| CORRECTIVE REPRINT |
| PRIOR PRINTER'S NO. 1871 | PRINTER'S NO. 1872 |
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| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
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| HOUSE BILL |
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| INTRODUCED BY EACHUS, DeLUCA, DeWEESE, BISHOP, BRIGGS, CALTAGIRONE, DALEY, DONATUCCI, FRANKEL, GIBBONS, GRUCELLA, HARHAI, HOUGHTON, MARKOSEK, McGEEHAN, McILVAINE SMITH, MELIO, READSHAW, SANTARSIERO, SEIP, SIPTROTH, SOLOBAY AND STABACK, MAY 21, 2009 |
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| REFERRED TO COMMITTEE ON INSURANCE, MAY 21, 2009 |
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| AN ACT |
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1 | Establishing the Expanded Adult Basic Coverage Insurance |
2 | Program; making appropriations; and making related repeals. |
3 | TABLE OF CONTENTS |
4 | Chapter 1. Preliminary Provisions |
5 | Section 101. Short title. |
6 | Section 102. Definitions. |
7 | Chapter 3. Pennsylvania Expanded Adult Basic Coverage Insurance |
8 | Program |
9 | Section 301. Scope of chapter. |
10 | Section 302. Definitions. |
11 | Section 303. Pennsylvania Expanded Adult Basic Coverage |
12 | Insurance Program. |
13 | Section 304. Duties of contractors. |
14 | Section 305. Premiums and charges. |
15 | Section 306. Data matching. |
16 | Section 307. Information sharing. |
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1 | Section 308. Regulations. |
2 | Section 309. Funding. |
3 | Section 310. Federal waivers or State plan amendments. |
4 | Section 311. Federal funds. |
5 | Section 312. Federal programs. |
6 | Section 313. Establishment. |
7 | Section 314. Deposits into fund and appropriation. |
8 | Chapter 51. Miscellaneous Provisions |
9 | Section 5101. Repeals. |
10 | Section 5102. Effective date. |
11 | The General Assembly of the Commonwealth of Pennsylvania |
12 | hereby enacts as follows: |
13 | CHAPTER 1 |
14 | PRELIMINARY PROVISIONS |
15 | Section 101. Short title. |
16 | This act shall be known and may be cited as the Expanded |
17 | Adult Basic Coverage Insurance Program Act. |
18 | Section 102. Definitions. |
19 | The following words and phrases when used in this act shall |
20 | have the meanings given to them in this section unless the |
21 | context clearly indicates otherwise: |
22 | "Commissioner." The Insurance Commissioner of the |
23 | Commonwealth. |
24 | "Department." The Insurance Department of the Commonwealth. |
25 | CHAPTER 3 |
26 | PENNSYLVANIA EXPANDED ADULT BASIC COVERAGE INSURANCE PROGRAM |
27 | Section 301. Scope of chapter. |
28 | This chapter relates to offering health care coverage to |
29 | eligible adults. |
30 | Section 302. Definitions. |
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1 | The following words and phrases when used in this chapter |
2 | shall have the meanings given to them in this section unless the |
3 | context clearly indicates otherwise: |
4 | "Behavioral health services." Mental health or substance |
5 | abuse services. |
6 | "Benefit package." Insurance coverage which provides the |
7 | benefits set forth under section 303(h) for eligible adults. |
8 | "Children's Health Insurance Program." The Children's Health |
9 | Care Program established under Article XXIII of the act of May |
10 | 17, 1921 (P.L.682, No.284), known as The Insurance Company Law |
11 | of 1921. |
12 | "Chronic care and disease management." A model of health |
13 | care that manages chronic diseases in accordance with evidence- |
14 | based treatment guidelines and includes all of the following: |
15 | (1) Planned, regular interactions with caregivers to |
16 | systematically assess the patient's condition and guide |
17 | patient self-care to prevent exacerbation and complications |
18 | of the chronic illness. |
19 | (2) Support for the patient's role as self-manager |
20 | through education and continuing follow-up initiated by the |
21 | health care practice. |
22 | (3) Use of information systems to organize care and |
23 | monitor patient progress. |
24 | "Contractor." An insurer or other entity or its subsidiaries |
25 | awarded a contract to provide health care services under this |
26 | chapter. |
27 | "Eligible adult." A low-income adult who meets all of the |
28 | following: |
29 | (1) Legally resides within the United States. |
30 | (2) Is a resident of this Commonwealth at the time of |
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1 | application to the program. |
2 | (3) Is not currently covered by a health insurance plan, |
3 | a self-insurance plan or a self-funded plan. |
4 | (4) Has not been covered by a health insurance plan, a |
5 | self-insurance plan or a self-funded plan during the six |
6 | months immediately preceding the determination of |
7 | eligibility, except if one of the following apply: |
8 | (i) The low-income adult is eligible to receive |
9 | benefits under the act of December 5, 1936 (2nd Sp.Sess., |
10 | 1937 P.L.2897, No.1), known as the Unemployment |
11 | Compensation Law. |
12 | (ii) The low-income adult was covered under a health |
13 | insurance plan, a self-insurance plan or a self-funded |
14 | plan, but, at the time of application for coverage, is no |
15 | longer employed and is ineligible to receive benefits |
16 | under the Unemployment Compensation Law. |
17 | (iii) The low-income adult lost coverage as a result |
18 | of divorce or separation from a covered individual or the |
19 | death of a covered individual. |
20 | (iv) The low-income adult lost coverage as a result |
21 | of a change in employment status of a covered individual |
22 | resulting in either of the exceptions set forth under |
23 | subparagraph (i) or (ii) and both the eligible adult and |
24 | the spouse are low-income adults and applying for |
25 | coverage. |
26 | (v) The low-income adult is transferring from |
27 | another government-subsidized health insurance program, |
28 | including a transfer that occurs as a result of failure |
29 | to meet income eligibility requirements. |
30 | (5) The low-income adult is ineligible to receive |
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1 | continuous eligibility coverage under Title XIX or XXI of the |
2 | Social Security Act (49 Stat. 620, 42 U.S.C. § 301 et seq.), |
3 | except for benefits authorized under a waiver granted by the |
4 | United States Department of Health and Human Services to |
5 | implement the program. |
6 | (6) The low-income adult is ineligible for Medicare. |
7 | "Enrollee." An eligible adult who meets all the requirements |
8 | of this chapter and is enrolled in the Pennsylvania Expanded |
9 | Adult Basic Coverage Insurance Program. |
10 | "Health benefit plan." An insurance coverage plan that |
11 | provides the benefits set forth under section 303(h). The term |
12 | shall not include any of the following: |
13 | (1) An accident-only policy. |
14 | (2) A credit-only policy. |
15 | (3) A long-term care or disability income policy. |
16 | (4) A specified-disease policy. |
17 | (5) A Medicare supplement policy. |
18 | (6) A Civilian Health and Medical Program of the |
19 | Uniformed Services (CHAMPUS) supplement policy. |
20 | (7) A fixed-indemnity policy. |
21 | (8) A dental-only policy. |
22 | (9) A vision-only policy. |
23 | (10) A workers' compensation policy. |
24 | (11) An automobile medical payment policy under 75 |
25 | Pa.C.S. (relating to vehicles). |
26 | (12) Other similar policies providing for limited |
27 | benefits. |
28 | "Health maintenance organization" or "HMO." An entity |
29 | organized and regulated under the act of December 29, 1972 |
30 | (P.L.1701, No.364), known as the Health Maintenance Organization |
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1 | Act. |
2 | "Hospital." A hospital as defined and licensed under the act |
3 | of July 19, 1979 (P.L.130, No.48), known as the Health Care |
4 | Facilities Act. |
5 | "Hospital plan corporation." A hospital plan corporation as |
6 | defined in 40 Pa.C.S. § 6101 (relating to definitions). |
7 | "Insurer." A company or health insurance entity licensed in |
8 | this Commonwealth to issue any individual or group health, |
9 | sickness or accident policy or subscriber contract or |
10 | certificate or plan that provides medical or health care |
11 | coverage by a health care facility or licensed health care |
12 | provider that is offered or governed under any of the following: |
13 | (1) The act of May 17, 1921 (P.L.682, No.284), known as |
14 | The Insurance Company Law of 1921. |
15 | (2) The act of December 29, 1972 (P.L.1701, No.364), |
16 | known as the Health Maintenance Organization Act. |
17 | (3) The act of May 18, 1976 (P.L.123, No.54), known as |
18 | the Individual Accident and Sickness Insurance Minimum |
19 | Standards Act. |
20 | (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan |
21 | corporations) or 63 (relating to professional health services |
22 | plan corporations). |
23 | "Low-income adult." An individual who is at least 19 years |
24 | of age but less than 65 years of age and whose household income |
25 | is less than 200% of the Federal poverty level at the time of |
26 | eligibility determination. |
27 | "Medical assistance." The State program of medical |
28 | assistance established under the Act of June 13, 1967 (P.L.31, |
29 | No.21), known as the Public Welfare Code. |
30 | "Medicare." The Federal program established under Title |
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1 | XVIII of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1395 |
2 | et seq.). |
3 | "Offeror." An insurer that submits a bid or proposal in |
4 | response to a solicitation issued under section 303(h). |
5 | "Pre-existing condition." A disease or physical condition |
6 | for which medical advice, diagnosis, care or treatment was |
7 | recommended or received prior to the effective date of coverage. |
8 | "Premium assistance program." A component of the |
9 | Pennsylvania Expanded Adult Basic Coverage Insurance Program, |
10 | approved under a State plan or approved waiver, under which the |
11 | Commonwealth pays part or all of the premium for an enrollee’s |
12 | group health insurance or coverage under a group health plan. |
13 | "Prescription drug." A controlled substance, other drug or |
14 | device for medication dispensed by order of an appropriately |
15 | licensed medical professional. |
16 | "Professional health services plan corporation." A not-for- |
17 | profit corporation operating under the provisions of 40 Pa.C.S. |
18 | Ch. 63 (relating to professional health services plan |
19 | corporations). |
20 | "Program." The Pennsylvania Expanded Adult Basic Coverage |
21 | Insurance Program. |
22 | "Unemployment Compensation Law." The act of December 5, 1936 |
23 | (1937 2nd Sp.Sess., P.L.2897, No.1), known as the Unemployment |
24 | Compensation Law. |
25 | "Wait-list enrollee." An eligible adult who meets all the |
26 | requirements of this chapter who is not enrolled in the program |
27 | due to insufficient appropriations, but who individually |
28 | purchases the benefit package. |
29 | Section 303. Pennsylvania Expanded Adult Basic Coverage |
30 | Insurance Program. |
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1 | (a) Program establishment.--There is established in the |
2 | department the Pennsylvania Expanded Adult Basic Coverage |
3 | Insurance Program. The program is contingent on, and shall not |
4 | be authorized without, sufficient Federal financial |
5 | participation to fund the program. Appropriations to the |
6 | department for the program shall be used for contracts to |
7 | provide basic health care insurance for eligible adults and |
8 | administration of outreach activities and for program operating |
9 | costs. The department shall, to the greatest extent practicable, |
10 | ensure that all eligible adults in this Commonwealth have access |
11 | to the program established in this section. |
12 | (b) Eligible adult responsibilities.--An eligible adult |
13 | seeking to purchase coverage under the program shall: |
14 | (1) Submit an application to the department or a |
15 | contractor. |
16 | (2) Pay to the department, or the contractor with whom |
17 | the eligible adult is to be enrolled, the amount of the |
18 | premium specified under this subsection. Except to the extent |
19 | that changes may be necessary to meet Federal requirements |
20 | under section 310, subsidies for the 2009-2010 fiscal year |
21 | shall result in the following premium amount based on |
22 | household income for a health benefit plan: |
23 | (i) For an enrollee whose household income is not |
24 | greater than 150% of the Federal poverty level, a monthly |
25 | premium of $0. |
26 | (ii) For an enrollee whose household income is |
27 | greater than 150% but not greater than 175% of the |
28 | Federal poverty level, a monthly premium of $40. |
29 | (iii) For an enrollee whose household income is |
30 | greater than 175% but not greater than 200% of the |
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1 | Federal poverty level, a monthly premium of $50. |
2 | (3) Be responsible for any required copayments for |
3 | health care services rendered under the benefit package in |
4 | subsection (h). |
5 | (4) Notify the department or the contractor with whom |
6 | the eligible adult is enrolled of any change in the eligible |
7 | adult's household income. |
8 | (c) Purchase of insurance.--An eligible adult's payment to |
9 | the department or the contractor with whom the eligible adult is |
10 | enrolled under subsection (b)(2) shall be used to purchase the |
11 | benefit package and shall be remitted so that it is received by |
12 | the department or the contractor before the first day of the |
13 | month for which coverage is provided. A grace period for |
14 | remittance shall be permitted as provided by Federal or State |
15 | law. |
16 | (d) Premium assistance program.--The department shall |
17 | implement a premium assistance program permitted under Federal |
18 | regulations and as permitted through a Federal waiver or State |
19 | plan amendment made under this chapter. Notwithstanding any |
20 | other law to the contrary, in the event that it is more cost- |
21 | effective to purchase health care from an enrollee's employer- |
22 | based program and the employer-based program provides, at a |
23 | minimum, the benefits package described in subsection (h)(8), |
24 | employer-based coverage may be purchased in place of enrollment |
25 | in the program established under this chapter. An insurer shall |
26 | honor a request for enrollment and purchase of employee group |
27 | health insurance requested on behalf of an enrollee. |
28 | (e) Waiting list.—-The department shall maintain a waiting |
29 | list of eligible adults who have applied for coverage under the |
30 | program but who are not enrolled due to insufficient |
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1 | appropriations. An eligible adult on the waiting list may |
2 | purchase the benefit package at the monthly per-member premium |
3 | cost negotiated by the department. The department shall create a |
4 | procedure to remove eligible adults from the waiting list and |
5 | enroll them in the program based upon available funding. |
6 | (f) Entitlements and claims.--Nothing in this chapter shall |
7 | constitute an entitlement derived from the Commonwealth or a |
8 | claim on any funds of the Commonwealth. The Department of Public |
9 | Welfare, in conjunction with the department, shall seek approval |
10 | of State plan amendments and revisions to Federal waivers as are |
11 | necessary to ensure that expenditures in the program shall not |
12 | exceed available funding. |
13 | (g) Department responsibilities.--The department shall work |
14 | in consultation and cooperation with other appropriate |
15 | Commonwealth agencies, including the Department of Public |
16 | Welfare, to carry out the functions of this chapter and shall: |
17 | (1) Administer the program on a Statewide basis. |
18 | (2) Enter into contracts for health care insurance for |
19 | the benefit package. Contracts may be awarded on a multiple- |
20 | award basis. |
21 | (3) (i) In order to effectuate the program promptly |
22 | upon receipt of all applicable waivers and approvals from |
23 | the Federal government, contracts as currently exist |
24 | under the Adult Basic Program or the Physical Health |
25 | Health Choices Program of the Department of Public |
26 | Welfare may be amended to provide benefits under the |
27 | program established in this section or may otherwise |
28 | procure services outside the competitive procurement |
29 | process. |
30 | (ii) This paragraph shall expire at the same time as |
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1 | the contracts awarded under this section, but not later |
2 | than 18 months after the effective date of this section. |
3 | (4) Subject to Federal requirements, impose reasonable |
4 | cost-sharing arrangements establishing and adjusting |
5 | copayments to be incorporated into the program by |
6 | contractors, thereby encouraging appropriate use by |
7 | contractors of cost-effective health care providers who will |
8 | provide quality health care. Changes to copayments shall be |
9 | forwarded to the Legislative Reference Bureau for publication |
10 | as notices in the Pennsylvania Bulletin. |
11 | (5) Conduct monitoring, oversight and audits of executed |
12 | contracts for enforcement purposes. |
13 | (6) Ensure that the eligibility of enrollees receiving |
14 | subsidization of the benefit package is redetermined on an |
15 | annual basis. |
16 | (7) Monitor, review and evaluate each contractor’s |
17 | benefit package for the adequacy, accessibility and |
18 | availability of the services required under subsection (h). |
19 | (8) Establish and coordinate development, implementation |
20 | and supervision of an outreach plan to ensure that all those |
21 | who may be eligible are aware of the program. The outreach |
22 | plan 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. |
28 | (iii) Assuring that special efforts are coordinated |
29 | within the overall outreach activities throughout this |
30 | Commonwealth. |
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1 | (iv) Allowing for the acceptance of applications at |
2 | county assistance offices operated by the Department of |
3 | Public Welfare. |
4 | (9) Prepare and submit, by March 1, 2010, and annually |
5 | thereafter, a report to the chairman and minority chairman of |
6 | the Banking and Insurance Committee of the Senate and to the |
7 | chairman and minority chairman of the Insurance Committee of |
8 | the House of Representatives regarding the number of eligible |
9 | adults purchasing coverage under the program with a |
10 | geographic distribution, the identity of the contractors, the |
11 | scope of the services being provided, the level of outreach, |
12 | the cost of the insurance and the amount an eligible adult |
13 | contributes toward the insurance, including any copayments |
14 | and adjustments to the premiums. The annual report shall be |
15 | made available for public inspection and posted on the |
16 | department's publicly accessible Internet website. |
17 | (10) Undertake efforts as are required to seek receipt |
18 | of and qualify for Federal financial participation. |
19 | (h) Solicitation.--The department shall solicit bids or |
20 | proposals for the program. The solicitation shall require an |
21 | offeror to assure that if selected as a contractor it will do |
22 | all of the following: |
23 | (1) Ensure that enrollees and wait-list enrollees have |
24 | access to qualified, cost-effective health care providers. |
25 | (2) Contract with qualified, cost-effective health care |
26 | providers, which shall include primary health care |
27 | physicians, certified registered nurse practitioners, |
28 | physician assistants, clinical nurse specialists, nurse- |
29 | midwives, clinics and health maintenance organizations, to |
30 | provide health care for organizations, to provide health care |
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1 | for enrollees and wait-list enrollees in a manner that best |
2 | manages the costs of the services and utilizes other |
3 | appropriate medical cost-effective methods and in a manner |
4 | consistent with the provider's permitted scope of practice. |
5 | (3) Ensure that the individual applying for coverage is |
6 | an eligible adult. If a review of the individual's |
7 | application for coverage indicates that the individual is not |
8 | eligible for adult basic coverage insurance, but may be |
9 | eligible for medical assistance, the application for benefits |
10 | and all accompanying documentation shall be promptly |
11 | transmitted to the appropriate county assistance office for a |
12 | determination of eligibility for medical assistance or other |
13 | Federal, State and local resources available to the |
14 | individual. |
15 | (4) Not prohibit enrollment based upon a preexisting |
16 | condition nor exclude a diagnosis or treatment for the |
17 | condition based on the condition's preexistence. |
18 | (5) Provide an insurance identification card to each |
19 | enrollee or wait-list enrollee covered under a contract |
20 | executed under this section. The card shall not identify the |
21 | enrollee or wait-list enrollee as low income. |
22 | (6) Require each provider providing primary care |
23 | services under this section to make necessary arrangements |
24 | for admission to hospitals and for necessary specialty care. |
25 | (7) Not pay any claim on behalf of an enrollee or wait- |
26 | list enrollee unless all other Federal, State and local |
27 | resources are first utilized and utilize subrogation and |
28 | coordination of benefits processes so that the program is the |
29 | payor of last resort. |
30 | (8) Provide a benefit package to enrollees and wait-list |
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1 | enrollees consistent with the scope and duration requirements |
2 | determined by the department. The Commonwealth may elect to |
3 | provide any benefit independently and outside the scope of |
4 | any contract entered into with any contractor to provide the |
5 | benefit package under the program. The benefit package |
6 | determined by the department may include any of the following |
7 | services: |
8 | (i) Preventive and wellness care. |
9 | (ii) Outpatient primary care and specialist |
10 | services. |
11 | (iii) Inpatient hospitalization. |
12 | (iv) Outpatient services. |
13 | (v) Emergency care. |
14 | (vi) Laboratory and radiology. |
15 | (vii) Clinic services. |
16 | (viii) Prescription drugs. |
17 | (ix) Diabetic medical supplies and equipment. |
18 | (x) Emergency dental care. |
19 | (xi) Maternity care. |
20 | (xii) Skilled nursing. |
21 | (xiii) Home health, palliative and hospice care. |
22 | (xiv) Chronic care and disease management. |
23 | (xv) Inpatient and outpatient behavioral health |
24 | services. |
25 | (i) Bids or proposals.--Each professional health service |
26 | plan corporation, hospital plan corporation, health maintenance |
27 | organization owned or controlled by a professional health |
28 | service plan corporation or a hospital plan corporation and each |
29 | entity that provides services under the Department of Public |
30 | Welfare's Physical Health HealthChoices Program shall be |
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1 | required to submit a bid or proposal to the department to carry |
2 | out the purposes of this chapter. Each professional health |
3 | service plan corporation and hospital plan corporation, and |
4 | subsidiaries and affiliates doing business in this Commonwealth, |
5 | shall submit a bid or proposal to the department to carry out |
6 | the purposes of this section in the geographic area serviced by |
7 | that entity. Each health maintenance organization owned or |
8 | controlled by a health service plan corporation or hospital plan |
9 | corporation shall submit a bid or proposal with all eligible |
10 | licenses and certificates of authority under its control, in all |
11 | service zones in which it is licensed to do business in more |
12 | than 50% of the counties in that zone. The service zones shall |
13 | be determined by the department in consultation with the |
14 | Department of Health and the Department of Public Welfare. Each |
15 | entity that provides services under the Physical Health |
16 | HealthChoices Program of the Department of Public Welfare shall |
17 | submit a bid or proposal in all counties in which it provides |
18 | the services. All other insurers may submit a bid or proposal to |
19 | the department to carry out the purposes of this section. |
20 | (j) Reviewing, scoring and selecting bids or proposals.--The |
21 | department, in consultation with the Department of Public |
22 | Welfare, shall review and score bids or proposals on the basis |
23 | of all of the requirements for the program. The department may |
24 | include other criteria in the solicitation and in the scoring |
25 | and selection of the bids or proposals that the department, in |
26 | the exercise of its administrative duties under this section and |
27 | in consultation with the Department of Public Welfare, deems |
28 | necessary. The department shall: |
29 | (1) Select, to the greatest extent practicable, offerors |
30 | that contract with providers to provide health care services |
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1 | on a cost-effective basis and that use appropriate cost- |
2 | management methods that enable the program to provide |
3 | coverage to the maximum number of eligible adults and that, |
4 | whenever possible, pursue and utilize available public and |
5 | private funds. |
6 | (2) Select, to the greatest extent practicable, only |
7 | offerors that comply with all procedures relating to |
8 | coordination of benefits as required by the department and |
9 | the Department of Public Welfare. |
10 | (3) Select offerors that limit administrative expenses |
11 | to no more than 10% of the amount of the contract. If a |
12 | contractor presents documented evidence that administrative |
13 | expenses for operational changes from the previous AdultBasic |
14 | Program to the program implemented under this act are in |
15 | excess of 10% of the amount of the contract, the department |
16 | shall make an additional allotment of funds, not to exceed 1% |
17 | of the amount of the contract, to the contractor to the |
18 | extent that the department finds the expenses reasonable and |
19 | necessary. |
20 | (k) Rates and negotiations.--Rates for the program shall be |
21 | approved annually by the department and may vary by region and |
22 | contractor. Rates shall be based on an actuarially sound and |
23 | adequate review. The department shall not negotiate a contract |
24 | for a period in excess of four years. |
25 | (l) Limitation.--In no case shall the total aggregate amount |
26 | of annual contracts entered into pursuant to this section exceed |
27 | the amount of the aggregate annual appropriations to the |
28 | department for the program. |
29 | Section 304. Duties of contractors. |
30 | A contractor that contracts with the department to provide a |
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1 | health benefit plan to eligible adults: |
2 | (1) Shall process claims for the coverage. |
3 | (2) Shall implement copayment adjustments as soon as |
4 | practicable following publication in the Pennsylvania |
5 | Bulletin, but in no event more than 120 days following |
6 | publication. |
7 | (3) May not deny coverage to an eligible adult who has |
8 | been approved by the department to participate in the |
9 | program. |
10 | (4) Shall provide to the department all data, including |
11 | individual claims data, as the department determines is |
12 | necessary for use in performance measurement and program |
13 | improvement. |
14 | (5) Shall fulfill all requirements of any contract |
15 | issued to it pursuant to this section. |
16 | Section 305. Premiums and charges. |
17 | (a) Limitation on fees.--No eligible adult shall be assessed |
18 | a fee or other charge, other than those specified in this |
19 | chapter, as a requirement for participating in the program. |
20 | (b) Premium adjustment.--For each fiscal year beginning |
21 | after June 30, 2010, the department may adjust the premium |
22 | amounts under section 303(b)(2) to reflect changes in the cost |
23 | of medical services and shall forward notice of the new premium |
24 | amounts to the Legislative Reference Bureau for publication as a |
25 | notice in the Pennsylvania Bulletin. |
26 | (c) Copayment adjustment.--For each fiscal year beginning |
27 | after June 30, 2010, the department may adjust the copayment |
28 | amounts under section 303(b)(3) to reflect changes in the cost |
29 | of medical services and shall forward notice of the new premium |
30 | amounts to the Legislative Reference Bureau for publication as a |
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1 | notice in the Pennsylvania Bulletin. |
2 | Section 306. Data matching. |
3 | (a) Covered adults.--All entities providing health insurance |
4 | or health care coverage within this Commonwealth shall, at least |
5 | once every month, provide the names, identifying information and |
6 | any additional information on coverage and benefits as the |
7 | department may specify for persons for whom the entities provide |
8 | insurance or coverage. |
9 | (b) Use of information.--The department shall use the |
10 | information obtained under subsection (a) to determine whether |
11 | another entity has primary liability for health care claims paid |
12 | by the program. If a determination is made that the enrollee or |
13 | wait-list enrollee has other health care coverage, the |
14 | eligibility of the enrollee or wait-list enrollee shall be |
15 | reevaluated, as shall the most cost-effective means of providing |
16 | coverage for that enrollee or wait-list enrollee. |
17 | Section 307. Information sharing. |
18 | Notwithstanding any provision of law to the contrary, the |
19 | program and other departments or programs of the Commonwealth |
20 | with information relating to the eligibility of individuals for |
21 | a Commonwealth program, shall share the information with each |
22 | other for purposes of determining and coordinating eligibility |
23 | for any State program. Those departments and programs include, |
24 | but are not limited to, the Department of Revenue, the |
25 | Department of Labor and Industry, the Department of Public |
26 | Welfare, the Children's Health Insurance Program and the |
27 | program. The information shall be confidential, shall be exempt |
28 | from disclosure under the act of February 14, 2008 (P.L.6, |
29 | No.3), known as the Right-to-Know Law, and may not be subject to |
30 | subpoena and may not be made public by any department or |
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1 | program, except that it may be disclosed to another Commonwealth |
2 | agency or law enforcement official of the Federal or State |
3 | government at any time so long as the agency or office receiving |
4 | the information agrees in writing to hold it confidential and in |
5 | a manner consistent with this act. No individual who receives |
6 | information while acting under the authority of this act shall |
7 | be permitted or required to testify in a private civil or other |
8 | action concerning the information subject to this section. |
9 | Section 308. Regulations. |
10 | The department may promulgate regulations for the |
11 | implementation and administration of the program. Until final |
12 | regulations are adopted, the department shall operate the |
13 | program under interim guidelines consistent with this chapter. |
14 | Section 309. Funding. |
15 | (a) Funding contingency for subsidization.--Subsidization of |
16 | premiums and copayments paid under subsection (b) is contingent |
17 | upon the amount of the funding available to the program and the |
18 | Federal poverty levels approved by the Federal waiver or State |
19 | plan amendments granted under section 310, and is limited to |
20 | eligible adults who are in compliance with the requirements |
21 | under this chapter. |
22 | (b) Use of funding.--Funding shall be used by the department |
23 | to pay the difference between the total monthly cost of the |
24 | health benefit plan and the premium payments and copayments by |
25 | the eligible adult and for administration and outreach |
26 | activities required under subsection 303(f). |
27 | Section 310. Federal waivers or State plan amendments. |
28 | (a) Application for waivers or amendments.--The Department |
29 | of Public Welfare, in cooperation with the department, shall |
30 | apply for all applicable waivers from the Federal Government and |
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1 | shall seek approval to amend the State plan under Title XIX of |
2 | the Social Security Act (49 Stat. 620, 42 U.S.C. § 1396 et seq.) |
3 | as necessary to carry out the provisions of this chapter. |
4 | (b) Notice of approval.--If the Department of Public Welfare |
5 | receives approval of a waiver or approval of a State plan |
6 | amendment, it shall notify the department and shall transmit |
7 | notice of the waiver or State plan amendment approvals to the |
8 | Legislative Reference Bureau for publication as a notice in the |
9 | Pennsylvania Bulletin. |
10 | (c) Program changes.--The department is authorized to change |
11 | the benefits under section 303(h), the premium amounts payable |
12 | under section 303(b) and any eligibility requirements under this |
13 | chapter in order for the program to meet Federal requirements. |
14 | Section 311. Federal funds. |
15 | Notwithstanding any other provision of law, the Department of |
16 | Public Welfare, in cooperation with the department, shall do all |
17 | of the following: |
18 | (1) Seek the receipt of Federal financial participation |
19 | under Title XIX of the Social Security Act (49 Stat. 620, 42 |
20 | U.S.C. § 1396 et seq.) for coverage and services provided |
21 | under this article. |
22 | (2) Qualify for available Federal financial |
23 | participation under Title XIX of the Social Security Act. |
24 | Section 312. Federal programs. |
25 | If the Federal Government enacts programs similar to the |
26 | program, the program shall be construed to only supplement the |
27 | Federal programs; and adults qualified for coverage under the |
28 | Federal program shall utilize that Federal program before |
29 | utilizing the program. |
30 | Section 313. Establishment. |
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1 | There is established within the State Treasury a special fund |
2 | to be known as the Pennsylvania Expanded Adult Basic Coverage |
3 | Insurance Program Fund. |
4 | Section 314. Deposits into fund and appropriation. |
5 | (a) Health Care Provider Retention Account.--On the |
6 | effective date of this section, the sum of $362,000,000 shall be |
7 | transferred from the Health Care Provider Retention Account to |
8 | the Pennsylvania Expanded Adult Basic Coverage Insurance Program |
9 | Fund. |
10 | (b) Tobacco Settlement Act.--Notwithstanding section |
11 | 5101(b), funds appropriated under section 306(b)(1)(vi) of the |
12 | act of June 26, 2001 (P.L.755, No.77), known as the Tobacco |
13 | Settlement Act, for the program established in former Chapter 13 |
14 | of that act, shall be deposited into the Pennsylvania Expanded |
15 | Adult Basic Coverage Insurance Program Fund. |
16 | (c) Premium tax.--Commencing with calendar years beginning |
17 | after December 31, 2010, every hospital plan corporation and |
18 | professional health service plan corporation operating in this |
19 | Commonwealth shall pay the tax on gross premiums payable under |
20 | Article IX of the act of March 4, 1971 (P.L.6, No.2), known as |
21 | the Tax Reform Code of 1971. The tax payable in calendar year |
22 | 2011 shall be for gross premiums received in calendar year 2010. |
23 | Notwithstanding the provisions of any law to the contrary, the |
24 | sums received by the Commonwealth as a result of this tax shall |
25 | be deposited into the Pennsylvania Expanded Adult Basic Coverage |
26 | Insurance Program Fund. This subsection shall not be effective |
27 | if the Agreement on Community Health Reinvestment entered into |
28 | February 2, 2005, by the department and Capital BlueCross, |
29 | Highmark, Inc., Hospital Service Association of Northeastern |
30 | Pennsylvania and Independence Blue Cross and published in the |
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1 | Pennsylvania Bulletin at 35 Pa.B. 4155 (July 23, 2005) is |
2 | extended or otherwise renegotiated to continue, at least, at the |
3 | level of Annual Community Health Reinvestment contributed under |
4 | that agreement. In that event, the sums received by the |
5 | Commonwealth shall be deposited into the Pennsylvania Expanded |
6 | Adult Basic Coverage Insurance Program Fund. |
7 | (d) Appropriation.--Money in the Pennsylvania Expanded Adult |
8 | Basic Coverage Insurance Program Fund is appropriated, upon |
9 | approval of the Governor, for health care coverage and services |
10 | under this chapter. |
11 | CHAPTER 51 |
12 | MISCELLANEOUS PROVISIONS |
13 | Section 5101. Repeals. |
14 | (a) Declaration of policy.--The General Assembly declares |
15 | that the repeal under subsection (b) is necessary to effectuate |
16 | this act. |
17 | (b) Specific.--Chapter 13 of the act of June 26, 2001 |
18 | (P.L.755, No.77), known as the Tobacco Settlement Act, is |
19 | repealed. |
20 | (c) Inconsistent.--All acts and parts of acts are repealed |
21 | insofar as they are inconsistent with this act. |
22 | Section 5102. Effective date. |
23 | This act shall take effect in 90 days. |
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