PRINTER'S NO. 2195
No. 1660 Session of 2007
INTRODUCED BY MANDERINO, McILVAINE SMITH, BELFANTI, BISHOP,
BLACKWELL, BRENNAN, CALTAGIRONE, CURRY, FREEMAN, GALLOWAY,
GIBBONS, HANNA, HARKINS, JAMES, MAHONEY, McGEEHAN, MYERS,
M. O'BRIEN, OLIVER, PARKER, PETRONE, ROEBUCK, SIPTROTH,
STEIL, TANGRETTI, WALKO, WOJNAROSKI, YOUNGBLOOD, CRUZ AND
THOMAS, JULY 3, 2007
REFERRED TO COMMITTEE ON HEALTH AND HUMAN SERVICES, JULY 3, 2007
AN ACT
1 Providing for a Statewide comprehensive health care system;
2 establishing the Pennsylvania Health Care Plan and providing
3 for eligibility, services, coverages, subrogation,
4 participating providers, cost containment, reduction of
5 errors, tort remedies, administrative remedies and
6 procedures, attorney fees, quality assurance,
7 nonparticipating providers, transitional support and
8 training; and establishing the Pennsylvania Health Care
9 Agency, the Employer Health Services Levy, the Individual
10 Wellness Tax and the Pennsylvania Health Care Board and
11 providing for their powers and duties.
12 TABLE OF CONTENTS
13 Chapter 1. Preliminary Provisions
14 Section 101. Short title.
15 Section 102. Definitions.
16 Chapter 3. Administration and Oversight of the Pennsylvania
17 Health Care Plan
18 Subchapter A. Pennsylvania Health Care Board
19 Section 301. Organization.
20 Section 302. Duties of board.
1 Subchapter B. Pennsylvania Health Care Agency
2 Section 321. Pennsylvania Health Care Agency.
3 Section 322. Executive director duties.
4 Section 323. Administrator for planning, research and
5 development.
6 Section 324. Administrator for consumer affairs and health
7 education.
8 Section 325. Administrator for quality assurance.
9 Section 326. Administrator for finance.
10 Section 327. Administrator for claims.
11 Section 328. Administrator for volunteer services.
12 Section 329. Administrator for provider coordination.
13 Section 330. Administrator for law.
14 Section 331. Administrator for transition services.
15 Section 332. Administrator for beneficiary advocate.
16 Subchapter C. (Reserved).
17 Subchapter D. (Reserved).
18 Subchapter E. (Reserved).
19 Subchapter F. Immunity
20 Section 371. Immunity.
21 Chapter 5. Pennsylvania Health Care Plan
22 Section 501. General provisions.
23 Section 502. Universal health care access eligibility.
24 Section 503. Covered services.
25 Section 504. Excess and collective bargaining agreement health
26 insurance coverage.
27 Section 505. Duplicate coverage.
28 Section 506. Subrogation.
29 Section 507. Eligible participating providers and availability
30 of services.
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1 Section 508. Rational cost containment.
2 Chapter 7. No-Fault Administrative Remedies
3 Section 701. Rationalization of remedies for errors and
4 complications.
5 Section 702. Voluntary waiver of tort remedies and choice
6 to retain tort remedies.
7 Section 703. No-fault administrative remedies for those not
8 opting out.
9 Section 704. Administrative claims procedures.
10 Section 705. Beneficiary right to counsel.
11 Section 706. Quality assurance follow-up to claims.
12 Section 707. Surviving tort claims against participating
13 providers.
14 Section 708. Claims against nonparticipating providers.
15 Section 709. Parallel no-fault compensation for beneficiaries
16 injured by nonparticipating providers.
17 Chapter 9. Pennsylvania Health Care Trust Fund
18 Section 901. Pennsylvania Health Care Trust Fund.
19 Section 902. Rolling budget process.
20 Section 903. Limitation on administrative expense.
21 Section 904. Funding sources.
22 Chapter 11. Transitional Support and Training for Displaced
23 Workers
24 Section 1101. Transitional support and training for displaced
25 workers.
26 Chapter 13. Volunteer Emergency Responder Network
27 Section 1301. Preservation of volunteer emergency responder
28 network.
29 Section 1302. Eligibility certification.
30 Section 1303. Eligibility criteria.
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1 Section 1304. Amount of tax credit.
2 Section 1305. Reimbursement of Department of Revenue.
3 Chapter 15. Miscellaneous Provisions
4 Section 1501. Effective date.
5 The General Assembly of the Commonwealth of Pennsylvania
6 hereby enacts as follows:
7 CHAPTER 1
8 PRELIMINARY PROVISIONS
9 Section 101. Short title.
10 This act shall be known and may be cited as the Family and
11 Business Healthcare Security Act.
12 Section 102. Definitions.
13 The following words and phrases when used in this act shall
14 have the meanings given to them in this section unless the
15 context clearly indicates otherwise:
16 "Agency." The Pennsylvania Health Care Agency established
17 under this act.
18 "Board." The Pennsylvania Health Care Board established
19 under this act.
20 "Department." The Department of Health of the Commonwealth.
21 "Executive director." The Executive Director of the
22 Pennsylvania Health Care Board.
23 "Fund." The Pennsylvania Health Care Trust Fund established
24 under this act.
25 "Individual Wellness Tax" or "IWT." The Individual Wellness
26 Tax established under this act.
27 "Plan." The Pennsylvania Health Care Plan established under
28 this act.
29 "Tax." The Employer Health Services Levy established under
30 this act.
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1 CHAPTER 3
2 ADMINISTRATION AND OVERSIGHT OF THE
3 PENNSYLVANIA HEALTH CARE PLAN
4 SUBCHAPTER A
5 PENNSYLVANIA HEALTH CARE BOARD
6 Section 301. Organization.
7 (a) Composition.--The Pennsylvania Health Care Board shall
8 be composed of 11 voting members and shall be chaired by the
9 executive director.
10 (b) Appointments.--
11 (1) The executive director shall be appointed by the
12 Governor. The members of the board shall be appointed by the
13 Governor, the President pro tempore of the Senate, and the
14 Speaker of the House of Representatives who collectively
15 shall make appointments of members from individuals
16 representative of each of the following constituencies:
17 (i) Hospitals.
18 (ii) Organized labor, private sector.
19 (iii) Consumers.
20 (iv) Business.
21 (v) Agriculture.
22 (vi) Physicians.
23 (vii) Public sector employees.
24 (viii) Nurses.
25 (ix) Pharmacists.
26 (x) Long-term care facilities.
27 (xi) Social workers.
28 (2) The Governor shall initially appoint the executive
29 director, who shall serve as chair of the board, appointments
30 of the members shall thereafter be made in a rotating fashion
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1 beginning with the President pro tempore of the Senate, then
2 the Speaker of the House of Representatives and then the
3 Governor, with each in turn making an appointment from a
4 constituency category not previously filled.
5 (c) Terms of members.--Each member appointed or reappointed
6 under this section shall hold office for three years, starting
7 on the first day of the first month following the member's
8 appointment. A serving member of the board shall continue to
9 serve following the expiration of the member's term until a
10 successor takes office or a period of 90 days has elapsed,
11 whichever occurs first.
12 (d) Midterm vacancies.--Midterm vacancies shall be filled by
13 the same appointer and the individual appointed to fill a
14 vacancy occurring prior to the expiration of the term for which
15 a member is appointed shall hold office for the remainder of the
16 predecessor's term.
17 (e) Compensation, benefits and expenses.--The executive
18 director and members of the board shall receive an annual
19 salary, benefits and expense reimbursement established by the
20 board, to be paid from the trust. The initial board shall
21 establish its own compensation. No increase or decrease in
22 salary or benefits adopted by the board for the executive
23 director or members shall become effective within the same
24 three-year term.
25 (f) Meetings.--
26 (1) The executive director shall set the time, place and
27 date for the initial and subsequent meetings of the board and
28 shall preside over its meetings. The initial meeting shall be
29 set not sooner than 50 nor later than 100 days after the
30 appointment of the executive director. Subsequent meetings
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1 shall occur at least monthly thereafter.
2 (2) All meetings of the board are open to the public
3 unless questions of patient confidentiality arise. The board
4 may go into closed executive session with regard to issues
5 related to confidential patient information.
6 (g) Quorum.--Two-thirds of the appointed members of the
7 board shall constitute a quorum for the conducting of business
8 at meetings of the board. Decisions at ordinary meetings of the
9 board shall be reached by majority vote of those actually
10 present or, in the event of emergency meeting, those also
11 present by electronic or telephonic means. Where there is a tie
12 vote, the executive director shall be granted an additional vote
13 to break the tie.
14 (h) Ethics.--The executive director, the members and their
15 immediate families are prohibited from having any pecuniary
16 interest in any business with a contract or in negotiation for a
17 contract with the agency. The board shall also adopt rules of
18 ethics and definitions of irreconcilable conflicts of interest
19 that will determine under what circumstances members must recuse
20 themselves from voting.
21 (i) Prohibitions.--No member of the board, except for the
22 executive director, who shall receive no additional salary or
23 benefits by virtue of serving on the board, shall hold any other
24 salaried Commonwealth public position, either elected or
25 appointed, during the member's tenure on the board.
26 Section 302. Duties of board.
27 (a) General duties.--The board is responsible for directing
28 the agency in the performance of all duties, the exercise of all
29 powers, and the assumption and discharge of all functions vested
30 in the agency. The board shall adopt and publish its rules and
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1 procedures in the Pennsylvania Bulletin no later than 180 days
2 after the first meeting of the board.
3 (b) Specific duties.--The duties and functions of the board
4 include, but are not limited to, the following:
5 (1) Implementing statutory eligibility standards for
6 benefits.
7 (2) Annually adopting a benefits package for
8 participants of the plan.
9 (3) Acting directly or through one or more contractors
10 as the single payer administrator for all claims for health
11 care services made under the plan.
12 (4) At least annually reviewing the appropriateness and
13 sufficiency of reimbursements.
14 (5) Providing for timely payments to participating
15 providers through a structure that is well organized and that
16 eliminates unnecessary administrative costs.
17 (6) Implementing standardized claims and reporting
18 methods for use by the plan.
19 (7) Developing a system of centralized electronic claims
20 and payments accounting.
21 (8) Establishing an enrollment system that will ensure
22 that those who travel frequently and cannot read or speak
23 English are aware of their right to health care and are
24 formally enrolled in the plan.
25 (9) Reporting annually to the General Assembly and to
26 the Governor, on or before the first day of October, on the
27 performance of the plan, the fiscal condition of the plan,
28 recommendations for statutory changes, the receipt of
29 payments from the Federal Government, whether current year
30 goals and priorities were met, future goals and priorities,
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1 and major new technology or prescription drugs that may
2 affect the cost of the health care services provided by the
3 plan.
4 (10) Administering the revenues of the trust.
5 (11) Obtaining appropriate liability and other forms of
6 insurance to provide coverage for the plan, the board, the
7 agency and their employees and agents.
8 (12) Establishing, appointing and funding appropriate
9 staff, office space, equipment, training and administrative
10 support for the agency throughout this Commonwealth, all to
11 be paid from the trust.
12 (13) Administering aspects of the agency by taking
13 actions that include, but are not limited to, the following:
14 (i) Establishing standards and criteria for the
15 allocation of operating funds.
16 (ii) Meeting regularly to review the performance of
17 the agency and to adopt and revise its policies.
18 (iii) Establishing goals for the health care system
19 established pursuant to the plan in measurable terms.
20 (iv) Establishing Statewide health care databases to
21 support health care services planning.
22 (v) Implementing policies and developing mechanisms
23 and incentives to assure culturally and linguistically
24 sensitive care.
25 (vi) Establishing rules and procedures for
26 implementation and staffing of a no-fault compensation
27 system for iatrogenic injuries or complications of care
28 whereby a patient's condition is made worse or an
29 opportunity for cure or improvement is lost due to the
30 health care or medications provided or appropriate care
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1 not provided by participating providers under the plan.
2 (vii) Establishing standards and criteria for the
3 determination of appropriate transitional support and
4 training for residents of this Commonwealth who are
5 displaced from work during the first two years of the
6 implementation of the plan.
7 (viii) Evaluating the state of the art in proven
8 technical innovations, medications and procedures and
9 adopting policies to expedite the rapid introduction
10 thereof in this Commonwealth.
11 (ix) Establishing methods for the recovery of costs
12 for health care services provided pursuant to the plan to
13 a beneficiary who is also covered under the terms of a
14 policy of insurance, a health benefit plan or other
15 collateral source available to the participant under
16 which the participant has a right of action for
17 compensation. Receipt of health care services pursuant to
18 the plan shall be deemed an assignment by the participant
19 of any right to payment for services from any such
20 policy, plan or other source. The other source of health
21 care benefits shall pay to the trust all amounts it is
22 obligated to pay to, or on behalf of, the participant for
23 covered health care services. The board may commence any
24 action necessary to recover the amounts due.
25 (14) Recruiting the Health Advisory Panel of seven
26 members made up of a cross section of the medical and
27 provider community. The members of the advisory panel shall
28 be paid a per diem rate, established by the board, for
29 attendance at meetings and further be reimbursed for actual
30 and necessary expenses incurred in the performance of their
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1 duties, which shall include:
2 (i) Advising the board on the establishment of
3 policy on medical issues, population-based public health
4 issues, research priorities, scope of services, expansion
5 of access to health care services and evaluation of the
6 performance of the plan.
7 (ii) Investigating proposals for innovative
8 approaches to the promotion of health, the prevention of
9 disease and injury, patient education, research and
10 health care delivery.
11 (iii) Advising the board on the establishment of
12 standards and criteria to evaluate requests from health
13 care facilities for capital improvements.
14 (iv) Evaluating and advising the board on requests
15 from providers, or their representatives, for adjustments
16 to reimbursements.
17 (15) Establishing a secure and centralized electronic
18 health record system wherein a beneficiary's entire health
19 record can be readily and reliably accessed by authorized
20 persons with the objective of eliminating the errors and
21 expense associated with paper records and diagnostic films.
22 SUBCHAPTER B
23 PENNSYLVANIA HEALTH CARE AGENCY
24 Section 321. Pennsylvania Health Care Agency.
25 (a) Establishment of agency.--There is hereby established
26 the Pennsylvania Health Care Agency. The agency shall administer
27 the plan and is the sole agency authorized to accept applicable
28 grants-in-aid from the Federal Government and State government.
29 It shall use such funds in order to secure full compliance with
30 provisions of Federal and State law and to carry out the
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1 purposes established under this act. All grants-in-aid accepted
2 by the agency shall be deposited into the Pennsylvania Health
3 Care Trust Fund established under this act, together with other
4 revenues raised within this Commonwealth to fund the plan.
5 (b) Appointment of executive director.--The executive
6 director of the agency shall be appointed by the Governor for a
7 term of three years and is the chief administrator of the plan.
8 (c) Personnel and employees.--The board shall employ and fix
9 the compensation of agency personnel as needed by the agency to
10 properly discharge the agency's duties. The employment of
11 personnel by the board is subject to the civil service laws of
12 this Commonwealth. The board shall employ personnel including,
13 but not limited to, the following leadership positions, all of
14 whom will report to the executive director of the agency:
15 (1) Administrator for planning, research and
16 development.
17 (2) Administrator for finance.
18 (3) Administrator for quality assurance.
19 (4) Administrator for consumer affairs and health
20 education.
21 (5) Administrator of health claims.
22 (6) Administrator for volunteer services.
23 (7) Administrator for provider coordination.
24 (8) Administrator for law.
25 (9) Administrator of transition services until the
26 termination of this position on December 31, 2012.
27 (10) Beneficiary advocate.
28 Section 322. Executive director duties.
29 The executive director shall oversee the operation of the
30 agency and the agency's performance of any duties assigned by
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1 the board.
2 Section 323. Administrator for planning, research and
3 development.
4 The executive director of the agency shall determine the
5 duties of the administrator of planning, research and
6 development. Those duties shall include, but not be limited to,
7 the following:
8 (1) Establishing policy on medical issues, population-
9 based public health issues, research priorities, scope of
10 services, the expansion of participants' access to health
11 care services and the evaluation of the performance of the
12 plan.
13 (2) Investigating proposals for innovative approaches
14 for the promotion of health, the prevention of disease and
15 injury, patient education, research and the delivery of
16 health care services.
17 (3) Establishing standards and criteria for evaluating
18 applications from health care facilities for capital
19 improvements.
20 (4) Evaluating environmental risks and coordinating
21 agency policy with other governmental and nongovernmental
22 entities committed to assuring health by reducing
23 environmental hazards.
24 Section 324. Administrator for consumer affairs and health
25 education.
26 The executive director of the agency shall determine the
27 duties of the administrator for consumer affairs and health
28 education. Those duties shall include, but not be limited to,
29 the following:
30 (1) Developing educational and informational guides for
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1 consumers that describe consumer rights and responsibilities
2 and that inform consumers of effective ways to exercise
3 consumer rights to obtain health care services. The guides
4 shall be easy to read and understand and available in English
5 and in other languages. The agency shall make the guide
6 available to the public through public outreach and
7 educational programs and through the Internet website of the
8 agency.
9 (2) Establishing a toll-free telephone number to receive
10 questions and complaints regarding the agency and the
11 agency's services. The agency's Internet website shall
12 provide complaint forms and instructions online.
13 (3) Examining suggestions from the public.
14 (4) Making recommendations for improvements to the
15 board.
16 (5) Examining the extent to which individual health care
17 facilities in a region meet the needs of the community in
18 which they are located.
19 (6) Receiving, investigating and responding to all
20 consumer complaints about any aspect of the plan and, where
21 appropriate, referring the results of all investigations of
22 questioned care to the appropriate provider or health care
23 facility licensing board or, in cases of possible violation
24 of law, to a law enforcement agency.
25 (7) Publishing an annual report for the public, the
26 Governor and the General Assembly that contains a Statewide
27 evaluation of the agency.
28 (8) Holding public hearings in each congressional
29 district, at least annually, for public input.
30 Section 325. Administrator for quality assurance.
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1 The executive director of the agency shall determine the
2 duties of the administrator of quality assurance. Those duties
3 shall include, but not be limited to, the following:
4 (1) Studying and reporting on the efficacy of health
5 care treatments and medications for particular conditions.
6 (2) Identifying causes of medical errors and devising
7 procedures to reduce their frequency.
8 (3) Establishing an evidence-based formulary.
9 (4) Identifying treatments and medications that are
10 unsafe or have no proven value.
11 (5) Establishing a process for soliciting information on
12 medical standards from providers and consumers for purposes
13 of this section.
14 (6) Independently reviewing all claims submitted to the
15 administrator of health claims to determine if correctable
16 errors have occurred or whether there are patterns of errors
17 or complications which require closer investigation,
18 evaluation and correction, and then to assure all such
19 appropriate measures are recommended in writing to the
20 executive director.
21 Section 326. Administrator for finance.
22 The executive director of the agency shall determine the
23 duties of the administrator of finance. Those duties shall
24 include, but not be limited to, the following:
25 (1) Administering the trust.
26 (2) Making payments to participating providers within
27 five business days of submission and to other providers
28 within 30 days of submission.
29 (3) Developing a system of simplified, secure and
30 centralized electronic claims and payments employing the best
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1 technology with assured backup and catastrophe recovery
2 contingencies and facilities.
3 (4) Communicating to the State Treasurer when funds are
4 needed from the trust for the operation of the plan.
5 (5) Developing information systems for utilization
6 review.
7 (6) Investigating and recommending for appropriate civil
8 and/or criminal prosecution possible provider or consumer
9 fraud.
10 Section 327. Administrator for claims.
11 The executive director of the agency shall determine the
12 duties of the administrator of claims. Those duties shall
13 include, but not be limited to, the following:
14 (1) Establishing a system of administrative procedures,
15 health claim hearing officers and appeal panel for the
16 processing of patient claims.
17 (2) Supervising the health claims hearing officers to
18 assure swift and fair processing of claims.
19 (3) Reviewing all appeals from the determinations of the
20 health claims hearing officers, and then advising the
21 executive director who shall then make the final agency
22 determination.
23 (4) Supervising follow-up oversight of awarded claims to
24 determine when or if adjustments to the awarded compensation
25 is appropriate given improvement in the awardee's condition
26 and if so to initiate appropriate review procedures before
27 the health claims hearing officers.
28 Section 328. Administrator for volunteer services.
29 The executive director of the agency shall determine the
30 duties of the administrator for volunteer services. Those duties
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1 shall include, but not be limited to, the following:
2 (1) Coordinating with the State Treasurer to establish
3 procedures necessary to implement the volunteer tax rebate
4 provisions of this act.
5 (2) Investigating the status of volunteerism in this
6 Commonwealth in firefighting, search and rescue, emergency
7 response and otherwise as it pertains to the health of
8 Pennsylvanians and the means by which citizens can be
9 encouraged to volunteer.
10 (3) Developing programs to encourage blood and organ
11 donation in this Commonwealth.
12 (4) Making recommendations to the executive director and
13 the board for programs and initiatives that will best support
14 and encourage health-related volunteerism in this
15 Commonwealth.
16 Section 329. Administrator for provider coordination.
17 The executive director of the agency shall determine the
18 duties of the administrator for provider coordination. Those
19 duties shall include, but not be limited to, all of the
20 following:
21 (1) Processing all applications for participating
22 provider status.
23 (2) Assisting participating providers in their efforts
24 to meet the qualification requirements established by the
25 board.
26 (3) Establishing an inquiry office to assist
27 participating providers with regard to proper submission of
28 requests for reimbursements.
29 Section 330. Administrator for law.
30 The executive director of the agency shall determine the
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1 duties of the administrator for law. Those duties shall include,
2 but not be limited to, the following:
3 (1) Establishing, supervising and maintaining a team of
4 legal professionals as necessary to support all of the legal
5 representation needs of the agency.
6 (2) Defending the interests of the plan before the
7 health claims hearing officers and before the courts against
8 nonmeritorious claims.
9 (3) Representing the board in disciplinary actions
10 against participating providers.
11 (4) Serving as the principal ethics officer for the
12 agency.
13 Section 331. Administrator for transition services.
14 The executive director of the agency shall determine the
15 duties of the administrator of transition services. Those duties
16 shall include, but not be limited to, the following:
17 (1) Establishing procedures for identifying
18 Pennsylvanians whose livelihood will be detrimentally
19 affected by the passage of this act.
20 (2) Establishing procedures to most efficiently and
21 effectively transition such persons into positions with the
22 agency where appropriate or to other health-related fields
23 where the passage of this act will create an immediate need
24 for qualified employees.
25 (3) Reporting to the administrator of finance with
26 respect to the financial requirements to support the eligible
27 displaced citizens and to assist in the filing for
28 transitional wage replacement benefits approved by the board.
29 (4) Planning for the discontinuance of this division of
30 the board on December 31, 2012.
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1 Section 332. Administrator for beneficiary advocate.
2 The executive director of the agency shall determine the
3 duties of the beneficiary advocate. Those duties shall include,
4 but not be limited to, the following:
5 (1) Establishment of a readily accessible beneficiary
6 telephone and Internet website resource in instances where
7 they are having difficulties securing necessary care through
8 the plan. This office shall make immediate inquiries to
9 ascertain the nature of the difficulties and to resolve the
10 beneficiary's problem.
11 (2) Where a beneficiary seeks specialized care from
12 outside this Commonwealth and from other than a participating
13 provider, the beneficiary advocate shall assist in the proper
14 application for an extension of benefits on behalf of the
15 beneficiary.
16 (3) Management of death claim dependent trusts.
17 SUBCHAPTER C
18 (Reserved)
19 SUBCHAPTER D
20 (Reserved)
21 SUBCHAPTER E
22 (Reserved)
23 SUBCHAPTER F
24 IMMUNITY
25 Section 371. Immunity.
26 In the absence of fraud or bad faith, the advisory panel, the
27 board and agency and their respective members and employees
28 shall incur no liability in relation to the performance of their
29 duties and responsibilities under this act. The Commonwealth
30 shall incur no liability in relation to the implementation and
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1 operation of the plan.
2 CHAPTER 5
3 PENNSYLVANIA HEALTH CARE PLAN
4 Section 501. General provisions.
5 (a) Establishment of plan.--There is hereby established the
6 Pennsylvania Health Care Plan that shall be administered by the
7 independent Pennsylvania Health Care Agency under the direction
8 of the Pennsylvania Health Care Board.
9 (b) Coverage.--The plan shall provide health care coverage
10 for all citizens of this Commonwealth and for certain eligible
11 visitors. The agency shall work simultaneously to control health
12 care costs, achieve measurable improvement in health care
13 outcomes, promote a culture of health awareness, increase
14 satisfaction with the health care system, adopt an optional no-
15 fault administrative system to fairly compensate those whose
16 conditions are made worse by the treatments they receive or
17 through failures to receive appropriate care, implement policies
18 that strengthen and improve culturally sensitive care, and
19 develop an integrated health care database to support health
20 care planning and quality assurance.
21 (c) Reforms.--The board shall implement the reforms adopted
22 by the General Assembly hereby on January 1, 2008.
23 Section 502. Universal health care access eligibility.
24 (a) Eligibility.--All Pennsylvania citizens, including
25 documented aliens, full-time out-of-State students attending
26 school in this Commonwealth, homeless persons and migrant
27 agricultural workers and their accompanying families are
28 eligible beneficiaries under the plan. The board shall establish
29 standards and a simple procedure to demonstrate proof of
30 eligibility.
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1 (b) Enrollment.--Enrollment in the plan shall be automatic
2 and beneficiaries shall be provided with access cards with
3 appropriate proof of identity technology and privacy protection.
4 Individuals covered under a collective bargaining agreement that
5 provides health benefits at least as extensive as the plan, as
6 certified by the executive director, shall not be eligible for
7 plan benefits.
8 (c) Waivers.--If waivers are not obtained from the medical
9 assistance and/or Medicare programs operated under Title XVIII
10 or XIX of the Social Security Act (49 Stat. 620, 42 U.S.C. § 301
11 et seq.), the medical assistance and Medicare nonwaived programs
12 shall act as the primary insurers for those eligible for such
13 coverage, and the plan shall serve as the secondary or
14 supplemental plan of health coverage. Until such time as waivers
15 are obtained, the plan will not pay for services for persons
16 otherwise eligible for the same benefits under Medicare or
17 Medicaid. The plan shall also be secondary to benefits provided
18 to military veterans except where reasonable and timely access,
19 as defined by the board, is denied or unavailable through the
20 United States Veterans' Administration, in which instance the
21 plan will be primary and will seek reasonable reimbursement from
22 the United States Veterans' Administration for the services
23 provided to veterans.
24 (d) Priority of plans.--A plan of employee health coverage
25 provided by an out-of-State employer to a Pennsylvania resident
26 working outside of this Commonwealth shall serve as the
27 employee's primary plan of health coverage, and the plan shall
28 serve as the employee's secondary plan of health coverage.
29 (e) Reimbursement.--The plan shall reimburse participating
30 providers practicing outside of this Commonwealth at plan rates,
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1 or reasonable locally prevailing rate, for health care services
2 rendered to a beneficiary while the beneficiary is out of this
3 Commonwealth. Services provided to a beneficiary out of this
4 Commonwealth by other than a participating provider shall be
5 reimbursed to the beneficiary or to the provider at a fair and
6 reasonable rate for that location.
7 (f) Presumption of eligibility.--Any individual who arrives
8 at a health care facility unconscious or otherwise unable due to
9 their mental or physical condition to document eligibility for
10 coverage shall be presumed to be eligible, and emergency care
11 shall be provided without delay occasioned over issues of
12 ability to pay.
13 (g) Rules.--The board shall adopt rules assuring that any
14 participating provider who renders humanitarian emergency or
15 urgent care within this Commonwealth to a not actually eligible
16 recipient shall nevertheless be reimbursed for such care from
17 the plan subject to such rules as will reasonably limit the
18 frequency of such events to protect the fiscal integrity of the
19 plan. It shall be the agency's responsibility to secure
20 reimbursement for the costs paid for such care from any
21 appropriate third party funding source, or from the individual
22 to whom the services were rendered.
23 Section 503. Covered services.
24 (a) Benefits package.--The board shall establish a single
25 health benefits package within the plan that shall include, but
26 not be limited to, all of the following:
27 (1) Inpatient and outpatient care, both primary and
28 secondary.
29 (2) Emergency services.
30 (3) Emergency and other medically necessary transport to
20070H1660B2195 - 22 -
1 covered health services.
2 (4) Rehabilitation services, including speech,
3 occupational and physical therapy.
4 (5) Inpatient and outpatient mental health services and
5 substance abuse treatment.
6 (6) Hospice care.
7 (7) Prescription drugs and prescribed medical nutrition.
8 (8) Vision care, aids and equipment.
9 (9) Hearing care, hearing aids and equipment.
10 (10) Diagnostic medical tests, including laboratory
11 tests and imaging procedures.
12 (11) Medical supplies and prescribed medical equipment.
13 (12) Immunizations, preventive care, health maintenance
14 care and screening.
15 (13) Dental care.
16 (14) Home health care services.
17 (15) Chiropractic and massage therapy.
18 (16) Long-term care for those unable to care for
19 themselves independently and including assisted and skilled
20 care.
21 (b) Exclusions for preexisting conditions.--The plan shall
22 not exclude or limit coverage due to preexisting conditions.
23 (c) Copayments, deductibles, etc.--Beneficiaries of the plan
24 are not subject to copayments, deductibles, point-of-service
25 charges or any other fee or charge for a service within the
26 package and shall not be directly billed nor balance billed by
27 participating providers for covered benefits provided to the
28 beneficiary. Where a beneficiary has directly paid for
29 nonemergency services of a nonparticipating provider, the
30 beneficiary may submit a claim for reimbursement from the plan
20070H1660B2195 - 23 -
1 for the amount the plan would have paid a participating provider
2 for the same service. Where emergency services are rendered by a
3 nonparticipating provider, the beneficiary shall receive
4 reimbursement of the full amount paid to such nonparticipating
5 provider not to exceed 125% of the amount the plan would have
6 paid a participating provider for the same service.
7 (d) Exclusions of coverage.--The board shall remove or
8 exclude procedures and treatments, equipment and prescription
9 drugs from the plan benefit package that the board finds unsafe
10 or that add no therapeutic value.
11 (e) The board shall exclude coverage for any surgical,
12 orthodontic or other procedure or drug that the board determines
13 was or will be provided primarily for cosmetic purposes unless
14 required to correct a congenital defect, to restore or correct
15 disfigurements resulting from injury or disease or that is
16 certified to be medically necessary by a qualified, licensed
17 provider.
18 (f) Choice by beneficiary.--Beneficiaries shall normally be
19 granted free choice of the participating providers, including
20 specialists, without preapprovals or referrals. However, the
21 board shall adopt procedures to restrict such free choice for
22 those individuals who engage in patterns of wasteful or abusive
23 self-referrals to specialists. Specialists who provide primary
24 care to a self-referred beneficiary will be reimbursed at the
25 board-approved primary care rate established for the service in
26 that community.
27 (g) Service.--No participating provider shall be compelled
28 to offer any particular service so long as the refusal is
29 general, consistent and not discriminatory.
30 (h) Discrimination.--The plan and participating providers
20070H1660B2195 - 24 -
1 shall not discriminate on the basis of race, ethnicity, national
2 origin, gender, age, religion, sexual orientation, health
3 status, mental or physical disability, employment status,
4 veteran status or occupation.
5 Section 504. Excess and collective bargaining agreement health
6 insurance coverage.
7 Subject to the regulations of the Insurance Commissioner and
8 all applicable laws, private health insurers shall be authorized
9 to offer coverage supplemental to the package approved and
10 provided automatically under this act. Private insurers shall
11 also be authorized to offer programs to support the health care
12 terms of a collective bargaining agreement provided that such
13 benefits are at least as comprehensive as those provided under
14 the plan.
15 Section 505. Duplicate coverage.
16 The agency is subrogated to and shall be deemed an assignee
17 of all rights of a beneficiary who has received duplicate health
18 care benefits, or who has a right to such benefits, under any
19 other policy or contract of health care or under any government
20 program.
21 Section 506. Subrogation.
22 (a) General rule.--The agency shall have no right of
23 subrogation against a beneficiary's third-party claims for harm
24 or losses not covered under this act. Nor shall any beneficiary
25 under this act have a claim against a third-party tortfeasor for
26 the services provided or available to the beneficiary under this
27 act. In all personal injury actions accruing and prosecuted by a
28 beneficiary on or after January 1, 2008, the presiding judge
29 shall advise any jury that all health care expenses have been or
30 will be paid under the plan, and, therefore, no claim for past
20070H1660B2195 - 25 -
1 or future health care benefits is pending before the court.
2 (b) Exception.--The exception to the general rule of no
3 subrogation shall be that the agency retains its equitable right
4 to subrogation to the recovery, including the recovery for
5 noneconomic damages, of those persons opting out of the no-fault
6 administrative remedies adopted herein and who successfully
7 prosecute to verdict or settlement a claim for health care
8 professional or institutional negligence. The agency's right to
9 subrogation shall be absolute and shall not be subject to
10 reduction for attorney fees or costs of litigation.
11 Section 507. Eligible participating providers and availability
12 of services.
13 (a) General rule.--All licensed health care providers and
14 facilities are eligible to become a participating provider in
15 the plan in which instance they shall enjoy the rights and have
16 the duties as set forth in the plan as stated in this section or
17 as adopted by the board from time to time. Nonparticipating
18 providers shall not enjoy the rights nor bear the duties of
19 participating providers.
20 (b) Required notice.--In advance of initially providing
21 services to a beneficiary, nonparticipating providers shall
22 advise the beneficiary at the time the appointment is made that
23 the person or entity is a nonparticipating provider and that the
24 recipient of the service will be initially personally
25 responsible for the entire cost of the service and ultimately
26 responsible for the cost in excess of the reimbursement approved
27 by the board for participating providers. Failure to make such
28 financial disclosure will be deemed a fraud on the beneficiary
29 and entitle the beneficiary to a refund equal to 200% of the
30 amount paid to the nonparticipating provider in excess of the
20070H1660B2195 - 26 -
1 board-approved reimbursement for the services rendered, plus all
2 reasonable fees for collection. The burden of proof that such
3 disclosure was made shall be on the nonparticipating provider.
4 (c) Plan by board.--The board shall assess the number of
5 primary and specialty providers needed to supply adequate health
6 care services in this Commonwealth generally and in all
7 geographic areas and shall develop a plan to meet that need. The
8 board shall develop financial incentives for participating
9 providers in order to maintain and increase access to health
10 care services in underserved areas of this Commonwealth.
11 (d) Reimbursements.--Reimbursements shall be determined by
12 the board in such a fashion as to assure that a participating
13 provider receives compensation for services that fairly and
14 fully reflect the skill, training, operating overhead included
15 in the costs of providing the service, capital costs of
16 facilities and equipment, cost of consumables and the expense of
17 safely discarding medical waste, plus a reasonable profit
18 sufficient to encourage talented individuals to enter the field
19 and for investors to make capital available for the construction
20 of state-of-the-art health care facilities in this Commonwealth.
21 (e) Adjustments to reimbursements.--Participating providers
22 shall have the right alone or collectively to petition the board
23 for adjustments to reimbursements believed to be too low. Such
24 petitions shall be initially evaluated by the administrator of
25 provider services, with input from the Health Advisory Panel,
26 who shall submit a report to the executive director within 30
27 days. The executive director will then submit a recommendation
28 to the board for action at the next scheduled board meeting.
29 Participating providers who remain dissatisfied after the board
30 has ruled may appeal the board's determination to the Court of
20070H1660B2195 - 27 -
1 Common Pleas of Dauphin County, which shall review the action of
2 the board on an abuse of discretion standard.
3 (f) Evaluation of access to care.--The board annually shall
4 evaluate access to trauma care, diagnostic imaging technology,
5 emergency transport and other vital urgent care requirements and
6 shall establish measures to assure beneficiaries have equitable
7 and ready access to such resources regardless of where in this
8 Commonwealth they may be.
9 (g) Performance reports.--The board, with the assistance of
10 the Health Advisory Panel and the administrator of quality
11 assurance, shall define performance criteria and goals for the
12 plan and shall make a written report to the General Assembly at
13 least annually on the plan's performance. All such reports,
14 including the survey results obtained, shall be made publicly
15 available with the goal of total transparency and open self-
16 analysis as a defining quality of the agency. The board shall
17 establish a system to monitor the quality of health care and
18 patient and provider satisfaction and to adopt a system to
19 devise improvements and efficiencies to the provision of health
20 care services.
21 (h) Data reporting.--All participating providers shall
22 provide data to the agency promptly upon the request of the
23 executive director.
24 (i) Coordination of services.--The board shall coordinate
25 the provision of health care services with any other
26 Commonwealth and local agencies that provide health care
27 services directly to their charges or residents.
28 Section 508. Rational cost containment.
29 (a) Approval of expenditures.--As part of its cost
30 containment mission, the board shall screen and approve or
20070H1660B2195 - 28 -
1 disapprove private or public expenditures for new health care
2 facilities and other capital investments that may lead to
3 redundant and inefficient health care provider capacity.
4 Procedures shall be adopted for this purpose with an emphasis
5 upon efficiency and a fair and open consideration of all
6 applications.
7 (b) Capital investments.--All capital investments valued at
8 one million dollars or greater, including the costs of studies,
9 surveys, design plans and working drawing specifications, and
10 other activities essential to planning and execution of capital
11 investment and all capital investments that change the bed
12 capacity of a health care facility by more than 10% over a 24-
13 month period or that add a new service or license category shall
14 require the approval of the board. When a facility, an
15 individual acting on behalf of a facility or any other purchaser
16 obtains by lease or comparable arrangement any facility or part
17 of a facility, or any equipment for a facility, the market value
18 of which would have been a capital expenditure, the lease or
19 arrangement shall be considered a capital expenditure for
20 purposes of this section.
21 (c) Deemed approval.--Capital investment programs submitted
22 for approval shall be deemed approved unless specifically
23 rejected by the board within 60 days from the date the
24 submissions are received by the executive director.
25 (d) Recommendations.--Recommendations of the Pennsylvania
26 Heath Cost Containment Council, Pittsburgh Regional Health Care
27 Initiative and such other public and private authoritative
28 bodies as shall be identified from time to time by the board
29 shall be received by the executive director and submitted to the
30 board with the executive director's recommendation regarding
20070H1660B2195 - 29 -
1 implementation of the recommended reforms. The board shall
2 receive input from all interested parties and then shall vote
3 upon all such recommendations within 60 days. Where procedural
4 or protocol reforms are adopted, participating providers will be
5 required to implement such designated best practices within the
6 next 60 days.
7 (e) Required investments.--If mandated reforms require the
8 acquisition of additional equipment, participating providers
9 shall make such investments within one year, and, upon
10 application, the board shall provide financing for such mandated
11 equipment on reasonable terms.
12 (f) Sanctions.--Participating providers refusing to adopt
13 recommended reforms shall, after a reasonable opportunity to be
14 heard, be subject to such sanctions as the board shall deem
15 appropriate and necessary up to and including the suspension or
16 permanent decertification of the provider.
17 CHAPTER 7
18 NO-FAULT ADMINISTRATIVE REMEDIES
19 Section 701. Rationalization of remedies for errors and
20 complications.
21 A primary objective of the board shall be to reduce the
22 frequency of medical errors and complications and to establish a
23 no-fault administrative procedure for fair and expeditious
24 compensation to those who suffer injuries or complications
25 relating to their care.
26 Section 702. Voluntary waiver of tort remedies and choice to
27 retain tort remedies.
28 Beneficiaries under the plan shall be conclusively deemed to
29 have voluntarily waived all other common law and statutory tort
30 remedies against any participating provider for alleged
20070H1660B2195 - 30 -
1 professional negligence, error of judgment or failure to secure
2 informed consent. Beneficiaries under the plan not willing to
3 waive such common law and statutory remedies may opt out of the
4 no-fault administrative remedies set forth in this act at any
5 time prior to the events complained of. Nonparticipating
6 providers shall not fall within the protections of the waiver of
7 tort remedies.
8 Section 703. No-fault administrative remedies for those not
9 opting out.
10 (a) Compensation.--In exchange for the waiver of their
11 traditional tort remedies, beneficiaries who suffer a new injury
12 or complication directly related to the care provided by, or
13 medications or treatments prescribed by a participating provider
14 shall be entitled to expedited compensation without proof of
15 professional negligence or error of judgment. Where the
16 application for compensation does not arise from a new injury or
17 complication but rather asserts a failure of a participating
18 provider to properly intervene, and thus mitigate the natural
19 progress of a disease or injury, proof of a departure from the
20 standard of care must be demonstrated by a preponderance of the
21 credible evidence for the claimant to qualify for compensation.
22 Out-of-state patients seeking care in Pennsylvania from a
23 participating provider shall, prior to treatment unless
24 unconscious or other circumstances prevent it, be provided with
25 a form approved by the board on which the patient can opt in or
26 opt out of the no-fault administrative remedies. Where no
27 election is made, the patient shall be conclusively presumed to
28 have chosen to participate in the no-fault administrative
29 remedies should the occasion arise.
30 (b) Other compensation.--In further exchange for the waiver
20070H1660B2195 - 31 -
1 of their traditional tort remedies, beneficiaries not opting out
2 of the no-fault administrative remedies and who assert that they
3 did not give their informed consent to an invasive procedure or
4 treatment, but who have not suffered a new injury or
5 complication thereby, shall be entitled to compensation upon
6 proof of the failure of the participating provider, or the
7 provider's representative, to provide at least the level of
8 information required for the procedure at issue pursuant to
9 guidelines adopted by the board.
10 (c) Award of damages.--Eligible claimants not opting out of
11 the no-fault administrative remedies shall be entitled to awards
12 to be determined by the health claims hearing officers as
13 follows:
14 (1) For past and/or continuing lost earning capacity, up
15 to a maximum of $5,000 per month.
16 (2) For noneconomic harm, defined as past and/or
17 continuing pain, suffering, disfigurement and/or
18 inconvenience, up to a maximum of $5,000 per month.
19 (3) For a failure of informed consent, either alone or
20 in conjunction with an award for past and or continuing lost
21 earning capacity and/or noneconomic harm, a maximum single
22 lump-sum payment of $10,000.
23 (4) For death, and in addition to the lost earning
24 capacity and noneconomic harm endured prior to death, up to a
25 maximum of $10,000 per month for 120 months to be placed in
26 trust for the benefit of the decedent's dependents. The trust
27 shall be managed by the office of the beneficiary advocate
28 under guidelines adopted by the board.
29 (d) Adjustments of limits.--The board shall adjust the
30 limits of compensation annually to account for inflation, and
20070H1660B2195 - 32 -
1 all awards for continuing lost earning capacity and/or
2 noneconomic damages shall be adjusted annually at the same rate
3 of inflation as determined by the board.
4 (e) Payment from trust.--The cost of all such compensation
5 shall be paid from the trust. No participating provider shall be
6 held financially responsible for any portion of the compensation
7 award nor shall participating providers be required to fund the
8 cost of such awards collectively through any assessment or
9 premium.
10 Section 704. Administrative claims procedures.
11 (a) Application for compensation.--The board shall adopt
12 simplified procedures for the submission of applications for no-
13 fault compensation under this act to the administrator of health
14 claims. The procedures shall provide for the expeditious
15 handling and approval of any clearly qualifying claims. Where
16 fact-finding is required in whole or in part, such claims shall
17 be presented expeditiously to a health claims hearing officer
18 for findings. Administrative appeals to the executive director
19 shall be permitted, and, where a claimant has been denied
20 compensation or contests the sufficiency of the award, claimant
21 shall have an appeal to the Court of Common Pleas of Dauphin
22 County which will consider the adequacy of the compensation on a
23 de novo basis with the power to increase or decrease the amount
24 awarded administratively. However, such court shall not have the
25 power to award compensation in excess of the limits established
26 by this act.
27 (b) Attorney fees.--Where on appeal to the Court of Common
28 Pleas of Dauphin County a denied claim is approved or an
29 administrative award is increased by at least 25%, the court
30 shall also award a reasonable attorney fee of no more than 20%
20070H1660B2195 - 33 -
1 and all reasonable litigation expenses including the cost of
2 expert witnesses and exhibits.
3 (c) Adjustment of awards.--The board shall further adopt
4 procedures whereby awards granted under this section for
5 continuing harms shall be subject to increase, not to exceed the
6 limits, or decrease upon a showing of a material change in the
7 claimant's condition. Continuing benefits shall be contingent
8 upon the reasonable cooperation of the claimant with respect to
9 the rehabilitation and mitigation of the claimant's injury.
10 (d) Administrative procedure.--The board shall adopt
11 administrative procedure to review appeals of participating
12 providers with respect to denials or adjustment of reimbursement
13 which appeals must be filed within 90 days of the notice of a
14 denied or adjusted reimbursement.
15 Section 705. Beneficiary right to counsel.
16 (a) Choice of counsel.--Beneficiaries seeking to file a
17 claim for no-fault compensation under this act shall have the
18 right to be represented by legal counsel of their choice.
19 (b) Fee agreement.--Any contingent fee agreement entered
20 into between a beneficiary claimant and their legal counsel
21 shall be limited as follows:
22 (1) Five percent where the claim is administratively
23 approved without a hearing.
24 (2) Ten percent where the claim proceeds to a hearing.
25 (3) Twenty percent where the claim is resolved after
26 appeal.
27 Section 706. Quality assurance follow-up to claims.
28 (a) Investigations.--All claims of error, complication or
29 failure of informed consent shall simultaneously be submitted
30 for analysis and quality assurance investigation through the
20070H1660B2195 - 34 -
1 office of the administrator for quality assurance. The
2 beneficiary submitting the claim shall be advised of the
3 progress of the inquiry and invited to present such information
4 or testimony as they deem necessary to the full and fair
5 consideration of the matters reported. Beneficiaries may attend
6 and/or be represented during this process by counsel of their
7 choosing at their own expense or may request the assistance at
8 no cost of a qualified advocate from the office of the
9 administrator of consumer affairs.
10 (b) Representation of providers.--Participating providers
11 who are the subject of an inquiry initiated by a beneficiary
12 application for compensation may attend and/or be represented by
13 counsel of their choosing at their own expense or may request
14 the assistance at no cost of a qualified advocate from the
15 office of the administrator for provider coordination.
16 (c) Reports.--At the conclusion of the inquiry, the
17 administrator of quality assurance shall submit a report and
18 recommendations to the executive director who shall then take
19 such action as they deem necessary under the circumstances to
20 avoid a recurrence of any avoidable errors. A copy of the
21 recommendations shall be provided to the beneficiary who
22 initiated the claim and also to the participating provider
23 involved in the inquiry. The report will be forwarded to
24 appropriate licensing authorities for further action.
25 Section 707. Surviving tort claims against participating
26 providers.
27 (a) Optional remedies.--Otherwise eligible persons who have
28 opted out of the no-fault administrative remedies of the plan
29 shall retain their right to pursue traditional tort remedies
30 against participating providers through the courts of this
20070H1660B2195 - 35 -
1 Commonwealth and, where jurisdictional requirements are
2 satisfied, through the courts of the United States.
3 (b) Legal counsel.--In all such cases participating
4 providers shall have the right to legal counsel of their choice
5 the reasonable cost of which shall be paid by the plan as will
6 the reasonable cost of experts and other trial expenses. In the
7 event of a final award in favor of the persons filing the claim,
8 the plan shall further provide primary indemnification of up to
9 three million dollars per claim and six million dollars per
10 annual aggregate claims per participating provider.
11 (c) Excess liability coverage.--In the event the private
12 insurance market does not make excess coverage available to
13 participating providers at reasonable cost, the board shall
14 recommend to the General Assembly the establishment of an excess
15 liability insurance pool sponsored by the Commonwealth and
16 financed with premiums to be paid by those participating
17 providers who seek additional protection above and beyond the
18 protection provided in subsection (b).
19 Section 708. Claims against nonparticipating providers.
20 Health care providers opting out of the plan shall be
21 responsible for the cost of their legal defense and shall be
22 further responsible to the patient and/or the plan for any
23 settlement or award, if any. Where the plan has paid for health
24 care-related costs arising from an alleged failure of due care
25 by a nonparticipating provider and where the injured party has
26 otherwise been made whole, the plan shall be subrogated to the
27 claim to the extent of the medical expenses incurred or that
28 have been found will be incurred.
29 Section 709. Parallel no-fault compensation for beneficiaries
30 injured by nonparticipating providers.
20070H1660B2195 - 36 -
1 Beneficiaries who have not opted out of the no-fault
2 administrative remedies pursuant to section 702, and who believe
3 they have been harmed by the negligence of a nonparticipating
4 provider, may elect, alone or in addition to pursuing
5 traditional tort claims against the nonparticipating providers,
6 to submit a claim under section 704, in which instance the plan
7 shall be subrogated to and/or credited with the beneficiary's
8 recovery, net of reasonable attorney fees and expenses, from the
9 nonparticipating provider to the extent of economic, noneconomic
10 and/or failure of informed consent benefits paid to such
11 beneficiaries.
12 CHAPTER 9
13 PENNSYLVANIA HEALTH CARE TRUST FUND
14 Section 901. Pennsylvania Health Care Trust Fund.
15 (a) Establishment.--The Pennsylvania Health Care Trust Fund
16 is hereby established within the State Treasury. All moneys
17 collected and received by the plan shall be transmitted to the
18 State Treasurer for deposit into the fund, to be used
19 exclusively to finance the plan.
20 (b) State Treasurer.--The State Treasurer may invest the
21 principal and interest earned by the fund in any manner
22 authorized under law for the investment of Commonwealth moneys.
23 Any revenue or interest earned from the investments shall be
24 credited to the fund.
25 (c) Administrator of finance.--The administrator of finance
26 of the agency shall notify the board when the monthly
27 expenditures or anticipated future expenditures of the plan
28 appear to be in excess of the anticipated future revenues for
29 the same period. The board shall implement appropriate measures
30 upon such notification. Such measures shall include the
20070H1660B2195 - 37 -
1 adjustment of the Wellness Tax as necessary to ensure the
2 solvency of the trust.
3 Section 902. Rolling budget process.
4 (a) Estimated annual budget.--The board shall prepare and
5 recommend to the General Assembly an estimated annual budget for
6 health care, which budget specifies an estimated requirement for
7 health care provided under this act. The budget shall include
8 all of the following components:
9 (1) A system budget covering all expenditures for the
10 agency.
11 (2) A capital investment budget.
12 (3) A purchasing budget.
13 (4) A research and innovation budget.
14 (b) Budget projections.--In preparing the budget, the board
15 shall consider anticipated increased expenditures and savings,
16 including, but not limited to, projected increases in
17 expenditures due to improved access for underserved populations
18 and improved reimbursement for primary care, projected
19 administrative savings under the single-payer mechanism,
20 projected savings in prescription drug expenditures under
21 competitive bidding and a single buyer, and projected savings
22 due to provision of primary care rather than emergency room
23 treatment.
24 (c) Rolling budget.--The board shall operate on a rolling
25 budget whereby it will anticipate its funding needs 90 days in
26 advance and shall seek adjustments from the General Assembly to
27 The Employer Health Services Levy and/or The Individual Wellness
28 Tax to assure solvency of the plan and to avoid unnecessary cash
29 surpluses in the trust.
30 Section 903. Limitation on administrative expense.
20070H1660B2195 - 38 -
1 The system budget referred to in this chapter shall comprise
2 the cost of the agency, services and benefits provided,
3 administration, data gathering, planning and other activities
4 and revenues deposited with the system account of the trust. The
5 board shall limit administrative costs to 5% of the agency
6 budget and shall annually evaluate methods to reduce
7 administrative costs and publicly report the results of that
8 evaluation.
9 Section 904. Funding sources.
10 Funding of the plan shall be obtained from the following
11 dedicated sources:
12 (1) Funds obtained from existing or future Federal
13 health care programs.
14 (2) Funds from dedicated sources specified by the
15 General Assembly.
16 (3) Receipts from the tax of 10% of gross payroll,
17 including self-employment profits. One percent of the tax
18 shall become effective the date that shall be the first day
19 of a calendar month no less than 32 days after the effective
20 date of this act, and the tax shall become fully effective
21 November 1, 2007. Employers who are part of a collective
22 bargaining agreement whereby the health care benefits are no
23 less generous than those provided under the plan shall be
24 excused from paying 90% of the tax.
25 (4) Receipts from the Individual Wellness Tax of 3% of
26 personal earned, passive, pension and investment income. One-
27 half of one percent of the Individual Wellness Tax shall
28 become effective the date that shall be the first day of a
29 calendar month no less than 32 days after the effective date
30 of this act, and the IWT tax shall become fully effective
20070H1660B2195 - 39 -
1 November 1, 2007. Employees who are part of a collective
2 bargaining agreement whereby the health care benefits are no
3 less generous than those provided under the plan shall be
4 excused from paying 90% of the Individual Wellness Tax.
5 (5) In the event the General Assembly has not responded
6 to a request by the board for an increase in funding in
7 anticipation of projected expenses, the board is hereby
8 authorized to order a temporary increase, for no more than 90
9 days, in the Employer Health Services Tax and/or the
10 Individual Wellness Tax of no more than 250 basis points each
11 to respond to a threatened insolvency of the plan.
12 CHAPTER 11
13 TRANSITIONAL SUPPORT AND TRAINING FOR DISPLACED WORKERS
14 Section 1101. Transitional support and training for displaced
15 workers.
16 (a) Determination of administrator.--The administrator of
17 transition services shall determine which citizens of this
18 Commonwealth employed by a health care insurer, health insuring
19 corporation or other health care-related business have lost
20 their employment as a result of the implementation and operation
21 of the plan. The administrator also shall determine the amount
22 of monthly wages that the individual has lost due to the plan's
23 implementation. The department shall attempt to position these
24 displaced workers in comparable positions of employment or
25 assist in the retraining and placement of such displaced
26 employees elsewhere.
27 (b) Information.--The administrator of transition services
28 shall forward the information on the amount of monthly wages
29 lost by Commonwealth residents due to the implementation of the
30 plan to the board. The board shall determine the amount of
20070H1660B2195 - 40 -
1 compensation required to assure income maintenance and training
2 that each displaced worker shall receive on a case-by-case basis
3 and shall submit a claim to the trust for payment. A displaced
4 worker, however, shall not receive compensation or training
5 assistance from the trust in excess of $5,000 per month for two
6 years. Compensation paid to the displaced worker under this
7 section shall serve as a supplement to any compensation the
8 worker receives from any other source including unemployment
9 insurance.
10 (c) Coordination of services.--The administrator of
11 transition services shall fully coordinate activity with public
12 and private services also available or actually participating in
13 the assistance to the affected individuals.
14 (d) Appeals.--Persons dissatisfied with the level of
15 assistance they are receiving may appeal to the office of the
16 executive director whose determination shall be final and not
17 subject to appeal.
18 CHAPTER 13
19 VOLUNTEER EMERGENCY RESPONDER NETWORK
20 Section 1301. Preservation of volunteer emergency responder
21 network.
22 Because this Commonwealth is dependent upon the volunteered
23 services of firefighters, emergency medical technicians and
24 search and rescue workers, the board is further charged with
25 administering a Commonwealth income tax credit program for such
26 volunteers.
27 Section 1302. Eligibility certification.
28 Annually, in January, administrators of volunteer
29 firefighting and rescue departments, emergency medical
30 technicians and paramedics stations and similar volunteer
20070H1660B2195 - 41 -
1 emergency entities shall certify the identity of Commonwealth
2 residents providing active services during the prior calendar
3 year.
4 Section 1303. Eligibility criteria.
5 Active status shall require a minimum of 200 hours of service
6 during the preceding year and response to no less than 50% of
7 the emergency calls during at least three of the four calendar
8 quarters.
9 Section 1304. Amount of tax credit.
10 Each volunteer certified as active shall be granted a credit
11 equal to $1,000 toward their State income tax obligation under
12 Article III of the act of March 4, 1971 (P.L.6, No.2), known as
13 the Tax Reform Code of 1971. Any eligible volunteer who does not
14 incur $1,000 in annual State income tax liability shall
15 nevertheless be eligible for a refund equal to the amount the
16 credit exceeds that volunteer's tax obligation.
17 Section 1305. Reimbursement of Department of Revenue.
18 The State Treasury shall be reimbursed the value of such
19 volunteer credits from the fund.
20 CHAPTER 15
21 MISCELLANEOUS PROVISIONS
22 Section 1501. Effective date.
23 This act shall take effect immediately.
F20L35JAM/20070H1660B2195 - 42 -