PRINTER'S NO. 1011
No. 700 Session of 2007
INTRODUCED BY EACHUS, DeLUCA, DeWEESE, McCALL, D. EVANS, COHEN, DERMODY, SURRA, STURLA, OLIVER AND MUNDY, MARCH 22, 2007
REFERRED TO COMMITTEE ON INSURANCE, MARCH 22, 2007
AN ACT 1 Amending Title 40 (Insurance) of the Pennsylvania Consolidated 2 Statutes, reforming the health care system by providing for 3 access to affordable health insurance coverage for previously 4 uninsured individuals and for small businesses, ensuring that 5 charitable health care institutions meet their community 6 benefit requirements, strengthening Commonwealth oversight of 7 health insurance rate increases, imposing certain duties on 8 retail drug stores, hospitals and certain outpatient 9 facilities to report price information, establishing the 10 Pennsylvania Center for Health Careers and the Health Careers 11 Leadership Council, removing barriers to individual health 12 care providers from practicing to the full extent of their 13 scope of practice, education and training, imposing certain 14 health information technology requirements on health care 15 providers, imposing patient safety obligations on hospitals 16 and nursing homes, prohibiting smoking in areas open to the 17 public, food service establishments and places of employment, 18 providing for administration, imposing penalties and making 19 repeals. 20 The General Assembly of the Commonwealth of Pennsylvania 21 hereby enacts as follows: 22 Section 1. Title 40 of the Pennsylvania Consolidated 23 Statutes is amended by adding a part to read: 24 SUBPART IV 25 HEALTH CARE REFORM 26 Chapter
1 71. General Provisions 2 72. Affordability 3 73. Accessibility 4 74. Quality of Care and Healthy Lifestyles 5 75. Miscellaneous Provisions 6 CHAPTER 71 7 GENERAL PROVISIONS 8 Sec. 9 7101. Scope and short title. 10 7102. Legislative intent. 11 7103. Definitions. 12 § 7101. Scope and short title. 13 This part relates to health care reform and shall be known 14 and may be cited as the Pennsylvania Health Care Reform Act. 15 § 7102. Legislative intent. 16 The General Assembly recognizes the following public policy 17 purposes and declares that the following objectives of this 18 Commonwealth are to be served by this part: 19 (1) Health care costs have been increasing twice as fast 20 as average wages in this Commonwealth. Yet at the same time 21 as health care costs are skyrocketing and nearly one million 22 Pennsylvanians remain uninsured, the Commonwealth is paying 23 billions of dollars each year in avoidable health care costs. 24 (2) The large number of uninsured workers in this 25 Commonwealth has a negative impact on the Commonwealth's 26 economy and productivity because insured workers are 27 healthier and more productive and use fewer sick days. The 28 Commonwealth should play a role in making health care 29 coverage affordable for small businesses and for uninsured 30 individuals. 20070H0700B1011 - 2 -
1 (3) The health care crisis is of national concern, but 2 it is possible to create a solution in Pennsylvania that 3 drives down the cost of health care and improves the well- 4 being of Pennsylvania's citizens by addressing three 5 fundamental issues: affordability, accessibility and quality. 6 (4) The Commonwealth has a clear interest in ensuring 7 that Pennsylvania families and small employers can afford 8 health insurance. In addition to the staggering human impact 9 of inadequate health care, paying for the uninsured drives up 10 the cost of health care for all insured Pennsylvanians. The 11 extra charge in insurance premiums resulting from this 12 amounts to over a billion dollars each year. 13 (5) Individual and small group health insurance rates 14 are volatile. In order to ensure that affordable individual 15 and small group health insurance is available, the 16 Commonwealth must do all of the following: 17 (i) Contain health care coverage premium increases 18 for small employers. 19 (ii) Spread the risks. 20 (iii) Ensure that affordable health care coverage is 21 available to those who have lost their employer-based 22 coverage. 23 (iv) Ensure that a substantial portion of the 24 premiums for small employers is used to pay medical 25 claims. 26 (v) Require justification for premium increases. 27 (6) The Commonwealth's not-for-profit hospitals receive 28 tax and other benefits as a result of their classification as 29 charitable institutions and, in return, are required to 30 provide a substantial community benefit. However, there is 20070H0700B1011 - 3 -
1 currently no uniform method of assessing whether a hospital 2 has met this obligation. Not-for-profit hospitals that enjoy 3 these benefits must demonstrate how they are meeting their 4 obligations to the community. 5 (7) With regard to quality and price, Pennsylvania's 6 health care market should be as transparent as possible, so 7 that all consumers will have the information they need to 8 make informed decisions on where they can obtain the best 9 quality health care at the best price. 10 (8) To expand access to quality health care, all health 11 care professionals need to be able to practice to the fullest 12 extent of their education, training and skills. Pennsylvania 13 lags behind the rest of the nation in ensuring that nurses, 14 nurse practitioners, physician assistants and other health 15 care providers are permitted to play critical roles to 16 support, coach and treat the patient, resulting in better 17 outcomes for all Pennsylvanians. Barriers that limit licensed 18 health care providers from performing up to the fullest 19 extent of their scope of practice, education and training in 20 this Commonwealth should be eliminated. 21 (9) The unnecessary use of emergency room services in 22 this Commonwealth affects both the outcome of patient care 23 and the cost to the entire health care system. Access to 24 clinics that can function as places where individuals go on a 25 regular basis to receive health care should be expanded and 26 Pennsylvanians should be educated about the appropriate use 27 of emergency rooms and alternative sites of care. 28 (10) The primary goals of the Commonwealth's health care 29 system must be the safety of its patients and the quality of 30 health care services delivered. In order to further these 20070H0700B1011 - 4 -
1 goals and to continue to improve the safety of patients, 2 hospital-acquired infections, which lead to thousands of 3 unnecessary deaths each year and drive up health care costs, 4 must be eliminated. Hospitals need to focus on infection and 5 error trends in their facilities and adopt safe practices and 6 quality management systems to reduce them. Not only 7 individual health care providers, but administrators and 8 boards of directors must be accountable for understanding the 9 importance of patient safety in reducing risk, improving 10 quality and reducing the cost of health care. 11 (11) Breathing secondhand smoke is a significant health 12 hazard for nonsmokers. It is in the best interests of the 13 citizens of this Commonwealth to protect nonsmokers from 14 involuntary exposure to secondhand tobacco smoke in indoor 15 areas open to the public, food service establishments and 16 places of employment. In addition, adults who smoke, are 17 overweight or inactive are at an increased risk of developing 18 high blood pressure, type 2 diabetes, heart disease and some 19 types of cancers and become an economic burden to all health 20 care payers in this Commonwealth. 21 § 7103. Definitions. 22 The following words and phrases when used in this part shall 23 have the meanings given to them in this section unless the 24 context clearly indicates otherwise: 25 "Accident and Health Filing Reform Act." The act of December 26 18, 1996 (P.L.1066, No.159), known as the Accident and Health 27 Filing Reform Act. 28 "Ambulatory surgical facility." An entity licensed as an 29 ambulatory surgical facility under the act of July 19, 1979 30 (P.L.130, No.48), known as the Health Care Facilities Act. 20070H0700B1011 - 5 -
1 "Behavioral health services." Mental health or substance 2 abuse services. 3 "Birth center." An entity licensed as a birth center under 4 the act of July 19, 1979 (P.L.130, No.48), known as the Health 5 Care Facilities Act. 6 "CAP" or "Cover All Pennsylvanians." The health insurance 7 program established under section 7202 (relating to Cover All 8 Pennsylvanians health insurance program). 9 "CAP Fund." The restricted account established under section 10 7202 (relating to Cover All Pennsylvanians health insurance 11 program). 12 "Children's Health Care Program" or "CHIP." The Children's 13 Health Care Program established under Article XXIII of the act 14 of May 17, 1921 (P.L.682, No.284), known as The Insurance 15 Company Law of 1921. 16 "Commonwealth Attorneys Act." The act of October 15, 1980 17 (P.L.950, No.164), known as the Commonwealth Attorneys Act. 18 "Commonwealth Documents Law." The act of July 31, 1968 19 (P.L.769, No.240), referred to as the Commonwealth Documents 20 Law. 21 "Council." The Health Care Cost Containment Council 22 established under the act of July 8, 1986 (P.L.408, No.89), 23 known as the Health Care Cost Containment Act. 24 "Employer." The term shall include: 25 (1) Any of the following who or which employ one or more 26 employees to perform services for remuneration for any period 27 of time: 28 (i) An individual, copartnership, association, 29 domestic or foreign corporation or other entity. 30 (ii) The legal representative, trustee in 20070H0700B1011 - 6 -
1 bankruptcy, receiver or trustee of any individual, 2 copartnership, association or corporation or other 3 entity. 4 (iii) The legal representative of a deceased 5 individual. 6 (2) Individuals who are self-employed. 7 (3) The executive, legislative and judicial branches of 8 the Commonwealth and any of its political subdivisions. 9 "Fiscal year." A period of 12 consecutive calendar months 10 commencing with July 1. 11 "Health Care Cost Containment Act." The act of July 8, 1986 12 (P.L.408, No.89), known as the Health Care Cost Containment Act. 13 "Health Care Facilities Act." The act of July 19, 1979 14 (P.L.130, No.48), known as the Health Care Facilities Act. 15 "Health care facility." An ambulatory surgical facility, 16 birth center, hospital or nursing home. 17 "Health care provider." Any of the following: 18 (1) A licensee. 19 (2) A health care facility. 20 (3) An officer, employee or agent of any of the entities 21 under paragraph (1) or (2) acting in the course and scope of 22 employment. 23 "Hospital." An entity licensed as an acute-care general 24 hospital, a specialty hospital or rehabilitation hospital under 25 the act of July 19, 1979 (P.L.130, No.48), known as the Health 26 Care Facilities Act. 27 "Institutions of Purely Public Charity Act." The act of 28 November 26, 1997 (P.L.508, No.55), known as the Institutions of 29 Purely Public Charity Act. 30 "Insurer." A company or health insurance entity licensed in 20070H0700B1011 - 7 -
1 this Commonwealth to issue any individual or group health, 2 sickness or accident policy or subscriber contract or 3 certificate or plan that provides medical or health care 4 coverage by a health care facility or licensed health care 5 provider that is offered or governed under the act of May 17, 6 1921 (P.L.682, No.284), known as The Insurance Company Law of 7 1921, or any of the following: 8 (1) The act of December 29, 1972 (P.L.1701, No.364), 9 known as the Health Maintenance Organization Act. 10 (2) The act of May 18, 1976 (P.L.123, No.54), known as 11 the Individual Accident and Sickness Insurance Minimum 12 Standards Act. 13 (3) Chapter 61 (relating to hospital plan corporations) 14 or 63 (relating to professional health services plan 15 corporations). 16 (4) Section 630 of The Insurance Company Law of 1921. 17 (5) Sections 2401 through 2466 of The Insurance Company 18 Law of 1921. 19 "Licensee." An individual who is licensed by the Department 20 of State to provide professional health care services in this 21 Commonwealth. 22 "Mcare." The act of March 20, 2002 (P.L.154, No.13), known 23 as the Medical Care Availability and Reduction of Error (Mcare) 24 Act. 25 "Medical assistance." The program of medical assistance 26 established under the act of June 13, 1967 (P.L.31, No.21), 27 known as the Public Welfare Code. 28 "Medicare." The Federal program established under Title 29 XVIII of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1395 30 et seq.). 20070H0700B1011 - 8 -
1 "Nursing home." An entity licensed as a long-term care 2 nursing facility under the act of July 19, 1979 (P.L.130, 3 No.48), known as the Health Care Facilities Act. 4 "PACE." The Pharmaceutical Assistance Contract for the 5 Elderly established under the act of August 26, 1971 (P.L.351, 6 No.91), known as the State Lottery Law. 7 "Prevailing Wage Act." The act of August 15, 1961 (P.L.987, 8 No.442), known as the Pennsylvania Prevailing Wage Act. 9 "Public Welfare Code." The act of June 13, 1967 (P.L.31, 10 No.21), known as the Public Welfare Code. 11 "Regulatory Review Act." The act of June 25, 1982 (P.L.633, 12 No.181), known as the Regulatory Review Act. 13 "Tax Reform Code." The act of March 4, 1971 (P.L.6, No.2), 14 known as the Tax Reform Code of 1971. 15 "Tobacco Settlement Act." The act of June 26, 2001 (P.L.755, 16 No.77), known as the Tobacco Settlement Act. 17 "Unemployment Compensation Law." The act of December 5, 1936 18 (2nd Sp.Sess., 1936 P.L.2897, No.1), known as the Unemployment 19 Compensation Law. 20 CHAPTER 72 21 AFFORDABILITY 22 Sec. 23 7201. Definitions. 24 7202. Cover All Pennsylvanians health insurance program. 25 7203. Fair share tax. 26 7204. Health insurance rate increases and standard plans. 27 7205. Health insurance coverage for full-time students. 28 7206. Health insurance coverage for certain children of insured 29 parents. 30 7207. Hospital community benefit requirements. 20070H0700B1011 - 9 -
1 7208. Uniform admission and fair billing and collection 2 practices. 3 7209. Transparency in price and quality for consumers. 4 § 7201. Definitions. 5 The following words and phrases, when used in this chapter, 6 shall have the meanings given to them in this section unless the 7 context clearly indicates otherwise: 8 "AdultBasic." The health investment insurance program 9 established under Chapter 13 of the Tobacco Settlement Act. 10 "Average annual wage." The total annual wages paid by an 11 employer divided by the number of the employer's employees. 12 "Basic benefit package." The minimum health benefit 13 insurance plan determined by the Insurance Commissioner under 14 section 7202 (relating to Cover All Pennsylvanians health 15 insurance program). 16 "CAP contracts." The contracts entered into under section 17 7202 (relating to Cover All Pennsylvanians health insurance 18 program). 19 "Charitable institution." A hospital that possesses an 20 exemption from tax under Article II of the Tax Reform Code 21 because it meets the criteria for being an institution of purely 22 public charity as set forth in section 5 of the Institutions of 23 Purely Public Charity Act. 24 "Chronic care model." A model based on the redesign of 25 health care delivery so that patients, who are supported by a 26 health care team, play an active role in their care and so that 27 there is an infrastructure to ensure compliance with established 28 practice guidelines. The model includes the following six 29 components: 30 (1) Providing patients with chronic conditions support 20070H0700B1011 - 10 -
1 and information so they can effectively manage their health. 2 (2) Ensuring that treatment decisions by health care 3 providers are based on evidence-based medicine. 4 (3) Ensuring that the patients get the care needed by 5 clarifying roles and tasks and ensuring that all who take 6 care of patients have centralized, up-to-date information 7 about the patient and that follow-up care is provided as a 8 standard procedure. 9 (4) Creating and maintaining a patient registry which is 10 the clinical information system that is the foundation for 11 successful integration of all the components of the model 12 because it permits tracking of individual patients and a 13 population of patients and helps guide the course of 14 treatment, anticipate problems and track problems. 15 (5) Engaging the entire organization in the chronic care 16 improvement effort. 17 (6) Forming alliances with state, local, business, 18 religious and other organizations to support or expand care 19 for those with chronic disease. 20 "Chronic disease." A disease that is long lasting or 21 recurrent, does not resolve spontaneously and is rarely 22 completely cured. 23 "Commissioner." The Insurance Commissioner of the 24 Commonwealth. 25 "Commonwealth average annual wage." The average annual wage 26 in this Commonwealth for a calendar year determined by the 27 Department of Labor and Industry under section 404(e)(2) of the 28 Unemployment Compensation Law. 29 "Community benefit." The community service requirement of an 30 institution of purely public charity under the Institutions of 20070H0700B1011 - 11 -
1 Purely Public Charity Act. 2 "Community Health Reinvestment Agreement." The Agreement on 3 Community Health Reinvestment entered into February 2, 2005, by 4 the Insurance Department and Capital BlueCross, Highmark Inc., 5 Hospital Service Association of Northeastern Pennsylvania and 6 Independence Blue Cross and published in the Pennsylvania 7 Bulletin at 35 Pa.B. 4155 (July 23, 2005). 8 "Contractor." A person with whom the Insurance Department 9 has entered into a contract for the purposes of section 7202 10 (relating to Cover All Pennsylvanians health insurance program). 11 "Department." The Insurance Department of the Commonwealth. 12 "Drug price registry." The Pennsylvania Drug Retail Price 13 Registry established by the council under section 7209 (relating 14 to transparency in price and quality for consumers). 15 "Eligible employee enrollee." An individual who is 19 years 16 of age or older, is an employee of an eligible small low-wage 17 employer participant and has enrolled in CAP. 18 "Eligible individual." As follows: 19 (1) An individual who meets all of the following 20 criteria: 21 (i) Is at least 19 years of age but no older than 64 22 years of age. 23 (ii) Has been a resident of this Commonwealth at 24 least 90 days prior to enrollment in CAP. 25 (iii) Is ineligible to receive continuous 26 eligibility coverage under Title XIX or XXI of the Social 27 Security Act (49 Stat. 620, 42 U.S.C. § 301 et seq.), 28 except for benefits authorized under a waiver granted by 29 the United States Department of Health and Human Services 30 to implement CAP. 20070H0700B1011 - 12 -
1 (iv) Meets one of the following: 2 (A) Is currently enrolled in the health 3 investment insurance program established under 4 Chapter 13 of the Tobacco Settlement Act or is wait- 5 listed for the program on the effective date of this 6 section. 7 (B) Has a household income that is no greater 8 than 200% of the Federal poverty level at the time of 9 application and has not been covered by any health 10 insurance plan or program for at least 90 days 11 immediately preceding the date of application, except 12 that the foregoing 90-day period shall not apply to 13 an individual who meets one of the following: 14 (I) Is eligible to receive benefits under 15 the Unemployment Compensation Law. 16 (II) Was covered under a health insurance 17 plan or program provided by an employer but at 18 the time of application is no longer covered 19 because of a change in the individual's 20 employment status and is ineligible to receive 21 benefits under the Unemployment Compensation Law. 22 (III) Lost coverage as a result of divorce 23 or separation from a covered individual, the 24 death of a covered individual or a change in 25 employment status of a covered individual. 26 (IV) Is transferring from another 27 government-subsidized health insurance program, 28 including as a result of failure to meet income 29 eligibility requirements. 30 (C) Has a household income that is greater than 20070H0700B1011 - 13 -
1 200% of the Federal poverty level and has not been 2 covered by any health insurance plan or program 3 during the 180 days immediately preceding the date of 4 application, except that the foregoing 180-day period 5 shall not apply to an individual who meets one of the 6 following: 7 (I) Is eligible to receive benefits under 8 the Unemployment Compensation Law. 9 (II) Was covered under a health insurance 10 plan or program provided by an employer but at 11 the time of application is no longer covered 12 because of a change in the individual's 13 employment status and is ineligible to receive 14 benefits under the Unemployment Compensation Law. 15 (III) Lost coverage as a result of divorce 16 or separation from a covered individual, the 17 death of a covered individual or a change in 18 employment status of a covered individual. 19 (IV) Is transferring from another 20 government-subsidized health insurance program, 21 including as a result of failure to meet income 22 eligibility requirements. 23 (2) If an individual who otherwise meets the definition 24 in paragraph (1) is attending an institution of higher 25 education in this Commonwealth, he shall be required to meet 26 the domiciliary requirements of 22 Pa. Code Ch. 507 (relating 27 to finance and administration) prior to enrollment in CAP. 28 "Eligible individual enrollee." An eligible individual who 29 is enrolled in CAP. The term does not include an eligible 30 employee enrollee. 20070H0700B1011 - 14 -
1 "Eligible small low-wage employer." An employer that meets 2 all of the following: 3 (1) Has at least two, but not more than 50 full-time- 4 equivalent employees. 5 (2) Has not offered health care insurance through any 6 plan or program during the 180 days immediately preceding the 7 date of application for participation in CAP. 8 (3) Pays an average annual wage that is less than the 9 Commonwealth average annual wage. 10 (4) Will enroll in CAP at least 75% of all of its 11 employees who work 20 hours or more per week. 12 "Eligible small low-wage employer participant." An eligible 13 small low-wage employer who is participating in CAP. 14 "Employee." Any individual from whose wages an employer is 15 required under the Internal Revenue Code of 1986 (Public Law 99- 16 514, 26 U.S.C. § 1 et seq.) to withhold Federal income tax. 17 "Enrollee." An eligible employee enrollee or an eligible 18 individual enrollee, as the context may require. 19 "Fair share tax." The tax imposed under section 7203 20 (relating to fair share tax). 21 "Health benefit plan." An individual or group health 22 insurance policy, subscriber contract, certificate or plan which 23 provides health or sickness and accident coverage which is 24 offered by an insurer. The term shall not include any of the 25 following: 26 (1) An accident only policy. 27 (2) A limited benefit policy. 28 (3) A credit only policy. 29 (4) A long-term or disability income policy. 30 (5) A specified disease policy. 20070H0700B1011 - 15 -
1 (6) A Medicare supplement policy. 2 (7) A Civilian Health and Medical Program of the 3 Uniformed Services (CHAMPUS) supplement policy. 4 (8) A fixed indemnity policy. 5 (9) A dental only policy. 6 (10) A vision only policy. 7 (11) A workers' compensation policy. 8 (12) An automobile medical payment policy pursuant to 75 9 Pa.C.S. (relating to vehicles). 10 "Hospital payment registry." The Pennsylvania Hospital 11 Payment Registry established by the council under section 7209 12 (relating to transparency in price and quality for consumers). 13 "Hospital plan corporation." A not-for-profit corporation 14 operating under the provisions of Chapter 61 (relating to 15 hospital plan corporations). 16 "Imaging center." An outpatient facility used to assist 17 health care providers in diagnosis through noninvasive imaging 18 of internal body organs. 19 "Individual health benefit plan." A health benefit plan 20 offered to an individual. 21 "Institution of higher education." A public or private two- 22 year or four-year college, university or post baccalaureate 23 program. 24 "Medical loss ratio." The ratio of incurred medical claim 25 costs to earned premiums. 26 "Offeror." A hospital plan corporation, professional health 27 service corporation or other insurer that submits a proposal in 28 response to the Insurance Department's solicitation of bids or 29 proposals issued under section 7202 (relating to Cover All 30 Pennsylvanians health insurance program). 20070H0700B1011 - 16 -
1 "Outpatient procedure payment registry." The Pennsylvania 2 Outpatient Procedure Payment Registry established by the council 3 under section 7209 (relating to transparency in price and 4 quality for consumers). 5 "Patient representative." An individual designated to act as 6 the patient's health care agent or health care representative 7 under 20 Pa.C.S. Ch. 54 (relating to health care) or who has 8 informed the hospital that he will be financially responsible 9 for the patient's medical care. 10 "Preexisting condition." A disease or physical condition for 11 which medical advice, diagnosis, care or treatment has been 12 recommended or received prior to the effective date of coverage. 13 "Prescription drug." A controlled substance, other drug or 14 device for medication dispensed by order of a health care 15 provider with prescriptive authority under the laws of this 16 Commonwealth. 17 "Professional health service plan corporation." A not-for- 18 profit corporation operating under the provisions of Chapter 63 19 (relating to professional health services plan corporations). 20 "Qualifying health care coverage." A health benefit plan or 21 other form of health care coverage that qualifies an employer 22 for the credit under section 7203 (relating to fair share tax). 23 "Small employer." In connection with a group health plan 24 with respect to a calendar year and a plan year, an employer who 25 employs an average of at least two but not more than 50 26 employees on business days during the preceding calendar year 27 and who employs at least two such employees on the first day of 28 the plan year. In the case of an employer which was not in 29 existence throughout the preceding calendar year, the 30 determination whether an employer is a small employer shall be 20070H0700B1011 - 17 -
1 based on the average number of employees that it is reasonably 2 expected that the employer will employ on business days in the 3 current calendar year. 4 "Small group health benefit plan." A health benefit plan 5 offered to a small employer. 6 "Standard plan." One of the health benefit packages 7 established by the Insurance Department in accordance with 8 section 7204(d) (relating to health insurance rate increases and 9 standard plans). 10 "Wages." All remuneration, including the cash value of 11 mediums of payment other than cash, paid by an employer to all 12 employees for services performed in this Commonwealth, including 13 amounts withheld from the employees' pay by the employer. The 14 term shall not include remuneration excluded from wages under 15 the provisions of the definition of "wages" under section 4(x) 16 of the Unemployment Compensation Law, other than the provisions 17 of the definition of "wages" under section 4(x)(1). This 18 paragraph shall not exclude remuneration included in wages under 19 the provisions of the definition of "wages" under section 20 4(x)(6) of the Unemployment Compensation Law. 21 § 7202. Cover All Pennsylvanians health insurance program. 22 (a) Establishment.--The Cover All Pennsylvanians health 23 insurance program is established within the department. 24 (b) Purpose.--The purpose of CAP is to assist certain small 25 business employers to cover their uninsured employees and to 26 provide access to affordable health insurance coverage for 27 uninsured adult Pennsylvanians. 28 (c) Administration.--The department shall administer CAP 29 under subsection (f)(1). 30 (d) CAP Fund.-- 20070H0700B1011 - 18 -
1 (1) There is established a restricted account in the 2 General Fund, to be known as the CAP Fund. 3 (2) The following are the sources of money for the CAP 4 Fund: 5 (i) Appropriations to the fund. 6 (ii) Money received from the Federal Government or 7 other sources. 8 (iii) Money required to be deposited pursuant to 9 other provisions of this part or any other law. 10 (iv) Money received under section 7203 (relating to 11 fair share tax). 12 (v) Upon implementation of CAP: 13 (A) Money appropriated for adultBasic under 14 section 306(b)(1)(vi) of the Tobacco Settlement Act. 15 (B) Money required to be dedicated to adultBasic 16 or any alternative program to benefit persons of low- 17 income under the Community Health Reinvestment 18 Agreement within the respective service areas for 19 each party to that agreement. Money under this clause 20 shall only be used to defray the cost of the 21 subsidies approved under subsection (e)(6). 22 (vi) Return on money in the fund. 23 (3) Money in the fund is hereby appropriated, upon 24 approval of the Governor, to the fund to be used exclusively 25 for the implementation and administration of CAP. 26 (e) Rates, premiums, discounts, and subsidies.--Rates, 27 premiums, discounts and subsidies shall be determined in 28 accordance with this subsection. 29 (1) Rates for CAP shall be approved annually by the 30 department and may vary by region and contractor. Rates shall 20070H0700B1011 - 19 -
1 be based on actuarially sound and adequate review. 2 (2) Premiums for CAP: 3 (i) shall be established annually by the 4 commissioner; and 5 (ii) may vary by region and contractor. 6 (3) Premiums to be paid by eligible small low-wage 7 employer participants and enrollees under this subsection 8 shall be increased by a factor no higher than the average of 9 the change in the medical care component of the Consumer 10 Price Index and the change in average wage for this 11 Commonwealth as determined by the Department of Labor and 12 Industry. 13 (4) Except as set forth in paragraph (7), the premium 14 for eligible employee enrollees shall be discounted from the 15 amount established under paragraph (2) in an amount 16 determined annually by the commissioner. The premium discount 17 shall not exceed 30%. The following apply: 18 (i) An eligible small low-wage employer participant: 19 (A) shall pay at least 65% of the discounted 20 premium for each employee enrolled; and 21 (B) may pay more than 65% of the discounted 22 premium for each employee. 23 (ii) An eligible employee enrollee not receiving a 24 subsidy under paragraph (6) shall pay the balance of the 25 discounted premium. 26 (iii) An eligible small low-wage employer 27 participant shall sponsor a program that allows health 28 insurance premiums paid by its employees to be made on a 29 pretax basis and shall inform its employees of the 30 availability of such program. The program shall include 20070H0700B1011 - 20 -
1 the following payments: 2 (A) that portion of the discounted premium less 3 applicable subsidies to be paid by its eligible 4 employee enrollees; 5 (B) CAP premiums paid for dependents of the 6 employees; and 7 (C) premiums paid by employees for CHIP. 8 (5) The premiums for eligible individual enrollees not 9 receiving subsidies under paragraph (6) shall be at the full 10 premium level. 11 (6) Subject to paragraph (7), an enrollee whose 12 household income is at or below 300% of the Federal poverty 13 level may apply to the department for a premium subsidy as 14 follows: 15 (i) The department shall review and approve 16 applications for subsidies under this paragraph. 17 (ii) Except to the extent that changes may be 18 necessary to meet Federal requirements or to encourage 19 eligible small low-wage employer participation or 20 enrollment by eligible individuals, subsidies for the 21 2007-2008 fiscal year are preliminarily estimated to 22 result in the following premium amount based on household 23 income: 24 (A) For an enrollee whose household income is 25 not greater than 100% of the Federal poverty level, a 26 monthly premium of $10. 27 (B) For an enrollee whose household income is 28 greater than 100% but not greater than 200% of the 29 Federal poverty level, a monthly premium of $40. 30 (C) For an enrollee whose household income is 20070H0700B1011 - 21 -
1 greater than 200% but not greater than 300% of the 2 Federal poverty level, a monthly premium of $60. 3 (iii) For fiscal years beginning after June 30, 4 2008, the commissioner may establish different subsidy 5 amounts and shall forward notice of the new premium 6 amounts to the Legislative Reference Bureau for 7 publication in the Pennsylvania Bulletin. 8 (iv) An enrollee who receives a subsidy under this 9 paragraph must do all of the following: 10 (A) Verify household income and household 11 composition with the department every six months. 12 (B) Notify the department in writing within 30 13 days of a change in household income or composition. 14 (7) The following apply: 15 (i) An enrollee who is paid the prevailing wage 16 while working on a public work as required by the 17 Prevailing Wage Act, and who is otherwise entitled to a 18 subsidy under paragraph (6), shall be subject to a 19 reduction of the subsidy on a dollar-for-dollar basis for 20 every dollar paid to the enrollee as part of the 21 prevailing wage requirement which is allocable for use in 22 the purchase of health care benefits. 23 (ii) A small low-wage employer participant that has 24 a contract to perform work on a public work subject to 25 the Prevailing Wage Act shall not be entitled to the 26 premium discount provided under paragraph (4) during the 27 term of the contract. 28 (8) The department shall freeze enrollment and establish 29 waiting lists to assure that the Commonwealth's costs to 30 implement and administer CAP do not exceed funds made 20070H0700B1011 - 22 -
1 available for CAP. 2 (9) Notwithstanding any other law to the contrary, 3 employer-based coverage may, in the commissioner's sole 4 discretion, be purchased in place of enrollment in CAP or may 5 be purchased in conjunction with any portion of CAP provided 6 outside the scope of CAP contracts by the Commonwealth paying 7 the employee's share of the premium to the employer if it is 8 more cost effective for the Commonwealth to purchase health 9 care coverage from an enrollee's employer-based program than 10 to pay the Commonwealth's share of a subsidized premium. This 11 paragraph shall apply to any employer-based program, whether 12 individual or family, such that if the Commonwealth's share 13 of the enrollee plus its share for any spouse under CAP or 14 children under CHIP is greater than the enrollee's premium 15 share for family coverage under the employer-based program, 16 the Commonwealth may choose to pay the latter alone or in 17 combination with providing any benefit the Commonwealth does 18 not provide through its CAP contracts. 19 (f) Duties of department.--The department has the following 20 duties: 21 (1) Administer CAP on a Statewide basis. 22 (2) Solicit bids or proposals and award contracts for 23 the basic benefit package through a competitive procurement 24 in accordance with 62 Pa.C.S. (relating to procurement) and 25 subsection (g). The department may award contracts on a 26 multiple award basis as described in 62 Pa.C.S. § 517 27 (relating to multiple awards). 28 (3) Impose reasonable cost-sharing arrangements and 29 encourage appropriate use by contractors of cost-effective 30 health care providers who will provide quality health care by 20070H0700B1011 - 23 -
1 establishing and adjusting copayments to be incorporated into 2 CAP by contractors. The department shall forward changes to 3 copayments to the Legislative Reference Bureau for 4 publication in the Pennsylvania Bulletin. Changes shall be 5 implemented by contractors as soon as practicable following 6 publication, but in no event more than 120 days following 7 publication. 8 (4) Ensure that the eligibility of eligible small low- 9 wage employer participants and enrollees receiving subsidies 10 are redetermined every six months. 11 (5) In consultation with other appropriate Commonwealth 12 agencies, conduct monitoring and oversight of contracts 13 entered into with contractors. 14 (6) In consultation with other appropriate Commonwealth 15 agencies, monitor, review and evaluate the adequacy, 16 accessibility and availability of services delivered to 17 enrollees. 18 (7) In consultation with other appropriate Commonwealth 19 agencies, establish and coordinate the development, 20 implementation and supervision of an outreach plan to ensure 21 that all those who may be eligible are aware of CAP. The plan 22 shall include provisions for: 23 (i) reaching special populations, including nonwhite 24 and non-English-speaking individuals and individuals with 25 disabilities; 26 (ii) reaching different geographic areas, including 27 rural and inner-city areas; and 28 (iii) assuring that special efforts are coordinated 29 within the overall outreach activities throughout this 30 Commonwealth. 20070H0700B1011 - 24 -
1 (8) At the request of an individual enrollee, facilitate 2 the payment on a pretax basis of premiums: 3 (i) for CAP and dependents covered under CAP; or 4 (ii) if applicable, for CHIP. 5 (9) To establish penalties for persons who enroll in 6 CAP, drop enrollment and subsequently re-enroll for the 7 purpose of avoiding the ongoing payment of premiums. 8 (g) Submitting proposals and awarding contracts.-- 9 (1) Each professional health service plan corporation 10 and hospital plan corporation and their subsidiaries and 11 affiliates doing business in this Commonwealth shall submit a 12 bid or proposal to the department to carry out the purposes 13 of this section in the geographic area serviced by the 14 corporation. All other insurers may submit a bid or proposal 15 to the department to carry out the purposes of this section. 16 (2) The department shall review and score the bids or 17 proposals on the basis of all of the requirements for CAP. 18 The department may include other criteria in the solicitation 19 and in the scoring and selection of the bids or proposals 20 that the department, in the exercise of its duties under 21 subsection (f), deems necessary. The department shall do all 22 of the following: 23 (i) Select, to the greatest extent practicable, 24 offerors that contract with health care providers to 25 provide health care services on a cost-effective basis. 26 The department shall select offerors that use appropriate 27 cost-management methods, including the chronic care 28 model, which will enable CAP to provide coverage to the 29 maximum number of enrollees. 30 (ii) Select, to the greatest extent practicable, 20070H0700B1011 - 25 -
1 only offerors that comply with all procedures relating to 2 coordination of benefits as required by the department 3 and the Department of Public Welfare. 4 (3) Contracts may be for an initial term of up to five 5 years, with options to extend for five one-year periods. 6 (h) Rates and charges.-- 7 (1) The medical loss ratio for a contract shall be no 8 less than 85%. 9 (2) No enrollee shall be charged a fee by any person as 10 a requirement for enrolling in CAP. 11 (i) Participation by eligible small low-wage employers.-- 12 (1) An eligible small low-wage employer seeking to 13 participate in the CAP program must do all of the following: 14 (i) Select and contact a contractor that services 15 its geographic area from a list of CAP contractors posted 16 on the department's CAP website or otherwise obtained 17 from the department upon request. 18 (ii) Adequately inform employees of the opportunity 19 to enroll in CAP and the process for enrollment required 20 by the contractor. 21 (iii) Comply with all other relevant provisions of 22 this part. 23 (2) Eligible employee enrollees must do all of the 24 following: 25 (i) Comply with the application and other enrollment 26 requirements of the contractor. 27 (ii) Pay the required premium. 28 (j) Termination of employment.--An eligible employee 29 enrollee who is terminated from employment shall be eligible to 30 continue participating in CAP if the eligible employee enrollee 20070H0700B1011 - 26 -
1 continues to meet the requirements of an eligible individual 2 enrollee and pays any increased premium required. 3 (k) Enrollment by eligible individuals.--An eligible 4 individual seeking to purchase insurance through CAP must do all 5 of the following: 6 (1) Select and contact a contractor that services the 7 eligible individual's geographic area from a list of CAP 8 contractors posted on the department's CAP website or 9 otherwise obtained from the department upon request. 10 (2) Comply with the application and other enrollment 11 requirements of the contractor. 12 (3) Pay the required premium directly to the contractor. 13 (4) Comply with all other relevant provisions of this 14 part. 15 (l) Basic benefit package.-- 16 (1) The basic benefit package to be offered under CAP 17 shall be of the scope and duration as the department 18 determines and shall provide for all of the following which 19 may be limited or unlimited as the department may determine: 20 preliminary and annual health assessments; emergency care; 21 inpatient and outpatient care; prescription drugs, medical 22 supplies and equipment; emergency dental care; maternity 23 care; skilled nursing; home health and hospice care; chronic 24 disease management; preventive and wellness care; and 25 inpatient and outpatient behavioral health services. 26 (2) The Commonwealth may elect to provide any benefit 27 independently and outside the scope of CAP contracts. 28 (3) Enrollment in CAP shall not be prohibited based upon 29 a preexisting condition, nor shall a CAP benefit plan exclude 30 a diagnosis or treatment for a condition based upon its 20070H0700B1011 - 27 -
1 preexistence. 2 (m) Data matching.-- 3 (1) All entities providing health insurance or health 4 care coverage within this Commonwealth shall, not less 5 frequently than once every month, provide the names, 6 identifying information and such additional information on 7 coverage and benefits as the department may specify for all 8 individuals for whom the entities provide insurance or 9 coverage. 10 (2) The department shall use the information obtained in 11 paragraph (1) to determine whether any portion of an 12 enrollee's premium is being paid from any other source and to 13 determine whether another entity has primary liability for 14 any health care claims paid under any program administered by 15 the department. If a determination is made that an enrollee's 16 premium is being paid from another source, the department 17 shall not make any additional payments to the insurer for 18 such enrollee. 19 (3) If any payment has been made to an insurer by the 20 department for an enrollee for whom any portion of the 21 premium paid by the department is being paid from another 22 source, the insurer shall reimburse the department the amount 23 of any such excess payment or payments. 24 (4) The department may seek reimbursement from an entity 25 that provides health insurance or health care coverage that 26 is primary to the coverage provided under any program 27 administered by the department. 28 (5) To the maximum extent permitted by law, and 29 notwithstanding any policy or plan provision to the contrary, 30 a claim by the department for reimbursement under paragraph 20070H0700B1011 - 28 -
1 (3) or (4) shall be deemed timely filed if it is filed with 2 the insurer or entity within three years following the date 3 of payment. 4 (6) The department is authorized to enter into 5 agreements with entities providing health insurance and 6 health care coverage for the purpose of carrying out the 7 provisions of this subsection. The agreements shall provide 8 for the electronic exchange of data between the parties at a 9 mutually agreed upon frequency, but no less than once every 10 two months, and may also allow for payment of a fee by the 11 department to the entity providing health insurance or health 12 care coverage. 13 (7) The department shall determine that no other health 14 care coverage is available to the enrollee through an alimony 15 agreement or an employment-related or other group basis. If 16 such health care coverage is available, the department shall 17 re-evaluate the enrollee's eligibility under this section. 18 (8) The commissioner may impose a penalty of up to 19 $1,000 per violation upon any entity that fails to comply 20 with the obligations imposed by this section. All funds 21 collected under this paragraph shall be deposited into the 22 CAP Fund. 23 (9) The department shall coordinate with the Department 24 of Public Welfare in the implementation of this section and 25 may designate the Department of Public Welfare to perform 26 such duties as are appropriate under this section. 27 (n) Information to be provided by insurers.-- 28 (1) Each hospital plan corporation and professional 29 health services corporation shall provide an individual in 30 this Commonwealth who has applied for insurance through its 20070H0700B1011 - 29 -
1 Special Care product with written information in plain 2 language about the existence of CAP, the benefits it covers 3 and the cost to the individual to purchase so that the 4 individual applying for insurance through Special Care can 5 compare the costs and benefits of it and CAP. 6 (2) Each hospital plan corporation and a professional 7 health services corporation shall develop written materials 8 which comply with paragraph (1) and submit them to the 9 department for review and approval. 10 (3) Only materials approved by the department under 11 paragraph (2) may be provided to applicants for a Special 12 Care product offered in this Commonwealth. 13 (o) Regulations.--The department may promulgate regulations 14 for the implementation and administration of this section. 15 (p) Federal waivers.--The Department of Public Welfare, in 16 cooperation with the department, shall apply for all applicable 17 waivers from the Federal Government and shall seek approval to 18 amend the State plan as necessary to carry out the provisions of 19 this part. If the Department of Public Welfare receives approval 20 of a waiver or approval of a State plan amendment as required by 21 this subsection, it shall notify the department and shall 22 transmit notice of the waiver or State plan amendment approvals 23 to the Legislative Reference Bureau for publication as a notice 24 in the Pennsylvania Bulletin. The department is authorized to 25 change the benefits and the premium and copayment amounts 26 payable under subsection (e) in order for CAP to meet Federal 27 requirements. 28 (q) Federal funds.--Notwithstanding any other provision of 29 law, the Department of Public Welfare, in cooperation with the 30 department, shall take any action necessary to do all of the 20070H0700B1011 - 30 -
1 following: 2 (1) Ensure the receipt of Federal financial 3 participation under Title XIX of the Social Security Act (49 4 Stat. 620, 42 U.S.C. § 1396 et seq.) for coverage and for 5 services provided under this part. 6 (2) Qualify for available Federal financial 7 participation under Title XIX of the Social Security Act. 8 (r) Entitlements and claims.--Nothing in this section shall 9 constitute an entitlement derived from the Commonwealth or a 10 claim on any funds of the Commonwealth. 11 (s) Option to limit or not to proceed.--Notwithstanding any 12 other provision of this section, in the event that Federal 13 waiver requirements limit CAP such that only a portion of those 14 individuals otherwise eligible may be covered, the Commonwealth 15 may limit CAP to that portion or, at its option, determine not 16 to proceed with the CAP program. 17 § 7203. Fair share tax. 18 (a) Imposition of tax.--In order to help fund the 19 Commonwealth's cost of implementing and administering CAP, each 20 employer shall be subject to a fair share tax as follows: 21 (1) For fiscal years 2007-2008 through 2009-2010, 3% of 22 the wages paid by the employer. 23 (2) For fiscal years commencing after June 30, 2010, 24 3.5% of the wages paid by the employer. 25 (b) Credits against tax.-- 26 (1) For fiscal years 2007-2008 through 2011-2012, the 27 amount of the tax to which an employer is otherwise subject 28 may be reduced by the amount of a quarterly start-up credit 29 as follows: 30 (i) Fiscal year 2007-2008 $15,000.00 20070H0700B1011 - 31 -
1 (ii) Fiscal year 2008-2009 $12,000.00 2 (iii) Fiscal year 2009-2010 $ 9,750.00 3 (iv) Fiscal year 2010-2011 $ 7,700.00 4 (v) Fiscal year 2011-2012 $ 3,981.25 5 (vi) Fiscal year 2012-2013 and thereafter $ 0.00 6 (2) The following apply: 7 (i) An employer that offers qualifying health care 8 coverage to each of its employees who works 30 hours per 9 week or more following no more than 90 days of continued 10 employment shall be entitled to a credit against the fair 11 share tax in an amount equal to 3% of the employer's 12 wages for fiscal years 2007-2008 through 2009-2010 and 13 3.5% of the employer's wages for fiscal years commencing 14 after June 30, 2010. 15 (ii) The Department of Labor and Industry, in 16 consultation with the department, shall determine whether 17 the employer's offer shall be considered as qualifying 18 health care coverage based on the premium and out-of- 19 pocket costs to the employee and the level of employee 20 participation. In the case of multiple plans offered by 21 the same employer, the determination shall be based on 22 the cost to the lowest wage employees of the employer and 23 the relative participation of those employees. 24 (3) The total amount of the credits under this 25 subsection shall not exceed the amount of fair share tax 26 imposed under subsection (a) for the year the credit is 27 granted. 28 (4) The credits under this subsection may not be carried 29 back or carried forward to other years, refunded, assigned or 30 sold. 20070H0700B1011 - 32 -
1 (c) Reports by employers.-- 2 (1) If an employer's liability for fair share tax for a 3 calendar quarter, determined without regard to subsection 4 (b)(2), exceeds the amount of credit available to the 5 employer pursuant to subsection (b)(1) for that calendar 6 quarter, the employer shall file a report with the Department 7 of Labor and Industry for that calendar quarter. The report 8 shall be due by the last day of the month immediately 9 following the calendar quarter. The report shall be made in a 10 manner prescribed by the Department of Labor and Industry and 11 shall contain all information required by the Department of 12 Labor and Industry, including the following: 13 (i) The amount of wages paid by the employer during 14 the calendar quarter. 15 (ii) A certification that the employer did or did 16 not satisfy the requirements for the credit under 17 subsection (b)(2) throughout the calendar quarter. 18 (2) Each employer shall file any other reports required 19 by the Department of Labor and Industry in the administration 20 of this section, which reports shall be made in the manner 21 prescribed by the Department of Labor and Industry and 22 contain all information required by the Department of Labor 23 and Industry. 24 (d) Payment of tax.--Concurrently with each report required 25 under subsection (c), the employer shall pay to the Department 26 of Labor and Industry the amount of fair share tax imposed under 27 this section for the period covered by the report. 28 (e) Penalties.-- 29 (1) An employer that does not make and file the periodic 30 reports required by subsection (c) in the manner prescribed 20070H0700B1011 - 33 -
1 by the Department of Labor and Industry on or before the date 2 such report is required to be filed shall pay a penalty. 3 (2) The amount of the penalty shall be 10% of the amount 4 of fair share tax due for the period and shall be not less 5 than $50 or more than $5,000. 6 (3) All penalties collected under this subsection shall 7 be deposited into the CAP Fund. 8 (f) Interest.-- 9 (1) Fair share taxes or penalties unpaid on the date on 10 which they are due and payable shall bear interest at the 11 greater of: 12 (i) one-twelfth of the annual rate determined by the 13 Secretary of Revenue under section 806 of the act of 14 April 9, 1929 (P.L.343, No.176), known as The Fiscal 15 Code, per month or fraction of a month; or 16 (ii) the rate of 0.75% per month or fraction of a 17 month from the date they become due until paid. 18 (2) All interest collected under this subsection shall 19 be deposited into the CAP Fund. 20 (g) Refunds.-- 21 (1) If an employer applies for refund or credit of any 22 amount paid as fair share tax, interest or penalties and the 23 Department of Labor and Industry determines that such amount, 24 or any portion thereof, was erroneously collected, the 25 Department of Labor and Industry may at its discretion either 26 allow a credit, without interest, against subsequent fair 27 share tax payments or shall refund from the CAP Fund, without 28 interest, the amount erroneously paid. 29 (2) No refund or credit shall be allowed with respect to 30 a payment as fair share tax, interest or penalties, unless 20070H0700B1011 - 34 -
1 the employer files an application on or before the later of: 2 (i) one year from the date on which such payment was 3 made; or 4 (ii) four years from the reporting due date of the 5 reporting period with respect to which such payment was 6 made. 7 (3) For a like cause and within the same period, a 8 refund may be made or a credit allowed on the initiative of 9 the Department of Labor and Industry. 10 (h) Collections and enforcement.-- 11 (1) Records maintained by employers pursuant to section 12 206(a) of the Unemployment Compensation Law and corresponding 13 regulations shall be open to inspection by the Department of 14 Labor and Industry for purposes of this section to the same 15 extent that they are open to inspection for purposes of the 16 Unemployment Compensation Law. 17 (2) The provisions of sections 304(a) through (d), 18 305(c), 308.1, 309 and 309.2 of the Unemployment Compensation 19 Law are incorporated into this section and shall be 20 applicable to the fair share tax, interest and penalties. 21 References in such provisions of the Unemployment 22 Compensation Law to contributions shall be deemed to be 23 references to the fair share tax for purposes of this 24 section. 25 (i) False statements and representations and other 26 offenses.-- 27 (1) An employer, whether or not liable for the payment 28 of fair share taxes under this subsection, or an officer or 29 agent of an employer or any other person who does any of the 30 following commits a summary offense and shall, upon 20070H0700B1011 - 35 -
1 conviction, be sentenced to pay a fine of not less than $100 2 nor more than $1,500 or to imprisonment for not longer than 3 30 days, or both: 4 (i) makes a false statement or representation 5 knowing it to be false, or knowingly fails to disclose a 6 material fact to avoid becoming or remaining subject 7 hereto or to avoid or reduce any fair share tax or other 8 payment required from an employer under this section; 9 (ii) willfully fails or refuses to make fair share 10 tax or other payment required under this section; 11 (iii) willfully fails or refuses to produce or 12 permit the inspection or copying of records as required 13 under this section; or 14 (iv) willfully fails or refuses to furnish any 15 report required by subsection (c) or the rules or 16 regulations of the Department of Labor and Industry. 17 (2) The number of offenses under paragraph (1) shall be 18 determined as follows: 19 (i) Each false statement or representation or 20 failure to disclose a material fact shall constitute a 21 separate offense under paragraph (1)(i). 22 (ii) Each day of failure or refusal shall constitute 23 a separate offense under paragraph (1)(ii), (iii) and 24 (iv). 25 (iii) Each report required by subsection (c) or the 26 rules or regulations of the Department of Labor and 27 Industry shall be the basis of a separate offense under 28 paragraph (1)(iv). 29 (3) In addition to any other sanction, an employer, 30 officer, agent or other person convicted under this section 20070H0700B1011 - 36 -
1 for willful failure or refusal to make a payment shall be 2 ordered to make restitution of the unpaid amounts, including 3 interest and penalty from the date the payment was due 4 through the date of payment. 5 (4) For purposes of this subsection, the term 6 "willfully" shall have the meaning given to it under 18 7 Pa.C.S. § 302 (relating to general requirements of 8 culpability). 9 (j) Powers and duties of Department of Labor and Industry.-- 10 (1) The Department of Labor and Industry shall 11 administer and enforce this section and adopt, amend and 12 rescind such rules, regulations and guidance, require such 13 reports from employers, employees and any other person deemed 14 by the Department of Labor and Industry to be affected by 15 this section, make such investigations and take such other 16 action as it deems necessary or suitable. Such rules, 17 regulations and guidance shall not be inconsistent with the 18 provisions of this section. 19 (2) In the discharge of the duties imposed by this 20 section, the Secretary of Labor and Industry and any agent 21 duly authorized in writing by him shall have the power to 22 administer oaths and affirmations, take depositions and 23 certify to official acts. 24 (3) The Department of Labor and Industry may issue 25 subpoenas to compel the attendance of witnesses and the 26 production of books, papers, correspondence, memoranda and 27 other records deemed necessary in the administration of this 28 section. 29 § 7204. Health insurance rate increases and standard plans. 30 (a) Applicability.--This section applies to all insurers 20070H0700B1011 - 37 -
1 that offer small group health benefit plans and individual 2 health benefit plans that are issued, made effective, delivered 3 or renewed in this Commonwealth after the effective date of this 4 section. 5 (b) Premium rates.-- 6 (1) An insurer shall establish a community rate for 7 plans subject to this section and shall file the community 8 rate with the department as required by law. An insurer may 9 adjust its community rate for the following: 10 (i) age; 11 (ii) geographic region as approved by the 12 department; and 13 (iii) family composition. 14 (2) An insurer shall apply all risk adjustment factors 15 under paragraph (1) consistently with respect to all plans 16 subject to this section. 17 (3) An insurer shall not charge a rate that is more than 18 33% above or below the community rate, as adjusted as 19 permitted under paragraph (1). 20 (4) An insurer shall base its rating methods and 21 practices on commonly accepted actuarial assumptions and 22 sound actuarial principles. Rates shall not be excessive, 23 inadequate or unfairly discriminatory. 24 (5) For purposes of this subsection, an insurer's 25 "community rate" for a plan shall refer to a rating 26 methodology that is based on the experience of all risks 27 covered by the plan without regard to health status, 28 occupation or any other factor. 29 (c) Additional rate review.-- 30 (1) In conjunction with and in addition to the standards 20070H0700B1011 - 38 -
1 set forth in the Accident and Health Filing Reform Act and 2 all other applicable statutory and regulatory requirements, 3 the department may disapprove a rate filing based on any of 4 the following: 5 (i) The rate is not actuarially sound. 6 (ii) The increase is requested because the insurer 7 has not operated efficiently or has factored in 8 experience that conflicts with recognized best practices 9 in the health care industry. 10 (iii) The increase is requested because the insurer 11 has incurred costs of additional care due to avoidable 12 hospital-acquired infections and avoidable 13 hospitalizations due to ineffective chronic care 14 management, after data for the incidents has become 15 available to and can be analyzed by the insurer and the 16 department. 17 (iv) For small group health plans, the medical loss 18 ratio is less than 85%. 19 (2) In the event a small group health benefit plan has a 20 medical loss ratio of less than 85%, the department may, in 21 addition to any other remedies available under law, require 22 the insurer to refund the difference to policyholders on a 23 pro rata basis as soon as practicable following receipt of 24 notice from the department of the requirement but in no event 25 later than 120 days following receipt of the notice. The 26 department shall establish procedures for the circumstances 27 under which such refunds will be required. 28 (3) The filing and review procedures set forth in the 29 Accident and Health Filing Reform Act shall apply to any 30 filing conducted pursuant to this section. 20070H0700B1011 - 39 -
1 (d) Standard plans required.-- 2 (1) An insurer shall not offer a plan that does not meet 3 the minimum benefits specified in one of the standard plans 4 developed by the department in accordance with the following 5 criteria: 6 (i) The standard plans shall at least include all of 7 the benefits of the basic benefit package, except that 8 they shall not include coverage for behavioral health 9 services. 10 (ii) The standard plans may not contain any 11 preexisting condition exclusions. 12 (2) Standard plans may include options for deductible 13 and cost-sharing provisions if the department determines that 14 the provisions: 15 (i) Dissuade consumers from seeking unnecessary 16 services. 17 (ii) Balance the effect of cost sharing in reducing 18 premiums and in effecting utilization of appropriate 19 services. 20 (iii) Limit the total cost sharing that may be 21 incurred by an individual in a year. 22 (3) Each individual in this Commonwealth who applies to 23 an insurer for enrollment in one of the standard plans 24 offered by an insurer shall be enrolled. 25 (4) The following apply: 26 (i) The department shall forward the elements of the 27 standard plans to the Legislative Reference Bureau for 28 publication as a notice in the Pennsylvania Bulletin. 29 (ii) An insurer subject to the provisions of this 30 section shall be required to begin offering its standard 20070H0700B1011 - 40 -
1 plans as soon as practicable following the publication 2 but in no event later than 120 days following the 3 publication. 4 (e) Additional benefits.-- 5 (1) An insurer shall offer as an additional benefit to 6 every standard plan a behavioral health services benefit that 7 complies with the provisions of sections 601-A, 602-A, 603-A, 8 604-A, 605-A, 606-A, 607-A and 608-A of the act of May 17, 9 1921 (P.L.682, No.284), known as The Insurance Company Law of 10 1921. 11 (2) An insurer may offer benefits in addition to those 12 in any of its standard plans. 13 (3) Each additional benefit shall: 14 (i) Be offered and priced separately from benefits 15 specified in the standard plan with which the benefits 16 are being offered. 17 (ii) Not have the effect of duplicating any of the 18 benefits in the standard plan with which the benefits are 19 being offered. 20 (iii) Be clearly specified as additions to the 21 standard plan with which the benefits are being offered. 22 (4) The department may prohibit an insurer from offering 23 an additional benefit under this section if the department 24 finds that the additional benefit will be sold in conjunction 25 with one of the insurer's standard plans in a manner designed 26 to promote risk selection or underwriting practices otherwise 27 prohibited by this section or other State law. 28 (f) Regulations.--The department may promulgate regulations 29 necessary for the implementation and administration of this 30 section. 20070H0700B1011 - 41 -
1 § 7205. Health insurance coverage for full-time students. 2 (a) Minimum health benefit package.--Within 90 days 3 following the effective date of this section, the commissioner 4 shall establish a minimum health benefit package for full-time 5 students enrolled in public or private baccalaureate and post 6 baccalaureate programs in Pennsylvania and transmit a 7 description of the package to the Legislative Reference Bureau 8 for publication in the Pennsylvania Bulletin. As soon as 9 practicable after the date of publication of the package, but in 10 no event later than 120 days following such publication, all 11 insurers shall offer the package as individual coverage 12 available to students and as group coverage through the 13 institution. The commissioner may make revisions to the minimum 14 health benefit package periodically, but no more than one time 15 per 12-month period. Each revision shall be implemented by 16 insurers as soon as practicable following publication of the 17 revision in the Pennsylvania Bulletin but in no event later than 18 120 days following such publication. 19 (b) Mandatory coverage.-- 20 (1) Every full-time student enrolled in a public or 21 private baccalaureate or post baccalaureate program in 22 Pennsylvania shall maintain health insurance coverage which 23 provides the minimum benefit package established in this 24 section. The coverage shall be maintained throughout the 25 period of the student's enrollment. 26 (2) Every student required to have mandatory coverage 27 under this section shall present evidence of such coverage to 28 the institution in which the student is enrolled at least 29 annually, in a manner prescribed by the institution. 30 (3) Every public or private college or university or 20070H0700B1011 - 42 -
1 post baccalaureate program in Pennsylvania shall make 2 available health insurance coverage, including CAP for those 3 who are eligible under section 7202 (relating to Cover All 4 Pennsylvanians health insurance program), on a group or 5 individual basis for purchase by students who are required to 6 maintain the coverage pursuant to this section. 7 (4) Notwithstanding the provisions of paragraphs (1), 8 (2) and (3), the requirements of this section may be 9 satisfied if the baccalaureate or post baccalaureate program 10 provides on-campus student health care coverage equivalent to 11 the minimum benefit package through its own clinics and 12 health care facilities and receives approval from the 13 department that such equivalent coverage meets the minimum 14 benefit package. Such coverage shall provide that the student 15 is covered for hospital admissions and emergency services at 16 facilities throughout this Commonwealth. 17 (c) Annual certification.--Every public or private 18 baccalaureate or post baccalaureate program in this Commonwealth 19 shall certify to the department at least annually that the 20 requirements of this section have been met for all periods of 21 the preceding year. 22 (d) Penalty for failure to comply.--The commissioner may 23 impose a fine of up to $500 per day for each day that a public 24 or private baccalaureate or post baccalaureate program fails to 25 meet any of its obligations in this section. The fine shall be 26 due within 30 days following receipt by the institution of 27 notice of the violation. Funds collected under this subsection 28 shall be deposited into the CAP Fund. 29 § 7206. Health insurance coverage for certain children of 30 insured parents. 20070H0700B1011 - 43 -
1 (a) Option to cover certain children.--An insurer that 2 issues, delivers, executes or renews health care insurance in 3 this Commonwealth, under which coverage of a child would 4 otherwise terminate at a specified age, shall, at the option of 5 the child's parent or guardian, provide coverage to a child of 6 the insured beyond that specified age, up through the age of 29, 7 provided that the child meets all of the following requirements: 8 (1) Is not married. 9 (2) Has no dependents. 10 (3) Is a resident of this Commonwealth or is enrolled as 11 a full-time student at an institution of higher education in 12 this Commonwealth. 13 (4) Is not covered by another health insurance policy. 14 (b) Exercise of option.--An insured may exercise the option 15 provided by subsection (a) at any time during the term of the 16 policy by notice to the insurer. 17 (c) Employer contribution.--Employers shall not be required 18 to contribute to any increased premium charged by the insurer 19 for the exercise of the option provided by subsection (a), but 20 such contributions may be agreed to by the employer. 21 § 7207. Hospital community benefit requirements. 22 (a) Community needs assessment.-- 23 (1) By January 1, 2008, each hospital operating as a 24 charitable institution shall complete a community needs 25 assessment in accordance with guidelines established by the 26 Department of Health in order to identify, for its primary 27 service area as determined by the hospital, unmet needs to 28 improve or maintain health status in the community, 29 particularly with respect to those vulnerable populations 30 exposed to medical or financial risk by virtue of being 20070H0700B1011 - 44 -
1 uninsured, underinsured or eligible for public health 2 programs. The hospital may conduct the assessment: 3 (i) alone; 4 (ii) in conjunction with other health care 5 providers; or 6 (iii) through other organizational arrangements. 7 (2) The hospital shall conduct its community needs 8 assessment by including a process for consulting with 9 community groups and local government officials in 10 identifying and prioritizing community needs that the 11 hospital can address directly, in collaboration with others 12 or through other organizational arrangements. The community 13 needs assessment shall be updated at least once every three 14 years. 15 (b) Community benefits report.-- 16 (1) On or before April 1, 2008, and every calendar year 17 thereafter, each hospital subject to the provisions of 18 subsection (a) shall prepare a community benefits report 19 containing the following information with respect to the 20 immediately preceding calendar year: 21 (i) The specific criterion under section 5(d)(1) of 22 the Institutions of Purely Public Charity Act that the 23 hospital asserts qualifies it as providing benefits to 24 the community and the calculation of the dollar amount 25 that the criterion requires the hospital to meet. 26 (ii) A description and dollar value of the 27 uncompensated goods or services that the hospital has 28 provided to address the specific community needs 29 identified in the community needs assessment. 30 (2) The amount attributed to uncompensated goods or 20070H0700B1011 - 45 -
1 services as set forth in the Institutions of Purely Public 2 Charity Act for the purposes of this report shall be further 3 limited as follows: 4 (i) The full cost of uncompensated health care 5 services shall be calculated as the Medicare 6 reimbursement the hospital would otherwise receive for 7 those services. 8 (ii) The reasonable value of volunteer assistance 9 donated by individuals who are employed or otherwise 10 affiliated with the provision of health care services by 11 the hospital shall only include community services or 12 programs related to the mission of the hospital, but 13 which are not provided in or by the hospital. 14 (iii) The term uncompensated goods or services shall 15 not include the following: 16 (A) Bad debt. 17 (B) Health screening, health education classes 18 or other programs either designed to increase market 19 share or for which a fee is charged or a referral to 20 the hospital is made. 21 (C) Programs provided as an employee benefit. 22 (D) Use of facility space to hold meetings for 23 community groups. 24 (E) Expenses for in-service training, continuing 25 education, orientation, mentoring or joint 26 appointments. 27 (c) Filing and publication.--Each hospital subject to the 28 provisions of subsection (a) shall file its report on or before 29 April 15 of each calendar year with the Department of Health and 30 shall publish its community needs assessment and annual report 20070H0700B1011 - 46 -
1 on its hospital website and make them available to any member of 2 the community upon request. 3 (d) Audit.--The Department of Health shall have authority to 4 audit a hospital's community benefit report at any time and 5 disallow any amount claimed for uncompensated goods and services 6 that does not comply with this section. A hospital shall retain 7 records documenting the calculations contained in its community 8 benefit report for a period of three years following issuance of 9 the report. 10 (e) Fines.-- 11 (1) A hospital that reports an amount of uncompensated 12 goods and services under subsection (b)(1)(ii) that is lower 13 than the amount it is required to provide under subsection 14 (b)(1)(i) shall pay the difference to the Department of 15 Health within 60 days following receipt of written notice 16 from the Department of Health that the same is due. 17 (2) A false or misleading statement contained in a 18 hospital's community benefit report or a failure to comply 19 with the provisions of this section shall subject the 20 hospital to a fine of $1,000 per day to be imposed and 21 collected by the Department of Health. 22 (3) The fines imposed by paragraphs (1) and (2) shall be 23 in addition to any other fine or penalty that may be imposed 24 upon a hospital under the Institutions of Purely Public 25 Charity Act. 26 (4) All fines collected under this subsection, as well 27 as any fines or penalties collected from hospitals under the 28 Institutions of Purely Public Charity Act, shall be deposited 29 into the CAP Fund. 30 (f) Uncompensated care program.--Notwithstanding the 20070H0700B1011 - 47 -
1 provisions of Chapter 11 of the Tobacco Settlement Act to the 2 contrary, a hospital subject to the provisions of this section 3 shall only be entitled to apply for payment from the Hospital 4 Uncompensated Care Program established under Chapter 11 equal to 5 the amount by which the amount of uncompensated goods and 6 services reported under the provisions of subsection (b)(1)(ii) 7 exceeds the amount it is required to provide under subsection 8 (b)(1)(i). 9 § 7208. Uniform admission and fair billing and collection 10 practices. 11 (a) Admission criteria.--A hospital shall be subject to the 12 following with respect to its admission criteria: 13 (1) A hospital may not deny admission, and a health care 14 provider may not refuse to provide services, for reasons not 15 based on sound medical practice to individuals seeking 16 medical services requiring admission to the hospital. 17 Admission policies and protocols shall be in plain language 18 and available upon request. Admissions shall be prioritized 19 on the basis of urgency of the medical condition and the 20 immediate and long-term risk to the individual of going 21 without medical care. 22 (2) No individual shall be denied necessary medical 23 services from a hospital based on race, color, religion, 24 gender, disability, sexual orientation, national origin or 25 source of payment. 26 (3) A hospital shall facilitate the completion of an 27 application for enrollment in medical assistance or CAP and, 28 if applicable, CHIP, by any uninsured individual who presents 29 at the hospital for admission or emergency services. The 30 hospital shall deliver the completed application or 20070H0700B1011 - 48 -
1 applications by facsimile or other expeditious means to the 2 appropriate county assistance office or, for CAP or CHIP, a 3 contractor providing coverage for the individual's county of 4 residence. 5 (4) When a hospital cannot provide the specific medical 6 services required by a patient, the hospital shall make 7 appropriate arrangements for transferring the patient to 8 another hospital or other source of health care that can 9 provide the required medical services. 10 (5) A hospital is not required to provide services or 11 make a referral that is contrary to its stated ethical policy 12 in accordance with the act of December 9, 2002 (P.L.1701, 13 No.214), known as the Religious Freedom Protection Act, 14 provided, however, that such hospital shall provide express 15 notice to its patients of its policies regarding those health 16 care services. 17 (b) Billing policies.--A hospital shall be subject to the 18 following with respect to its billing policies: 19 (1) A hospital shall provide to the patient or the 20 patient representative upon request an itemized bill and an 21 explanation of all charges in plain language. 22 (2) Prior to admission or as soon as practicable 23 thereafter, the hospital shall inform the patient or the 24 patient representative if the hospital, its staff, 25 contractors or subcontractors will not accept the patient's 26 third-party payment. 27 (3) A hospital shall provide the patient, or the patient 28 representative, with information and counseling on the 29 availability of known financial resources for his health care 30 and assist the patient or patient representative in enrolling 20070H0700B1011 - 49 -
1 in public programs, including CAP and CHIP, for which the 2 patient may be eligible and in securing such other financial 3 resources as may be available. 4 (4) A deposit shall not be required by a hospital where 5 there is a reasonable expectation that the individual will 6 qualify for CAP, CHIP, Medicare, medical assistance, other 7 government programs or a private insurance program that will 8 cover the services to be provided at the hospital. 9 (5) A hospital shall establish a process for receiving 10 and reviewing billing complaints that includes a requirement 11 that hospital staff address them in a specified, timely 12 manner and shall notify the patient or patient representative 13 of the complaint process upon admission to and at discharge 14 from the hospital. 15 (6) In no event shall uninsured patients or self-pay 16 patients be compelled to pay more than the Medicare 17 reimbursement rate for the services provided. 18 (7) A hospital shall not, directly or indirectly, cause, 19 facilitate, enable or otherwise require any patient or 20 patient representative to enter into any third-party credit 21 arrangement for the purpose of paying or securing payment for 22 medical care. 23 (c) Collection policies.--A hospital shall be subject to the 24 following with respect to its collection policies: 25 (1) It shall work with each patient to establish a 26 reasonable payment plan consistent with this section and 27 applicable Federal and State laws and regulations. 28 (2) It shall take legal action only when there is 29 evidence that the patient or responsible party has income or 30 assets or both to meet the financial obligation. 20070H0700B1011 - 50 -
1 (3) It shall not force the sale or foreclosure of a 2 patient's primary residence to pay an outstanding medical 3 bill. 4 (4) It shall require that any collection agency engaged 5 by the hospital follow the requirements of this subsection 6 and any other obligations under Federal and State laws and 7 regulations. 8 § 7209. Transparency in price and quality for consumers. 9 (a) The Pennsylvania Drug Retail Price Registry.-- 10 (1) The council shall establish and maintain a registry 11 to be known as the Pennsylvania Drug Retail Price Registry 12 for the purpose of making retail price information for the 13 150-most-frequently prescribed prescription drugs, together 14 with their generic equivalents where applicable, readily 15 available to consumers in this Commonwealth. 16 (i) The drug price registry shall include the 17 information submitted to the council under this 18 subsection and the name and address of each pharmacy 19 providing the information and shall be organized by zip 20 code. 21 (ii) The drug price registry shall be updated 22 monthly by the council and shall be posted on the 23 council's Internet website in a format that is conducive 24 to review and comparison by consumers of prescription 25 drug retail prices charged by pharmacies in each zip code 26 within this Commonwealth. It shall include a toll-free 27 telephone number maintained by the council that consumers 28 may call to obtain reprints of the registry. 29 (iii) The website shall be designed so that the 30 consumer may download and print the displayed information 20070H0700B1011 - 51 -
1 and shall include at least the following: 2 (A) Internet web links to other government 3 resources that provide information relating to the 4 regulation of prescription drugs and Federal and 5 State health care coverage and pharmaceutical 6 assistance programs. 7 (B) An advisory statement alerting consumers of 8 the need to tell their health care practitioner and 9 pharmacist about all the medications they may be 10 taking and to ask them how to avoid harmful 11 interactions between those drugs, if any. 12 (C) Clearly understandable language that is 13 designed to assist consumers in understanding the 14 content of and how to access the information made 15 available on the website pursuant to this subsection. 16 (2) Within 30 days following the effective date of this 17 section, the director of PACE shall determine and submit to 18 the Pennsylvania Bulletin for publication a list of the 150- 19 most-frequently prescribed prescription drugs in this 20 Commonwealth and their generic equivalents and the unit 21 amount to be used for price reporting purposes. The list 22 shall be updated by the director of PACE annually thereafter, 23 and each such update shall be submitted to the Legislative 24 Reference Bureau for publication as a notice in the 25 Pennsylvania Bulletin. 26 (3) Every pharmacy selling pharmaceuticals at retail in 27 this Commonwealth shall submit to the council for inclusion 28 in the drug price registry, in a form and manner prescribed 29 by the council, on the 10th day of each calendar month 30 beginning with the first calendar month following publication 20070H0700B1011 - 52 -
1 of the list described in paragraph (2), its prior monthly 2 retail prices for each drug on the list and its generic 3 equivalent, together with the amount of the dispensing fee. 4 In addition, each such pharmacy shall make the list and its 5 prices available to its customers at the pharmacy retail site 6 upon request. 7 (i) Each pharmacy retail site shall post a sign that 8 notifies customers of the availability of its price list 9 in a conspicuous location that is either at or adjacent 10 to the place where prescriptions are presented for 11 compounding and dispensing, in the customer waiting area 12 or in the area where prescribed drugs are delivered. 13 (ii) The provisions of this paragraph shall not be 14 construed to prevent a pharmacy from changing its current 15 retail price at any time, provided that the listed price 16 available at the pharmacy retail site is updated at least 17 weekly to reflect the new retail price. 18 (4) The State Board of Pharmacy may impose a fine of up 19 to $1,000 per day for each day that a pharmacy fails to 20 comply with any of the provisions of this paragraph. A 21 separate fine may be imposed for each failure to comply. All 22 fines shall be due 30 days from receipt of notice of each 23 such failure. Funds collected pursuant to this paragraph 24 shall be deposited into the CAP Fund. 25 (b) The Pennsylvania Hospital Payment Registry.-- 26 (1) The council shall also establish and maintain a 27 registry to be known as the Pennsylvania Hospital Payment 28 Registry for the purpose of making readily available to 29 consumers information regarding the payments received by 30 hospitals for the 150-most-frequent admission diagnoses and 20070H0700B1011 - 53 -
1 the 150-most-frequently dispensed drugs. 2 (i) The hospital payment registry shall include the 3 information submitted to the council under this 4 subsection and the name and address of each hospital 5 providing the information and shall be organized by zip 6 code. 7 (ii) The hospital payment registry shall be updated 8 annually by the council and shall be posted on the 9 council's Internet website in a format that is conducive 10 to review and comparison by consumers of reimbursement 11 data from hospitals in each zip code of this 12 Commonwealth. It shall include a toll-free telephone 13 number maintained by the council that consumers may call 14 to obtain reprints of the registry. 15 (iii) The website shall be designed so that the 16 consumer may download and print the displayed information 17 and shall include at least the following: 18 (A) Internet web links to other government 19 resources that provide information relating to the 20 regulation of hospitals and health insurance. 21 (B) Clearly understandable language that is 22 designed to assist consumers in understanding the 23 content of and how to access the information made 24 available on the website pursuant to this subsection. 25 (iv) The information on the hospital payment 26 registry may be combined with other data collected by the 27 council and posted on the council's Internet website to 28 provide comparative information useful to consumers 29 selecting a hospital for medical care. 30 (2) Within 90 days following the effective date of this 20070H0700B1011 - 54 -
1 section and on or before January 31 of each year thereafter, 2 all hospitals shall submit to the council for inclusion in 3 the hospital payment registry, in a form and manner 4 prescribed by the council, all of the following: 5 (i) The 150-most-frequent admission diagnoses and 6 the 150-most-frequently dispensed drugs (both 7 prescription and nonprescription) in the hospital during 8 the preceding year. 9 (ii) The amount an individual enrolled in a high 10 deductible health plan with a health savings account is 11 required to pay for the diagnoses and drugs described in 12 subparagraph (i). 13 (iii) The average payment the hospital has 14 negotiated with third-party payers for the diagnoses and 15 drugs described in subparagraph (i). 16 (iv) The amount an uninsured patient is charged for 17 the diagnoses and drugs described in subparagraph (i). 18 (3) A hospital shall make the list and payments received 19 available to its patients at the hospital site upon request. 20 The hospital shall post a sign that notifies patients of the 21 availability of the list at or adjacent to the place where 22 patients are admitted to the hospital and at the place where 23 patients receive financial counseling. 24 (c) The Pennsylvania Outpatient Procedure Payment 25 Registry.-- 26 (1) The council shall also establish and maintain a 27 registry to be known as the Pennsylvania Outpatient Procedure 28 Payment Registry for the purpose of making readily available 29 to consumers information regarding the payments received by 30 ambulatory surgical facilities and imaging centers for the 20070H0700B1011 - 55 -
1 50-most-frequent outpatient procedures. 2 (i) The outpatient procedure payment registry shall 3 include the information submitted to the council under 4 this subsection and the name and address of each 5 outpatient facility providing the information and shall 6 be organized by zip code. 7 (ii) The outpatient procedure payment registry shall 8 be updated annually by the council and shall be posted on 9 the council's Internet website in a format that is 10 conducive to review and comparison by consumers of 11 reimbursement data from outpatient facilities in each zip 12 code of this Commonwealth. It shall include a toll-free 13 telephone number maintained by the council that consumers 14 may call to obtain reprints of the registry. 15 (iii) The website shall be designed so that the 16 consumer may download and print the displayed information 17 and shall include at least the following: 18 (A) Internet web links to other government 19 resources that provide information relating to the 20 regulation of outpatient facilities and health 21 insurance. 22 (B) Clearly understandable language that is 23 designed to assist consumers in understanding the 24 content of and how to access the information made 25 available on the website pursuant to this subsection. 26 (iv) The information on the outpatient procedure 27 payment registry may be combined with other data 28 collected by the council and posted on the council's 29 Internet website to provide comparative information 30 useful to consumers selecting a provider of medical care. 20070H0700B1011 - 56 -
1 (2) Within 90 days following the effective date of this 2 section and on or before January 31 of each year thereafter, 3 all ambulatory surgical facilities and all imaging centers 4 shall submit to the council for inclusion in the outpatient 5 procedure payment registry, in a form and manner prescribed 6 by the council, the 50-most-frequent procedures performed at 7 the ambulatory surgical facility or imaging center during the 8 preceding year, the charge for each such procedure and the 9 average third-party reimbursement for each such procedure. 10 (3) The council, in consultation with the Department of 11 Health, may determine that the same information should be 12 obtained from other health care providers that primarily 13 perform outpatient procedures other than for primary or 14 chronic care, and, 90 days following publication of notice in 15 the Pennsylvania Bulletin, those health care providers shall 16 submit to the council for inclusion in the outpatient 17 procedure payment registry the information set forth in 18 paragraph (2). 19 (d) Guidelines.--The council may adopt guidelines to 20 effectuate the purposes of this section. 21 (e) Enforcement.--In addition to any other remedy available, 22 the council may impose a civil penalty of up to $500 per day for 23 each failure of a facility to provide the council the 24 information required under this section. All fines collected 25 under this subsection shall be deposited in the CAP Fund. 26 CHAPTER 73 27 ACCESSIBILITY 28 Sec. 29 7301. Definitions. 30 7302. Pennsylvania Center for Health Careers. 20070H0700B1011 - 57 -
1 7303. Health care provider practice. 2 7304. Hospice licensure. 3 § 7301. Definitions. 4 The following words and phrases, when used in this chapter, 5 shall have the meanings given to them in this section unless the 6 context clearly indicates otherwise: 7 "Center." The Pennsylvania Center for Health Careers 8 established under section 7302 (relating to Pennsylvania Center 9 for Health Careers). 10 "Certified registered nurse anesthetist." A registered nurse 11 certified by the State Board of Nursing to administer anesthesia 12 and who meets the requirements of section 7303(j) (relating to 13 health care provider practice). 14 "Clinical nurse specialist." An individual who is licensed 15 by the State Board of Nursing and holds: 16 (1) A graduate degree, master's degree, doctoral degree, 17 or post-master's certificate from an educational program that 18 is recognized by the State Board of Nursing or a national 19 nursing accrediting body accepted by the board and that 20 prepares graduates to practice as a clinical nurse 21 specialist. 22 (2) A national certification as a clinical nurse 23 specialist in a designated specialty or in an area pertinent 24 to the designated specialty or meets equivalence requirements 25 as specified in regulations of the State Board of Nursing 26 when there is no certification examination available in the 27 clinical nurse specialist specialty area. 28 "CODA." American Dental Association's Commission on Dental 29 Accreditation. 30 "Collaboration." A relationship between or among health care 20070H0700B1011 - 58 -
1 providers to deliver health care services with each contributing 2 their expertise within the scope of their license, education and 3 training. In the case of collaboration between a physician or 4 dentist and a certified registered nurse practitioner, nurse 5 midwife, clinical nurse specialist, certified registered nurse 6 anesthetist or physician's assistant, the process allows the 7 health care provider to perform acts of medical diagnosis and, 8 pursuant to a collaborative or written agreement, to prescribe 9 medical therapeutic and corrective measures. Collaboration 10 includes all of the following: 11 (1) Immediate availability of a licensed physician or 12 dentist to the health care provider through direct 13 communications or by radio, telephone or telecommunications. 14 (2) A predetermined plan for emergency services. 15 (3) A physician or dentist available to the health care 16 provider on a regularly scheduled basis for referrals, review 17 of the standards of clinical practice incorporating 18 consultation and chart review, review of drug and other 19 clinical protocols within the practice setting, periodic 20 updating in diagnosis and therapeutics and cosigning records 21 when necessary to document accountability by both parties. 22 "Collaborative or written agreement." An agreement between a 23 physician and a health care provider that is not a physician 24 where such an agreement has been required under law for the 25 health care provider to provide health care services. 26 "Debridement." The removal of dental calculus from teeth. 27 "Department." The Department of Labor and Industry of the 28 Commonwealth. 29 "Expanded primary care availability." The provision of 30 primary and urgent care during evenings and weekends on a walk- 20070H0700B1011 - 59 -
1 in or same-day appointment basis. 2 "General supervision." Supervision by a dentist who has 3 authorized dental hygiene services for a patient to be 4 administered in accordance with the dentist's diagnosis and 5 treatment plan without the dentist being present, including 6 being present in the treatment location. 7 "Health care worker." An employee, independent contractor, 8 licensee or other individual authorized to provide health care 9 services in a health care facility or who is engaged in public 10 health activities. 11 "Independent dental hygiene practitioner." A dental 12 hygienist who performs educational, preventative, therapeutic 13 and intra-oral procedures which the hygienist is educated to 14 perform and which require the hygienist's professional 15 competence and skill but which do not require the professional 16 competence and skill of a dentist without the authorization, 17 assignment or examination of a dentist, and who is certified by 18 the State Board of Dentistry as having satisfied the 19 requirements of section 7303(h) (relating to health care 20 provider practice). 21 "Leadership council." The Health Careers Leadership Council 22 established under section 7302 (relating to Pennsylvania Center 23 for Health Careers). 24 "Local anesthesia." A drug administered by injection in the 25 mouth to temporarily eliminate or diminish the sensation of pain 26 during routine dental care. 27 "Nurse midwife." An individual licensed by the State Board 28 of Medicine to practice midwifery. 29 "Physician assistant." An individual certified as a 30 physician assistant by the State Board of Medicine. 20070H0700B1011 - 60 -
1 "Primary care." The provision of family, adult, pediatric, 2 men's or women's health care services or chronic care management 3 at a point of entry to the health care system other than an 4 emergency room. 5 "Primary care provider." A licensee who is a physician, 6 physician assistant, certified registered nurse practitioner, 7 clinical nurse specialist practicing primary care, nurse midwife 8 or any group practice consisting of some or all of the 9 foregoing. 10 "Radiologic procedure." A medical or dental procedure, such 11 as an X-ray, that uses radiation or other sources to create 12 images useful in diagnosis. 13 "Secretary." The Secretary of Labor and Industry. 14 "Soft tissue curettage." The removal of soft tissue in the 15 mouth with a curette. 16 § 7302. Pennsylvania Center for Health Careers. 17 (a) Establishment.--The Pennsylvania Center for Health 18 Careers is hereby established within the department. The center 19 will provide a focused direction and purpose for the development 20 of strategies to address the Commonwealth's short-term and long- 21 term health care work force challenges to ensure the quality and 22 supply of such work force by: 23 (1) Increasing the capacity of nursing education in this 24 Commonwealth. 25 (2) Retaining health care workers. 26 (3) Increasing diversity of health care workers. 27 (4) Responding to the demand for allied health 28 professionals that provide critical care. 29 (5) Addressing the needs of direct care workers. 30 (b) Powers and duties.--The center shall have the following 20070H0700B1011 - 61 -
1 powers and duties: 2 (1) Determine the health care work force needs of this 3 Commonwealth through research, outreach and study. 4 (2) Research best practices in addressing similar work 5 force needs in other states. 6 (3) Assess the effectiveness of the initiatives, 7 programs and projects the center undertakes. 8 (4) Assist and implement the initiatives and strategies 9 of the council. 10 (5) Develop recruitment and workplace tools that assist 11 health care facilities to increase the diversity of their 12 work force and promote the delivery of culturally appropriate 13 care. 14 (6) Assess the current capacity of medical education 15 within the Commonwealth's medical schools and training 16 programs. 17 (7) Assess current and needed efforts addressing 18 recruitment and retention of physicians and other health care 19 professionals. 20 (c) Leadership council.--The center shall be governed by the 21 Health Careers Leadership Council which shall consist of the 22 following members: 23 (1) The secretary, the Secretary of State, the Secretary 24 of Health, the Secretary of Public Welfare or their 25 designees. 26 (2) Four members of the General Assembly: 27 (i) Two members of the Senate, one appointed by the 28 President pro tempore of the Senate and one appointed by 29 the Minority Leader of the Senate. 30 (ii) Two members of the House of Representatives, 20070H0700B1011 - 62 -
1 one appointed by the Speaker of the House of 2 Representatives and one appointed by the Minority Leader 3 of the House of Representatives. 4 (3) Additional members that are representatives of 5 health care-related professionals and organizations, 6 including employers, employees and educators, in such number 7 as may be determined by the Governor and to be appointed by 8 the Governor in consultation with the Pennsylvania Workforce 9 Investment Board created by the act of December 18, 2001 10 (P.L.949, No.114), known as the Workforce Development Act. 11 (4) Members of the leadership council shall serve at the 12 pleasure of their respective appointing authorities. Members 13 shall not receive compensation for their service as members 14 of the council but shall be reimbursed for reasonable and 15 necessary expenses in the performance of their duties in 16 accordance with Commonwealth policy with the approval of the 17 secretary. 18 (5) The Governor shall designate a member or members of 19 the leadership council to serve as chair or cochairs. 20 (6) The leadership council shall have the following 21 powers and duties: 22 (i) Determine the organization, procedures and 23 priorities of the center. 24 (ii) Develop initiatives, programs and projects for 25 the center to address the health care work force needs of 26 the Commonwealth. 27 (iii) Apply for grants and seek other revenue 28 sources, including General Fund appropriations through 29 the department's budget. 30 (iv) Do all other acts necessary to carry out the 20070H0700B1011 - 63 -
1 purposes and policies of this section. 2 (d) Administration.--The department shall provide 3 administrative support to the leadership council. The center 4 shall use and have access to any information, services, 5 functions and other resources in the possession of Commonwealth 6 agencies deemed necessary to the fulfillment of its 7 responsibilities under this section. 8 § 7303. Health care provider practice. 9 (a) General rule.--Except with respect to those laws or 10 regulations applying to the medical staff of a hospital or the 11 oversight of inpatient clinical services performed in a 12 hospital, wherever in any law or regulation of the Commonwealth 13 the terms "physician," "medical doctor," "doctor of osteopathy," 14 "dentist" or similar term is used to define an individual who 15 shall take medical histories, perform physical or mental 16 examinations or provide acute illness, minor injury or chronic 17 disease management care, those terms shall be deemed to include 18 certified registered nurse practitioners, clinical nurse 19 specialists, physician assistants, nurse midwives and 20 independent dental hygienist practitioners; provided that such 21 activities fall within the individual's specialty certification 22 and scope of practice as determined by the applicable State 23 licensing board. 24 (b) Professional liability.--A certified registered nurse 25 practitioner, clinical nurse specialist, nurse midwife or 26 physician assistant practicing in this Commonwealth whose 27 employer does not provide professional liability coverage shall 28 maintain a level of professional liability coverage required by 29 law of a physician providing similar health care services in 30 this Commonwealth, but shall not be eligible to participate in 20070H0700B1011 - 64 -
1 the fund established under Mcare. 2 (c) Collaborative and written agreements.-- 3 (1) There shall be no limit to the number of certified 4 registered nurse practitioners with prescriptive authority or 5 physician assistants for whom a physician has responsibility 6 or supervises under a collaborative or written agreement at 7 any time. 8 (2) Collaborative and written agreements shall not 9 unreasonably restrict any health care provider's ability to 10 practice to the fullest extent permitted by his scope of 11 practice, clinical education and experience. 12 (3) The Department of State, Bureau of Professional and 13 Occupational Affairs, shall accept complaints in a form and 14 manner prescribed by the bureau with respect to the 15 following: 16 (i) the unwillingness of physicians in a given 17 geographic area to enter into an agreement with any 18 member of a class of health care providers; or 19 (ii) any unduly restrictive provisions contained in 20 an agreement. 21 The bureau shall establish a process for resolving complaints 22 it determines are credible, including required mediation 23 among the parties. 24 (4) The provisions of 49 Pa. Code §§ 18.57 (relating to 25 physician supervision) and 21.287 (relating to physician 26 supervision) are abrogated to the extent such provisions 27 restrict the number of certified registered nurse 28 practitioners a physician may supervise at any time. The 29 provisions of 49 Pa. Code § 18.152(b)(2) (relating to 30 prohibitions) are abrogated to the extent that the number of 20070H0700B1011 - 65 -
1 physician assistants for which a physician may have primary 2 responsibility is restricted. 3 (d) Certified registered nurse practitioners.--Except as 4 limited by the scope of his specialty certification or in a 5 collaborative or written agreement: 6 (1) A certified registered nurse practitioner shall not 7 be limited in prescribing any drug, including a controlled 8 substance on Schedules II through V, nor shall there be any 9 limit on the number of refills or dosages except as may be 10 provided under Federal law, except that the certified 11 registered nurse practitioner shall use his own Drug 12 Enforcement Administration number and not that of any 13 collaborating physician in writing the prescription. 14 (2) In addition to existing authority, a certified 15 registered nurse practitioner shall have authority to do all 16 of the following: 17 (i) Order home health and hospice care. 18 (ii) Order durable medical equipment. 19 (iii) Issue oral orders under the same conditions 20 and in the same facilities as physicians are permitted to 21 do. 22 (iv) Perform and sign workers compensation 23 physicals. 24 (v) Perform physical therapy and dietitian 25 referrals. 26 (vi) Order respiratory or occupational therapy. 27 (vii) Perform disability assessments for the program 28 providing Temporary Assistance to Needy Families. 29 (viii) Perform and sign methadone treatment 30 evaluations. 20070H0700B1011 - 66 -
1 (ix) Perform and sign cosmetology license physicals. 2 (x) Issue home schooling certifications. 3 (xi) Make commitments under the act of July 9, 1976 4 (P.L.817, No.143), known as the Mental Health Procedures 5 Act. 6 (xii) Perform and sign psychiatric evaluations. 7 (xiii) Perform other similar activities. 8 (e) Nurse midwives.--Notwithstanding the provisions of any 9 other law or regulation: 10 (1) A nurse midwife is authorized to provide and manage 11 primary health care of women during pregnancy, childbirth, 12 and the postpartum period, provide care of the neonate and 13 provide office gynecological care and family planning 14 services. 15 (2) A nurse midwife may, consistent with the midwife's 16 academic educational preparation and national certification, 17 prescribe, dispense, order and administer the following: 18 (i) Legend drugs and Schedule II through Schedule V 19 controlled substances provided that the midwife: 20 (A) Has successfully completed at least 45 hours 21 of coursework specific to advanced pharmacology at a 22 level above that required by a professional nursing 23 education program. 24 (B) In the two years prior to the biennial 25 renewal of the nurse midwife's license, successfully 26 completes at least 16 hours of continuing education 27 in pharmacology approved by the State Board of 28 Medicine. The nurse midwife shall provide the board 29 with evidence that the nurse midwife has completed 30 such training as part of the biennial renewal 20070H0700B1011 - 67 -
1 process. 2 (C) Acts in collaboration with a physician as 3 set forth in a written agreement which shall at a 4 minimum identify the categories of drugs from which 5 the nurse midwife may prescribe or dispense and the 6 circumstances under which the collaborating physician 7 will personally see the patient. 8 (D) Acts in accordance with regulations 9 promulgated by the State Board of Medicine, which 10 shall not unreasonably restrict the midwife's 11 practice. 12 (ii) Medical devices. 13 (iii) Immunizing agents. 14 (iv) Laboratory tests. 15 (v) Therapeutic, diagnostic and preventative 16 measures. 17 (f) Clinical nurse specialists.--Any individual who holds a 18 license to practice professional nursing in this Commonwealth 19 who meets the requirements to be a clinical nurse specialist 20 shall have the right to use the title "clinical nurse 21 specialist" and the abbreviation "CNS." No other individual 22 shall have that right. 23 (g) Dental hygienists.-- 24 (1) Classifications developed by the American Society of 25 Anesthesiologists shall not be a factor in determining the 26 level of supervision required by dental hygienists. The 27 supervising dentist and the dental hygienist shall determine 28 the appropriate level of supervision for each patient based 29 on the patient's health and history. 30 (2) In addition to existing authority, a dental 20070H0700B1011 - 68 -
1 hygienist may perform the following in any setting under the 2 general supervision of a dentist: 3 (i) Radiologic procedures. 4 (ii) Debridement. 5 (iii) Soft tissue curettage. 6 (iv) Suture removal. 7 (v) Teeth filling. 8 (3) A dental hygienist may administer local anesthesia 9 under the following conditions: 10 (i) The dental hygienist holds a current license in 11 good standing, is certified in basic life support and has 12 provided the board documentation evidencing one of the 13 following: 14 (A) Graduation within the five years immediately 15 preceding the filing of the application from a dental 16 hygiene school accredited by CODA, which included the 17 successful completion of a course in the 18 administration of local anesthesia. 19 (B) Successful completion within the five years 20 immediately preceding the filing of the application 21 of a course consisting of a minimum of 30 hours of 22 instruction in the administration of local anesthesia 23 sponsored by an education program accredited by CODA. 24 (C) Possession of a current license or permit 25 issued by the proper licensing authority of another 26 state, territory or district, or by Canada, where the 27 dental hygienist is authorized under the laws of that 28 jurisdiction to administer local anesthesia, provided 29 that the dental hygienist has been actively engaged 30 in the administration of local anesthesia within the 20070H0700B1011 - 69 -
1 five years immediately preceding the filing of the 2 application and that the applicable jurisdiction 3 required, as a condition of receiving the license or 4 permit, that the dental hygienist complete a course 5 in the administration of local anesthesia accredited 6 by CODA or its Canadian counterpart. 7 (ii) The dental hygienist has applied for and 8 received a permit from the State Board of Dentistry and 9 paid any required permit fee. 10 (4) In addition to other locations set forth in law, a 11 dental hygienist may provide dental services in free clinics. 12 (h) Independent dental hygiene practitioners.-- 13 (1) An independent dental hygiene practitioner must be 14 certified by the State Board of Dentistry upon meeting the 15 following criteria: 16 (i) completion of 1,800 hours of practice under the 17 supervision of a dentist; and 18 (ii) purchase of a professional liability policy in 19 an amount determined to be adequate by the board. 20 (2) Following certification by the State Board of 21 Dentistry under paragraph (1), an independent dental hygiene 22 practitioner may, without the supervision of a dentist: 23 (i) Perform any procedure a dental hygienist may 24 perform. 25 (ii) Order and administer fluoride treatments and 26 products, to include fluoride varnish, home fluoride 27 treatment and other such fluoride-containing products as 28 may be necessary to prevent dental caries. 29 (iii) Order dental equipment. 30 (3) An independent dental hygiene practitioner shall 20070H0700B1011 - 70 -
1 limit his professional practice to the following practice 2 sites: 3 (i) Schools. 4 (ii) Correctional facilities. 5 (iii) Health care facilities. 6 (iv) "Personal care homes" as defined in section 7 1001 of the Public Welfare Code. 8 (v) "Domiciliary care" as defined in section 2202-A 9 of the act of April 9, 1929 (P.L.177, No.175), known as 10 The Administrative Code of 1929. 11 (vi) An "older adult daily living center" as defined 12 in section 2 of the act of July 11, 1990 (P.L.499, 13 No.118), known as the Older Adult Daily Living Centers 14 Licensing Act. 15 (vii) A "facility" as defined in section 3 of the 16 act of June 18, 1984 (P.L.391, No.82), known as the 17 Continuing-Care Provider Registration and Disclosure Act. 18 (viii) A public or private institution under the 19 jurisdiction of a Federal, State or local agency. 20 (ix) Day-care centers as defined in Articles IX and 21 X of the Public Welfare Code. 22 (x) Facilities operating Head Start programs 23 established by the Omnibus Budget and Reconciliation Act 24 of 1981 (Public Law 97-35, 95 Stat. 357). 25 (xi) Free clinics. 26 (xii) Other institutions the State Board of 27 Dentistry deems appropriate. 28 (i) Pharmacists.--In addition to the activities authorized 29 by the act of September 27, 1961 (P.L.1700, No.699), known as 30 the Pharmacy Act, pharmacists may manage drug therapy in any 20070H0700B1011 - 71 -
1 integrated health setting such as academic health centers and 2 group practice settings where the pharmacist is an integral 3 member of the interdisciplinary clinical team and has access to 4 the patient's medical record. In such practice settings, the 5 pharmacist shall follow the same protocols and procedures as 6 that required for drug therapy management in "institutions" as 7 defined in the Pharmacy Act. 8 (j) Certified registered nurse anesthetists.--The State 9 Board of Nursing shall certify a registered nurse as a certified 10 registered nurse anesthetist if the nurse satisfies the 11 requirements established by this subsection and any regulations 12 promulgated by the board. The certification of a nurse under 13 this subsection shall expire on the same date as the nurse's 14 license expires. 15 (1) In order to be certified, a registered nurse must 16 satisfy the following criteria: 17 (i) Completion of the educational program of a 18 school for nurse anesthetists accredited by an 19 accrediting agency recognized by the State Board of 20 Nursing. 21 (ii) Receipt of certification as a certified 22 registered nurse anesthetist by a board-recognized 23 national certification organization. 24 (2) A registered nurse who is enrolled in an educational 25 program of a school for nurse anesthetists accredited by an 26 accrediting agency recognized by the State Board of Nursing 27 may, during such enrollment, administer anesthesia under the 28 direction of the chief or director of anesthesia services, an 29 anesthesiologist or a certified registered nurse anesthetist. 30 (3) A registered nurse who has obtained the education 20070H0700B1011 - 72 -
1 required by this subsection but who has not yet obtained 2 certification as a certified registered nurse anesthetist may 3 administer anesthesia under the direction of the chief or 4 director of anesthesia services, an anesthesiologist or a 5 certified registered nurse anesthetist until the announcement 6 of results of the first examination taken for certification 7 for which the registered nurse is eligible. If the registered 8 nurse fails to take or fails to pass that examination, the 9 registered nurse shall immediately cease practicing as a 10 nurse anesthetist, provided, however, that the registered 11 nurse may appeal to the State Board of Nursing for authority 12 to continue practicing as a nurse anesthetist if, due to 13 extenuating circumstances, the registered nurse is unable to 14 take the examination in a time period specified by the board 15 following completion of the required education. 16 (4) A certified registered nurse anesthetist shall be 17 subject to all of the following: 18 (i) A certified registered nurse anesthetist shall 19 administer anesthesia in collaboration with a physician 20 or dentist. 21 (ii) A certified registered nurse anesthetist's 22 performance shall be under the overall direction of the 23 chief or director of anesthesia services, provided, 24 however, that in situations or health care facilities 25 where anesthesia services are not mandatory, the 26 certified registered nurse anesthetist's performance 27 shall be under the overall direction of the collaborating 28 physician or dentist. 29 (iii) When the operating or anesthesia team consists 30 entirely of nonphysicians, an anesthesiologist or 20070H0700B1011 - 73 -
1 consulting physician of the certified registered nurse 2 anesthetist's choice shall be available to the certified 3 registered nurse anesthetist by physical presence or 4 electronic communication. 5 (5) Nothing in this subsection shall be construed to 6 prohibit the continued practice of certified registered nurse 7 anesthetists who were authorized to practice in this 8 Commonwealth on the effective date of this subsection. 9 (k) Health insurers.--An insurer issuing health insurance 10 coverage within this Commonwealth is: 11 (1) Required to include the following classes of health 12 care providers as primary care providers in each of its 13 provider networks: 14 (i) certified registered nurse practitioners, 15 physician assistants, clinical nurse specialists 16 practicing in primary care and nurse midwives; and 17 (ii) urgent care, convenient care, nurse-managed 18 care or federally qualified health centers if they are 19 geographically available to provide services to those 20 insured by the insurer. 21 The Insurance Commissioner may modify the foregoing list from 22 time to time by publication of a notice in the Pennsylvania 23 Bulletin. 24 (2) Required to establish a credentialing process to 25 enroll qualified health care providers to create an adequate 26 provider network that includes the classes of health care 27 providers required under paragraph (1). The process shall be 28 submitted to the Department of Health for approval within 180 29 days following the effective date of this section and shall 30 be resubmitted to the Department of Health for approval every 20070H0700B1011 - 74 -
1 two years thereafter. The process shall include written 2 criteria and procedures for initial enrollment, renewal, 3 restrictions and termination of credentials for health care 4 providers, disclose relevant credentialing criteria and 5 procedures to health care providers that apply to participate 6 or that are participating in the insurer's provider network 7 and provide any health care provider denied credentials or 8 renewal of credentials with timely written notice containing 9 a clear explanation of the reason for the denial. 10 (3) Required to timely pay health care providers for 11 health care services at rates sufficient to assure the 12 availability of and access to adequate health care providers 13 in all networks, taking into account the need for fiscal 14 restraint. 15 (4) Required to pay health care providers incentives for 16 providing expanded primary care availability. 17 (5) Required to pay a primary care provider and 18 certified registered nurse anesthetist directly for services 19 provided unless the provider or certified registered nurse 20 anesthetist notifies the insurer otherwise. 21 (6) Required to pay certified registered nurse 22 practitioners, clinical nurse specialists, physician 23 assistants and nurse midwives as primary care providers for 24 primary care services and reasonable rates for providing 25 specialty health care services that are within their scope of 26 practice to provide. 27 (7) Prohibited from excluding minor children with 28 behavioral health conditions from coverage or excluding from 29 covered services behavioral therapy services for minor 30 children. 20070H0700B1011 - 75 -
1 § 7304. Hospice licensure. 2 (a) Regulations.--Within 180 days following the effective 3 date of this section, the Department of Health shall promulgate 4 proposed regulations, and within 270 days following the 5 effective date of this section the Department of Health shall 6 promulgate final regulations for licensure of residential 7 hospice facilities which shall include licensure of the 8 following: 9 (1) small residential hospices with 22 or fewer beds; 10 and 11 (2) hospices for children or units for children within 12 licensed hospices or other health care facilities provided 13 that the children's hospice units are physically separated 14 and secured from units providing services to adults. 15 (b) Alternative.--In developing its regulations, the 16 Department of Health shall establish for small residential 17 hospices an alternative to the fire and safety regulations for 18 hospices certified as providers of the Medicare program under 19 Title XVIII of the Social Security Act (49 Stat. 620, U.S.C. § 20 1395 et seq.) that currently require hospices to meet standards 21 for nursing homes contained in the 2000 edition of the Life 22 Safety Code of the National Fire Protection Association. In 23 developing the alternative, the Department of Health shall 24 consider as a minimum the requirements for large board and care 25 occupancies set forth in the 2006 edition of the Life Safety 26 Code. 27 CHAPTER 74 28 QUALITY OF CARE AND HEALTHY LIFESTYLES 29 Sec. 30 7401. Definitions. 20070H0700B1011 - 76 -
1 7402. Patient safety. 2 7403. Smoking restrictions. 3 § 7401. Definitions. 4 The following words and phrases when used in this chapter 5 shall have the meanings given to them in this section unless the 6 context clearly indicates otherwise: 7 "Authority." The Patient Safety Authority established under 8 Mcare. 9 "Bar." Any area, including outdoor seating areas, devoted to 10 the sale and service of alcoholic beverages for on-premises 11 consumption and where the service of food is only incidental to 12 the consumption of such beverages. 13 "Consumer Price Index." The Consumer Price Index for All 14 Urban Consumers (CPI-U) for the Pennsylvania, New Jersey, 15 Delaware and Maryland area, for the most recent 12-month period 16 for which figures have been officially reported by the United 17 States Department of Labor, Bureau of Labor Statistics, 18 immediately prior to the subject date. 19 "Department." The Department of Health of the Commonwealth. 20 "Enforcement officer." The board of health of a county or an 21 officer designated under section 7403(g) (relating to smoking 22 restrictions). 23 "Food service establishment." Any area, including outdoor 24 seating areas, or portion of an area in which the business is 25 the sale of food for on-premises consumption. 26 "Health-care-acquired-infection." An infection acquired in a 27 health care facility. 28 "Impaired professional program." The program established 29 under the act of December 20, 1985 (P.L.457, No.112), known as 30 the Medical Practice Act of 1985. 20070H0700B1011 - 77 -
1 "MRSA." Methicillin-resistant staphylococcus aureus, a more 2 serious form of bacterial health-care-acquired infection that is 3 resistant to commonly used antibiotics. 4 "Patient safety report." The Patient Safety and Quality 5 Improvement Report required under section 7402(f) (relating to 6 patient safety). 7 "Places of employment." An indoor area or portion of an 8 indoor area under the control of an employer in which employees 9 of the employer perform services. The term includes offices, 10 school grounds, retail stores, banquet facilities, theaters, 11 food stores, banks, financial institutions, factories, 12 warehouses, employee cafeterias, lounges, auditoriums, 13 gymnasiums, restrooms, elevators, hallways, museums, libraries, 14 bowling establishments, employee medical facilities, rooms or 15 areas containing photocopying equipment or other office 16 equipment used in common and company vehicles. 17 "Retail tobacco business." A sole proprietorship, limited 18 liability company, corporation, partnership or other enterprise 19 in which the primary activity is the retail sale of tobacco 20 products and accessories and in which the sale of other products 21 is merely incidental. 22 "Safe practices." The set of standards endorsed by the 23 National Quality Forum that should be used by health care 24 providers to reduce the risk of harm to patients. 25 "School grounds." A building, structure and surrounding 26 outdoor grounds contained within a public or private preschool, 27 nursery school, elementary or secondary school's legally defined 28 property boundaries and any vehicles used to transport children 29 or school personnel. 30 "Smoking." The burning of a lighted cigar, cigarette, pipe 20070H0700B1011 - 78 -
1 or any other matter or substance which contains tobacco. 2 § 7402. Patient safety. 3 (a) Electronic surveillance of health-care-acquired 4 infections.-- 5 (1) By September 1, 2008, all hospitals shall use a 6 uniform electronic surveillance system to report health-care- 7 acquired infections to the council in a form and manner 8 prescribed by the council. The system shall provide for all 9 of the following: 10 (i) Extraction of existing electronic clinical data 11 from hospital systems on an ongoing basis. 12 (ii) Translation of nonstandardized laboratory data 13 into uniform information that can be analyzed on a 14 population-wide basis. 15 (iii) Clinical support, educational tools and 16 training to ensure that information provided under this 17 paragraph will lead to change. 18 (iv) Clinical improvement measurement and the 19 structure to provide ongoing positive and negative 20 feedback to hospital staff who implement change. 21 (2) Within 30 days following the effective date of this 22 section, the council shall identify and certify a specific 23 system or systems that meet the criteria described in 24 paragraph (1) and shall forward the identity of the certified 25 system or systems to the Legislative Reference Bureau for 26 publication as a notice in the Pennsylvania Bulletin. 27 (b) Reporting emergency services.--The council, in 28 consultation with the department, shall determine the manner and 29 scope of reporting to the council that hospitals shall undertake 30 with respect to individuals presenting at hospitals for 20070H0700B1011 - 79 -
1 emergency services. The council shall forward requirements 2 concerning the reporting, including the date the reporting is to 3 commence, to the Legislative Reference Bureau for publication as 4 a notice in the Pennsylvania Bulletin. After the date the 5 reporting is to commence, compliance with the requirements shall 6 be a condition of licensure for hospitals. 7 (c) Reporting by nursing homes.--Nursing homes shall report 8 to the council the same infections and in the same manner that 9 hospitals are required to report to the council under the Health 10 Care Cost Containment Act. Reporting shall begin within 30 days 11 following the effective date of this section. For purposes of 12 this section, nursing homes shall be additional data sources as 13 defined in the Health Care Cost Containment Act, and covered 14 services, as defined in that act, shall include those services 15 provided by nursing homes. 16 (d) Analysis of nursing home data by Patient Safety 17 Authority.-- 18 (1) At the request of the department, but no less 19 frequently than once per year, the authority shall analyze 20 data without patient identifying information reported to the 21 department by nursing homes with respect to events 22 compromising patient safety as required by 28 Pa. Code § 51.3 23 (relating to notification). 24 (2) The authority shall conduct analyses as it 25 determines are appropriate to provide information to nursing 26 homes which can be used to improve patient safety and quality 27 of care. 28 (3) The authority shall provide nursing homes with 29 patient safety advisories issued by the authority and permit 30 any nursing home administrator to attend any patient safety 20070H0700B1011 - 80 -
1 training program it offers. 2 (4) Nursing homes shall pay the department a surcharge 3 on their licensing fees to provide sufficient revenues to the 4 authority for its responsibilities under this section. The 5 department shall determine the proportionate share to be paid 6 by each nursing home on a per-bed basis within 60 days 7 following the effective date of this section. 8 (i) The total surcharge for all nursing homes shall 9 not exceed $1,000,000 in fiscal year 2007-2008 and shall 10 be increased by the Consumer Price Index in each 11 succeeding fiscal year. All surcharges shall be paid by 12 the end of each fiscal year. 13 (ii) The department shall transfer the total 14 surcharges collected to the Patient Safety Trust Fund 15 within 30 days of receipt. 16 (iii) In the event that the Patient Safety Trust 17 Fund is discontinued or the authority is dissolved, any 18 balance of the surcharges paid by nursing homes remaining 19 in the Patient Safety Trust Fund, after deducting 20 administrative costs of liquidation, shall be returned to 21 the nursing homes in proportion to their financial 22 contributions to the Patient Safety Trust Fund in the 23 preceding licensing period. 24 (iv) If, after 30 days' notice, a nursing home fails 25 to pay a surcharge levied by the department under this 26 subsection, the department may assess an administrative 27 penalty of $1,000 per day until the surcharge is paid. 28 The penalty shall be imposed from the date of the notice 29 and deposited into the CAP Fund. 30 (e) E-prescribing.-- 20070H0700B1011 - 81 -
1 (1) Within 60 days following the effective date of this 2 section, each health care facility shall develop a full and 3 complete implementation plan with specific goals, key 4 performance indicators and timelines in order to meet the 5 following requirements: 6 (i) Commencing September 1, 2008, a health care 7 facility shall provide easy and timely access to an e- 8 prescribing system for all of its staff, employees or 9 contractors who have prescriptive authority in this 10 Commonwealth and who write prescriptions for patients of 11 the health care facility in order to allow them to write 12 prescriptions electronically and check for potentially 13 harmful drug interactions. 14 (ii) Thereafter, the health care facility shall 15 certify to the department on its application for license 16 or license renewal that it provides access for all staff, 17 employees and contractors with prescriptive authority to 18 an e-prescribing system and requires its use. 19 (2) Within 60 days following the effective date of this 20 section, the State Board of Medicine shall determine the date 21 after which it will require physicians, as a condition of 22 licensure, to use an e-prescribing system to write 23 prescriptions electronically and check for potentially 24 harmful drug interactions. The State Board of Medicine shall 25 forward a notice of the date to the Legislative Reference 26 Bureau for publication in the Pennsylvania Bulletin. 27 Effective as of that date, the State Board of Medicine shall 28 require a physician to certify on the physician's application 29 for license or license renewal that the physician has access 30 to and uses an e-prescribing system. 20070H0700B1011 - 82 -
1 (3) (i) Any false or misleading statement on a 2 certification by a health care facility shall subject the 3 health care facility to a civil penalty of $5,000 per 4 instance, which shall be imposed and collected by the 5 department and deposited into the CAP Fund. 6 (ii) Any false or misleading statement on a 7 certification by a physician shall subject the physician 8 to a civil penalty of $5,000 per instance, which shall be 9 imposed and collected by the State Board of Medicine and 10 deposited into the CAP Fund. 11 (4) Notwithstanding any provision of law or regulation, 12 oral orders for medication or treatment shall be issued or 13 accepted only in emergency circumstances if no alternative 14 method is available. 15 (5) Up to $25,000,000 of the funds appropriated by the 16 General Assembly for the Machinery and Equipment Loan Fund 17 shall be made available for grants to health care facilities 18 to assist in acquiring the systems described under this 19 subsection. Grants shall not exceed 50% of a hospital's 20 costs, which shall be approved by the Department of Community 21 and Economic Development. The Department of Community and 22 Economic Development shall develop criteria for evaluating 23 applications for grants that considers the fiscal condition 24 of the hospital, the ability of the hospital to implement the 25 technology and the potential savings through avoided costs 26 and reduced errors. The criteria shall be forwarded by the 27 Department of Community and Economic Development to the 28 Legislative Reference Bureau for publication as a notice in 29 the Pennsylvania Bulletin. 30 (f) Health care facilities annual report.-- 20070H0700B1011 - 83 -
1 (1) A hospital shall, on or before April 1 of each 2 calendar year, submit to the department a Patient Safety and 3 Quality Improvement Report for each facility that it 4 operates. The patient safety report shall cover the prior 5 calendar year and shall contain at least the following 6 information: 7 (i) Three-year trends in the rates of health-care- 8 acquired infections, medication errors, readmissions and 9 procedure complications, failures to rescue and falls. 10 (ii) The recommendations of the authority and 11 approved by the department under section 301 of Mcare 12 that have been implemented at the hospital. 13 (iii) The specific safe practices that each hospital 14 facility will adopt and implement during the next 15 calendar year to reduce health-care-acquired infections, 16 medication errors, readmissions and procedure 17 complications, failures to rescue and falls. 18 (iv) Beginning with the second report submitted 19 under this subsection and with each report submitted 20 thereafter, the progress of implementation of safe 21 practices adopted during the previous calendar year, 22 whether the hospital will continue any of the practices 23 and the reason the hospital will discontinue any safe 24 practice previously adopted. 25 (v) The hospital's plan to implement facility-wide 26 and data-driven error-reduction or quality improvement 27 programs that the hospital intends to adopt and implement 28 at each hospital facility, including a computer physician 29 order entry system, medication bar coding and programs to 30 identify and correct systemic causes of error and achieve 20070H0700B1011 - 84 -
1 reliable quality outcomes. 2 (2) Submission of the report shall be a condition of 3 hospital licensure. 4 (3) The department may use information reported to it 5 under paragraph (1) for the purposes of providing information 6 to consumers and developing performance and quality standards 7 and best practices and shall cooperate with the council in 8 making the information available on a single consumer 9 accessible Internet website that may be used by consumers for 10 comparative purposes to determine where they wish to receive 11 health care. 12 (g) Standards to reduce health-care-acquired infections and 13 medical errors.-- 14 (1) All hospitals and nursing homes shall adopt 15 evidence-based universal screening of patients and residents 16 for MRSA upon admission and randomized screening of 17 inpatients, residents and staff. If a screening results in a 18 positive culture, the patient or resident shall be isolated 19 and the hospital or nursing home shall take all actions 20 necessary to prevent the spread of MRSA to other inpatients, 21 residents or staff. The department shall develop acceptable 22 protocols for such screening and necessary isolation and 23 treatment and forward them to the Legislative Reference 24 Bureau for publication as a notice in the Pennsylvania 25 Bulletin within 180 days following the effective date of this 26 section. 27 (2) The department shall establish all of the following: 28 (i) Standardized best practices for health care 29 facilities to adopt to eliminate health-care-acquired 30 infections and medical errors and to maintain patient 20070H0700B1011 - 85 -
1 safety. 2 (ii) A date by which health care facilities shall 3 adopt the standards as a condition of licensure. 4 (3) The department shall not issue or renew a license to 5 a health care facility that fails to meet the requirements of 6 this subsection and demonstrates that it has made substantial 7 progress toward the elimination of health-care-acquired 8 infections and medical errors. 9 (h) Patient safety training.-- 10 (1) As a condition of receiving a license from the 11 department under the Health Care Facilities Act and as a 12 condition of continued licensure under that act, the 13 following shall apply: 14 (i) Each hospital shall ensure that every licensee 15 providing clinical services in the hospital, every chief 16 executive officer, chief financial officer and chief 17 medical officer, and every officer and director of the 18 hospital board of directors receives at least six hours 19 of in-person and monitored training in patient safety and 20 continuous quality improvement every two years. 21 (ii) Each nursing home shall ensure that its nursing 22 home administrator and director of nursing receives at 23 least six hours of in-person and monitored training in 24 patient safety and continuous quality improvement every 25 two years. 26 (2) Hospitals and nursing homes currently licensed will 27 have 12 months following the effective date of this section 28 to comply with this subsection. Hospitals and nursing homes 29 applying for a license for the first time following the 30 effective date of this section shall certify to the 20070H0700B1011 - 86 -
1 department that the persons described under paragraph (1) 2 have completed the requisite training within the preceding 3 12-month period as a condition of being licensed. 4 (3) The department shall issue guidelines with respect 5 to the particular types of patient safety education classes 6 that will be acceptable. The training shall emphasize the 7 integrated nature of patient safety and continuous quality 8 improvement. 9 (4) Documentation of training shall be maintained as 10 part of the records of the hospital or nursing home. 11 (5) The training requirements of this subsection are not 12 to be construed to add to any continuing education 13 requirements imposed by a State licensing board. 14 (6) For the fiscal year 2008-2009 and thereafter, the 15 State Board of Medicine shall not approve for accreditation 16 any graduate medical education program in this Commonwealth 17 that does not require a minimum of six hours of patient 18 safety training focused on eliminating health-care-acquired 19 infections, preventing medical errors and integrating safe 20 practices into the clinical environment. 21 (i) Clinical skills assessments.--The State Board of 22 Medicine may utilize a program similar to the impaired 23 professional program through which a licensee may be referred 24 for a clinical skills assessment and undertake a subsequent plan 25 to improve clinical skills or otherwise address any clinical 26 skills deficiencies, if the State Board of Medicine has 27 evaluated the program and approved its use by licensees of the 28 board. Once approved, the board shall have the authority to 29 defer disciplinary or corrective action, provided that the 30 licensee enters into an agreement with the board to undergo the 20070H0700B1011 - 87 -
1 assessment and continues to completion with a plan acceptable to 2 the board to address any deficiency. 3 (j) Enforcement.--In addition to any other remedy available, 4 the council may impose a civil penalty of up to $500 per day for 5 each failure of a facility to provide the council the 6 information required under this section. All fines collected 7 under this subsection shall be deposited in the CAP Fund. 8 § 7403. Smoking restrictions. 9 (a) Restrictions.--Smoking shall not be permitted and no 10 individual shall smoke in any of the following indoor areas: 11 (1) Places of employment. 12 (2) Bars. 13 (3) Food service establishments. 14 (4) Enclosed indoor areas open to the public. 15 (5) Means of mass transportation, including subways, 16 underground subway stations and, when occupied by passengers, 17 buses, including school buses, vans, taxicabs and limousines. 18 (6) Ticketing, boarding and waiting areas in public 19 transportation terminals. 20 (7) A public or private facility that houses or treats 21 children and youth, including youth detention centers and 22 group homes except for facilities in private homes. 23 (8) A facility that provides child-care services. 24 Services provided in a private home are excluded from this 25 paragraph if children enrolled in the child-care services are 26 not present. 27 (9) Public and private colleges, universities and other 28 educational and vocational institutions. 29 (10) Health care facilities where individuals reside. 30 This paragraph shall not prohibit smoking by patients in 20070H0700B1011 - 88 -
1 separate enclosed rooms of residential health care 2 facilities, adult care facilities, community mental health 3 residences or facilities where day treatment programs are 4 provided, which are designated as smoking rooms for patients 5 of the facilities or programs and which are ventilated to the 6 outside. 7 (11) Commercial establishments used for the purpose of 8 carrying on or exercising any trade, profession, vocation or 9 charitable activity. 10 (12) Indoor arenas. 11 (13) Zoos. 12 (14) Facilities where bingo, as defined in the act of 13 July 10, 1981 (P.L.214, No.67), known as the Bingo Law, is 14 played. 15 (15) Licensed facilities, as defined under 4 Pa.C.S. § 16 1103 (relating to definitions), or any other similar type of 17 facility authorized under State law. 18 (b) Signage.--"Smoking" or "No Smoking" signs, or the 19 international "No Smoking" symbol, which consists of a pictorial 20 representation of a burning cigarette in a circle with a bar 21 across it, shall be prominently posted and properly maintained 22 where smoking is regulated by this section, by the owner, 23 operator, manager or other person having control of the area. 24 The owner, operator or manager of a hotel or motel that chooses 25 to develop and implement a smoking policy for rooms rented to 26 guests shall post a notice at the reception area of the 27 establishment as to the availability, upon request, of rooms in 28 which no smoking is allowed. 29 (c) Exceptions.--The provisions of this section shall not 30 apply to any of the following: 20070H0700B1011 - 89 -
1 (1) Private homes, private residences and private 2 automobiles. 3 (2) A hotel or motel room rented to one or more guests. 4 (3) Retail tobacco businesses. 5 (4) Cigar bars that, in the calendar year ending 6 December 31, 2005, generated 10% or more of their total 7 annual gross income from the onsite sale of tobacco products 8 and the rental of onsite humidors, not including any sales 9 from vending machines. 10 (d) Relationship to other laws.--Smoking may not be 11 permitted where prohibited by any other law, rule or regulation 12 of any Commonwealth agency or any political subdivision. Nothing 13 in this section shall be construed to restrict the power of any 14 political subdivision to adopt and enforce additional local 15 laws, ordinances or regulations which comply with at least the 16 minimum applicable standards set forth under this section. 17 (e) Prohibited acts.--The following shall be unlawful: 18 (1) For any person that owns, manages, operates or 19 otherwise controls the use of an area in which smoking is 20 prohibited or restricted under this section to fail to comply 21 with the provisions of this section, except that it shall be 22 an affirmative defense that during the relevant time period 23 actual control of the area was not exercised by the person, 24 but rather by a lessee, a sublessee or another person. To 25 establish an affirmative defense, the owner, manager, 26 operator or person who controls the area shall submit an 27 affidavit and may submit any other relevant proof indicating 28 that the person did not exercise actual control of the area 29 during the relevant time period. The affidavit and other 30 proof shall be sent by certified mail to the appropriate 20070H0700B1011 - 90 -
1 enforcement officer within 30 days of receipt by the person 2 of a notice of violation. 3 (2) For an employer whose place of employment is subject 4 to this section to fail to comply with the provisions of this 5 section, except that it shall be an affirmative defense that 6 the employer has made a good faith effort to ensure that 7 employees comply with the provisions of this section. 8 (3) For an individual to smoke in any area where smoking 9 is prohibited or restricted under this section. 10 (f) Penalty for unlawful conduct.-- 11 (1) If the enforcement officer determines that a 12 violation of subsection (e) has occurred, the enforcement 13 officer may impose a civil penalty of not less than $250 for 14 the first offense, $500 for the second offense and $1,000 for 15 each subsequent offense. In addition, a court of competent 16 jurisdiction may order immediate compliance with the 17 provisions of this section. 18 (2) The enforcement officer may bring an action to 19 recover the civil penalty provided under paragraph (1) in any 20 court of competent jurisdiction. A civil penalty recovered 21 under the provisions of this section shall be recovered by 22 and in the name of the county board of health or the county 23 for whom the enforcement officer has been designated. 24 (g) Enforcement officer.--If a county does not have a board 25 of health, the governing body of the county shall, by resolution 26 adopted within 30 days following the effective date of this 27 section, designate an officer for the purpose of enforcing this 28 section. The designation shall be filed with the department 29 within 30 days after adoption and shall be effective 30 days 30 after it is filed with the department. The enforcement officer 20070H0700B1011 - 91 -
1 shall have sole jurisdiction to enforce the provisions of this 2 section on a countywide basis under the guidelines developed and 3 published by the department. Any person who desires to register 4 a complaint under this section may do so with the appropriate 5 enforcement officer. 6 CHAPTER 75 7 MISCELLANEOUS PROVISIONS 8 Sec. 9 7501. Regulations. 10 7502. Enforcement. 11 7503. Severability. 12 § 7501. Regulations. 13 (a) Regulations promulgated under this part.--Except as 14 otherwise provided in this part, the promulgation of regulations 15 under this part by Commonwealth agencies given the authority to 16 promulgate regulations shall, until three years from the 17 effective date of this section, be exempt from the following: 18 (1) Section 205 of the Commonwealth Documents Law. 19 (2) The Commonwealth Attorneys Act. 20 (3) The Regulatory Review Act. 21 (b) Other regulations.--If, in the determination of the head 22 of a Commonwealth agency given authority to promulgate 23 regulations under this part, rulemaking is needed for purposes 24 of the safety of patients in this Commonwealth, the Commonwealth 25 agency may promulgate a final-omitted regulation under the 26 Regulatory Review Act. 27 § 7502. Enforcement. 28 (a) Determination of violation.--Upon a determination that a 29 person licensed by the Insurance Department has violated any 30 provision of this part, the department may, subject to 2 Pa.C.S. 20070H0700B1011 - 92 -
1 Chs. 5 Subch. A (relating to practice and procedure of 2 Commonwealth agencies) and 7 Subch. A (relating to judicial 3 review of Commonwealth agency action) do any of the following: 4 (1) Issue an order requiring the person to cease and 5 desist from engaging in the violation. 6 (2) Suspend or revoke or refuse to issue or renew the 7 certificate or license of the offending party or parties. 8 (3) Impose an administrative penalty of up to $5,000 for 9 each violation. 10 (4) Seek restitution. 11 (5) Impose any other penalty or pursue any other remedy 12 deemed appropriate by the commissioner. 13 (b) Other remedies.--The enforcement remedies imposed under 14 this section are in addition to any other remedies or penalties 15 which be imposed by any other applicable statute, including the 16 act of July 22, 1974 (P.L.589, No.205), known as the Unfair 17 Insurance Practices Act. A violation by any person of this part 18 is deemed an unfair method of competition and an unfair or 19 deceptive act of practice under the Unfair Insurance Practices 20 Act. 21 (c) No private cause of action.--Nothing in this part shall 22 be construed as to create or imply a private cause of action for 23 violation of this part. 24 § 7503. Severability. 25 (a) General rule.--The provisions of this part are 26 severable. If any provision of this part or its application to 27 any person or circumstance is held invalid, the invalidity shall 28 not affect other provisions or applications of this part which 29 can be given effect without the invalid provision or 30 application. 20070H0700B1011 - 93 -
1 (b) Limitation.--If the provisions of section 7203(b)(2) 2 (relating to fair share tax) are declared invalid by a court of 3 competent jurisdiction and the decision is affirmed on its 4 highest appeal or the appeal period expires without appeal being 5 filed, the commissioner shall transmit notice of this fact to 6 the Legislative Reference Bureau for publication as a notice in 7 the Pennsylvania Bulletin. Thereafter, subsection (c) shall be 8 effective in its place and stead. 9 (c) Alternate provision.--An employer that offers health 10 care coverage to each of its employees who works 30 hours per 11 week or more following no more than 90 days of continued 12 employment during any fiscal year shall be entitled to an annual 13 credit against the fair share tax in an amount equal to 3% of 14 the employer's wages for fiscal years 2007-2008 through 2009- 15 2010 and 3.5% of the employer's wages for fiscal years 16 commencing after June 30, 2010. 17 Section 2. Repeals are as follows: 18 (1) The General Assembly declares as follows: 19 (i) The repeal under paragraph (2)(vi) is necessary 20 to effectuate the addition of 40 Pa.C.S. § 7202. 21 (ii) The repeal under paragraph (2)(v) is necessary 22 to effectuate the addition 40 Pa.C.S. § 7204. 23 (iii) The repeal under paragraph (2)(iv) is 24 necessary to effectuate the addition of 40 Pa.C.S. §§ 25 7209 and 7402. 26 (iv) The repeals under paragraph (2)(i), (ii) and 27 (iii) are necessary to effectuate the addition of 40 28 Pa.C.S. § 7303. 29 (2) Subject to section 3 of this act, the following acts 30 and parts of acts are repealed to the extent specified: 20070H0700B1011 - 94 -
1 (i) The last sentence of section 8.3(b) of the act 2 of May 22, 1951 (P.L.317, No.69), known as The 3 Professional Nursing Law, absolutely. 4 (ii) Section 8.4 of The Professional Nursing Law, 5 absolutely. 6 (iii) The last sentence of section 13(e) of the act 7 of December 20, 1985 (P.L.457, No.112), known as the 8 Medical Practice Act of 1985, absolutely. 9 (iv) The first sentence of section 19 of the act of 10 July 8, 1986 (P.L.408, No.89), known as the Health Care 11 Cost Containment Act, absolutely. 12 (v) Section 3(e)(4) and (5) of the act of December 13 18, 1996 (P.L.1066, No.159), known as the Accident and 14 Health Filing Reform Act, absolutely. 15 (vi) Chapter 13 of the act of June 26, 2001 16 (P.L.755, No.77), known as the Tobacco Settlement Act, 17 absolutely. 18 (3) All other acts and parts of acts are repealed 19 insofar as they are inconsistent with this act. 20 Section 3. Savings from repeal are as follows: 21 (1) Notwithstanding section 2(2)(iv) of this act, the 22 Legislative Budget and Finance Committee shall prepare the 23 report required by section 19 of the act of July 8, 1986 24 (P.L.408, No.89), known as the Health Care Cost Containment 25 Act, but the committee need not comment on the 26 reauthorization of the Health Care Cost Containment Council. 27 (2) Notwithstanding section 2(2)(vi) of this act, funds 28 appropriated under section 306(b)(1)(vi) of the act of June 29 26, 2001 (P.L.755, No.77), known as the Tobacco Settlement 30 Act, for the program established in former Chapter 13 of that 20070H0700B1011 - 95 -
1 act shall be deposited in the CAP Fund under 40 Pa.C.S. § 2 7202. 3 Section 4. The tax imposed by 40 Pa.C.S. § 7203(a) shall 4 apply to wages paid by employers commencing with the first full 5 calendar quarter after the effective date of 40 Pa.C.S. § 6 7203(a). 7 Section 5. This act shall take effect as follows: 8 (1) The addition of 40 Pa.C.S. § 7202(a) through (o) and 9 (q) shall take effect 30 days after publication of the notice 10 under 40 Pa.C.S. § 7202(p). 11 (2) The addition of the following provisions of Title 40 12 shall take effect in 30 days: 13 (i) Section 7203. 14 (ii) Section 7205. 15 (iii) Section 7303. 16 (3) Section 2(2)(vi) of this act shall take effect upon 17 publication of the notice under 40 Pa.C.S. § 7202(p). 18 (4) The remainder of this act shall take effect 19 immediately. C14L40RLE/20070H0700B1011 - 96 -