H1013B1709A09120 NAD:JMT 09/07/18 #90 A09120
AMENDMENTS TO HOUSE BILL NO. 1013
Sponsor: SENATOR WHITE
Printer's No. 1709
Amend Bill, page 1, lines 12 and 13, by striking out "FOR
DEFINITIONS AND"
Amend Bill, page 1, line 13, by inserting after "services"
and providing for quality eye care for insured Pennsylvanians
Amend Bill, page 1, lines 19 through 21; page 2, lines 1
through 22; by striking out all of said lines on said pages and
inserting
Section 1. Section 2116 of the act of May 17, 1921 (P.L.682,
No.284), known as The Insurance Company Law of 1921, is amended
to read:
Amend Bill, page 2, line 29, by inserting a bracket before
"The"
Amend Bill, page 3, line 1, by inserting after "emergency."
] The managed care plan shall pay all reasonably necessary
costs associated with emergency services provided during the
period of emergency, subject to all copayments, coinsurances or
deductibles.
Amend Bill, page 3, lines 12 through 24, by striking out all
of said lines and inserting
( b) For emergency services rendered by a licensed emergency
medical services agency, as defined in 35 Pa.C.S. ยง 8103
(relating to definitions), that has the ability to transport
patients or is providing and billing for emergency services
under an agreement with an emergency medical services agency
that has that ability, the managed care plan may not deny a
claim for payment solely because the enrollee did not require
transport or refused to be transported.
(c) For emergency services provided to medical assistance
participants, the following provisions shall apply:
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(1) The provisions of subsection (b) shall apply to the same
services provided to medical assistance participants under
Article IV of the act of June 13, 1967 (P.L.31, No.21), known as
the Human Services Code.
(2) Payment for the services shall be in accordance with the
current managed care contracted rates.
(3) Sufficient funds shall be appropriated each fiscal year
for payment of the services.
(d) The provisions of subsection (b) shall apply to all
group and individual major medical health insurance policies
issued by a licensed health insurer.
Section 2. The act is amended by adding an article to read:
ARTICLE XXVII
QUALITY EYE CARE FOR INSURED PENNSYLVANIANS
Section 2701. Short title of article.
This article shall be known and may be cited as the Quality
Eye Care for Insured Pennsylvanians Act.
Section 2702. 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:
"Covered vision care ." Vision services and materials for
which reimbursement is available under a health insurance
policy, regardless of whether the reimbursement is contractually
limited by a deductible, copayment, coinsurance, waiting period,
annual or lifetime maximum, frequency limitation or alternative
benefit payment.
"Department." The Insurance Department of the Commonwealth.
"Health insurance policy." An individual or group health
insurance policy, subscriber contract , certificate or plan
issued by or through an insurer that provides covered vision
care. The term does not include accident only, fixed indemnity,
limited benefit, credit, dental, specified disease, Civilian
Health and Medical Program of the Uniformed Services (CHAMPUS)
supplement, long-term care or disability income, workers'
compensation or automobile medical payment insurance.
"Health insurer." An entity licensed by the department with
accident and health authority to issue a policy, subscriber
contract, certificate or plan that provides medical or health
care coverage and is offered or governed under any of the
following:
(1) Section 630, Article XXIV or other provision of this
act .
(2) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
(3) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations).
(4) 40 Pa.C.S. Ch. 63 (relating to professional health
services plan corporations).
"Insured." An individual on whose behalf a health insurer is
obligated to pay for vision care under a health insurance
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policy.
"Materials." Ophthalmic devices, including, but not limited
to, lenses, devices containing lenses, ophthalmic frames and
other lens mounting apparatus, prisms, lens treatments and
coating, contact lenses and prosthetic devices to correct,
relieve or treat defects or abnormal conditions of the human eye
or its adnexa associated with the delivery of vision care.
"Noncovered services." Vision care that is not covered but
for which a discount may be provided under the terms of a health
insurance policy.
"Vision care." A provision of eye care services, materials
or both.
"Vision care provider." A licensed doctor of optometry
practicing under the authority of the act of June 6, 1980
(P.L.197, No.57), known as the Optometric Practice and Licensure
Act, or a licensed physician who has also completed a residency
in ophthalmology.
"Vision care supplier." A person or entity that creates,
promotes, sells, provides, advertises or administers vision care
supplies , including an optical laboratory. The term includes
persons or entities affiliated with a health insurer.
Section 2703. Vision care provider and vision care supplier
selection .
A health insurance policy shall allow an insured who receives
vision care from an in-network vision care provider to select an
out-of-network vision care supplier for related vision care on
the recommendation or referral of the in-network vision care
provider, provided that the in-network vision care provider
gives to the insured, prior to recommending, referring,
prescribing or ordering any vision care from the out-of-network
vision care supplier, written notice that:
(1) The out-of-network vision care supplier is not an
in-network vision care supplier.
(2) The insured has the option of selecting an in-
network vision care supplier.
(3) The insured may have different financial obligations
depending on whether the vision care supplier is in-network
or out-of-network.
Section 2704. Discount access.
A health insurance policy that has a discount program for
noncovered services shall permit an insured who receives vision
care from an in-network vision care provider to receive a
noncovered service from the in-network vision care provider at a
nondiscounted rate, provided that the vision care provider gives
to the insured, prior to receipt of the noncovered service,
written disclosure that the vision care provider does not
participate in the insured's discount program.
Section 2705. Enforcement.
(a) Scope.--The department may investigate and enforce the
provisions of this article only insofar as the actions or
inactions being investigated relate to coverage under a health
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insurance policy.
(b) Insurance Commissioner power.--Upon satisfactory
evidence of a violation of this article by any insurer or other
person within the scope of the department's investigative and
enforcement authority under subsection (a), the Insurance
Commissioner may, in the Insurance Commissioner's discretion,
pursue any of the following actions:
(1) Suspend, revoke or refuse to renew the license of
the offending person.
(2) Enter a cease and desist order.
(3) Impose a civil penalty of not more than $5,000 for
each action in violation of this article.
(4) Impose a civil penalty of not more than $10,000 for
each action in willful violation of this article.
(c) Limitation.--Penalties imposed under this article shall
not exceed $500,000 in the aggregate during a calender year.
(d) Violations by optometrists and opthalmologists.--A
violation of this article by an optometrist shall constitute
unprofessional conduct under the act of June 6, 1980 (P.L.197,
No.57), known as the Optometric Practice and Licensure Act. A
violation of this article by an ophthalmologist shall constitute
unprofessional conduct under the act of December 20, 1985
(P.L.457, No.112), known as the Medical Practice Act of 1985, or
the act of October 5, 1978 (P.L.1109, No.261), known as the
Osteopathic Medical Practice Act.
Section 2706. Regulations.
The department may promulgate regulations as may be necessary
or appropriate to implement this article.
Section 2707. Applicability.
This article shall apply as follows:
(1) For health insurance policies for which either rates
or forms are required to be filed with the Federal Government
or the department, this article shall apply to any policy for
which a form or rate is first filed on or after the effective
date of this section.
(2) For health insurance policies for which neither
rates nor forms are required to be filed with the Federal
Government or the department, this article shall apply to any
policy issued or renewed on or after 180 days after the
effective date of this section.
Section 3. The amendment of section 2116 of the act shall
apply as follows:
(1) For health insurance policies for which either rates
or forms are required to be filed with the Federal Government
or the Insurance Department, this section shall apply to any
policy for which a form or rate is first filed on or after
the effective date of this section.
(2) For health insurance policies for which neither
rates nor forms are required to be filed with the Federal
Government or the Insurance Department, this section shall
apply to any policy issued or renewed on or after 180 days
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after the effective date of this section.
Amend Bill, page 3, line 25, by striking out "3" and
inserting
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See A09120 in
the context
of HB1013