PRIOR PRINTER'S NOS. 1778, 2923 PRINTER'S NO. 3319
No. 1516 Session of 1991
INTRODUCED BY WAMBACH, HECKLER, RICHARDSON, E. Z. TAYLOR,
DeWEESE, EVANS, THOMAS, PESCI, KUKOVICH, DeLUCA, STABACK,
BELARDI, BELFANTI, LEVDANSKY, BLAUM, TANGRETTI, VEON,
JOSEPHS, ITKIN, MELIO, TRELLO, LAUGHLIN, FREEMAN, JAMES,
BILLOW, WILLIAMS, JAROLIN, COLAIZZO, MIHALICH, BISHOP,
HARPER, CAWLEY, STURLA, R. C. WRIGHT, FEE, COY, NOYE,
PISTELLA, ADOLPH, RUDY, ALLEN, McCALL, D. W. SNYDER,
MICOZZIE, CIVERA, SCHULER, CLYMER, KRUSZEWSKI, JOHNSON,
ACOSTA, GRUITZA, DEMPSEY, KENNEY, ANGSTADT, RITTER, PHILLIPS,
GEIST, O'BRIEN, STEIGHNER, MURPHY, TRICH, LEH, OLIVER,
JADLOWIEC, STUBAN, MAYERNIK, CALTAGIRONE, CAPPABIANCA,
NICKOL, HAYES, COLAFELLA, COHEN, DENT, F. TAYLOR, HESS,
PETRONE, ARGALL, KOSINSKI, GALLEN, CORNELL, PICCOLA,
VAN HORNE, ULIANA, HUGHES, B. SMITH, COWELL, PETRARCA,
RAYMOND, CLARK, J. TAYLOR, MARSICO, ARNOLD, HERMAN, LUCYK,
STAIRS, M. N. WRIGHT, WOGAN, PRESTON, GIGLIOTTI, McNALLY,
CORRIGAN, SURRA, ROEBUCK, PERZEL, HANNA, DERMODY, GEORGE,
MICHLOVIC, BOWLEY, OLASZ, FAJT, COLE, MARKOSEK, ROBINSON,
CARONE, BLACK, TELEK, DAVIES, CARLSON, BUSH, GERLACH, KING,
LESCOVITZ, LINTON, STETLER, STEELMAN, VANCE, BUTKOVITZ AND
McHUGH, JUNE 3, 1991
AS AMENDED ON THIRD CONSIDERATION, HOUSE OF REPRESENTATIVES,
MARCH 24, 1992
AN ACT
1 Amending the act of December 29, 1972 (P.L.1701, No.364),
2 entitled "An act providing for the establishment of nonprofit
3 corporations having the purpose of establishing, maintaining
4 and operating a health service plan; providing for
5 supervision and certain regulations by the Insurance
6 Department and the Department of Health; giving the Insurance
7 Commissioner and the Secretary of Health certain powers and
8 duties; exempting the nonprofit corporations from certain
9 taxes and providing penalties," establishing minimum
10 requirements to be satisfied by health maintenance
11 organizations in providing certain drug and alcohol services.
12 The General Assembly of the Commonwealth of Pennsylvania
1 hereby enacts as follows:
2 Section 1. The act of December 29, 1972 (P.L.1701, No.364),
3 known as the Health Maintenance Organization Act, is amended by
4 adding a section to read:
5 Section 4.1. Requirements for Alcohol and Drug Services.--
6 (a) In the implementation of sections 601-A through 606-A of
7 the act of May 17, 1921 (P.L.682, No.284), known as "The
8 Insurance Company Law of 1921," health maintenance organizations
9 shall satisfy all the requirements of this section.
10 (b) (1) Every health maintenance organization shall
11 disclose to every member of that organization the specific <--
12 criteria used by that health maintenance organization, any
13 primary care physician and the utilization, review and appeal
14 personnel to determine the type, level and course of treatment
15 that will be available for any member suffering from alcohol or
16 drug abuse or chemical dependency. Criteria shall be filed with
17 and maintained by the Department of Health and with members of <--
18 the health maintenance organization. Health maintenance
19 organizations that subcontract any drug or alcohol abuse or
20 chemical dependency services shall file criteria with members
21 and the Department of Health for each of their subcontractors.
22 Filing of such criteria with the department and members shall <--
23 occur within sixty days of the effective date of this act and
24 within sixty days of issuance or renewal of any contract
25 thereafter.
26 (2) Any criteria employed by health maintenance <--
27 organizations, their subcontractors or personnel involved in
28 patient interviewing or assessment and utilization and review
29 shall utilize criteria submitted to the Department of Health,
30 Office of Drug and Alcohol Programs by the Physicians Advisory
19910H1516B3319 - 2 -
1 Task Force to the Department of Health on December 22, 1989, or
2 may submit altered or alternative criteria to the appeals board
3 for approval. When the appeals board disapproves any criteria,
4 such criteria shall be returned to the health maintenance
5 organization or subcontractor with indications of deficiencies
6 and recommendations to correct such deficiencies. Pending
7 approval of any alternative criteria, the health maintenance
8 organization and/or subcontractor shall utilize the criteria
9 developed by the Physicians Advisory Task Force on December 22,
10 1989.
11 (3) Any additions, deletions or modifications to such
12 criteria shall be submitted to the appeals board for approval or
13 disapproval. THE EXISTENCE AND NAME OF SUCH CRITERIA SHALL BE <--
14 DISCLOSED TO MEMBERS IN EACH HEALTH MAINTENANCE ORGANIZATION'S
15 MEMBER CONTRACT, AND THE CRITERIA SHALL BE PROVIDED TO THE
16 MEMBER BY THE HEALTH MAINTENANCE ORGANIZATION AT NO COST
17 IMMEDIATELY UPON REQUEST.
18 (2) HEALTH MAINTENANCE ORGANIZATIONS, THEIR SUBCONTRACTORS
19 OR PERSONNEL INVOLVED IN PATIENT INTERVIEWING OR ASSESSMENT AND
20 UTILIZATION AND REVIEW SHALL UTILIZE CRITERIA ESTABLISHED BY
21 ASAM OR CRITERIA ESTABLISHED BY THE CLEVELAND CLINIC (CLEVELAND
22 CRITERIA). IN ADDITION, WITH THE APPROVAL OF THE OFFICE OF DRUG
23 AND ALCOHOL PROGRAMS OF THE DEPARTMENT OF HEALTH, NATIONALLY
24 RECOGNIZED CRITERIA, CRITERIA ESTABLISHED BY THE PHYSICIANS
25 ADVISORY TASK FORCE OR ALTERNATIVE CRITERIA MAY BE UTILIZED.
26 HEALTH MAINTENANCE ORGANIZATIONS MAY UTILIZE SUCH CRITERIA
27 BEGINNING SIXTY DAYS AFTER SUBMISSION, PENDING APPROVAL OR
28 DISAPPROVAL BY THE OFFICE OF DRUG AND ALCOHOL PROGRAMS.
29 DISAPPROVAL SHALL BE PROVIDED IN WRITING BY THE OFFICE OF DRUG
30 AND ALCOHOL PROGRAMS BASED ON THE ADEQUACY OF THE CRITERIA TO
19910H1516B3319 - 3 -
1 PROTECT THE HEALTH OF SUBSCRIBERS OF THE HEALTH MAINTENANCE
2 ORGANIZATION.
3 (3) ANY CHANGES TO ASAM OR CLEVELAND CRITERIA, BY THEIR
4 RESPECTIVE ORGANIZATIONS, WILL NOT REQUIRE REVIEW BY THE OFFICE
5 OF DRUG AND ALCOHOL PROGRAMS. ANY CHANGES TO ALL OTHER CRITERIA
6 SHALL BE SUBMITTED TO THE OFFICE OF DRUG AND ALCOHOL PROGRAMS,
7 FOR APPROVAL OR DISAPPROVAL.
8 (4) In addition to the assessment criteria established in
9 clause (2), certain complicating factors effecting AFFECTING the <--
10 determination of type, level of care and course of treatment
11 shall also be addressed CONSIDERED AND ADDRESSED WITHIN THE <--
12 LIMITATIONS OF THE HEALTH MAINTENANCE ORGANIZATION IN DEVELOPING
13 ALTERNATIVE CRITERIA. These factors shall include, but not be
14 limited, to all of the following:
15 (i) Job safety and job security.
16 (ii) Public safety.
17 (iii) Drug or alcohol use by the immediate family.
18 (iv) Drug or alcohol use by the extended family.
19 (v) Drug or alcohol use within the environment of the
20 member.
21 (vi) Length and severity of addiction.
22 (vii) Age of onset.
23 (viii) Drug or combination of drugs and alcohol.
24 (ix) Employer standards for alcohol or drug use relative to
25 employes.
26 (x) Pressures for the creation of drug-free workplaces.
27 (xi) Geographic availability of treatment programs.
28 (xii) Supportiveness of living and work environment and
29 other complicating factors.
30 (c) (1) All decisions for care, all assessments, interviews <--
19910H1516B3319 - 4 -
1 and reviews of individuals and families with alcohol and drug
2 problems shall be completed by trained personnel with
3 acknowledged certification in the area of drug and alcohol abuse
4 or chemical dependency. In no case shall treatment provided be
5 less than the mandated minimums specified under the act of May
6 17, 1921 (P.L.682, No.284), known as "The Insurance Company Law
7 of 1921."
8 (C) (1) ALL DECISIONS AND ASSESSMENTS USING THE APPROVED <--
9 CRITERIA FOR DRUG AND ALCOHOL TREATMENT AND REVIEWS OF
10 INDIVIDUALS, INCLUDING COUNSELING AND INTERVENTION PROVIDED TO
11 FAMILIES WITH ALCOHOL AND DRUG PROBLEMS SHALL BE COMPLETED IN
12 ACCORDANCE WITH SECTIONS 601-A THROUGH 606-A OF "THE INSURANCE
13 COMPANY LAW OF 1921," BY TRAINED PERSONNEL WITH ACKNOWLEDGED
14 CERTIFICATION IN THE AREA OF DRUG AND ALCOHOL ABUSE OR CHEMICAL
15 DEPENDENCY. IN NO CASE SHALL COVERAGE BE LESS THAN THE MANDATED
16 MINIMUMS SPECIFIED UNDER "THE INSURANCE COMPANY LAW OF 1921."
17 (2) Acknowledged certification as described in clause (1)
18 shall mean:
19 (i) Certification by ASAM in the area of drug and alcohol
20 treatment.
21 (ii) Certification as a certified addiction counselor (CAC).
22 (iii) Certification under any drug and alcohol program
23 recognized by ASAM.
24 (iv) Certification in any three-year training program or
25 equivalent life experience in an ODAP-licensed facility or
26 equivalent out-of-State facility.
27 (d) No health maintenance organization OR EMPLOYE ASSISTANCE <--
28 PROGRAM OR TREATMENT PROVIDER shall provide or establish
29 contracts or arrangements to complete initial patient
30 interviews, assessments, pre-certification, concurrent review or
19910H1516B3319 - 5 -
1 any subsequent review where DIRECT compensation or any SPECIFIC <--
2 part of compensation TO INDIVIDUAL OR CLINICAL DECISION MAKERS <--
3 OR MANAGED-CARE FIRMS depends on the determination of type or
4 course of treatment, length of stay or level of care FOR AN <--
5 INDIVIDUAL PATIENT OR GROUPS OF PATIENTS, WHETHER THE INDIVIDUAL
6 IS AN INDIVIDUAL SUBSCRIBER OR A SUBSCRIBER IN A GROUP PLAN.
7 (e) No health maintenance organization or subcontractor may <--
8 establish its own drug and alcohol treatment facility.
9 (f) Whenever any dispute arises concerning the need for or
10 the specific course of or duration of any treatment between the
11 health maintenance organization or subcontractor and employe
12 assistance program administrator or student assistance program,
13 the determination of the employe assistance program or the
14 student assistance program or the appeals board shall prevail
15 over the determination of the health maintenance organization.
16 (g) All costs, associated with the settlement of disputes
17 under this subsection shall be initially paid by the health
18 maintenance organization. All costs shall include costs of
19 treatment until resolution of the dispute.
20 (E) NO HEALTH MAINTENANCE ORGANIZATION OR MANAGED-CARE <--
21 SUBCONTRACTOR MAY ESTABLISH DRUG AND ALCOHOL TREATMENT SERVICES
22 TO AVOID PROVISION OF TREATMENT SERVICES REQUIRED UNDER ARTICLE
23 VI-A OF "THE INSURANCE COMPANY LAW OF 1921." NOTHING IN THIS
24 SECTION SHALL PROHIBIT HEALTH MAINTENANCE ORGANIZATIONS OR
25 MANAGED-CARE SUBCONTRACTORS FROM SUBCONTRACTING WITH DRUG AND
26 ALCOHOL TREATMENT PROGRAMS LICENSED BY THE OFFICE OF DRUG AND
27 ALCOHOL PROGRAMS.
28 (h) (F) (1) When a patient has begun treatment with a <--
29 provider of service licensed by the Office of Drug and Alcohol
30 Programs, the health maintenance organization or subcontractor
19910H1516B3319 - 6 -
1 shall not intercede in treatment until the mandated minimum
2 lengths of stay established by the program and the act of May <--
3 17, 1921 (P.L.682, No.284), known as "The Insurance Company Law
4 of 1921," have been satisfied. Nothing in this section
5 interferes with the ARTICLE VI-A OF "THE INSURANCE COMPANY LAW <--
6 OF 1921" HAVE BEEN SATISFIED UNLESS OTHERWISE INDICATED BASED ON
7 THE CRITERIA APPROVED UNDER CLAUSES (1) THROUGH (4) OF
8 SUBSECTION (B) OF THIS SECTION.
9 (2) NOTHING IN THIS SECTION INTERFERES WITH THE right of the
10 health maintenance organization to CONCURRENT AND/OR <--
11 retrospective review and to request documentation on the
12 progress of the individual at reasonable intervals, as provided
13 in the licensure standards of the Office of Drug and Alcohol
14 Programs. Alcohol and drug or alcohol or drug detoxification <--
15 shall be considered an emergency condition pursuant to the
16 emergency provisions of this act. CONCURRENT AND RETROSPECTIVE <--
17 REVIEW OF CARE SHALL BE BASED ON THE APPROVED CRITERIA FOR SUCH
18 CARE AND SHALL BE SUBJECT TO THE APPLICABLE GRIEVANCE PROCEDURE.
19 (3) USING CRITERIA ESTABLISHED BY THE HEALTH MAINTENANCE
20 ORGANIZATION IN SUBSECTIONS (A) AND (B) OF THIS SECTION, IF THE
21 PATIENT MEETS THE STANDARDS CALLING FOR DETOXIFICATION, THEN THE
22 CASE SHALL BE HANDLED AS EMERGENCY CARE. HOWEVER, ALL SUCH
23 DECISIONS ARE SUBJECT TO RETROSPECTIVE AND CONCURRENT REVIEW AND
24 THE GRIEVANCE PROCEDURE.
25 (4) ALL NONEMERGENCY ASSESSMENTS FOR CARE MUST BE COMPLETED
26 WITHIN FORTY-EIGHT HOURS OR THE PATIENT SHALL BE PERMITTED TO
27 ACCESS SERVICE FOR SUCH CARE, PENDING SUCH ASSESSMENT AND
28 SUBJECT TO RETROSPECTIVE OR CONCURRENT REVIEW AND GRIEVANCE
29 PROCEDURES.
30 (i) (G) Any time a health maintenance organization or <--
19910H1516B3319 - 7 -
1 managed-care subcontractor denies a specific ACCESS FOR A <--
2 SPECIFIC COVERED treatment or treatment modality or denies
3 continuation of existing treatment, such denial shall be
4 provided in writing to the patient, the referral source and the <--
5 treatment program and shall set forth the specific reasons for
6 such denial and the name of the individual making that decision.
7 (j) (1) All disputes arising under this section shall be <--
8 filed with and resolved by an appeals board established in the
9 Department of Health. The primary goal of the appeals board
10 shall be to insure that each member suffering from drug or
11 alcohol abuse or chemical dependency receives appropriate and
12 timely service to alleviate the problem.
13 (2) The appeals board shall be composed of members appointed
14 by the Governor, as follows:
15 (i) One member from an employe assistance program.
16 (ii) One member who is a certified addictions counselor.
17 (iii) One member who is certified by the American Society of
18 Addiction Medicine.
19 (iv) One member from a health maintenance organization.
20 (v) One member from Blue Cross/Blue Shield or other health
21 care insurance company.
22 (vi) One member from an inpatient treatment facility
23 licensed by the Office of Drug and Alcohol Programs.
24 (vii) One member from an outpatient treatment facility
25 licensed by the Office of Drug and Alcohol Programs.
26 (viii) One member from a detoxification treatment facility
27 licensed by the Office of Drug and Alcohol Programs.
28 (ix) One member who is an employe benefits manager.
29 (x) One member who is a past consumer of treatment services.
30 (xi) One member who represents the Department of Health.
19910H1516B3319 - 8 -
1 (3) The board shall serve without compensation but shall
2 receive actual expenses incurred.
3 (4) All appeals shall be resolved within thirty days of a
4 hearing.
5 (5) All costs of appeals shall be initially borne by the
6 health maintenance organization with the appropriate allocation
7 of costs to be made in any board decision.
8 (k) (1) All health maintenance organizations and
9 subcontractors shall provide an annual report to the Department
10 of Health. The report shall include, but not be limited to:
11 (H) (1) THE GRIEVANCE PROCEDURES OF THE HEALTH FINANCING <--
12 BUREAU SHALL BE IN FORCE WITH THE EXCEPTION THAT THERE SHALL BE
13 A SPECIFIC GRIEVANCE PROCESS FOR DRUG AND ALCOHOL TREATMENT
14 COMPLAINTS AND GRIEVANCES IN REGARD TO ARTICLE VI-A OF "THE
15 INSURANCE COMPANY LAW OF 1921," AND THAT PROCEDURE SHALL BE ONE
16 LEVEL, SHALL RESOLVE COMPLAINTS WITHIN THIRTY DAYS OF
17 SUBMISSION, SHALL HAVE A GRIEVANCE COMMITTEE COMPOSED OF: ONE
18 PHYSICIAN MEMBER OF ASAM APPOINTED BY THE PENNSYLVANIA
19 ASSOCIATION OF HEALTH MAINTENANCE ORGANIZATIONS, ONE TREATMENT
20 PROVIDER FROM A FACILITY LICENSED BY THE OFFICE OF DRUG AND
21 ALCOHOL PROGRAMS, APPOINTED BY THE DRUG AND ALCOHOL SERVICE
22 PROVIDERS ORGANIZATION, ONE PAST CONSUMER OF ADDICTION TREATMENT
23 SERVICES, APPOINTED BY THE OFFICE OF DRUG AND ALCOHOL PROGRAMS.
24 (2) THE SUBSCRIBER SHALL HAVE THE RIGHT TO ATTEND THE
25 PROCEDURE OR TO DESIGNATE OTHERS TO REPRESENT HIM OR HER IN THE
26 PROCEEDINGS. GRIEVANCES MAY BE BROUGHT BY THE PATIENT, FAMILY,
27 REFERRAL SOURCE, HEALTH MAINTENANCE ORGANIZATION, MANAGED-CARE
28 SUBCONTRACTOR OR TREATMENT PROVIDER.
29 (I) (1) AS PART OF THEIR ANNUAL REPORTING REQUIREMENTS TO
30 THE DEPARTMENT OF HEALTH, EACH HEALTH MAINTENANCE ORGANIZATION
19910H1516B3319 - 9 -
1 SHALL INCLUDE, FOR ITSELF AND ITS SUBCONTRACTORS, THE FOLLOWING
2 INFORMATION: total number of members, numbers receiving drug and
3 alcohol treatment benefits, drug alcohol treatment benefits
4 provided by type of service, level of care, length of stay
5 within each type of service, the names and addresses of all
6 subcontracting organizations handling this benefit and the names
7 of all drug and alcohol treatment facilities utilized within the
8 reporting year.
9 (2) The Department of Health shall review these annual <--
10 reports for general compliance and to determine that the health
11 maintenance organization and subcontractors are providing
12 treatment to its members and the full continuum of services as
13 required under the act of May 17, 1921 (P.L.682, No.284), known
14 as "The Insurance Company Law of 1921."
15 (2) THE DEPARTMENT OF HEALTH SHALL SUBMIT THESE REPORTS WITH <--
16 A SUMMARY TO THE GENERAL ASSEMBLY AT THE END OF TWO YEARS ON THE
17 EXTENT TO WHICH HEALTH MAINTENANCE ORGANIZATIONS ARE PROVIDING
18 TREATMENT FOR ALCOHOL AND DRUG ABUSE TO ITS MEMBERS AS REQUIRED
19 UNDER ARTICLE VI-A OF "THE INSURANCE COMPANY LAW OF 1921."
20 (l) (J) The Department of Health shall promulgate rules and <--
21 regulations to implement this section. The Department of Health
22 shall establish filing fees for health maintenance organizations
23 and subcontractors required under this section at a level
24 adequate to support all costs of the section.
25 (m) (K) As used in this section: <--
26 "ASAM" means the American Society of Addictive Medicine.
27 "ODAP" means the Office of Drug and Alcohol Policy in the
28 Department of Health.
29 Section 2. This act shall take effect in 60 days.
A9L35RZ/19910H1516B3319 - 10 -