEAST TWICE
PER YEAR AND MAY PROVIDE FOR SPECIAL MEETINGS AS IT DEEMS
NECESSARY. MEETING DATES SHALL BE SET BY A MAJORITY VOTE OF
MEMBERS OF THE COUNCIL OR BY CALL OF THE CHAIRPERSON UPON SEVEN
(7) DAYS' NOTICE TO ALL MEMBERS. THE COUNCIL SHALL PUBLISH
NOTICE OF ITS MEETINGS IN THE PENNSYLVANIA BULLETIN. NOTICE
SHALL SPECIFY THE DATE, TIME AND PLACE OF THE MEETING AND SHALL
STATE THAT THE COUNCIL'S MEETINGS ARE OPEN TO THE GENERAL
PUBLIC. ALL ACTION TAKEN BY THE COUNCIL SHALL BE TAKEN IN OPEN
PUBLIC SESSION AND SHALL NOT BE TAKEN EXCEPT UPON A MAJORITY
VOTE OF THE MEMBERS PRESENT AT A MEETING AT WHICH A QUORUM IS
PRESENT.
(6) THE MEMBERS OF THE COUNCIL SHALL NOT RECEIVE A SALARY OR
PER DIEM ALLOWANCE FOR SERVING AS MEMBERS OF THE COUNCIL BUT
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SHALL BE REIMBURSED FOR ACTUAL AND NECESSARY EXPENSES INCURRED
IN THE PERFORMANCE OF THEIR DUTIES.
(7) TERMS OF COUNCIL MEMBERS SHALL BE AS FOLLOWS:
(I) THE APPOINTED MEMBERS SHALL SERVE FOR A TERM OF THREE
(3) YEARS AND SHALL CONTINUE TO SERVE THEREAFTER UNTIL THEIR
SUCCESSORS ARE APPOINTED.
(II) AN APPOINTED MEMBER SHALL NOT BE ELIGIBLE TO SERVE MORE
THAN TWO FULL CONSECUTIVE TERMS OF THREE (3) YEARS. VACANCIES
SHALL BE FILLED IN THE SAME MANNER IN WHICH THEY WERE DESIGNATED
WITHIN SIXTY (60) DAYS OF THE VACANCY.
(III) AN APPOINTED MEMBER MAY BE REMOVED BY THE APPOINTING
AUTHORITY FOR JUST CAUSE AND BY A VOTE OF AT LEAST SEVEN MEMBERS
OF THE COUNCIL.
(8) THE COUNCIL SHALL REVIEW OUTREACH ACTIVITIES AND MAY
MAKE RECOMMENDATIONS TO THE DEPARTMENT.
(9) THE COUNCIL SHALL REVIEW AND EVALUATE THE ACCESSIBILITY
AND AVAILABILITY OF SERVICES DELIVERED TO CHILDREN ENROLLED IN
THE PROGRAM.
(J) THE DEPARTMENT SHALL SOLICIT BIDS AND AWARD CONTRACTS
THROUGH A COMPETITIVE PROCUREMENT PROCESS PURSUANT TO THE
FOLLOWING:
(1) TO THE FULLEST EXTENT PRACTICABLE, CONTRACTS SHALL BE
AWARDED TO INSURERS THAT CONTRACT WITH PROVIDERS TO PROVIDE
PRIMARY CARE SERVICES FOR ENROLLEES ON A COST-EFFECTIVE BASIS.
THE DEPARTMENT SHALL REQUIRE CONTRACTORS TO USE APPROPRIATE
COST-MANAGEMENT METHODS SO THAT BASIC PRIMARY BENEFIT SERVICES
CAN BE PROVIDED TO THE MAXIMUM NUMBER OF ELIGIBLE CHILDREN AND,
WHENEVER POSSIBLE, TO PURSUE AND UTILIZE AVAILABLE PUBLIC AND
PRIVATE FUNDS.
(2) TO THE FULLEST EXTENT PRACTICABLE, THE DEPARTMENT SHALL
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REQUIRE THAT ANY CONTRACTOR COMPLY WITH ALL PROCEDURES RELATING
TO COORDINATION OF BENEFITS AS REQUIRED BY THE DEPARTMENT OR THE
DEPARTMENT OF PUBLIC WELFARE.
(3) CONTRACTS MAY BE FOR A TERM OF UP TO THREE (3) YEARS,
WITH THE OPTION TO EXTEND FOR TWO ONE-YEAR PERIODS.
(K) UPON RECEIPT OF A SOLICITATION FROM THE DEPARTMENT, EACH
HEALTH SERVICE CORPORATION AND HOSPITAL PLAN CORPORATION OR
THEIR ENTITIES DOING BUSINESS IN THIS COMMONWEALTH SHALL SUBMIT
A BID OR PROPOSAL TO THE DEPARTMENT TO CARRY OUT THE PURPOSES OF
THIS SECTION IN THE AREA SERVICED BY THE CORPORATION. ALL OTHER
INSURERS MAY SUBMIT A BID OR PROPOSAL TO THE DEPARTMENT TO CARRY
OUT THE PURPOSES OF THIS SECTION.
(L) A CONTRACTOR WITH WHOM THE DEPARTMENT ENTERS INTO A
CONTRACT SHALL DO THE FOLLOWING:
(1) ENSURE TO THE MAXIMUM EXTENT POSSIBLE THAT ELIGIBLE
CHILDREN HAVE ACCESS TO PRIMARY HEALTH CARE PHYSICIANS AND NURSE
PRACTITIONERS WITHIN THE CONTRACTOR'S SERVICE AREA.
(2) CONTRACT WITH QUALIFIED, COST-EFFECTIVE PROVIDERS, WHICH
MAY INCLUDE PRIMARY HEALTH CARE PHYSICIANS, NURSE PRACTITIONERS,
CLINICS AND HEALTH MAINTENANCE ORGANIZATIONS, TO PROVIDE PRIMARY
AND PREVENTIVE HEALTH CARE FOR ENROLLEES ON A BASIS BEST
CALCULATED TO MANAGE THE COSTS OF THE SERVICES, INCLUDING, BUT
NOT LIMITED TO, USING MANAGED HEALTH CARE TECHNIQUES AND OTHER
APPROPRIATE MEDICAL COST-MANAGEMENT METHODS.
(3) ENSURE THAT THE FAMILY OF A CHILD WHO MAY BE ELIGIBLE
FOR MEDICAL ASSISTANCE RECEIVES ASSISTANCE IN APPLYING FOR
MEDICAL ASSISTANCE.
(4) MAINTAIN WAITING LISTS OF CHILDREN FINANCIALLY ELIGIBLE
FOR BENEFITS WHO HAVE APPLIED FOR BENEFITS BUT WHO WERE NOT
ENROLLED DUE TO LACK OF FUNDS.
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(4.1) NOTIFY FAMILIES OF CHILDREN WHO ARE PAYING A PREMIUM
OF ANY CHANGES IN SUCH PREMIUM OR COPAYMENT REQUIREMENTS.
(4.2) COLLECT SUCH PREMIUMS OR COPAYMENTS FROM THE FAMILY OF
ANY CHILD RECEIVING BENEFITS AS MAY BE REQUIRED.
(4.3) CANCEL POLICIES FOR NONPAYMENT OF PREMIUM, IN
ACCORDANCE WITH ALL OTHER APPLICABLE INSURANCE LAWS.
(5) STRONGLY ENCOURAGE ALL PROVIDERS WHO PROVIDE PRIMARY
CARE TO ELIGIBLE CHILDREN TO PARTICIPATE IN MEDICAL ASSISTANCE
AS QUALIFIED EPSDT PROVIDERS AND TO CONTINUE TO PROVIDE CARE TO
CHILDREN WHO BECOME INELIGIBLE FOR COVERAGE UNDER THE PROVISIONS
OF THIS ARTICLE BUT WHO QUALIFY FOR MEDICAL ASSISTANCE.
(6) SUBJECT TO ANY NECESSARY FEDERAL APPROVAL, PROVIDE THE
FOLLOWING MINIMUM BENEFIT PACKAGE FOR ELIGIBLE CHILDREN:
(I) PREVENTIVE CARE. THIS SUBPARAGRAPH INCLUDES WELL-CHILD
CARE VISITS IN ACCORDANCE WITH THE SCHEDULE ESTABLISHED BY THE
AMERICAN ACADEMY OF PEDIATRICS AND THE SERVICES RELATED TO THOSE
VISITS, INCLUDING, BUT NOT LIMITED TO, IMMUNIZATIONS, HEALTH
EDUCATION, TUBERCULOSIS TESTING AND DEVELOPMENTAL SCREENING IN
ACCORDANCE WITH ROUTINE SCHEDULE OF WELL-CHILD VISITS. CARE
SHALL ALSO INCLUDE A COMPREHENSIVE PHYSICAL EXAMINATION,
INCLUDING X-RAYS IF NECESSARY, FOR ANY CHILD EXHIBITING SYMPTOMS
OF POSSIBLE CHILD ABUSE.
(II) DIAGNOSIS AND TREATMENT OF ILLNESS OR INJURY, INCLUDING
ALL MEDICALLY NECESSARY SERVICES RELATED TO THE DIAGNOSIS AND
TREATMENT OF SICKNESS AND INJURY AND OTHER CONDITIONS PROVIDED
ON AN AMBULATORY BASIS, SUCH AS LABORATORY TESTS, WOUND DRESSING
AND CASTING TO IMMOBILIZE FRACTURES.
(III) INJECTIONS AND MEDICATIONS PROVIDED AT THE TIME OF THE
OFFICE VISIT OR THERAPY AND OUTPATIENT SURGERY PERFORMED IN THE
OFFICE, A HOSPITAL OR FREESTANDING AMBULATORY SERVICE CENTER,
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INCLUDING ANESTHESIA PROVIDED IN CONJUNCTION WITH SUCH SERVICE
OR DURING EMERGENCY MEDICAL SERVICE.
(IV) EMERGENCY ACCIDENT AND EMERGENCY MEDICAL CARE.
(V) PRESCRIPTION DRUGS.
(VI) EMERGENCY, PREVENTIVE AND ROUTINE DENTAL CARE. THIS
SUBPARAGRAPH DOES NOT INCLUDE ORTHODONTIA OR COSMETIC SURGERY.
(VII) EMERGENCY, PREVENTIVE AND ROUTINE VISION CARE,
INCLUDING THE COST OF CORRECTIVE LENSES AND FRAMES, NOT TO
EXCEED TWO PRESCRIPTIONS PER YEAR.
(VIII) EMERGENCY, PREVENTIVE AND ROUTINE HEARING CARE.
(IX) INPATIENT HOSPITALIZATION UP TO NINETY (90) DAYS PER
YEAR FOR ELIGIBLE CHILDREN.
(6.1) THE DEPARTMENT SHALL IMPLEMENT A PREMIUM ASSISTANCE
PROGRAM PERMITTED UNDER FEDERAL REGULATIONS AND AS PERMITTED
THROUGH FEDERAL WAIVER OR STATE PLAN AMENDMENT MADE PURSUANT TO
THIS ARTICLE. NOTWITHSTANDING ANY OTHER LAW TO THE CONTRARY, IN
THE EVENT IT IS MORE COST EFFECTIVE TO PURCHASE HEALTH CARE FROM
A PARENT'S EMPLOYER-BASED PROGRAM AND THE EMPLOYER-BASED PROGRAM
MEETS THE MINIMUM COVERAGE REQUIREMENTS, EMPLOYER-BASED COVERAGE
MAY BE PURCHASED IN PLACE OF ENROLLMENT IN THE HEALTH INSURANCE
PROGRAM ESTABLISHED UNDER THIS SUBDIVISION. AN INSURER SHALL
HONOR A REQUEST FOR ENROLLMENT AND PURCHASE OF EMPLOYE GROUP
HEALTH INSURANCE REQUESTED ON BEHALF OF AN INDIVIDUAL APPLYING
FOR COVERAGE UNDER THIS ARTICLE IF THAT INDIVIDUAL:
(I) IS A RESIDENT OF THIS COMMONWEALTH;
(II) IS QUALIFIED BASED ON INCOME UNDER SECTION 2311(D),
(E.1), (E.2) OR (E.3); AND
(III) MEETS THE CITIZENSHIP REQUIREMENTS OF SECTION 2311(C)
(1.1)(IV).
(6.2) THE DEPARTMENT SHALL HAVE THE AUTHORITY TO REVIEW,
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AUDIT AND APPROVE ANNUAL ADMINISTRATIVE EXPENSES INCURRED BY
CONTRACTORS PURSUANT TO THIS SECTION.
(7) EXCEPT FOR CHILDREN COVERED UNDER PARAGRAPH (6.1), EACH
CONTRACTOR SHALL PROVIDE AN INSURANCE IDENTIFICATION CARD TO
EACH ELIGIBLE CHILD COVERED UNDER CONTRACTS EXECUTED UNDER THIS
ARTICLE. THE CARD MUST NOT SPECIFICALLY IDENTIFY THE HOLDER AS
LOW INCOME.
(M) THE DEPARTMENT MAY GRANT A WAIVER OF THE MINIMUM BENEFIT
PACKAGE OF SUBSECTION (L)(6) UPON DEMONSTRATION BY THE APPLICANT
THAT IT IS PROVIDING HEALTH CARE SERVICES FOR ELIGIBLE CHILDREN
THAT MEET THE PURPOSES AND INTENT OF THIS SECTION.
(N) AFTER THE FIRST YEAR OF OPERATION AND PERIODICALLY
THEREAFTER, THE DEPARTMENT IN CONSULTATION WITH APPROPRIATE
COMMONWEALTH AGENCIES SHALL REVIEW ENROLLMENT PATTERNS FOR BOTH
THE FREE INSURANCE PROGRAM AND THE SUBSIDIZED INSURANCE PROGRAM.
THE DEPARTMENT SHALL CONSIDER THE RELATIONSHIP, IF ANY, AMONG
ENROLLMENT, ENROLLMENT FEES, INCOME LEVELS AND FAMILY
COMPOSITION. BASED ON THE RESULTS OF THIS STUDY AND THE
AVAILABILITY OF FUNDS, THE DEPARTMENT IS AUTHORIZED TO ADJUST
THE MAXIMUM INCOME CEILING FOR FREE INSURANCE AND THE MAXIMUM
INCOME CEILING FOR SUBSIDIZED INSURANCE BY REGULATION. IN NO
EVENT, HOWEVER, SHALL THE MAXIMUM INCOME CEILING FOR FREE
INSURANCE BE RAISED ABOVE TWO HUNDRED PER CENTUM (200%) OF THE
FEDERAL POVERTY LEVEL.
(O) NOTWITHSTANDING SUBSECTION (N), BEGINNING JANUARY 1,
2007, AND THEREAFTER, AND SUBJECT TO THE PROVISIONS OF SECTION
2314, THE MAXIMUM INCOME CEILING FOR SUBSIDIZED INSURANCE SHALL
NOT BE RAISED ABOVE THREE HUNDRED PER CENTUM (300%) OF THE
FEDERAL POVERTY LEVEL.
SECTION 2312. OUTREACH.--(A) THE DEPARTMENT, IN
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CONSULTATION WITH APPROPRIATE COMMONWEALTH AGENCIES, SHALL
COORDINATE THE DEVELOPMENT OF AN OUTREACH PLAN TO INFORM
POTENTIAL CONTRACTORS, PROVIDERS AND ENROLLEES REGARDING
ELIGIBILITY AND AVAILABLE BENEFITS. THE PLAN SHALL INCLUDE
PROVISIONS FOR REACHING SPECIAL POPULATIONS, INCLUDING NONWHITE
AND NON-ENGLISH-SPEAKING CHILDREN AND CHILDREN WITH
DISABILITIES; FOR REACHING DIFFERENT GEOGRAPHIC AREAS, INCLUDING
RURAL AND INNER-CITY AREAS; AND FOR ASSURING THAT SPECIAL
EFFORTS ARE COORDINATED WITHIN THE OVERALL OUTREACH ACTIVITIES
THROUGHOUT THIS COMMONWEALTH.
(B) THE COUNCIL SHALL REVIEW THE OUTREACH ACTIVITIES AND
RECOMMEND CHANGES AS IT DEEMS IN THE BEST INTERESTS OF THE
CHILDREN TO BE SERVED.
SECTION 2313. PAYOR OF LAST RESORT; INSURANCE COVERAGE.--THE
CONTRACTOR SHALL NOT PAY ANY CLAIM ON BEHALF OF AN ENROLLED
CHILD UNLESS ALL OTHER FEDERAL, STATE, LOCAL OR PRIVATE
RESOURCES AVAILABLE TO THE CHILD OR THE CHILD'S FAMILY ARE
UTILIZED FIRST. THE DEPARTMENT, IN COOPERATION WITH THE
DEPARTMENT OF PUBLIC WELFARE, SHALL DETERMINE IF ANY OTHER
INSURANCE COVERAGE IS AVAILABLE TO THE CHILD THROUGH A CUSTODIAL
OR NONCUSTODIAL PARENT ON AN EMPLOYMENT-RELATED OR OTHER GROUP
BASIS. IF SUCH INSURANCE COVERAGE IS AVAILABLE, THE CHILD'S
ELIGIBILITY UNDER SECTION 2311 SHALL BE REEVALUATED, AS SHALL
THE MOST COST-EFFECTIVE MEANS OF PROVIDING COVERAGE FOR THAT
CHILD.
SECTION 2314. STATE PLAN.--THE DEPARTMENT, IN COOPERATION
WITH THE DEPARTMENT OF PUBLIC WELFARE, SHALL AMEND THE STATE
PLAN AS DEEMED NECESSARY TO CARRY OUT THE PROVISIONS OF THIS
ARTICLE. THE REPEAL OF SECTION 2311(E) AND (F) AND THE EXPANSION
OF FINANCIAL ELIGIBILITY UNDER SECTION 2311(E.1), (E.2) AND
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(E.3) SHALL BE CONTINGENT UPON FEDERAL APPROVAL.
(C) (RESERVED).
(D) (RESERVED).
(E) (RESERVED).
(F) (RESERVED).
(G) MISCELLANEOUS PROVISIONS.
SECTION 2361. LIMITATION ON EXPENDITURE OF FUNDS.--IN NO
CASE SHALL THE TOTAL AMOUNT OF ANNUAL CONTRACT AWARDS AUTHORIZED
IN SUBDIVISION (B) EXCEED THE AMOUNT OF CIGARETTE TAX RECEIPTS
ANNUALLY DEPOSITED INTO THE FUND PURSUANT TO SECTION 1296 OF THE
ACT OF MARCH 4, 1971 (P.L.6, NO.2), KNOWN AS THE "TAX REFORM
CODE OF 1971," AND ANY OTHER FEDERAL OR STATE FUNDS RECEIVED
THROUGH THE FUND. THE PROVISION OF CHILDREN'S HEALTH CARE
THROUGH THE FUND SHALL IN NO WAY CONSTITUTE AN ENTITLEMENT
DERIVED FROM THE COMMONWEALTH OR A CLAIM ON ANY OTHER FUNDS OF
THE COMMONWEALTH.
SECTION 2362. EXPIRATION.--THIS ARTICLE SHALL EXPIRE
DECEMBER 31, 2015.]
SECTION 3. THE ACT IS AMENDED BY ADDING AN ARTICLE TO READ:
ARTICLE XXIII-A
COMPREHENSIVE HEALTH CARE
FOR UNINSURED CHILDREN
SECTION 2301-A . DEFINITIONS.
THE FOLLOWING WORDS AND PHRASES WHEN USED IN THIS ARTICLE
SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SECTION UNLESS THE
CONTEXT CLEARLY INDICATES OTHERWISE:
"CHILD." AN INDIVIDUAL UNDER 19 YEARS OF AGE.
"CONTRACTOR." AN INSURER AWARDED A CONTRACT UNDER SECTION
2304-A TO PROVIDE HEALTH CARE SERVICES UNDER THIS ARTICLE. THE
TERM INCLUDES AN ENTITY AND AN ENTITY'S SUBSIDIARY WHICH IS
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ESTABLISHED UNDER THIS ACT, 40 PA.C.S. CH. 61 (RELATING TO
HOSPITAL PLAN CORPORATIONS) OR 63 (RELATING TO PROFESSIONAL
HEALTH SERVICES PLAN CORPORATIONS), OR THE ACT OF DECEMBER 29,
1972 (P.L.1701, NO.364), KNOWN AS THE HEALTH MAINTENANCE
ORGANIZATION ACT.
"COUNCIL." THE CHILDREN'S HEALTH ADVISORY COUNCIL
ESTABLISHED IN SECTION 2303-A .
"DEPARTMENT." THE DEPARTMENT OF HUMAN SERVICES OF THE
COMMONWEALTH.
"EPSDT." EARLY AND PERIODIC SCREENING, DIAGNOSIS AND
TREATMENT.
"EXPRESS LANE ELIGIBILITY." A PROCESS WHICH PERMITS THE USE
OF FINDINGS FOR ELIGIBILITY FACTORS, INCLUDING INCOME AND
HOUSEHOLD SIZE FROM AN EXPRESS LANE PARTNER ADMINISTERING A
GOVERNMENT PROGRAM.
"EXPRESS LANE PARTNER." AN AGENCY DETERMINING ELIGIBILITY
FOR ASSISTANCE FOR ANY OF THE FOLLOWING PROGRAMS:
(1) SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP).
(2) CHILD CARE PROVIDED UNDER THE CHILD CARE AND
DEVELOPMENT BLOCK GRANT ACT OF 1990 (PUBLIC LAW 101-508, 42
U.S.C. ยง 9858 ET SEQ.).
"FUND." THE CHILDREN'S HEALTH FUND.
"GROUP." A GROUP FOR WHICH A HEALTH INSURANCE POLICY IS
WRITTEN IN THIS COMMONWEALTH.
"HEALTH SERVICE CORPORATION." A PROFESSIONAL HEALTH SERVICE
CORPORATION AS DEFINED IN SECTION 2302-A.
"HEALTHY BEGINNINGS PROGRAM." MEDICAL ASSISTANCE COVERAGE
FOR SERVICES TO CHILDREN AS REQUIRED UNDER TITLE XIX FOR THE
FOLLOWING:
(1) CHILDREN FROM BIRTH TO ONE YEAR OF AGE WHOSE FAMILY
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INCOME IS NOT GREATER THAN 185% OF THE FEDERAL POVERTY LEVEL.
(2) CHILDREN ONE THROUGH FIVE YEARS OF AGE WHOSE FAMILY
INCOME IS NOT GREATER THAN 133% OF THE FEDERAL POVERTY LEVEL.
(3) CHILDREN 6 THROUGH 18 YEARS OF AGE WHOSE FAMILY
INCOME IS NOT GREATER THAN 133% OF THE FEDERAL POVERTY LEVEL.
"HMO." AN ENTITY ORGANIZED AND REGULATED UNDER THE HEALTH
MAINTENANCE ORGANIZATION ACT.
"HOSPITAL." AN INSTITUTION HAVING AN ORGANIZED MEDICAL STAFF
WHICH IS ENGAGED PRIMARILY IN PROVIDING TO INPATIENTS, BY OR
UNDER THE SUPERVISION OF PHYSICIANS, DIAGNOSTIC AND THERAPEUTIC
SERVICES FOR THE CARE OF INJURED, DISABLED, PREGNANT, DISEASED
OR SICK OR MENTALLY ILL INDIVIDUALS. THE TERM INCLUDES
FACILITIES FOR THE DIAGNOSIS AND TREATMENT OF DISORDERS WITHIN
THE SCOPE OF SPECIFIC MEDICAL SPECIALTIES. THE TERM DOES NOT
INCLUDE FACILITIES CARING EXCLUSIVELY FOR THE MENTALLY ILL.
"HOSPITAL PLAN CORPORATION." A HOSPITAL PLAN CORPORATION AS
DEFINED IN 40 PA.C.S. ยง 6101 (RELATING TO DEFINITIONS).
"INSURER." A HEALTH INSURANCE ENTITY LICENSED IN THIS
COMMONWEALTH TO ISSUE ANY INDIVIDUAL OR GROUP HEALTH, SICKNESS
OR ACCIDENT POLICY OR SUBSCRIBER CONTRACT OR CERTIFICATE THAT
PROVIDES MEDICAL OR HEALTH CARE COVERAGE BY A HEALTH CARE
FACILITY OR LICENSED HEALTH CARE PROVIDER THAT IS OFFERED OR
GOVERNED UNDER ANY OF THE FOLLOWING:
(1) THIS ACT.
(2) THE HEALTH MAINTENANCE ORGANIZATION ACT.
(3) THE ACT OF MAY 18, 1976 (P.L.123, NO.54), KNOWN AS
THE INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM
STANDARDS ACT.
(4) 40 PA.C.S. CH. 61 (RELATING TO HOSPITAL PLAN
CORPORATIONS) OR 63 (RELATING TO PROFESSIONAL HEALTH SERVICES
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PLAN CORPORATIONS).
"MEDICAID." THE FEDERAL MEDICAL ASSISTANCE PROGRAM
ESTABLISHED UNDER TITLE XIX.
"MEDICAL ASSISTANCE." THE STATE PROGRAM OF MEDICAL
ASSISTANCE ESTABLISHED UNDER THE ACT OF JUNE 13, 1967 (P.L.31,
NO.21), KNOWN AS THE PUBLIC WELFARE CODE.
"MID-LEVEL HEALTH PROFESSIONAL." A PHYSICIAN ASSISTANT,
CERTIFIED REGISTERED NURSE PRACTITIONER, NURSE PRACTITIONER OR
CERTIFIED NURSE MIDWIFE.
"PARENT." A NATURAL PARENT, STEPPARENT, ADOPTIVE PARENT,
GUARDIAN OR CUSTODIAN OF A CHILD.
"PREMIUM ASSISTANCE PROGRAM." A COMPONENT OF A SEPARATE
CHILD HEALTH PROGRAM, APPROVED UNDER THE STATE PLAN, UNDER WHICH
THE COMMONWEALTH PAYS PART OR ALL OF THE PREMIUM FOR AN ENROLLEE
OR ENROLLEE'S GROUP HEALTH INSURANCE COVERAGE OR COVERAGE UNDER
A GROUP HEALTH PLAN.
"PRESCRIPTION DRUG." A CONTROLLED SUBSTANCE, OTHER DRUG OR
DEVICE FOR MEDICATION DISPENSED BY ORDER OF AN APPROPRIATELY
LICENSED MEDICAL PROFESSIONAL.
"SECRETARY." THE SECRETARY OF HUMAN SERVICES OF THE
COMMONWEALTH.
"TERMINATE." THE TERM INCLUDES CANCELLATION, NONRENEWAL AND
RESCISSION.
"TITLE XIX." TITLE XIX OF THE SOCIAL SECURITY ACT (49 STAT.
620, 42 U.S.C. ยง 301 ET SEQ.).
"TITLE XXI." TITLE XXI OF THE SOCIAL SECURITY ACT.
SECTION 2302-A. CHILDREN'S HEALTH CARE.
(A) FEDERAL FUNDS.--NOTWITHSTANDING ANY OTHER PROVISION OF
LAW, THE DEPARTMENT SHALL ENSURE THE RECEIPT OF FEDERAL
FINANCIAL PARTICIPATION UNDER TITLE XXI FOR SERVICES PROVIDED
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UNDER THIS CHAPTER.
(B) GENERAL CARE.--TO ENSURE THAT INPATIENT HOSPITAL CARE IS
PROVIDED TO ELIGIBLE CHILDREN, EACH PRIMARY CARE PROVIDER
FURNISHING PRIMARY CARE SERVICES SHALL MAKE NECESSARY
ARRANGEMENTS FOR ADMISSION TO THE HOSPITAL AND FOR NECESSARY
SPECIALTY CARE.
(C) ENROLLMENT.--SUBJECT TO THE PROVISIONS OF SECTION 2304-
A, AN INSURER RECEIVING FUNDS FROM THE DEPARTMENT TO PROVIDE
COVERAGE OF HEALTH CARE SERVICES UNDER THIS SECTION SHALL
ENROLL, TO THE EXTENT THAT FUNDS ARE AVAILABLE, ANY CHILD WHO
MEETS ALL OF THE FOLLOWING:
(1) IS A RESIDENT OF THIS COMMONWEALTH.
(2) IS NOT:
(I) COVERED BY A HEALTH INSURANCE PLAN.
(II) COVERED BY A SELF-INSURANCE PLAN.
(III) COVERED BY A SELF-FUNDED PLAN.
(IV) PROVIDED ACCESS TO HEALTH CARE COVERAGE BY
COURT ORDER.
(V) ELIGIBLE FOR OR COVERED BY A MEDICAL ASSISTANCE
PROGRAM ADMINISTERED BY THE DEPARTMENT, INCLUDING THE
HEALTHY BEGINNINGS PROGRAM.
(3) IS QUALIFIED BASED ON INCOME UNDER SUBSECTIONS (D)
AND (E).
(4) MEETS THE CITIZENSHIP REQUIREMENTS OF TITLE XXI.
(D) INCOME LEVELS.--THE PROVISION OF HEALTH CARE INSURANCE
FOR ELIGIBLE CHILDREN SHALL BE IN ACCORDANCE WITH THE FOLLOWING:
(1) FREE TO A CHILD WHOSE FAMILY INCOME IS NO GREATER
THAN 200% OF THE FEDERAL POVERTY LEVEL.
(2) MAY BE SUBSIDIZED BY THE FUND AT A RATE NOT TO
EXCEED 75% OF THE PER MEMBER PER MONTH PREMIUM COST FOR A
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CHILD WHOSE FAMILY INCOME IS GREATER THAN 200% OF THE FEDERAL
POVERTY LEVEL BUT NOT GREATER THAN 250% OF THE FEDERAL
POVERTY LEVEL.
(3) MAY BE SUBSIDIZED BY THE FUND AT A RATE NOT TO
EXCEED 65% OF THE PER MEMBER PER MONTH PREMIUM COST FOR A
CHILD WHOSE FAMILY INCOME IS GREATER THAN 250% OF THE FEDERAL
POVERTY LEVEL BUT NOT GREATER THAN 275% OF THE FEDERAL
POVERTY LEVEL.
(4) MAY BE SUBSIDIZED BY THE FUND AT A RATE NOT TO
EXCEED 60% OF THE PER MEMBER PER MONTH PREMIUM FOR A CHILD
WHOSE FAMILY INCOME IS GREATER THAN 275% OF THE FEDERAL
POVERTY LEVEL BUT NOT GREATER THAN 300% OF THE FEDERAL
POVERTY LEVEL.
(5) NOTWITHSTANDING PARAGRAPHS (1), (2), (3) AND (4),
FOR PURPOSES OF DETERMINING COST SHARING OBLIGATIONS OF A
FAMILY WITH INCOME LEVELS SPECIFIED UNDER PARAGRAPHS (2), (3)
AND (4), THE PER MEMBER PER MONTH PREMIUM SHALL EXCLUDE THE
COST RELATED TO AN ASSESSMENT IMPOSED ON A CONTRACTOR
RELATING TO MANAGED CARE ORGANIZATION ASSESSMENTS UNDER THE
ACT OF JUNE 13, 1967 (P.L.31, NO.21), KNOWN AS THE PUBLIC
WELFARE CODE.
(E) INCOME EXCEEDING LIMITS.--THE FOLLOWING APPLY:
(1) FOR AN ELIGIBLE CHILD WHOSE FAMILY INCOME IS GREATER
THAN THE MAXIMUM LEVEL ESTABLISHED UNDER SECTION 2304-A(H),
THE FAMILY MAY PURCHASE THE MINIMUM COVERAGE PACKAGE UNDER
2304-A(E)(9) FOR THAT CHILD AT THE PER MEMBER PER MONTH
PREMIUM COST. THE COST SHALL BE DERIVED SEPARATELY FROM THE
OTHER ELIGIBILITY CATEGORIES IN THE PROGRAM. THE FAMILY MAY
PURCHASE THE MINIMUM COVERAGE PACKAGE IF THE FAMILY
DEMONSTRATES ON AN ANNUAL BASIS AND IN A MANNER DETERMINED BY
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THE DEPARTMENT THAT THE FAMILY IS UNABLE TO AFFORD INDIVIDUAL
OR GROUP COVERAGE BECAUSE OF ONE OF THE FOLLOWING REASONS:
(I) THE COVERAGE WOULD EXCEED 10% OF THE FAMILY
INCOME.
(II) THE TOTAL COST OF COVERAGE FOR THE CHILD IS
150% OF THE GREATER OF:
(A) THE PREMIUM COST ESTABLISHED UNDER THIS
SUBSECTION FOR THAT SERVICE AREA; OR
(B) THE PREMIUM COST ESTABLISHED UNDER THE
PROGRAM FOR THAT SERVICE AREA.
(2) FOR PURPOSES OF THIS SUBSECTION, THE PER MEMBER PER
MONTH PREMIUM COST SHALL EXCLUDE THE COST RELATED TO THE
MANAGED CARE ORGANIZATION ASSESSMENT IMPOSED ON A CONTRACTOR
UNDER THE PUBLIC WELFARE CODE.
(3) FOR PURPOSES OF THIS SUBSECTION, THE TERM "COVERAGE"
MAY NOT INCLUDE COVERAGE OFFERED THROUGH ACCIDENT ONLY, FIXED
INDEMNITY, LIMITED BENEFIT, CREDIT, DENTAL, VISION, SPECIFIED
DISEASE, MEDICARE SUPPLEMENT, CIVILIAN HEALTH AND MEDICAL
PROGRAM OF THE UNIFORMED SERVICES (CHAMPUS) SUPPLEMENT, LONG-
TERM CARE OR DISABILITY INCOME, WORKERS' COMPENSATION OR
AUTOMOBILE MEDICAL PAYMENT INSURANCE.
(F) POWERS AND DUTIES.--
(1) FOR ENROLLEES UNDER SUBSECTION (D)(2), (3) OR (4) OR
(E), THE FOLLOWING APPLY:
(I) THE DEPARTMENT MAY IMPOSE COPAYMENTS FOR THE
FOLLOWING SERVICES, EXCEPT AS OTHERWISE PROHIBITED BY
LAW:
(A) OUTPATIENT VISITS.
(B) EMERGENCY ROOM VISITS.
(C) PRESCRIPTION MEDICATIONS.
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(D) ANY OTHER SERVICE DEFINED BY THE DEPARTMENT.
(II) THE DEPARTMENT MAY ESTABLISH AND ADJUST THE
LEVELS OF THESE COPAYMENTS IN ORDER TO IMPOSE REASONABLE
COST SHARING AND TO ENCOURAGE APPROPRIATE UTILIZATION OF
THESE SERVICES. THE PREMIUMS AND COPAYMENTS FOR ENROLLEES
UNDER SUBSECTION (D)(2), (3) OR (4) MAY NOT AMOUNT TO
MORE THAN THE PERCENT OF TOTAL HOUSEHOLD INCOME WHICH IS
IN ACCORDANCE WITH THE REQUIREMENTS OF THE CENTERS FOR
MEDICARE AND MEDICAID SERVICES.
(2) THE DEPARTMENT SHALL:
(I) ADMINISTER THE CHILDREN'S HEALTH INSURANCE
PROGRAM IN ACCORDANCE WITH THIS CHAPTER.
(II) REVIEW ALL BIDS AND APPROVE AND EXECUTE ALL
CONTRACTS FOR THE PURPOSE OF EXPANDING ACCESS TO HEALTH
CARE SERVICES FOR ELIGIBLE CHILDREN AS PROVIDED FOR IN
THIS ARTICLE.
(III) CONDUCT MONITORING AND OVERSIGHT OF CONTRACTS.
(IV) ISSUE AN ANNUAL REPORT TO THE GOVERNOR, THE
GENERAL ASSEMBLY AND THE PUBLIC FOR EACH CALENDAR YEAR NO
LATER THAN MARCH 1 OF EACH YEAR PROVIDING FOR THE
FOLLOWING:
(A) THE PRIMARY HEALTH SERVICES FUNDED FOR THE
YEAR.
(B) THE OUTREACH AND ENROLLMENT EFFORTS AND THE
NUMBER OF CHILDREN BY COUNTY AND BY PERCENT OF THE
FEDERAL POVERTY LEVEL WHO ARE RECEIVING HEALTH CARE
SERVICES.
(C) THE PROJECTED NUMBER OF ELIGIBLE CHILDREN BY
COUNTY AND BY PERCENT OF THE FEDERAL POVERTY LEVEL.
(D) THE NUMBER OF ELIGIBLE CHILDREN ON WAITING
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LISTS FOR ENROLLMENT IN THE CHILDREN'S HEALTH
INSURANCE PROGRAM ESTABLISHED UNDER THIS ARTICLE BY
COUNTY AND BY PERCENT OF THE FEDERAL POVERTY LEVEL.
(E) THE DETAILS OF THE DEPARTMENT'S EFFORTS ON
THE IMPLEMENTATION OF EXPRESS LANE ELIGIBILITY.
(V) IN CONSULTATION WITH APPROPRIATE COMMONWEALTH
AGENCIES, COORDINATE THE DEVELOPMENT AND SUPERVISION OF
THE OUTREACH PLAN REQUIRED UNDER SECTION 2305-A.
(VI) IN CONSULTATION WITH APPROPRIATE COMMONWEALTH
AGENCIES, MONITOR, REVIEW AND EVALUATE THE ADEQUACY,
ACCESSIBILITY AND AVAILABILITY OF SERVICES DELIVERED TO
CHILDREN WHO ARE ENROLLED IN THE CHILDREN'S HEALTH
INSURANCE PROGRAM ESTABLISHED UNDER THIS ARTICLE.
(VII) ENTER INTO ARRANGEMENTS, INCLUDING MEMORANDA
OF UNDERSTANDING, WITH THE INSURANCE DEPARTMENT AND OTHER
APPROPRIATE FEDERAL OR STATE AGENCIES, AS MAY BE
NECESSARY TO CARRY OUT THE DEPARTMENT'S DUTIES UNDER THIS
ARTICLE.
(3) THE DEPARTMENT MAY PROMULGATE REGULATIONS NECESSARY
FOR THE IMPLEMENTATION AND ADMINISTRATION OF THIS ARTICLE.
SECTION 2303-A . CHILDREN'S HEALTH ADVISORY COUNCIL.
THE CHILDREN'S HEALTH ADVISORY COUNCIL IS ESTABLISHED WITHIN
THE DEPARTMENT AS AN ADVISORY COUNCIL. THE FOLLOWING APPLY:
(1) THE COUNCIL SHALL CONSIST OF 16 VOTING MEMBERS.
MEMBERS PROVIDED FOR IN SUBPARAGRAPHS (IV), (V), (VI), (VII),
(VIII), (XIII), (XIV), (XV) AND (XVI) SHALL BE APPOINTED BY
THE SECRETARY. THE COUNCIL SHALL BE GEOGRAPHICALLY BALANCED
ON A STATEWIDE BASIS AND SHALL INCLUDE:
(I) THE SECRETARY OF HEALTH EX OFFICIO OR A
DESIGNEE.
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(II) THE INSURANCE COMMISSIONER EX OFFICIO OR A
DESIGNEE.
(III) THE SECRETARY EX OFFICIO OR A DESIGNEE.
(IV) A REPRESENTATIVE WITH EXPERIENCE IN CHILDREN'S
HEALTH FROM A SCHOOL OF PUBLIC HEALTH LOCATED IN THIS
COMMONWEALTH.
(V) A PHYSICIAN WITH EXPERIENCE IN CHILDREN'S HEALTH
APPOINTED FROM A LIST OF THREE QUALIFIED PERSONS
RECOMMENDED BY THE PENNSYLVANIA MEDICAL SOCIETY.
(VI) A REPRESENTATIVE OF A CHILDREN'S HOSPITAL OR A
HOSPITAL WITH A PEDIATRIC OUTPATIENT CLINIC APPOINTED
FROM A LIST OF THREE PERSONS SUBMITTED BY THE HOSPITAL
ASSOCIATION OF PENNSYLVANIA.
(VII) A PARENT OF A CHILD WHO RECEIVES PRIMARY
HEALTH CARE COVERAGE FROM THE FUND.
(VIII) A MID-LEVEL PROFESSIONAL APPOINTED FROM LISTS
OF NAMES RECOMMENDED BY STATEWIDE ASSOCIATIONS
REPRESENTING MID-LEVEL HEALTH PROFESSIONALS.
(IX) A SENATOR APPOINTED BY THE PRESIDENT PRO
TEMPORE OF THE SENATE.
(X) A SENATOR APPOINTED BY THE MINORITY LEADER OF
THE SENATE.
(XI) A REPRESENTATIVE APPOINTED BY THE SPEAKER OF
THE HOUSE OF REPRESENTATIVES.
(XII) A REPRESENTATIVE APPOINTED BY THE MINORITY
LEADER OF THE HOUSE OF REPRESENTATIVES.
(XIII) A REPRESENTATIVE FROM A PRIVATE NONPROFIT
FOUNDATION.
(XIV) A REPRESENTATIVE OF BUSINESS WHO IS NOT A
CONTRACTOR OR PROVIDER OF PRIMARY HEALTH CARE INSURANCE
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UNDER THIS ARTICLE.
(XV) A REPRESENTATIVE OF A NONPROFIT BUSINESS WHO IS
A CONTRACTOR OR PROVIDER OF PRIMARY HEALTH INSURANCE
UNDER THIS ARTICLE.
(XVI) A REPRESENTATIVE OF A FOR PROFIT BUSINESS WHO
IS A CONTRACTOR OR PROVIDER OF PRIMARY HEALTH INSURANCE
UNDER THIS ARTICLE.
(2) IF A SPECIFIED ORGANIZATION CEASES TO EXIST OR FAILS
TO MAKE A RECOMMENDATION WITHIN 90 DAYS OF A REQUEST, THE
COUNCIL SHALL SPECIFY A NEW EQUIVALENT ORGANIZATION TO
FULFILL THE RESPONSIBILITIES OF THIS SECTION.
(3) THE SECRETARY SHALL SERVE AS CHAIRPERSON OF THE
COUNCIL. THE MEMBERS OF THE COUNCIL SHALL ANNUALLY ELECT, BY
A MAJORITY VOTE OF THE MEMBERS, A VICE CHAIRPERSON FROM AMONG
THE MEMBERS OF THE COUNCIL.
(4) THE PRESENCE OF NINE MEMBERS SHALL CONSTITUTE A
QUORUM FOR THE TRANSACTING OF ANY BUSINESS. AN ACT BY A
MAJORITY OF THE MEMBERS PRESENT AT A MEETING AT WHICH THERE
IS A QUORUM SHALL BE DEEMED TO BE THAT OF THE COUNCIL.
(5) ALL MEETINGS OF THE COUNCIL SHALL BE CONDUCTED IN
ACCORDANCE WITH 65 PA.C.S. CH. 7 (RELATING TO OPEN MEETINGS),
EXCEPT AS PROVIDED IN THIS SECTION. MEETINGS MUST BE IN
ACCORDANCE WITH THE FOLLOWING:
(I) THE COUNCIL SHALL MEET AT LEAST TWICE PER YEAR
AND MAY PROVIDE FOR SPECIAL MEETINGS AS THE COUNCIL DEEMS
NECESSARY.
(II) MEETING DATES SHALL BE SET BY A MAJORITY VOTE
OF MEMBERS OF THE COUNCIL OR BY CALL OF THE CHAIRPERSON
UPON SEVEN DAYS' NOTICE TO ALL MEMBERS.
(III) THE COUNCIL SHALL PUBLISH NOTICE OF THE
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COUNCIL'S MEETINGS IN THE PENNSYLVANIA BULLETIN. THE
NOTICE MUST SPECIFY THE DATE, TIME AND PLACE OF THE
MEETING AND SHALL STATE THAT THE COUNCIL'S MEETINGS ARE
OPEN TO THE GENERAL PUBLIC.
(IV) ALL ACTION TAKEN BY THE COUNCIL SHALL BE TAKEN
IN OPEN PUBLIC SESSION AND MAY NOT BE TAKEN EXCEPT UPON A
MAJORITY VOTE OF THE MEMBERS PRESENT AT A MEETING AT
WHICH A QUORUM IS PRESENT.
(6) THE MEMBERS OF THE COUNCIL MAY NOT RECEIVE A SALARY
OR PER DIEM ALLOWANCE FOR SERVING AS MEMBERS OF THE COUNCIL
BUT SHALL BE REIMBURSED FOR ACTUAL AND NECESSARY EXPENSES
INCURRED IN THE PERFORMANCE OF THE MEMBERS' DUTIES.
(7) TERMS OF COUNCIL MEMBERS SHALL BE AS FOLLOWS:
(I) THE APPOINTED MEMBERS SHALL SERVE FOR A TERM OF
THREE YEARS AND SHALL CONTINUE TO SERVE UNTIL A SUCCESSOR
IS APPOINTED.
(II) AN APPOINTED MEMBER MAY NOT BE ELIGIBLE TO
SERVE MORE THAN TWO FULL CONSECUTIVE TERMS OF THREE
YEARS. VACANCIES SHALL BE FILLED IN THE SAME MANNER AS
THE ORIGINAL APPOINTMENT WITHIN 60 DAYS OF THE VACANCY.
(III) AN APPOINTED MEMBER MAY BE REMOVED BY THE
APPOINTING AUTHORITY FOR JUST CAUSE AND BY A VOTE OF AT
LEAST SEVEN MEMBERS OF THE COUNCIL.
(8) THE COUNCIL SHALL REVIEW OUTREACH ACTIVITIES AND MAY
MAKE RECOMMENDATIONS TO THE DEPARTMENT.
(9) THE COUNCIL SHALL REVIEW AND EVALUATE THE
ACCESSIBILITY AND AVAILABILITY OF SERVICES DELIVERED TO
CHILDREN ENROLLED IN THE PROGRAM.
SECTION 2304-A . CONTRACTS AND COVERAGE PACKAGES.
(A) PAID FROM FUND.--IN ADDITION TO ANY OTHER REQUIREMENTS
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PROVIDED BY LAW, THE FUND SHALL BE OPERATED IN ACCORDANCE WITH
THE FOLLOWING:
(1) THE FUND MUST BE DEDICATED EXCLUSIVELY FOR
DISTRIBUTION BY THE DEPARTMENT THROUGH CONTRACTS IN ORDER TO
PROVIDE FREE AND SUBSIDIZED HEALTH CARE SERVICES UNDER THIS
ARTICLE, BASED ON AN ACTUARIALLY SOUND AND ADEQUATE REVIEW,
AND TO DEVELOP AND IMPLEMENT OUTREACH ACTIVITIES REQUIRED
UNDER SECTION 2305-A.
(2) THE FUND, ALONG WITH FEDERAL, STATE AND OTHER FUNDS
AVAILABLE FOR THE PROGRAM, MUST BE USED FOR HEALTH CARE
COVERAGE FOR CHILDREN AS SPECIFIED IN THIS ARTICLE. THE
DEPARTMENT SHALL ENSURE THAT THE PROGRAM IS IMPLEMENTED
STATEWIDE.
(3) THE DEPARTMENT MUST AWARD CONTRACTS PAID FROM THE
FUND IN ACCORDANCE WITH THE FOLLOWING:
(I) ALL CONTRACTS AWARDED UNDER THIS SUBSECTION MUST
BE AWARDED THROUGH A COMPETITIVE PROCUREMENT PROCESS. THE
DEPARTMENT AND THE INSURANCE DEPARTMENT MUST USE THEIR
BEST EFFORTS TO ENSURE THAT ELIGIBLE CHILDREN ACROSS THIS
COMMONWEALTH HAVE ACCESS TO HEALTH CARE SERVICES TO BE
PROVIDED UNDER THIS ARTICLE.
(II) NO MORE THAN 10% OF THE AMOUNT OF THE CONTRACT
MAY BE USED FOR ADMINISTRATIVE EXPENSES OF THE
CONTRACTOR. IF A CONTRACTOR PRESENTS DOCUMENTED EVIDENCE
THAT ADMINISTRATIVE EXPENSES FOR PURPOSES OF EXPANDED
OUTREACH AND SYSTEMS AND OPERATIONAL CHANGES ARE IN
EXCESS OF 10% OF THE AMOUNT OF THE CONTRACT, THE
DEPARTMENT SHALL MAKE AN ADDITIONAL ALLOTMENT OF FUNDS,
NOT TO EXCEED 2% OF THE AMOUNT OF THE CONTRACT, TO THE
CONTRACTOR TO THE EXTENT THAT THE DEPARTMENT FINDS THE
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EXPENSES REASONABLE AND NECESSARY.
(III) AT LEAST 84% OF THE AMOUNT OF THE CONTRACT
SHALL BE USED TO PROVIDE HEALTH CARE SERVICES FOR
CHILDREN ELIGIBLE FOR CARE UNDER THIS ARTICLE.
(IV) IN DETERMINING THE AMOUNT OF THE CONTRACT WHICH
MAY BE USED FOR THE PURPOSES SPECIFIED IN SUBPARAGRAPHS
(II) AND (III), ANY FEDERAL AND STATE TAXES THAT WOULD BE
DEDUCTED FROM PREMIUM REVENUE IN DETERMINING AN ISSUER'S
MEDICAL LOSS RATIO UNDER 45 CFR 158.221 (RELATING TO
FORMULA FOR CALCULATING AN ISSUER'S MEDICAL LOSS RATIO),
INCLUDING A MANAGED CARE ORGANIZATION ASSESSMENT IMPOSED
ON A CONTRACTOR UNDER THE ACT OF JUNE 13, 1967 (P.L.31,
NO.21), KNOWN AS THE PUBLIC WELFARE CODE, SHALL BE
EXCLUDED.
(B) SOLICITATION OF CONTRACTS.--THE DEPARTMENT MUST SOLICIT
BIDS AND AWARD CONTRACTS THROUGH A COMPETITIVE PROCUREMENT
PROCESS IN ACCORDANCE WITH THE FOLLOWING:
(1) TO THE FULLEST EXTENT PRACTICABLE, CONTRACTS SHALL
BE AWARDED TO INSURERS THAT CONTRACT WITH PROVIDERS TO
PROVIDE PRIMARY CARE SERVICES FOR ENROLLEES ON A COST-
EFFECTIVE BASIS. THE DEPARTMENT SHALL REQUIRE CONTRACTORS TO
USE APPROPRIATE COST-MANAGEMENT METHODS SO THAT BASIC PRIMARY
COVERAGE SERVICES CAN BE PROVIDED TO THE MAXIMUM NUMBER OF
ELIGIBLE CHILDREN AND, IF POSSIBLE, TO PURSUE AND UTILIZE
AVAILABLE PUBLIC AND PRIVATE FUNDS.
(2) TO THE FULLEST EXTENT PRACTICABLE, THE DEPARTMENT
MUST REQUIRE THAT A CONTRACTOR COMPLY WITH ALL PROCEDURES
RELATING TO COORDINATION OF HEALTH CARE SERVICES AS REQUIRED
BY THE DEPARTMENT OR THE INSURANCE DEPARTMENT.
(3) CONTRACTS MAY BE FOR A TERM OF UP TO THREE YEARS,
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WITH THE OPTION TO EXTEND FOR TWO ONE-YEAR PERIODS.
(C) BIDDING.--UPON RECEIPT OF A SOLICITATION FROM THE
DEPARTMENT, EACH HEALTH SERVICE CORPORATION AND HOSPITAL PLAN
CORPORATION OR THEIR ENTITIES DOING BUSINESS IN THIS
COMMONWEALTH SHALL SUBMIT A BID OR PROPOSAL TO THE DEPARTMENT TO
CARRY OUT THE PURPOSES OF THIS ARTICLE IN THE AREA SERVICED BY
THE CORPORATION.
(D) BIDDING BY OTHER INSURERS.--ALL OTHER INSURERS MAY
SUBMIT A BID OR PROPOSAL TO THE DEPARTMENT TO CARRY OUT THE
PURPOSES OF THIS ARTICLE.
(E) DUTIES OF CONTRACTOR.--A CONTRACTOR WITH WHOM THE
DEPARTMENT ENTERS INTO A CONTRACT SHALL DO THE FOLLOWING:
(1) ENSURE TO THE MAXIMUM EXTENT POSSIBLE THAT ELIGIBLE
CHILDREN HAVE ACCESS TO PRIMARY HEALTH CARE PHYSICIANS AND
NURSE PRACTITIONERS WITHIN THE CONTRACTOR'S SERVICE AREA.
(2) CONTRACT WITH QUALIFIED, COST-EFFECTIVE PROVIDERS,
WHICH MAY INCLUDE PRIMARY HEALTH CARE PHYSICIANS, NURSE
PRACTITIONERS, CLINICS AND HMOS, TO PROVIDE PRIMARY AND
PREVENTIVE HEALTH CARE FOR ENROLLEES ON A BASIS BEST
CALCULATED TO MANAGE THE COSTS OF THE SERVICES, INCLUDING,
BUT NOT LIMITED TO, USING MANAGED HEALTH CARE TECHNIQUES AND
OTHER APPROPRIATE MEDICAL COST-MANAGEMENT METHODS.
(3) ENSURE THAT THE FAMILY OF A CHILD WHO MAY BE
ELIGIBLE FOR MEDICAL ASSISTANCE RECEIVES ASSISTANCE IN
APPLYING FOR MEDICAL ASSISTANCE.
(4) MAINTAIN WAITING LISTS OF CHILDREN FINANCIALLY
ELIGIBLE FOR COVERAGE WHO HAVE APPLIED FOR COVERAGE BUT WHO
WERE NOT ENROLLED DUE TO LACK OF FUNDS.
(5) NOTIFY FAMILIES OF CHILDREN WHO ARE PAYING A PREMIUM
OF ANY CHANGES IN SUCH PREMIUM OR COPAYMENT REQUIREMENTS.
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(6) COLLECT PREMIUMS OR COPAYMENTS FROM THE FAMILY OF A
CHILD RECEIVING COVERAGE AS MAY BE REQUIRED.
(7) CANCEL COVERAGE FOR NONPAYMENT OF PREMIUM, IN
ACCORDANCE WITH ALL APPLICABLE INSURANCE LAWS.
(8) STRONGLY ENCOURAGE ALL PROVIDERS WHO PROVIDE PRIMARY
CARE TO ELIGIBLE CHILDREN TO PARTICIPATE IN MEDICAL
ASSISTANCE AS QUALIFIED EPSDT PROVIDERS AND TO CONTINUE TO
PROVIDE CARE TO CHILDREN WHO BECOME INELIGIBLE FOR COVERAGE
UNDER THE PROVISIONS OF THIS ARTICLE BUT WHO QUALIFY FOR
MEDICAL ASSISTANCE.
(9) SUBJECT TO ANY NECESSARY FEDERAL APPROVAL, PROVIDE
THE FOLLOWING MINIMUM COVERAGE PACKAGE, WHICH MAY NOT
CONFLICT WITH FEDERAL LAW, REGULATION OR GUIDANCE, FOR
ELIGIBLE CHILDREN:
(I) PREVENTIVE CARE. THIS SUBPARAGRAPH SHALL
INCLUDE:
(A) WELL-CHILD CARE VISITS IN ACCORDANCE WITH
THE SCHEDULE ESTABLISHED BY THE AMERICAN ACADEMY OF
PEDIATRICS AND THE SERVICES RELATED TO THE VISITS,
INCLUDING IMMUNIZATIONS, HEALTH EDUCATION,
TUBERCULOSIS TESTING AND DEVELOPMENTAL SCREENING IN
ACCORDANCE WITH THE ROUTINE SCHEDULE OF WELL-CHILD
CARE VISITS.
(B) A COMPREHENSIVE PHYSICAL EXAMINATION,
INCLUDING X-RAYS IF NECESSARY, FOR ANY CHILD
EXHIBITING SYMPTOMS OF POSSIBLE CHILD ABUSE.
(II) DIAGNOSIS AND TREATMENT OF ILLNESS OR INJURY,
INCLUDING ALL MEDICALLY NECESSARY SERVICES RELATED TO THE
DIAGNOSIS AND TREATMENT OF SICKNESS AND INJURY AND OTHER
CONDITIONS PROVIDED ON AN AMBULATORY BASIS, SUCH AS
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LABORATORY TESTS, WOUND DRESSING AND CASTING TO
IMMOBILIZE FRACTURES.
(III) INJECTIONS AND MEDICATIONS PROVIDED AT THE
TIME OF THE OFFICE VISIT OR THERAPY AND OUTPATIENT
SURGERY PERFORMED IN THE OFFICE, A HOSPITAL OR
FREESTANDING AMBULATORY SERVICE CENTER, INCLUDING
ANESTHESIA PROVIDED IN CONJUNCTION WITH SUCH SERVICE OR
DURING EMERGENCY MEDICAL SERVICE.
(IV) EMERGENCY ACCIDENT AND EMERGENCY MEDICAL CARE.
(V) PRESCRIPTION DRUGS.
(VI) EMERGENCY, PREVENTIVE AND ROUTINE DENTAL CARE.
THIS SUBPARAGRAPH DOES NOT INCLUDE ORTHODONTIA OR
COSMETIC SURGERY.
(VII) EMERGENCY, PREVENTIVE AND ROUTINE VISION CARE,
INCLUDING THE COST OF CORRECTIVE LENSES AND FRAMES, NOT
TO EXCEED TWO PRESCRIPTIONS PER YEAR.
(VIII) EMERGENCY, PREVENTIVE AND ROUTINE HEARING
CARE.
(IX) INPATIENT HOSPITALIZATION.
(10) THE DEPARTMENT MAY IMPLEMENT A PREMIUM ASSISTANCE
PROGRAM PERMITTED UNDER FEDERAL REGULATIONS AND AS PERMITTED
THROUGH FEDERAL WAIVER OR STATE PLAN AMENDMENT MADE PURSUANT
TO THIS ARTICLE. NOTWITHSTANDING ANY OTHER LAW TO THE
CONTRARY, IF IT IS MORE COST EFFECTIVE TO PURCHASE HEALTH
CARE FROM A PARENT'S EMPLOYER-BASED PROGRAM AND THE EMPLOYER-
BASED PROGRAM MEETS THE MINIMUM COVERAGE REQUIREMENTS,
EMPLOYER-BASED COVERAGE MAY BE PURCHASED IN PLACE OF
ENROLLMENT IN THE CHILDREN'S HEALTH INSURANCE PROGRAM
ESTABLISHED UNDER THIS ARTICLE. AN INSURER MUST HONOR A
REQUEST FOR ENROLLMENT AND PURCHASE OF EMPLOYEE GROUP HEALTH
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INSURANCE REQUESTED ON BEHALF OF AN INDIVIDUAL APPLYING FOR
COVERAGE UNDER THIS CHAPTER IF THE INDIVIDUAL:
(I) IS A RESIDENT OF THIS COMMONWEALTH;
(II) IS QUALIFIED BASED ON INCOME UNDER SECTION
2302-A; AND
(III) MEETS THE CITIZENSHIP REQUIREMENTS OF SECTION
2302-A(C)(1)(IV).
(11) THE DEPARTMENT SHALL HAVE THE AUTHORITY TO REVIEW,
AUDIT AND APPROVE ANNUAL ADMINISTRATIVE EXPENSES INCURRED BY
CONTRACTORS UNDER THIS SECTION.
(12) EXCEPT FOR CHILDREN COVERED UNDER PARAGRAPH (10),
EACH CONTRACTOR SHALL PROVIDE A COVERAGE IDENTIFICATION CARD
TO EACH ELIGIBLE CHILD COVERED UNDER CONTRACTS EXECUTED UNDER
THIS ARTICLE. THE CARD MUST NOT SPECIFICALLY IDENTIFY THE
HOLDER AS LOW INCOME.
(F) WAIVER OF MINIMUM.--THE DEPARTMENT MAY GRANT A WAIVER OF
THE MINIMUM COVERAGE PACKAGE OF SUBSECTION (E)(9) UPON
DEMONSTRATION BY THE APPLICANT THAT THE APPLICANT IS PROVIDING
HEALTH CARE SERVICES FOR ELIGIBLE CHILDREN THAT MEET THE
PURPOSES AND INTENT OF THIS ARTICLE.
(G) REVIEW.--
(1) THE DEPARTMENT, IN CONSULTATION WITH APPROPRIATE
COMMONWEALTH AGENCIES, SHALL REVIEW ENROLLMENT PATTERNS FOR
BOTH THE FREE COVERAGE PROGRAM AND THE SUBSIDIZED COVERAGE
PROGRAM. THE DEPARTMENT SHALL CONSIDER THE RELATIONSHIP, IF
ANY, AMONG ENROLLMENT, ENROLLMENT FEES, INCOME LEVELS AND
FAMILY COMPOSITION.
(2) BASED ON THE RESULTS OF THIS STUDY AND THE
AVAILABILITY OF FUNDS, THE DEPARTMENT MAY ADJUST THE MAXIMUM
INCOME CEILING FOR FREE COVERAGE AND THE MAXIMUM INCOME
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CEILING FOR SUBSIDIZED COVERAGE BY REGULATION. THE MAXIMUM
INCOME CEILING FOR FREE COVERAGE MAY NOT BE RAISED ABOVE 200%
OF THE FEDERAL POVERTY LEVEL.
(H) LIMIT.--NOTWITHSTANDING SUBSECTION (G) AND SUBJECT TO
SECTION 2307-A, THE MAXIMUM INCOME CEILING FOR SUBSIDIZED
COVERAGE UNDER SECTION 2302-A(D)(2), (3) OR (4) MAY NOT BE
RAISED ABOVE 300% OF THE FEDERAL POVERTY LEVEL.
SECTION 2305-A. OUTREACH.
(A) PLAN.--THE DEPARTMENT, IN CONSULTATION WITH APPROPRIATE
COMMONWEALTH AGENCIES, MUST COORDINATE THE DEVELOPMENT OF AN
OUTREACH PLAN TO INFORM POTENTIAL CONTRACTORS, PROVIDERS AND
ENROLLEES REGARDING ELIGIBILITY AND AVAILABLE COVERAGE. THE PLAN
MUST INCLUDE PROVISIONS FOR ALL OF THE FOLLOWING:
(1) REACHING SPECIAL POPULATIONS, INCLUDING NONWHITE AND
NON-ENGLISH-SPEAKING CHILDREN AND CHILDREN WITH DISABILITIES.
(2) REACHING DIFFERENT GEOGRAPHIC AREAS, INCLUDING RURAL
AND INNER-CITY AREAS.
(3) ENSURING THAT SPECIAL EFFORTS ARE COORDINATED WITHIN
THE OVERALL OUTREACH ACTIVITIES THROUGHOUT THIS COMMONWEALTH.
(4) COMPARING CHILDREN ENROLLED IN CHILD CARE PROVIDED
UNDER THE CHILD CARE AND DEVELOPMENT BLOCK GRANT ACT OF 1990
(PUBLIC LAW 101-508, 42 U.S.C. ยง 9858 ET SEQ.) OR ENROLLED IN
THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM IN THE
DETERMINATION OF A CHILD'S ELIGIBILITY FOR COVERAGE UNDER
THIS ARTICLE AND IMPLEMENT EXPRESS LANE ELIGIBILITY AS
APPROPRIATE. THE DEPARTMENT IS AUTHORIZED TO EXPAND THE
AGENCIES IDENTIFIED AS EXPRESS LANE PARTNERS BY THE ISSUANCE
OF A STATEMENT OF POLICY.
(5) NOTICE OF THE EXISTENCE OF AND ELIGIBILITY FOR THE
PROGRAM SHALL BE PREPARED BY THE DEPARTMENT AND PROVIDED TO
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THE DEPARTMENT OF EDUCATION FOR DISSEMINATION TO NONPUBLIC
AND PUBLIC SCHOOLS ELECTRONICALLY, ON AN ANNUAL BASIS, NOT
LATER THAN AUGUST 15.
(B) REVIEW.--THE COUNCIL SHALL REVIEW THE OUTREACH
ACTIVITIES AND RECOMMEND CHANGES AS THE COUNCIL DEEMS TO BE IN
THE BEST INTERESTS OF THE CHILDREN TO BE SERVED.
SECTION 2306-A. PAYOR OF LAST RESORT AND INSURANCE COVERAGE.
THE CONTRACTOR MAY NOT PAY A CLAIM ON BEHALF OF AN ENROLLED
CHILD UNLESS ALL OTHER FEDERAL, STATE, LOCAL OR PRIVATE
RESOURCES AVAILABLE TO THE CHILD OR THE CHILD'S FAMILY ARE
UTILIZED FIRST. THE DEPARTMENT, IN COOPERATION WITH THE
INSURANCE DEPARTMENT, SHALL DETERMINE IF INSURANCE COVERAGE IS
AVAILABLE TO THE CHILD THROUGH A CUSTODIAL OR NONCUSTODIAL
PARENT ON AN EMPLOYMENT-RELATED OR OTHER GROUP BASIS. IF
INSURANCE COVERAGE IS AVAILABLE, THE CHILD'S ELIGIBILITY UNDER
SECTION 2302-A AND THE MOST COST-EFFECTIVE MEANS OF PROVIDING
COVERAGE FOR THAT CHILD MUST BE REEVALUATED.
SECTION 2307-A. STATE PLAN.
THE DEPARTMENT MAY AMEND THE STATE PLAN AS NECESSARY TO CARRY
OUT THE PROVISIONS OF THIS ARTICLE.
SECTION 2308-A. LIMITATION ON EXPENDITURE OF FUNDS.
THE TOTAL AMOUNT OF ANNUAL CONTRACT AWARDS AUTHORIZED UNDER
THIS ARTICLE MAY NOT EXCEED THE AMOUNT OF CIGARETTE TAX RECEIPTS
ANNUALLY DEPOSITED INTO THE FUND UNDER SECTION 1296 OF THE ACT
OF MARCH 4, 1971 (P.L.6, NO.2), KNOWN AS THE TAX REFORM CODE OF
1971, AND ANY OTHER FEDERAL OR STATE FUNDS RECEIVED THROUGH THE
FUND. THE PROVISION OF CHILDREN'S HEALTH CARE THROUGH THE FUND
MAY NOT CONSTITUTE AN ENTITLEMENT DERIVED FROM THE COMMONWEALTH
OR A CLAIM ON ANY OTHER FUNDS OF THE COMMONWEALTH.
SECTION 2309-A. EXPIRATION.
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(A) GENERAL RULE.--THIS ARTICLE SHALL EXPIRE ON THE EARLIER
OF:
(1) DECEMBER 31, 2017; OR
(2) NINETY DAYS AFTER THE DATE ON WHICH FEDERAL FUNDING
FOR THE PROGRAM CEASES TO BE AVAILABLE.
(B) NOTICE.--IF THE CHAPTER EXPIRES UNDER SUBSECTION (A)(2),
AS DETERMINED BY THE DEPARTMENT, THE DEPARTMENT SHALL TRANSMIT
NOTICE TO THE LEGISLATIVE REFERENCE BUREAU FOR PUBLICATION IN
THE PENNSYLVANIA BULLETIN.
SECTION 4. THE ADDITION OF ARTICLE XXIII-A OF THE ACT IS A
CONTINUATION OF FORMER ARTICLE XXIII OF THE ACT.
THE FOLLOWING APPLY:
(1) EXCEPT AS OTHERWISE PROVIDED IN ARTICLE XXIII-A OF
THE ACT, ALL ACTIVITIES INITIATED UNDER FORMER ARTICLE XXIII
OF THE ACT SHALL CONTINUE AND REMAIN IN FULL FORCE AND EFFECT
AND MAY BE COMPLETED UNDER ARTICLE XXIII-A. ORDERS,
REGULATIONS, RULES AND DECISIONS WHICH WERE MADE UNDER FORMER
ARTICLE XXIII AND WHICH ARE IN EFFECT ON THE EFFECTIVE DATE
OF THIS SECTION SHALL REMAIN IN FULL FORCE AND EFFECT UNTIL
REVOKED, VACATED OR MODIFIED UNDER ARTICLE XXIII-A .
CONTRACTS AND OBLIGATIONS ENTERED INTO UNDER FORMER ARTICLE
XXIII ARE NOT AFFECTED NOR IMPAIRED BY THE REPEAL OF ARTICLE
XXIII.
(2) EXCEPT AS SET FORTH IN PARAGRAPH (3), ANY DIFFERENCE
IN LANGUAGE BETWEEN ARTICLE XXIII-A AND FORMER ARTICLE XXIII
IS INTENDED ONLY TO CONFORM TO STYLE AND IS NOT INTENDED TO
CHANGE OR AFFECT THE LEGISLATIVE INTENT, JUDICIAL
CONSTRUCTION OR ADMINISTRATION AND IMPLEMENTATION OF FORMER
ARTICLE XXIII.
(3) PARAGRAPH (2) DOES NOT APPLY TO THE ADDITION OF THE
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FOLLOWING PROVISIONS:
(I) THE CHANGE IN THE DEFINITION OF "DEPARTMENT" IN
SECTION 2301-A OF THE ACT.
(II) THE PROVISIONS FOR ARRANGEMENTS WITH OTHER
AGENCIES UNDER SECTION 2302-A(F)(2)(VII) OF THE ACT.
(III) THE EXPIRATION PROVISION UNDER SECTION 2309-A
OF THE ACT.
(IV) THE ADDITION OF PARAGRAPHS (D)(5) AND (E)(3) OF
SECTION 2302-A OF THE ACT REGARDING THE EXCLUSION OF
COSTS RELATED TO THE MANAGED CARE ORGANIZATION
ASSESSMENTS UNDER THE ACT OF JUNE 13, 1967 (P.L.31,
NO.21), KNOWN AS THE PUBLIC WELFARE CODE.
(V) THE ADDITION OF SUBPARAGRAPH (A)(3)(IV) OF
SECTION 2304-A OF THE ACT REGARDING THE DETERMINATION OF
THE AMOUNT OF THE CONTRACT.
(4) ALL ENTITIES RECEIVING GRANTS UNDER FORMER ARTICLE
XXIII ON THE EFFECTIVE DATE OF THIS SECTION SHALL CONTINUE TO
RECEIVE FUNDS AND PROVIDE SERVICES AS REQUIRED UNDER FORMER
ARTICLE XXIII UNTIL NOTICE FROM THE DEPARTMENT OF HUMAN
SERVICES IS PUBLISHED IN THE PENNSYLVANIA BULLETIN.
SECTION 5. THE ADDITION OF SECTION 2007.1 OF THE ACT SHALL
APPLY TO ALL POLICIES ISSUED OR RENEWED ON OR AFTER 180 DAYS
AFTER THE EFFECTIVE DATE OF THIS SECTION.
SECTION 6. THIS ACT SHALL TAKE EFFECT AS FOLLOWS:
(1) THE ADDITION OF SECTION 635.7 OF THE ACT SHALL TAKE
EFFECT JANUARY 1, 2016, OR IMMEDIATELY, WHICHEVER IS LATER.
(2) THE REMAINDER OF THIS ACT SHALL TAKE EFFECT
IMMEDIATELY.
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