PRINTER'S NO. 1587
No. 1239 Session of 1999
INTRODUCED BY HUGHES, O'PAKE, KASUNIC, SCHWARTZ, WAGNER, MELLOW,
STAPLETON, BODACK, BELAN, COSTA, KITCHEN, TARTAGLIONE,
LAVALLE, MUSTO AND BOSCOLA, DECEMBER 8, 1999
REFERRED TO BANKING AND INSURANCE, DECEMBER 8, 1999
AN ACT
1 Establishing the Roxanne H. Jones Trust Fund and the Roxanne H.
2 Jones Trust Board; authorizing an adult health insurance
3 program for certain individuals; providing for enhancements
4 to certain children's health insurance benefits; and
5 authorizing the use of funds for certain purposes related to
6 the provision of health insurance and health care to certain
7 individuals.
8 The General Assembly finds and declares that:
9 (1) All citizens of this Commonwealth should have access
10 to affordable and reasonably priced health care and to
11 nondiscriminatory treatment by health insurers and providers.
12 (2) The uninsured health care population of this
13 Commonwealth is estimated to be over one million persons, and
14 many thousands more lack adequate insurance coverage. It is
15 also estimated that approximately two-thirds of the uninsured
16 are employed or dependents of employed persons.
17 (3) Over one-third of the uninsured health care
18 population are children. Uninsured children are of particular
19 concern because of their need for ongoing preventive and
20 primary care. Measures not taken to care for such children
1 now will result in higher human and financial costs later.
2 (4) Uninsured citizens lack access to timely and
3 appropriate primary and preventive care. As a result, health
4 care is often delayed or foregone resulting in increased risk
5 of developing more severe conditions, which, in turn, are
6 more expensive to treat. This tendency to delay care and to
7 seek ambulatory care in hospital-based settings also causes
8 inefficiencies in the health care system.
9 (5) Health care markets have been distorted through cost
10 shifts for the uncompensated health care costs of uninsured
11 citizens of this Commonwealth which have caused decreased
12 competitive capacity on the part of those health care
13 providers who serve the poor and increased costs of other
14 health care payors.
15 (6) No one sector can absorb the cost of providing
16 health care to citizens of this Commonwealth who cannot
17 afford health care on their own. The cost is too large for
18 the public sector alone to bear and instead requires the
19 establishment of a public and private partnership to share
20 the costs in a manner economically feasible for all
21 interests. The magnitude of this need also requires that it
22 be done on a time-phased, cost-managed and planned basis.
23 (7) Eligible citizens in this Commonwealth should have
24 access to cost-effective, comprehensive primary health
25 coverage if they are unable to afford or obtain that
26 coverage.
27 (8) Care should be provided in appropriate settings by
28 efficient providers, consistent with high quality care and at
29 an appropriate stage, soon enough to avert the need for
30 overly expensive treatment.
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1 (9) Equity should be assured among health providers and
2 payors by providing a mechanism for providers, employers, the
3 public sector and patients to share in financing indigent
4 citizens' health care.
5 The General Assembly of the Commonwealth of Pennsylvania
6 hereby enacts as follows:
7 Section 1. Short title.
8 This act shall be known and may be cited as the Improving
9 Access to Health Insurance Act.
10 Section 2. Definitions.
11 The following words and phrases when used in this act shall
12 have the meanings given to them in this section unless the
13 context clearly indicates otherwise:
14 "Board." The Roxanne H. Jones Trust Fund Board of Trustees.
15 "Department." The Department of Public Welfare of the
16 Commonwealth.
17 "Fund." The Roxanne H. Jones Trust Fund.
18 "Net proceeds of the tobacco settlement." The annual amount
19 received by the Commonwealth under the master settlement
20 agreement in the action filed by the Attorney General of the
21 Commonwealth of Pennsylvania against Phillip Morris and other
22 defendants in the Court of Common Pleas of Philadelphia and
23 approved by the court on January 13, 1999.
24 Section 3. The Roxanne H. Jones Trust Fund.
25 (a) Establishment.--The Roxanne H. Jones Trust Fund is
26 hereby established. The moneys of the fund are hereby
27 appropriated on a continuing basis to carry out the provisions
28 of this act.
29 (b) Funding.--For fiscal years 2000-2001, 2001-2002 and
30 2002-2003, 50% and for fiscal year 2003-2004 and thereafter,
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1 62.2% of the net proceeds of the tobacco settlement each year
2 shall be deposited into the fund for disbursement in accordance
3 with this act.
4 (c) Report.--The board shall report to the Governor and the
5 General Assembly annually on the amount of funds spent, the
6 amount projected to be spent, the amount projected to be
7 received and the amount, if any, by which the projected revenues
8 exceed projected expenditures.
9 Section 4. Board of trustees.
10 (a) Composition.--The fund shall be administered by a 25-
11 member board consisting of the following:
12 (1) The Majority Leader, Minority Leader, chairman and
13 minority chairman of the Public Health and Welfare Committee
14 of the Senate and the Majority Leader, Minority Leader,
15 chairman and minority chairman of the Health and Human
16 Services Committee of the House of Representatives.
17 (2) The Secretary of Health as an ex officio member.
18 (3) The Insurance Commissioner as an ex officio member.
19 (4) The Secretary of Public Welfare as an ex officio
20 member.
21 (5) A representative of organized labor, appointed by
22 the Governor and subject to the advice and consent of the
23 Senate.
24 (6) A representative of business who is not a provider
25 of health care insurance, appointed by the Governor and
26 subject to the advice and consent of the Senate.
27 (7) The Secretary of Aging as an ex-officio member.
28 (8) The Physician General as an ex-officio member.
29 (9) Ten members who shall be current recipients of
30 services described under this act. Two each shall be
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1 appointed by the Governor, the President pro tempore of the
2 Senate, the Minority Leader of the Senate, the Speaker of the
3 House of Representatives and the Minority Leader of the House
4 of Representatives.
5 (b) Terms and vacancies.--The members appointed to the board
6 shall have terms of four years. Vacancies shall be filled in the
7 same manner as originally provided.
8 (c) Compensation.--The members of the board shall serve
9 without compensation and shall be entitled to reimbursement for
10 the reasonable expenses incurred in the performance of their
11 duties on the board.
12 Section 5. Allowable expenditures.
13 (a) General rule.--The fund shall only be used to provide
14 health care coverage and services as specified in this act.
15 (b) Allocation of funds.--The board shall allocate not less
16 than 50% of the fund to be used to provide the health care
17 services provided for adults eligible for free care under
18 section 7 and no less than 35% to provide health care services
19 for children and their parents under sections 6 and 10. When the
20 Insurance Department determines that 50% of the fund is not
21 needed in order to achieve maximum enrollment of adults eligible
22 for free care and promulgates a final form regulation, with
23 proposed rulemaking omitted, this paragraph shall expire. As to
24 the remainder of the fund, the board shall make allocations for
25 services in the following order of priority:
26 (1) services provided under section 8; then
27 (2) services provided under any other section of this
28 act.
29 Section 6. Maximizing Federal funds under section 1931 of the
30 Social Security Act, equal to the Federal poverty
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1 level.
2 (a) Authorization.--The board shall disburse moneys from the
3 fund to the department for the purpose of changing medical
4 assistance eligibility rules to provide a disregard from income
5 in an amount equal to the Federal poverty level as authorized
6 under section 1931 of the Social Security Act (49 Stat. 620, 42
7 U.S.C. § 301 et seq.).
8 (b) Consideration of resources.--The board shall disburse
9 moneys from the fund to the department for the purpose of
10 changing medical assistance eligibility rules to provide that in
11 establishing or redetermining eligibility for medical
12 assistance, the department shall not consider any resources
13 owned by the applicant or recipient. This subsection shall not
14 apply when establishing or redetermining eligibility for nursing
15 facility services or home and community-based services.
16 Section 7. Adult health insurance program.
17 (a) Authorization.--The board shall disburse moneys from the
18 fund to the Insurance Department to establish a health insurance
19 program for uninsured low-income adults.
20 (b) Eligible persons.--Individuals not covered by a health
21 insurance plan with incomes at or below 200% of the Federal
22 poverty level as determined annually by the United States
23 Department of Health and Human Services and who are not eligible
24 for medical assistance or benefits under Article XXIII of the
25 act of May 17, 1921 (P.L.682, No.284), known as the Insurance
26 Company Law of 1921, shall be eligible for health care insurance
27 at no cost under the program. Individuals with incomes greater
28 than 200% of the Federal poverty level but no greater than 250%
29 of the Federal poverty level may be subsidized by the fund at a
30 rate not to exceed 50% of the cost of the health insurance
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1 premium. Individuals with incomes greater than 250% of the
2 Federal poverty level but no greater than 300% of the Federal
3 poverty level may be subsidized by the fund at a rate not to
4 exceed 35% of the cost of the health insurance premium.
5 Individuals with incomes greater than 300% of the Federal
6 poverty level but no greater than 400% of the Federal poverty
7 level may purchase coverage at cost.
8 (c) Nature of program.--The Insurance Department shall,
9 directly or through qualified contractors, do the following:
10 (1) Ensure to the maximum extent possible that eligible
11 adults have access to primary health care physicians and
12 nurse practitioners on an equitable Statewide basis.
13 (2) Contract with qualified, cost-effective providers,
14 which may include primary health care physicians, nurse
15 practitioners, clinics and health maintenance organizations,
16 to provide primary and preventive health care for enrollees
17 on a basis best calculated to manage the costs of the
18 services, including, but not limited to, using managed health
19 care techniques and other appropriate medical cost-management
20 methods.
21 (3) Ensure that any adult who may be eligible for
22 medical assistance receives assistance in applying for
23 medical assistance, including, at a minimum, written notice
24 of the telephone number and address of the county assistance
25 office where the family can apply for medical assistance.
26 (4) Maintain waiting lists of adults financially
27 eligible for benefits who have applied for benefits but who
28 were not enrolled due to lack of funds.
29 (5) Strongly encourage all providers who provide primary
30 care to eligible adults to participate in medical assistance
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1 as enrolled providers and to continue to provide care to
2 adults who become ineligible for payment under the fund but
3 who qualify for medical assistance.
4 (6) Provide the following minimum benefit package for
5 eligible adults:
6 (i) Preventive care. This subparagraph includes
7 preventive care visits, including, but not limited to,
8 cancer screenings, immunizations, health education,
9 tuberculosis testing and other age-appropriate
10 screenings, as well as a comprehensive physical
11 examination, including X-rays, if necessary.
12 (ii) Diagnosis and treatment of illness or injury,
13 including all medically necessary services related to the
14 diagnosis and treatment of sickness and injury and other
15 conditions provided on an ambulatory basis, such as
16 laboratory tests, wound dressing and casting to
17 immobilize fractures.
18 (iii) Maternity care.
19 (iv) Injections and medications provided at the time
20 of the office visit or therapy. Outpatient surgery
21 performed in the office, a hospital or freestanding
22 ambulatory service center, including anesthesia provided
23 in conjunction with such service or during emergency
24 medical service.
25 (v) Emergency accident and emergency medical care.
26 (vi) Prescription drugs.
27 (vii) Emergency, preventive and routine dental care.
28 This subparagraph does not include orthodontia or
29 cosmetic surgery.
30 (viii) Emergency, preventive and routine vision
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1 care, including the cost of corrective lenses and frames,
2 not to exceed two prescriptions per year.
3 (ix) Emergency, preventive and routine hearing care.
4 (x) Inpatient hospitalization up to 90 days per year
5 for eligible adults.
6 (xi) Family planning services to the same extent as
7 provided through the medical assistance program.
8 (7) Each contractor shall provide an insurance
9 identification card to each eligible adult covered under
10 contracts executed under this section. No card shall
11 specifically identify the holder as low income.
12 (8) The Insurance Department may grant a waiver of the
13 minimum benefit package upon demonstration by the applicant
14 that it is providing health care services for eligible adults
15 that meet the purposes and intent of this section.
16 (d) Consideration of resources.--In establishing or
17 redetermining eligibility for the program authorized under this
18 section, the Insurance Department may not consider any resources
19 owned by the applicant or recipient.
20 Section 8. Outreach and application assistance.
21 The board shall disburse moneys from the fund to the
22 Insurance Department for the purpose of outreach and application
23 assistance to individuals eligible for coverage under sections 6
24 and 7 and this section. The Insurance Department shall use the
25 funds set aside for outreach and application assistance to
26 contract with hospitals serving a disproportionate share of
27 uninsured persons and community-based nonprofit organizations
28 serving the uninsured to provide outreach and application
29 assistance.
30 Section 9. Covered services to include prescription drugs.
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1 The board shall disburse moneys from the fund to the
2 department for the purpose of adding prescription drugs to the
3 list of services covered under medical assistance for all
4 persons eligible for medically needy only benefits.
5 Section 10. Enhancements to Children's Health Care Act.
6 The board shall disburse moneys from the fund to the
7 Insurance Department for the purpose of making the following
8 enhancements under Article XXIII of the act of May 17, 1921
9 (P.L.682, No.284), known as the Insurance Company Law of 1921:
10 (1) Provide coverage for necessary medical services not
11 covered by health insurance plans for children who are
12 covered by a health insurance plan but are otherwise eligible
13 for assistance under that act.
14 (2) Expand eligibility for 50% subsidized coverage to
15 children with family incomes up to 250% of the Federal
16 poverty level.
17 (3) Expand eligibility for 35% subsidy for children with
18 family incomes up to 300% of the Federal poverty level.
19 (4) Permit children with family incomes between 300% and
20 400% of the Federal poverty level to purchase health
21 insurance at cost.
22 (5) Expand eligibility to include uninsured parents of
23 covered children.
24 (6) Add maternity care to the list of services covered
25 under that act.
26 (7) Add family planning services, to the same extent as
27 provided through the medical assistance program, to the list
28 of services covered under that act.
29 Section 11. Outreach to working families.
30 The board shall disburse moneys from the fund to the
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1 department for the purpose of an outreach and enrollment
2 assistance program targeted to working parents of children
3 eligible for medical assistance who are eligible for the Health
4 Insurance Premium Payment Program established under section
5 1906(c)(1)(B) of the Social Security Act (49 Stat. 620, 42
6 U.S.C. § 1396). The department shall contract with community-
7 based organizations to provide the outreach and enrollment
8 assistance services.
9 Section 12. Improve access and outreach for home and community-
10 based services.
11 The board shall disburse moneys from the fund to the
12 department for the purpose of:
13 (1) Establishing a new home and community-based services
14 waiver to provide in-home nursing services in the medical
15 assistance program for persons who are over 21 years of age.
16 These services shall be designed to cover the amount of
17 nursing care some young adults with serious medical
18 conditions need to remain at home.
19 (2) Establishing an outreach program to increase
20 awareness of and participation in home and community-based
21 services programs provided under waivers administered by the
22 department established on or after January 1, 1999.
23 Section 13. Covering health services for children with
24 disabilities receiving Social Security Survivor's
25 Benefits or child support.
26 The board shall disburse moneys from this fund to the
27 department for the purpose of changing medical assistance
28 eligibility rules to provide a disregard from income of Social
29 Security Survivor's Benefits and child support for children with
30 disabilities.
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1 Section 14. Providing fairness for the elderly and people with
2 disabilities.
3 The board shall disburse moneys from the fund to the
4 department for the purpose of changing medical assistance
5 eligibility rules to the nonmoney payment medical assistance
6 spenddown for the elderly and the disabled categories so that
7 applicants and recipients shall be eligible after they spend
8 down to 100% of the Federal poverty level. To minimize
9 administrative barriers to obtaining coverage for the nonmoney
10 payment spenddown program, face-to-face application or
11 redetermination interviews shall not be required.
12 Section 15. Cover assistive technology under medical
13 assistance.
14 The board shall disburse moneys from the fund to the
15 department for hearing aids for adults and other assistive
16 technology devices and services that allow persons with
17 disabilities to function to their maximum capabilities while
18 within their homes and while outside their homes for any
19 purpose, including, but not limited to, receiving health care,
20 going to work, shopping or recreation.
21 Section 16. Limitation on disbursement of funds.
22 In no case shall the total amount of disbursements authorized
23 exceed the amount of the net proceeds of the tobacco settlement
24 annually deposited into the fund and any other Federal or State
25 funds received through the fund. Unless otherwise authorized by
26 law, the provision of health care through the fund shall in no
27 way constitute an entitlement derived from the Commonwealth or a
28 claim on any other funds of the Commonwealth.
29 Section 17. Inconsistent repeal.
30 All acts and parts of acts are repealed insofar as they are
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1 inconsistent with this act.
2 Section 18. Effective date.
3 This act shall take effect in 60 days.
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