PRINTER'S NO. 3065
No. 2309 Session of 1998
INTRODUCED BY PESCI, BELARDI, READSHAW, LAUGHLIN, TRELLO,
STURLA, CURRY, LUCYK, MANDERINO, JOSEPHS, ROSS, HALUSKA,
ITKIN, OLASZ, YOUNGBLOOD, SERAFINI, MUNDY, DeLUCA, PETRARCA
AND WASHINGTON, MARCH 11, 1998
REFERRED TO COMMITTEE ON INSURANCE, MARCH 11, 1998
AN ACT
1 Providing consumers and employers access to information
2 regarding health insurance policies.
3 The General Assembly of the Commonwealth of Pennsylvania
4 hereby enacts as follows:
5 Section 1. Short title.
6 This act shall be known and may be cited as the Patients Fair
7 Disclosure Act.
8 Section 2. Definitions.
9 The following words and phrases when used in this act shall
10 have the meanings given to them in this section unless the
11 context clearly indicates otherwise:
12 "Health insurance policy." Except for specified disease
13 policies, any group health insurance policy, contract or plan,
14 or any individual policy, which provides medical coverage on an
15 expense-incurred, service or prepaid basis. The term includes
16 the following:
17 (1) A health insurance policy or contract issued by a
1 nonprofit corporation subject to 40 Pa.C.S. Ch. 61 (relating
2 to hospital plan corporations) or 63 (relating to
3 professional health services plan corporations) or the act of
4 December 14, 1992 (P.L.835, No.134), known as the Fraternal
5 Benefit Societies Code.
6 (2) A health service plan operating under the act of
7 December 29, 1972 (P.L.1701, No.364), known as the Health
8 Maintenance Organization Act.
9 Section 3. Disclosure of information.
10 (a) General rule.--Each subscriber to a health insurance
11 policy, and upon request each prospective subscriber to a health
12 insurance policy prior to enrollment, shall be supplied with
13 written disclosure information which shall be incorporated into
14 the member handbook and the subscriber contract or certificate
15 containing at least the information in subsection (b). In the
16 event of any inconsistency between any separate written
17 disclosure statement and the subscriber contract or certificate,
18 the terms of the subscriber contract or certificate shall be
19 controlling.
20 (b) Information.--The information to be disclosed shall
21 include at least the following:
22 (1) A description of health insurance policy coverage
23 provisions; health care benefits, including the percentage of
24 the premium charged by the issuer that is expended directly
25 for patient care, the "loss ratio"; benefit maximums,
26 including benefit limitations; and exclusions of coverage,
27 including the definition of medical necessity used in
28 determining whether benefits will be covered.
29 (2) A description of all prior authorization or other
30 requirements for treatments and services.
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1 (3) A description of utilization review policies and
2 procedures used by the health maintenance organization,
3 including the following:
4 (i) the circumstances under which utilization review
5 will be undertaken;
6 (ii) the toll-free telephone number of the
7 utilization review agent;
8 (iii) the timeframes under which utilization review
9 decisions must be made for prospective, retrospective and
10 concurrent decisions;
11 (iv) the right to reconsideration;
12 (v) the right to an appeal, including the expedited
13 and standard appeals processes and the timeframes for
14 such appeals;
15 (vi) the right to designate a representative;
16 (vii) a notice that all denials of claims will be
17 made by qualified clinical personnel and that all notices
18 of denials will include information about the basis of
19 the decision;
20 (viii) further appeal rights, if any;
21 (ix) summary information about the number and
22 disposition of grievances and appeals in the most recent
23 period for which complete and accurate information is
24 available;
25 (x) the percentage of utilization review
26 determinations made by the issuer that deny coverage for
27 treatment and diagnostic services recommended by the
28 treating health professional or provider; and
29 (xi) the percentage of such denials that are
30 reversed on appeal.
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1 (4) A description prepaid annually of the types of
2 methodologies the health maintenance organization uses to
3 reimburse providers specifying the type of methodology that
4 is used to reimburse particular types of providers or
5 reimburse for the provision of particular types of services;
6 financial arrangements and incentives between health care
7 practitioners and the health maintenance organization that
8 may limit the items and services furnished to an enrollee,
9 restrict referral or treatment options or reduce a health
10 care practitioner's income based wholly or partially on the
11 number of referrals to specialists, diagnostic tests or other
12 services provided to enrollees, or in any other way
13 negatively affect the fiduciary responsibility of a health
14 professional or provider to an enrollee; any incentive plan
15 under which a health care provider assumes financial risk;
16 other financial incentives for a health professional or
17 provider to reduce health care consumption. Nothing in this
18 paragraph should be construed to require disclosure of
19 individual contracts or the specific details of any financial
20 arrangement between a health maintenance organization and a
21 health care provider.
22 (5) An explanation of a subscriber's financial
23 responsibility for payment of premiums, coinsurance, co-
24 payments, deductibles and any other charges, annual limits on
25 a subscriber's financial responsibility, caps on payments for
26 covered services and financial responsibility for noncovered
27 health care procedures, treatments or services provided
28 within the health maintenance organization.
29 (6) An explanation of a subscriber's financial
30 responsibility for payment when services are provided by a
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1 health care provider who is not part of the health
2 maintenance organization or by any provider without required
3 authorization or when a procedure, treatment or service is
4 not a covered health care benefit.
5 (7) A description of the grievance procedures to be used
6 to resolve disputes between a health maintenance organization
7 and an enrollee, including the following:
8 (i) The right to file a grievance regarding any
9 dispute between an enrollee and a health maintenance
10 organization.
11 (ii) The right to file a grievance orally when the
12 dispute is about referrals or covered benefits.
13 (iii) The toll-free telephone number which enrollees
14 may use to file an oral grievance.
15 (iv) The timeframes and circumstances for expedited
16 and standard grievances.
17 (v) The right to appeal a grievance determination
18 and the procedures for filing such an appeal.
19 (vi) The timeframes and circumstances for expedited
20 and standard appeals.
21 (vii) The right to designate a representative.
22 (viii) A notice that all disputes involving clinical
23 decisions will be made by qualified clinical personnel.
24 (ix) A statement that all notices of determination
25 will include information about the basis of the decision
26 and further appeal rights, if any.
27 (x) Information about grievances and appeals,
28 including, at a minimum:
29 (A) The total number of grievances filed.
30 (B) The number of grievances filed by issue of
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1 dispute.
2 (C) The number of grievances resolved in favor
3 of the enrollee and the number resolved in favor of
4 the plan.
5 (D) The number of grievance decisions appealed.
6 (E) The number of appeals resolved in favor of
7 the enrollee and the number resolved in favor of the
8 plan.
9 (F) The number of enrollees who filed more than
10 one grievance.
11 (8) A description of the procedure for providing care
12 and coverage 24 hours a day for emergency services. The
13 description shall include a definition of emergency services
14 and notice that emergency services are not subject to prior
15 approval and shall describe the enrollee's financial and
16 other responsibilities regarding obtaining such services,
17 including when such services are received outside the health
18 maintenance organization's service area.
19 (9) A description of procedures for enrollees to select
20 and access the health maintenance organization's primary and
21 specialty care providers, including the ratio of enrollees to
22 participating health professionals and providers by category
23 and type of health professional and provider and notice of
24 how to determine whether a participating provider is
25 accepting new patients.
26 (10) A description of the procedures for changing
27 primary and specialty care providers within the health
28 maintenance organization.
29 (11) Notice that an enrollee may obtain a referral to a
30 health care provider outside of the health maintenance
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1 organization's network or panel when the health maintenance
2 organization does not have a health care provider with
3 appropriate training and experience in the network or panel
4 to meet the particular health care needs of the enrollee and
5 the procedure by which the enrollee can obtain such referral.
6 (12) Notice that an enrollee with a condition which
7 requires ongoing care from a specialist may request a
8 standing referral to such a specialist and the procedure for
9 requesting and obtaining such a standing referral.
10 (13) Notice that an enrollee with a life-threatening
11 condition or disease or a degenerative and disabling
12 condition or disease, either of which requires specialized
13 medical care over a prolonged period of time may request a
14 specialist responsible for providing or coordinating the
15 enrollee's medical care and the procedure for requesting and
16 obtaining such a specialist.
17 (14) Notice that an enrollee with a life-threatening
18 condition or disease or a degenerative and disabling
19 condition or disease, either of which requires specialized
20 medical care over a prolonged period of time, may request
21 access to a specialty care center and the procedure by which
22 such access may be obtained.
23 (15) A description of the mechanisms by which enrollees
24 may participate in the development of the policies of the
25 health maintenance organization.
26 (16) A description of how the health maintenance
27 organization addresses the needs of non-English speaking
28 enrollees.
29 (17) Notice of all appropriate mailing addresses and
30 telephone numbers to be utilized by enrollees seeking
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1 information or authorization.
2 (18) A listing by specialty, which may be in a separate
3 document that is updated annually, of the name, address and
4 telephone number of all participating providers, including
5 facilities, and, in addition, in the case of physicians,
6 appropriate board certification.
7 Section 4. Effective date.
8 This act shall take effect in 120 days.
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