PRINTER'S NO. 1734
No. 1192 Session of 2006
INTRODUCED BY MELLOW, BOSCOLA, FONTANA, TARTAGLIONE, MUSTO,
COSTA, O'PAKE, KITCHEN, FERLO, C. WILLIAMS, LAVALLE, LOGAN,
STACK, STOUT, KASUNIC, WASHINGTON, WOZNIAK, FUMO, HUGHES,
RHOADES, RAFFERTY, BROWNE AND GREENLEAF, APRIL 20, 2006
REFERRED TO PUBLIC HEALTH AND WELFARE, APRIL 20, 2006
AN ACT
1 Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
2 act relating to insurance; amending, revising, and
3 consolidating the law providing for the incorporation of
4 insurance companies, and the regulation, supervision, and
5 protection of home and foreign insurance companies, Lloyds
6 associations, reciprocal and inter-insurance exchanges, and
7 fire insurance rating bureaus, and the regulation and
8 supervision of insurance carried by such companies,
9 associations, and exchanges, including insurance carried by
10 the State Workmen's Insurance Fund; providing penalties; and
11 repealing existing laws," further providing for legislative
12 findings and intent, for definitions, for children's health
13 care, for outreach and for payor of last resort and insurance
14 coverage; providing for Federal waivers; and making a related
15 repeal.
16 The General Assembly of the Commonwealth of Pennsylvania
17 hereby enacts as follows:
18 Section 1. Sections 2302, 2303, 2311, 2312 and 2313 of the
19 act of May 17, 1921 (P.L.682, No.284), known as The Insurance
20 Company Law of 1921, added June 17, 1998 (P.L.464, No.68), are
21 amended to read:
22 Section 2302. Legislative Findings and Intent.--The General
23 Assembly finds and declares as follows:
1 (1) All citizens of this Commonwealth should have access to
2 affordable and reasonably priced health care and to
3 nondiscriminatory treatment by health insurers and providers.
4 (2) The uninsured health care population of this
5 Commonwealth is estimated to be [over] approximately one million
6 persons and many thousands more lack adequate insurance
7 coverage. It is also estimated that approximately two-thirds of
8 the uninsured are employed or dependents of employed persons.
9 (3) [Over one-third] Approximately fifteen per centum (15%)
10 of the uninsured health care population are children. Uninsured
11 children are of particular concern because of their need for
12 ongoing preventive and primary care. Measures not taken to care
13 for such children now will result in higher human and financial
14 costs later.
15 (4) Uninsured children lack access to timely and appropriate
16 primary and preventive care. As a result, health care is often
17 delayed or forgone, resulting in increased risk of developing
18 more severe conditions which in turn are more expensive to
19 treat. This tendency to delay care and to seek ambulatory care
20 in hospital-based settings also causes inefficiencies in the
21 health care system.
22 (5) Health care markets have been distorted through cost
23 shifts for the uncompensated health care costs of uninsured
24 citizens of this Commonwealth which has caused decreased
25 competitive capacity on the part of those health care providers
26 who serve the poor and increased costs of other health care
27 payors.
28 (6) No one sector can absorb the cost of providing health
29 care to citizens of this Commonwealth who cannot afford health
30 care on their own. The cost is too large for the public sector
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1 alone to bear and instead requires the establishment of a public
2 and private partnership to share the costs in a manner
3 economically feasible for all interests. The magnitude of this
4 need also requires that it be done on a time-phased, cost-
5 managed and planned basis.
6 (7) [Eligible] All uninsured children in this Commonwealth
7 should have access to affordable, cost-effective, comprehensive
8 primary health coverage if they are unable to afford coverage or
9 obtain it.
10 (8) Care should be provided in appropriate settings by
11 efficient providers, consistent with high quality care and at an
12 appropriate stage, soon enough to avert the need for overly
13 expensive treatment.
14 (9) Equity should be assured among health providers and
15 payors by providing a mechanism for providers, employers, the
16 public sector and patients to share in financing indigent
17 children's health care.
18 Section 2303. Definitions.--As used in this article, the
19 following words and phrases shall have the meanings given to
20 them in this section:
21 "Child." A person under nineteen (19) years of age.
22 ["Children's Medical Assistance." Medical assistance
23 services to children as required under Title XIV of the Social
24 Security Act (49 Stat. 620, 42 U.S.C. § 301 et seq.), including
25 EPSDT services.]
26 "Contractor." An entity awarded a contract under subdivision
27 (b) to provide health care services under this article. The term
28 includes an entity and its subsidiary which is established under
29 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63
30 (relating to professional health services plan corporations);
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1 this act; or the act of December 29, 1972 (P.L.1701, No.364),
2 known as the "Health Maintenance Organization Act."
3 "Council." The Children's Health Advisory Council
4 established in section 2311(i).
5 "Department." The Insurance Department of the Commonwealth.
6 "EPSDT." Early and periodic screening, diagnosis and
7 treatment.
8 "Fund." The Children's Health Fund for health care for
9 indigent children established by section 1296 of the act of
10 March 4, 1971 (P.L.6, No.2), known as the "Tax Reform Code of
11 1971."
12 ["Genetic status." The presence of a physical condition in
13 an individual which is a result of an inherited trait.]
14 "Group." A group for which a health insurance policy is
15 written in this Commonwealth.
16 "Health maintenance organization" or "HMO." An entity
17 organized and regulated under the act of December 29, 1972
18 (P.L.1701, No.364), known as the "Health Maintenance
19 Organization Act."
20 "Health service corporation." A professional health service
21 corporation as defined in 40 Pa.C.S. § 6302 (relating to
22 definitions).
23 "Healthy Beginnings Program." Medical assistance coverage
24 for:
25 (1) children from birth to age one (1) whose family income is
26 less than one hundred eighty-six per centum (186%) of the
27 Federal poverty level;
28 (2) children one (1) through five (5) years of age whose
29 family income is less than one hundred thirty-four per centum
30 (134%) of the Federal poverty level; and
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1 (3) children six (6) through eighteen (18) years of age whose
2 family income is less than one hundred one per centum (101%) of
3 the Federal poverty level.
4 "HIPP." The Health Insurance Premium Payment Program
5 administered by the Department of Public Welfare.
6 "Hospital." An institution having an organized medical staff
7 which is engaged primarily in providing to inpatients, by or
8 under the supervision of physicians, diagnostic and therapeutic
9 services for the care of injured, disabled, pregnant, diseased
10 or sick or mentally ill persons. The term includes facilities
11 for the diagnosis and treatment of disorders within the scope of
12 specific medical specialties. The term does not include
13 facilities caring exclusively for the mentally ill.
14 "Hospital plan corporation." A hospital plan corporation as
15 defined in 40 Pa.C.S. § 6101 (relating to definitions).
16 "Insurer." Any insurance company, association, reciprocal,
17 nonprofit hospital plan corporation, nonprofit professional
18 health service plan, health maintenance organization, fraternal
19 benefits society or a risk-bearing PPO or nonrisk-bearing PPO
20 not governed and regulated under the Employee Retirement Income
21 Security Act of 1974 (Public Law 93-406, 29 U.S.C. § 1001 et
22 seq.).
23 "MAAC." The Medical Assistance Advisory Committee.
24 "Managed care organization." Health maintenance organization
25 organized and regulated under the act of December 29, 1972
26 (P.L.1701, No.364), known as the "Health Maintenance
27 Organization Act," or a risk-assuming preferred provider
28 organization or exclusive provider organization, organized and
29 regulated under this act.
30 "MCH." Maternal and Child Health.
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1 "Medicaid." The Federal medical assistance program
2 established under Title XIX of the Social Security Act (49 Stat.
3 620, 42 U.S.C. § 1396 et seq.).
4 "Medical assistance." The State program of medical
5 assistance established under the act of June 13, 1967 (P.L.31,
6 No.21), known as the "Public Welfare Code."
7 "Mid-level health professional." A physician assistant,
8 certified registered nurse practitioner, nurse practitioner or a
9 certified nurse midwife.
10 "Parent." A natural parent, stepparent, adoptive parent,
11 guardian or custodian of a child.
12 "PPO." A preferred provider organization subject to the
13 provisions of section 630.
14 "Preexisting condition." A disease or physical condition for
15 which medical advice or treatment has been received prior to the
16 effective date of coverage.
17 "Prescription drugs." A controlled substance, other drug or
18 device for medication available only by order of a person
19 currently licensed under the laws of this Commonwealth to order
20 medication.
21 "Subgroup." An employer covered under a contract issued to a
22 multiple employer trust or to an association.
23 "Terminate." Includes cancellation, nonrenewal and
24 rescission.
25 "Uninsured period." A continuous period of time, but not
26 more than six (6) months, as determined by the department, and
27 approved by the Secretary of the United States Department of
28 Health and Human Services, during which a child has been without
29 a form of health care coverage.
30 "Waiting period." A period of time after the effective date
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1 of enrollment during which a health insurance plan excludes
2 coverage for the diagnosis or treatment of one or more medical
3 conditions.
4 "WIC." The Federal Supplemental Food Program for Women,
5 Infants and Children.
6 Section 2311. Children's Health Care.--(a) Notwithstanding
7 any other provision of law, the Department of Public Welfare in
8 coordination with the department shall take such actions as may
9 be necessary to ensure the receipt of Federal financial
10 participation under Title XIX of the Social Security Act (49
11 Stat. 620, 42 U.S.C. § 1396 et seq.) and Title XXI of the Social
12 Security Act (49 Stat. 620, 42 U.S.C. § 1397aa et seq.) for
13 services provided under this act, and to qualify the benefit
14 expansion provided by subsection (c)(1.1) for available Federal
15 financial participation.
16 (b) (1) The fund shall be dedicated exclusively for
17 distribution by the [Insurance Department] department through
18 contracts in order to provide free and subsidized health care
19 services under this section and to develop and implement
20 outreach activities required under section 2312.
21 [(b) (1)] (2) The fund, along with Federal, State and other
22 money available for the program, shall be used [to fund] for
23 health care services for children as specified in this section.
24 The [Insurance Department] department and the Department of
25 Public Welfare shall assure that the program is implemented
26 Statewide. All contracts awarded under this section shall be
27 awarded through a competitive procurement process. The
28 [Insurance Department shall use its] department and the
29 Department of Public Welfare shall use their best efforts to
30 ensure that eligible children across this Commonwealth have
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1 access to health care services to be provided under this
2 article.
3 [(2)] (3) No more than seven and one-half per centum (7
4 1/2%) of the amount of the contract may be used for
5 administrative expenses of the contractor. If after the first
6 three (3) full years of operation any contractor presents
7 documented evidence that administrative expenses are in excess
8 of seven and one-half per centum (7 1/2%) of the amount of the
9 contract, the [Insurance Department] department may make an
10 additional allotment of funds, not to exceed two and one-half
11 per centum (2 1/2%) of the amount of the contract, for future
12 administrative expenses to the contractor to the extent that the
13 [Insurance Department] department finds the expenses reasonable
14 and necessary.
15 [(3)] (4) No less than [seventy per centum (70%)] eighty-
16 eight per centum (88%) of the [fund] contract shall be used to
17 provide the health care services provided under this article for
18 children eligible for [free] care under [subsection (d)] this
19 act. [When the Insurance Department determines that seventy per
20 centum (70%) of the fund is not needed in order to achieve
21 maximum enrollment of children eligible for free care and
22 promulgates a final form regulation with proposed rulemaking
23 omitted, this paragraph shall expire.]
24 [(4)] (5) To ensure that inpatient hospital care is provided
25 to eligible children, each primary care [physician providing]
26 provider furnishing primary care services shall make necessary
27 arrangements for admission to the hospital and for necessary
28 specialty care.
29 (c) (1) Any organization or corporation receiving funds
30 from the [Insurance Department] department to provide coverage
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1 of health care services shall enroll[, to the extent that funds
2 are available,] any child who meets all of the following:
3 (i) [Except for newborns, has been] Is a resident of this
4 Commonwealth [for at least thirty (30) days prior to
5 enrollment].
6 (ii) Is not covered by a health insurance plan, a self-
7 insurance plan or a self-funded plan or is not eligible for or
8 covered by medical assistance, including the Healthy Beginnings
9 Program.
10 (iii) Is qualified based on income under subsection (d) or
11 (e).
12 (iv) Meets the citizenship requirements of the Medicaid
13 program administered by the Department of Public Welfare.
14 (1.1) Beginning January 1, 2007, and subject to the
15 provisions of section 2314, any organization or corporation
16 receiving funds from the department to provide coverage of
17 health care services under this section shall enroll any child
18 who meets all of the following:
19 (i) Is a resident of this Commonwealth.
20 (ii) Is not covered by a health insurance plan, a self-
21 insurance plan or a self-funded plan or is not eligible for or
22 covered by a medical assistance program administered by the
23 Department of Public Welfare, including the Healthy Beginnings
24 Program.
25 (iii) Is qualified based on income under subsection (d),
26 (e.1), (e.2), (e.3) or (e.4) and meets the uninsured period
27 requirements as provided in subsection (e.5).
28 (iv) Meets the citizenship requirements of the Medicaid
29 program administered by the Department of Public Welfare.
30 (2) Enrollment may not be denied on the basis of a
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1 preexisting condition, nor may diagnosis or treatment for the
2 condition be excluded based on the condition's preexistence.
3 (d) The provision of health care insurance for eligible
4 children shall be free to a child under nineteen (19) years of
5 age whose family income is no greater than two hundred per
6 centum (200%) of the Federal poverty level.
7 [(e) (1) The provision of health care insurance for an
8 eligible child who is under nineteen (19) years of age and whose
9 family income is greater than two hundred per centum (200%) of
10 the Federal poverty level but no greater than two hundred
11 thirty-five per centum (235%) of the Federal poverty level may
12 be subsidized by the fund at a rate not to exceed fifty per
13 centum (50%).
14 (2) The difference between the pure premium of the minimum
15 benefit package in subsection (l)(6) and the subsidy provided
16 under this subsection shall be the amount paid by the family of
17 the eligible child purchasing the minimum benefit package.
18 (f) The family of an eligible child whose family income
19 makes the child eligible for free or subsidized care but who
20 cannot receive care due to lack of funds in the fund may
21 purchase coverage for the child at cost.]
22 (e.1) The provision of health care insurance for an eligible
23 child who is under nineteen (19) years of age and whose family
24 income is greater than two hundred per centum (200%) of the
25 Federal poverty level but no greater than two hundred fifty per
26 centum (250%) of the Federal poverty level may be subsidized by
27 the department on a sliding scale rate based on the family
28 income.
29 (e.2) The provision of health care insurance for an eligible
30 child who is under nineteen (19) years of age and whose family
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1 income is greater than two hundred fifty per centum (250%) of
2 the Federal poverty level but no greater than three hundred per
3 centum (300%) of the Federal poverty level may be subsidized by
4 the department on a sliding scale rate based on the family
5 income.
6 (e.3) The department and the Department of Public Welfare
7 may, subject to Federal approval sought under section 2314,
8 provide health care insurance for an eligible child who is under
9 nineteen (19) years of age and whose family income is greater
10 than three hundred per centum (300%) of the Federal poverty
11 level, but no more than three hundred and fifty per centum
12 (350%) of the Federal poverty level on a sliding scale rate
13 based on the family income.
14 (e.4) In the event that Federal approval sought under
15 section 2314 does not permit expansion of eligibility to persons
16 under subsection (e.3), then for any child who is under nineteen
17 (19) years of age and whose family income is greater than the
18 Federal poverty level established for coverage under subsection
19 (e.2), the family may purchase the benefit package at the per
20 member per month premium cost negotiated by the department.
21 (e.5) To be eligible for coverage under subsections (e.1),
22 (e.2), (e.3) and (e.4), a child must have been uninsured for an
23 uninsured period unless:
24 (i) the child's parent is eligible to receive benefits
25 pursuant to the act of December 5, 1936 (2nd Sp.Sess., 1937
26 P.L.2897, No.1), known as the "Unemployment Compensation Law";
27 (ii) the child's parent was covered by a health insurance
28 plan, a self-insurance plan or a self-funded plan but at the
29 time of application for coverage is no longer employed and is
30 ineligible to receive benefits pursuant to the "Unemployment
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1 Compensation Law"; or
2 (iii) a child is transferring from one government-subsidized
3 health care program to another.
4 (e.6) The department shall publish a notice in the
5 Pennsylvania Bulletin which establishes the uninsured period for
6 purposes of eligibility under this section.
7 (g) The [Insurance Department] department, in coordination
8 with the Department of Public Welfare, shall:
9 (1) Administer the children's health care program pursuant
10 to this article.
11 (2) Review all bids and approve and execute all contracts
12 for the purpose of expanding access to health care services for
13 eligible children as provided for in this subdivision.
14 (3) Conduct monitoring and oversight of contracts entered
15 into.
16 (3.1) Establish sliding scale premiums based on family
17 income as permitted by the Federal Government under appropriate
18 waivers pursuant to section 2314. Notification of the initial
19 sliding scale premiums shall be published by notice in the
20 Pennsylvania Bulletin.
21 (4) Issue an annual report to the Governor, the General
22 Assembly and the public for each fiscal year outlining primary
23 health services funded for the year, detailing the outreach and
24 enrollment efforts and reporting by county the number of
25 children receiving health care services from the fund, the
26 projected number of eligible children and the number of eligible
27 children on waiting lists for health care services.
28 (5) In consultation with appropriate Commonwealth agencies,
29 coordinate the development and supervision of the outreach plan
30 required under section 2312.
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1 (6) In consultation with appropriate Commonwealth agencies,
2 monitor, review and evaluate the adequacy, accessibility and
3 availability of services delivered to children who are enrolled
4 in the health insurance program established under this
5 subdivision.
6 (h) The [Insurance Department] department may promulgate
7 regulations necessary for the implementation and administration
8 of this subdivision.
9 (i) The Children's Health Advisory Council is established
10 within the [Insurance Department] department as an advisory
11 council. The following shall apply:
12 (1) The council shall consist of fourteen voting members.
13 Members provided for in subparagraphs (iv), (v), (vi), (vii),
14 (viii), (x) and (xi) shall be appointed by the Insurance
15 Commissioner. The council shall be geographically balanced on a
16 Statewide basis, if possible, and shall include:
17 (i) The Secretary of Health ex officio or a designee.
18 (ii) The Insurance Commissioner ex officio or a designee.
19 (iii) The Secretary of Public Welfare ex officio or a
20 designee.
21 (iv) A representative with experience in children's health
22 from a school of public health located in this Commonwealth.
23 (v) A physician with experience in children's health
24 appointed from a list of three qualified persons recommended by
25 the Pennsylvania Medical Society.
26 (vi) A representative of a children's hospital or a hospital
27 with a pediatric outpatient clinic appointed from a list of
28 three persons submitted by the Hospital Association of
29 Pennsylvania.
30 (vii) A parent of a child who receives primary health care
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1 coverage from the fund.
2 (viii) A mid-level professional appointed from lists of
3 names recommended by Statewide associations representing mid-
4 level health professionals.
5 (ix) A senator appointed by the President pro tempore of the
6 Senate, a senator appointed by the minority leader of the
7 Senate, a representative appointed by the Speaker of the House
8 of Representatives and a representative appointed by the
9 minority leader of the House of Representatives.
10 (x) A representative from a private nonprofit foundation.
11 (xi) A representative of business who is not a contractor or
12 provider of primary health care insurance under this
13 subdivision.
14 (2) If any specified organization should cease to exist or
15 fail to make a recommendation within ninety (90) days of a
16 request to do so, the council shall specify a new equivalent
17 organization to fulfill the responsibilities of this section.
18 (3) The Insurance Commissioner shall chair the council. The
19 members of the council shall annually elect, by a majority vote
20 of the members, a vice chairperson from among the members of the
21 council.
22 (4) The presence of eight members shall constitute a quorum
23 for the transacting of any business. Any act by a majority of
24 the members present at any meeting at which there is a quorum
25 shall be deemed to be that of the council.
26 (5) All meetings of the council shall be conducted pursuant
27 to [the act of July 3, 1986 (P.L.388, No.84), known as the
28 "Sunshine Act,"] 65 Pa.C.S. Ch. 7 (relating to open meetings)
29 unless otherwise provided in this section. The council shall
30 meet at least annually and may provide for special meetings as
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1 it deems necessary. Meeting dates shall be set by a majority
2 vote of members of the council or by call of the chairperson
3 upon seven (7) days' notice to all members. The council shall
4 publish notice of its meetings in the Pennsylvania Bulletin.
5 Notice shall specify the date, time and place of the meeting and
6 shall state that the council's meetings are open to the general
7 public. All action taken by the council shall be taken in open
8 public session and shall not be taken except upon a majority
9 vote of the members present at a meeting at which a quorum is
10 present.
11 (6) The members of the council shall not receive a salary or
12 per diem allowance for serving as members of the council but
13 shall be reimbursed for actual and necessary expenses incurred
14 in the performance of their duties.
15 (7) Terms of council members shall be as follows:
16 (i) The appointed members shall serve for a term of three
17 (3) years and shall continue to serve thereafter until their
18 successors are appointed.
19 (ii) An appointed member shall not be eligible to serve more
20 than two full consecutive terms of three (3) years. Vacancies
21 shall be filled in the same manner in which they were designated
22 within sixty (60) days of the vacancy.
23 (iii) An appointed member may be removed by the appointing
24 authority for just cause and by a vote of at least seven members
25 of the council.
26 (8) The council shall review outreach activities and may
27 make recommendations to the [Insurance Department] department.
28 (9) The council shall review and evaluate the accessibility
29 and availability of services delivered to children enrolled in
30 the program.
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1 (j) The [Insurance Department] department shall solicit bids
2 and award contracts through a competitive procurement process
3 pursuant to the following:
4 (1) To the fullest extent practicable, contracts shall be
5 awarded to entities that contract with providers to provide
6 primary care services for enrollees on a cost-effective basis.
7 The [Insurance Department] department shall require contractors
8 to use appropriate cost-management methods so that [the fund can
9 be used to provide the] basic primary benefit services can be
10 provided to the maximum number of eligible children and,
11 whenever possible, to pursue and utilize available public and
12 private funds.
13 (2) To the fullest extent practicable, the [Insurance
14 Department] department shall require that any contractor comply
15 with all procedures relating to coordination of benefits as
16 required by the [Insurance Department] department or the
17 Department of Public Welfare.
18 (3) Contracts may be for a term of up to three (3) years[.],
19 with the option to extend for two one-year (1) periods.
20 (k) Upon receipt of a [request for proposal from the
21 Insurance Department] solicitation from the department, each
22 health plan corporation or its entities doing business in this
23 Commonwealth shall submit a bid or proposal to the [Insurance
24 Department] department to carry out the purposes of this section
25 in the area serviced by the corporation.
26 (l) A contractor with whom the [Insurance Department]
27 department enters into a contract shall do the following:
28 (1) Ensure to the maximum extent possible that eligible
29 children have access to primary health care physicians and nurse
30 practitioners on an equitable Statewide basis.
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1 (2) Contract with qualified, cost-effective providers, which
2 may include primary health care physicians, nurse practitioners,
3 clinics and health maintenance organizations, to provide primary
4 and preventive health care for enrollees on a basis best
5 calculated to manage the costs of the services, including, but
6 not limited to, using managed health care techniques and other
7 appropriate medical cost-management methods.
8 (3) Ensure that the family of a child who may be eligible
9 for medical assistance receives assistance in applying for
10 medical assistance.[, including, at a minimum, written notice of
11 the telephone number and address of the county assistance office
12 where the family can apply for medical assistance.
13 (4) Maintain waiting lists of children financially eligible
14 for benefits who have applied for benefits but who were not
15 enrolled due to lack of funds.]
16 (4.1) Notify families of children who are paying a premium
17 of any changes of such premium.
18 (4.2) Collect such premiums or copayments from the family of
19 any child receiving benefits as may be required.
20 (4.3) Cancel policies for nonpayment of premium, in
21 accordance with all other applicable insurance laws.
22 (5) Strongly encourage all providers who provide primary
23 care to eligible children to participate in medical assistance
24 as qualified EPSDT providers and to continue to provide care to
25 children who become ineligible for payment under the [fund]
26 program but who qualify for medical assistance.
27 (6) [Provide] Subject to any necessary Federal approval,
28 provide the following minimum benefit package for eligible
29 children:
30 (i) Preventive care. This subparagraph includes well-child
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1 care visits in accordance with the schedule established by the
2 American Academy of Pediatrics and the services related to those
3 visits, including, but not limited to, immunizations, health
4 education, tuberculosis testing and developmental screening in
5 accordance with routine schedule of well-child visits. Care
6 shall also include a comprehensive physical examination,
7 including X-rays if necessary, for any child exhibiting symptoms
8 of possible child abuse.
9 (ii) Diagnosis and treatment of illness or injury, including
10 all medically necessary services related to the diagnosis and
11 treatment of sickness and injury and other conditions provided
12 on an ambulatory basis, such as laboratory tests, wound dressing
13 and casting to immobilize fractures.
14 (iii) Injections and medications provided at the time of the
15 office visit or therapy and outpatient surgery performed in the
16 office, a hospital or freestanding ambulatory service center,
17 including anesthesia provided in conjunction with such service
18 or during emergency medical service.
19 (iv) Emergency accident and emergency medical care.
20 (v) Prescription drugs.
21 (vi) Emergency, preventive and routine dental care. This
22 subparagraph does not include orthodontia or cosmetic surgery.
23 (vii) Emergency, preventive and routine vision care,
24 including the cost of corrective lenses and frames, not to
25 exceed two prescriptions per year.
26 (viii) Emergency, preventive and routine hearing care.
27 (ix) Inpatient hospitalization up to ninety (90) days per
28 year for eligible children.
29 (6.1) Notwithstanding any other law to the contrary, in the
30 event it is more cost effective to purchase health care from a
20060S1192B1734 - 18 -
1 parent's employer-based program, no eligible child shall be
2 denied enrollment under this act while such determination is
3 being made. Employer-based coverage may be purchased, but no
4 enrollment restrictions shall delay enrollment in an employer-
5 based program more than ninety (90) days from the date of the
6 request. Any children's health care benefits not covered by the
7 employer's health care coverage will be separately purchased by
8 the Department of Public Welfare through the HIPP Program. These
9 children will receive a separate identification card to cover
10 the services not covered under the employer-based plan.
11 (7) [Each] Except for children covered under paragraph
12 (6.1), each contractor shall provide an insurance identification
13 card to each eligible child covered under contracts executed
14 under this article. The card must not specifically identify the
15 holder as low income.
16 (m) The [Insurance Department] department may grant a waiver
17 of the minimum benefit package of subsection (l)(6) upon
18 demonstration by the applicant that it is providing health care
19 services for eligible children that meet the purposes and intent
20 of this section.
21 (n) After the first year of operation and periodically
22 thereafter, the [Insurance Department] department in
23 consultation with appropriate Commonwealth agencies shall review
24 enrollment patterns for both the free insurance program and the
25 subsidized insurance program. The [Insurance Department]
26 department shall consider the relationship, if any, among
27 enrollment, enrollment fees, income levels and family
28 composition. Based on the results of this study and the
29 availability of funds, the [Insurance Department] department is
30 authorized to adjust the maximum income ceiling for free
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1 insurance and the maximum income ceiling for subsidized
2 insurance by regulation. In no event, however, shall the maximum
3 income ceiling for free insurance be raised above two hundred
4 per centum (200%) of the Federal poverty level.[, nor shall the
5 maximum income ceiling for subsidized insurance be raised above
6 two hundred thirty-five per centum (235%) of the Federal poverty
7 level. Changes in the maximum income ceiling shall be
8 promulgated as a final-form regulation with proposed rulemaking
9 omitted in accordance with the act of June 25, 1982 (P.L.633,
10 No.181), known as the "Regulatory Review Act."]
11 (o) Notwithstanding subsection (n), beginning January 1,
12 2007, and thereafter, and subject to the provisions of section
13 2314, the maximum income ceiling for subsidized insurance shall
14 not be raised above three hundred fifty per centum (350%) of the
15 Federal poverty level. The department shall publish a notice in
16 the Pennsylvania Bulletin establishing the maximum income
17 ceiling for subsidized insurance under this section.
18 Section 2312. Outreach.--(a) The [Insurance Department]
19 department, in consultation with appropriate Commonwealth
20 agencies, shall coordinate the development of an outreach plan
21 to inform potential contractors, providers and enrollees
22 regarding eligibility and available benefits. The plan shall
23 include provisions for reaching special populations, including
24 nonwhite and non-English-speaking children and children with
25 disabilities; for reaching different geographic areas, including
26 rural and inner-city areas; and for assuring that special
27 efforts are coordinated within the overall outreach activities
28 throughout this Commonwealth.
29 (b) The council shall review the outreach activities and
30 recommend changes as it deems in the best interests of the
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1 children to be served.
2 Section 2313. Payor of Last Resort; Insurance Coverage.--The
3 contractor shall not pay any claim on behalf of an enrolled
4 child unless all other Federal, State, local or private
5 resources available to the child or the child's family are
6 utilized first. The [Insurance Department] department, in
7 cooperation with the Department of Public Welfare, shall
8 determine [that no] whether any other insurance coverage is
9 available to the child through a custodial or noncustodial
10 parent on an employment-related or other group basis. If such
11 insurance coverage is available, the [Insurance Department shall
12 reevaluate the] child's eligibility under section 2311[.] shall
13 be reevaluated, as shall the most cost-effective means of
14 providing coverage for that child.
15 Section 2. The act is amended by adding a section to read:
16 Section 2314. Federal Waivers.--The Department of Public
17 Welfare, in cooperation with the department, shall apply for all
18 waivers from the Federal Government and shall amend the State
19 plan as deemed necessary to carry out the provisions of this
20 act. Upon approval of such waivers, the Department of Public
21 Welfare shall notify the Insurance Commissioner of such
22 approvals.
23 Section 3. When the Department of Public Welfare receives
24 Federal approval of the waivers requested under section 2314 of
25 that act, it shall transmit notice of that fact to the
26 Legislative Reference Bureau for publication as a notice in the
27 Pennsylvania Bulletin.
28 Section 4. The amendment or addition of the following
29 provisions shall take effect upon publication in the
30 Pennsylvania Bulletin of Federal approval of the waivers for
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1 which the Department of Public Welfare is applying under section
2 2314:
3 (1) Section 2311(c)(1.1) of the act.
4 (2) Section 2311(e.1), (e.2), (e.3), (e.4) and (e.5) of
5 the act.
6 (3) Section 2311(g)(3.1) of the act.
7 (4) Section 2311(l)(3), (4.1), (4.2), (4.3) and (6.1) of
8 the act.
9 (5) Section 2311(o) of the act.
10 Section 5. The repeal of the following provisions shall take
11 effect upon publication in the Pennsylvania Bulletin or upon
12 Federal approval of the waivers for which the Department of
13 Public Welfare is applying under section 2314 of the act:
14 (1) Section 2311(e) of the act.
15 (2) Section 2311(f) of the act.
16 (3) Section 2311(l)(4) of the act.
17 Section 6. This act shall take effect immediately.
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