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| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
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| SENATE BILL |
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| INTRODUCED BY FERLO, BOSCOLA, O'PAKE, FONTANA, FARNESE, LEACH, HUGHES, MUSTO AND WASHINGTON, JULY 17, 2009 |
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| REFERRED TO BANKING AND INSURANCE, JULY 17, 2009 |
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| AN ACT |
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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 | The General Assembly of the Commonwealth of Pennsylvania |
13 | hereby enacts as follows: |
14 | TABLE OF CONTENTS |
15 | Chapter 1. Preliminary Provisions |
16 | Section 101. Short title. |
17 | Section 102. Definitions. |
18 | Chapter 3. Administration and Oversight of the Pennsylvania |
19 | Health Care Plan |
20 | Subchapter A. Pennsylvania Health Care Board |
21 | Section 301. Organization. |
22 | Section 302. Duties of board. |
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1 | Subchapter B. Pennsylvania Health Care Agency |
2 | Section 321. Pennsylvania Health Care Agency. |
3 | Subchapter C. (Reserved). |
4 | Subchapter D. (Reserved). |
5 | Subchapter E. (Reserved). |
6 | Subchapter F. Immunity |
7 | Section 371. Immunity. |
8 | Chapter 5. Pennsylvania Health Care Plan |
9 | Section 501. General provisions. |
10 | Section 502. Universal health care access eligibility. |
11 | Section 503. Covered services. |
12 | Section 504. Excess and collective bargaining agreement health |
13 | insurance coverage. |
14 | Section 505. Duplicate coverage. |
15 | Section 506. Subrogation. |
16 | Section 507. Eligible participating providers and availability |
17 | of services. |
18 | Section 508. Rational cost containment. |
19 | Chapter 9. Pennsylvania Health Care Trust Fund |
20 | Section 901. Pennsylvania Health Care Trust Fund. |
21 | Section 902. Limitation on administrative expense. |
22 | Section 903. Funding sources. |
23 | Chapter 11. Transitional Support and Training for Displaced |
24 | Workers |
25 | Section 1101. Transitional support and training for displaced |
26 | workers. |
27 | Chapter 13. Volunteer Emergency Responder Network |
28 | Section 1301. Preservation of volunteer emergency responder |
29 | network. |
30 | Section 1302. Eligibility certification. |
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1 | Section 1303. Eligibility criteria. |
2 | Section 1304. Amount of tax credit. |
3 | Section 1305. Reimbursement of Department of Revenue. |
4 | Chapter 45. Miscellaneous Provisions |
5 | Section 4501. Effective date. |
6 | The General Assembly of the Commonwealth of Pennsylvania |
7 | hereby enacts as follows: |
8 | CHAPTER 1 |
9 | PRELIMINARY PROVISIONS |
10 | Section 101. Short title. |
11 | This act shall be known and may be cited as the Family and |
12 | Business Healthcare Security Act. |
13 | Section 102. Definitions. |
14 | The following words and phrases when used in this act shall |
15 | have the meanings given to them in this section unless the |
16 | context clearly indicates otherwise: |
17 | "Agency." The Pennsylvania Health Care Agency established |
18 | under this act. |
19 | "Board." The Pennsylvania Health Care Board established |
20 | under this act. |
21 | "Certificate of need." A notice of approval issued by |
22 | the Department of Health under the provisions of the act of July |
23 | 19, 1979 (P.L.130, No.48), known as the Health Care Facilities |
24 | Act, including those notices of approval issued as an amendment |
25 | to an existing certificate of need. |
26 | "Department." The Department of Health of the Commonwealth. |
27 | "Executive director." The Executive Director of the |
28 | Pennsylvania Health Care Board. |
29 | "Fund." The Pennsylvania Health Care Trust Fund established |
30 | under this act. |
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1 | "Individual Fair Share Health and Wellness Tax." The |
2 | Individual Fair Share Health and Wellness Tax established under |
3 | this act. |
4 | "Plan." The Pennsylvania Health Care Plan established under |
5 | this act. |
6 | "Tax." The Employer Fair Share Health and Wellness Tax |
7 | established under this act. |
8 | CHAPTER 3 |
9 | ADMINISTRATION AND OVERSIGHT OF THE |
10 | PENNSYLVANIA HEALTH CARE PLAN |
11 | SUBCHAPTER A |
12 | PENNSYLVANIA HEALTH CARE BOARD |
13 | Section 301. Organization. |
14 | (a) Composition.--The Pennsylvania Health Care Board shall |
15 | be composed of 11 voting members. It shall be chaired by the |
16 | executive director who may vote only in the event of a tie vote. |
17 | (b) Appointments.-- |
18 | (1) The executive director shall be appointed by the |
19 | Governor. The members of the board shall be appointed by the |
20 | Governor, the President pro tempore of the Senate, and the |
21 | Speaker of the House of Representatives who collectively |
22 | shall make appointments of members from individuals |
23 | representative of each of the following constituencies: |
24 | (i) Hospitals. |
25 | (ii) Organized labor, private sector. |
26 | (iii) Consumers. |
27 | (iv) Business. |
28 | (v) Agriculture. |
29 | (vi) Physicians. |
30 | (vii) Public sector employees. |
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1 | (viii) Nurses. |
2 | (ix) Pharmacists. |
3 | (x) Long-term care facilities. |
4 | (xi) Social workers. |
5 | (2) The Governor shall initially appoint the executive |
6 | director, who shall serve as chair of the board, appointments |
7 | of the members shall thereafter be made in a rotating fashion |
8 | beginning with the President pro tempore of the Senate, then |
9 | the Speaker of the House of Representatives and then the |
10 | Governor, with each in turn making an appointment from a |
11 | constituency category not previously filled. |
12 | (c) Terms of members.--Each member appointed or reappointed |
13 | under this section shall hold office for three years, starting |
14 | on the first day of the first month following the member's |
15 | appointment. A serving member of the board shall continue to |
16 | serve following the expiration of the member's term until a |
17 | successor takes office or a period of 90 days has elapsed, |
18 | whichever occurs first. |
19 | (d) Midterm vacancies.--Midterm vacancies shall be filled by |
20 | the same appointer and the individual appointed to fill a |
21 | vacancy occurring prior to the expiration of the term for which |
22 | a member is appointed shall hold office for the remainder of the |
23 | predecessor's term. |
24 | (e) Compensation, benefits and expenses.--The executive |
25 | director and members of the board shall receive an annual |
26 | salary, benefits and expense reimbursement established by the |
27 | board, to be paid from the fund. The initial board shall |
28 | establish its own compensation. No increase or decrease in |
29 | salary or benefits adopted by the board for the executive |
30 | director or members shall become effective within the same |
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1 | three-year term. |
2 | (f) Meetings.-- |
3 | (1) The executive director shall set the time, place and |
4 | date for the initial and subsequent meetings of the board and |
5 | shall preside over its meetings. The initial meeting shall be |
6 | set not sooner than 50 nor later than 100 days after the |
7 | appointment of the executive director. Subsequent meetings |
8 | shall occur at least monthly thereafter. |
9 | (2) All meetings of the board are open to the public |
10 | unless questions of patient confidentiality arise. The board |
11 | may go into closed executive session with regard to issues |
12 | related to confidential patient information. |
13 | (g) Quorum.--Two-thirds of the appointed members of the |
14 | board shall constitute a quorum for the conducting of business |
15 | at meetings of the board. Decisions at ordinary meetings of the |
16 | board shall be reached by majority vote of those actually |
17 | present or, in the event of emergency meeting, those also |
18 | present by electronic or telephonic means. Where there is a tie |
19 | vote, the executive director shall be granted an additional vote |
20 | to break the tie. |
21 | (h) Ethics.--The executive director, the members and their |
22 | immediate families are prohibited from having any pecuniary |
23 | interest in any business with a contract or in negotiation for a |
24 | contract with the agency. The board shall also adopt rules of |
25 | ethics and definitions of irreconcilable conflicts of interest |
26 | that will determine under what circumstances members must recuse |
27 | themselves from voting. |
28 | (i) Prohibitions.-- |
29 | (1) No member of the board, except for the executive |
30 | director, may receive any additional salary or benefits by |
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1 | virtue of serving on the board. |
2 | (2) No member of the board may hold any other salaried |
3 | Commonwealth public position, either elected or appointed, |
4 | during the member's tenure on the board, including, but not |
5 | limited to, the position of State legislator or member of the |
6 | Congress of the United States. |
7 | (3) The executive director may not be a State legislator |
8 | or member of the Congress of the United States. |
9 | Section 302. Duties of board. |
10 | (a) General duties.--The board is responsible for directing |
11 | the agency in the performance of all duties, the exercise of all |
12 | powers, and the assumption and discharge of all functions vested |
13 | in the agency. The board shall adopt and publish its rules and |
14 | procedures in the Pennsylvania Bulletin no later than 180 days |
15 | after the first meeting of the board. |
16 | (b) Specific duties.--The duties and functions of the board |
17 | include, but are not limited to, the following: |
18 | (1) Implementing statutory eligibility standards for |
19 | benefits. |
20 | (2) Annually adopting a benefits package for |
21 | participants of the plan. |
22 | (3) Acting directly or through one or more contractors |
23 | as the single payer administrator for all claims for health |
24 | care services made under the plan. |
25 | (4) At least annually, reviewing the appropriateness and |
26 | sufficiency of reimbursements and considering whether a |
27 | charge is fair and reasonable for its geographic region or |
28 | location. |
29 | (5) Providing for timely payments to participating |
30 | providers through a structure that is well organized and that |
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1 | eliminates unnecessary administrative costs. |
2 | (6) Implementing standardized claims and reporting |
3 | methods for use by the plan. |
4 | (7) Developing a system of centralized electronic claims |
5 | and payments accounting. |
6 | (8) Establishing an enrollment system that will ensure |
7 | that those who travel frequently and cannot read or speak |
8 | English are aware of their right to health care and are |
9 | formally enrolled in the plan. |
10 | (9) Reporting annually to the General Assembly and to |
11 | the Governor, on or before the first day of October, on the |
12 | performance of the plan, the fiscal condition of the plan, |
13 | recommendations for statutory changes, the receipt of |
14 | payments from the Federal Government, whether current year |
15 | goals and priorities were met, future goals and priorities, |
16 | and major new technology or prescription drugs that may |
17 | affect the cost of the health care services provided by the |
18 | plan. |
19 | (10) Administering the revenues of the fund. |
20 | (11) Obtaining appropriate liability and other forms of |
21 | insurance to provide coverage for the plan, the board, the |
22 | agency and their employees and agents. |
23 | (12) Establishing, appointing and funding appropriate |
24 | staff, office space, equipment, training and administrative |
25 | support for the agency throughout this Commonwealth, all to |
26 | be paid from the fund. |
27 | (13) Administering aspects of the agency by taking |
28 | actions that include, but are not limited to, the following: |
29 | (i) Establishing standards and criteria for the |
30 | allocation of operating funds. |
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1 | (ii) Meeting regularly to review the performance of |
2 | the agency and to adopt and revise its policies. |
3 | (iii) Establishing goals for the health care system |
4 | established pursuant to the plan in measurable terms. |
5 | (iv) Establishing Statewide health care databases to |
6 | support health care services planning. |
7 | (v) Implementing policies and developing mechanisms |
8 | and incentives to assure culturally and linguistically |
9 | sensitive care. |
10 | (vi) Establishing rules and procedures for |
11 | implementation and staffing of a no-fault compensation |
12 | system for iatrogenic injuries or complications of care |
13 | whereby a patient's condition is made worse or an |
14 | opportunity for cure or improvement is lost due to the |
15 | health care or medications provided or appropriate care |
16 | not provided by participating providers under the plan. |
17 | (vii) Establishing standards and criteria for the |
18 | determination of appropriate transitional support and |
19 | training for residents of this Commonwealth who are |
20 | displaced from work during the first two years of the |
21 | implementation of the plan. |
22 | (viii) Evaluating the state of the art in proven |
23 | technical innovations, medications and procedures and |
24 | adopting policies to expedite the rapid introduction |
25 | thereof in this Commonwealth. |
26 | (ix) Establishing methods for the recovery of costs |
27 | for health care services provided pursuant to the plan to |
28 | a beneficiary who is also covered under the terms of a |
29 | policy of insurance, a health benefit plan or other |
30 | collateral source available to the participant under |
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1 | which the participant has a right of action for |
2 | compensation. Receipt of health care services pursuant to |
3 | the plan shall be deemed an assignment by the participant |
4 | of any right to payment for services from any such |
5 | policy, plan or other source. The other source of health |
6 | care benefits shall pay to the trust all amounts it is |
7 | obligated to pay to, or on behalf of, the participant for |
8 | covered health care services. The board may commence any |
9 | action necessary to recover the amounts due. |
10 | (14) Recruiting the Health Advisory Panel of seven |
11 | members made up of a cross section of the medical and |
12 | provider community. The members of the advisory panel shall |
13 | be paid a per diem rate, established by the board, for |
14 | attendance at meetings and further be reimbursed for actual |
15 | and necessary expenses incurred in the performance of their |
16 | duties, which shall include: |
17 | (i) Advising the board on the establishment of |
18 | policy on medical issues, population-based public health |
19 | issues, research priorities, scope of services, expansion |
20 | of access to health care services and evaluation of the |
21 | performance of the plan. |
22 | (ii) Investigating proposals for innovative |
23 | approaches to the promotion of health, the prevention of |
24 | disease and injury, patient education, research and |
25 | health care delivery. |
26 | (iii) Advising the board on the establishment of |
27 | standards and criteria to evaluate requests from health |
28 | care facilities for capital improvements. |
29 | (iv) Evaluating and advising the board on requests |
30 | from providers, or their representatives, for adjustments |
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1 | to reimbursements. |
2 | (15) Establishing a secure and centralized electronic |
3 | health record system wherein a beneficiary's entire health |
4 | record can be readily and reliably accessed by authorized |
5 | persons with the objective of eliminating the errors and |
6 | expense associated with paper records and diagnostic films. |
7 | The system shall ensure the privacy of all health records it |
8 | contains. |
9 | SUBCHAPTER B |
10 | PENNSYLVANIA HEALTH CARE AGENCY |
11 | Section 321. Pennsylvania Health Care Agency. |
12 | (a) Establishment of agency.--There is hereby established |
13 | the Pennsylvania Health Care Agency. The agency shall administer |
14 | the plan and is the sole agency authorized to accept applicable |
15 | grants-in-aid from the Federal Government and State government. |
16 | It shall use such funds in order to secure full compliance with |
17 | provisions of Federal and State law and to carry out the |
18 | purposes established under this act. All grants-in-aid accepted |
19 | by the agency shall be deposited into the Pennsylvania Health |
20 | Care Trust Fund established under this act, together with other |
21 | revenues raised within this Commonwealth to fund the plan. |
22 | (b) Appointment of executive director.--The executive |
23 | director of the agency shall be appointed by the Governor for a |
24 | term of three years and is the chief administrator of the plan. |
25 | (c) Personnel and employees.--The board shall employ and fix |
26 | the compensation of agency personnel as needed by the agency to |
27 | properly discharge the agency's duties. The employment of |
28 | personnel by the board is subject to the civil service laws of |
29 | this Commonwealth. The executive director shall oversee the |
30 | operation of the agency and the agency's performance of any |
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1 | duties assigned by the board. |
2 | SUBCHAPTER C |
3 | (Reserved) |
4 | SUBCHAPTER D |
5 | (Reserved) |
6 | SUBCHAPTER E |
7 | (Reserved) |
8 | SUBCHAPTER F |
9 | IMMUNITY |
10 | Section 371. Immunity. |
11 | In the absence of fraud or bad faith, the advisory panel, the |
12 | board and agency and their respective members and employees |
13 | shall incur no liability in relation to the performance of their |
14 | duties and responsibilities under this act. The Commonwealth |
15 | shall incur no liability in relation to the implementation and |
16 | operation of the plan. |
17 | CHAPTER 5 |
18 | PENNSYLVANIA HEALTH CARE PLAN |
19 | Section 501. General provisions. |
20 | (a) Establishment of plan.--There is hereby established the |
21 | Pennsylvania Health Care Plan that shall be administered by the |
22 | independent Pennsylvania Health Care Agency under the direction |
23 | of the Pennsylvania Health Care Board. |
24 | (b) Coverage.--The plan shall provide health care coverage |
25 | for all citizens of this Commonwealth and for certain eligible |
26 | visitors. The agency shall work simultaneously to control health |
27 | care costs, achieve measurable improvement in health care |
28 | outcomes, promote a culture of health awareness and develop an |
29 | integrated health care database to support health care planning |
30 | and quality assurance. |
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1 | (c) Reforms.--The board shall implement the reforms adopted |
2 | by the General Assembly hereby within one year of the effective |
3 | date of the plan. |
4 | Section 502. Universal health care access eligibility. |
5 | (a) Eligibility.--All Pennsylvania citizens, including an |
6 | alien or immigrant lawfully given admission to the United States |
7 | under the Immigration and Nationality Act (66 Stat. 163, 8 |
8 | U.S.C. § 1101 et seq.), full-time out-of-State students |
9 | attending school in this Commonwealth, homeless persons and |
10 | migrant agricultural workers and their accompanying families are |
11 | eligible beneficiaries under the plan. The board shall establish |
12 | standards and a simple procedure to demonstrate proof of |
13 | eligibility. |
14 | (b) Enrollment.--Enrollment in the plan shall be automatic |
15 | and beneficiaries shall be provided with access cards with |
16 | appropriate proof of identity technology and privacy protection. |
17 | (c) Waivers.--If waivers are not obtained from the medical |
18 | assistance and/or Medicare programs operated under Title XVIII |
19 | or XIX of the Social Security Act (49 Stat. 620, 42 U.S.C. § 301 |
20 | et seq.), the medical assistance and Medicare nonwaived programs |
21 | shall act as the primary insurers for those eligible for such |
22 | coverage, and the plan shall serve as the secondary or |
23 | supplemental plan of health coverage. Until such time as waivers |
24 | are obtained, the plan will not pay for services for persons |
25 | otherwise eligible for the same benefits under Medicare or |
26 | Medicaid. The plan shall also be secondary to benefits provided |
27 | to military veterans except where reasonable and timely access, |
28 | as defined by the board, is denied or unavailable through the |
29 | United States Veterans' Administration, in which instance the |
30 | plan will be primary and will seek reasonable reimbursement from |
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1 | the United States Veterans' Administration for the services |
2 | provided to veterans. |
3 | (d) Priority of plans.--A plan of employee health coverage |
4 | provided by an out-of-State employer to a Pennsylvania resident |
5 | working outside of this Commonwealth shall serve as the |
6 | employee's primary plan of health coverage, and the plan shall |
7 | serve as the employee's secondary plan of health coverage. |
8 | (e) Reimbursement.--The plan shall reimburse providers |
9 | practicing outside of this Commonwealth at plan rates, or the |
10 | reasonable prevailing rate of the locale where the service is |
11 | provided, for health care services rendered to a beneficiary |
12 | while the beneficiary is out of this Commonwealth. Services |
13 | provided to a beneficiary out of this Commonwealth by other than |
14 | a participating provider shall be reimbursed to the beneficiary |
15 | or to the provider at a fair and reasonable rate for that |
16 | location. |
17 | (f) Presumption of eligibility.--Any individual who arrives |
18 | at a health care facility unconscious or otherwise unable due to |
19 | their mental or physical condition to document eligibility for |
20 | coverage shall be presumed to be eligible, and emergency care |
21 | shall be provided without delay occasioned over issues of |
22 | ability to pay. |
23 | (g) Rules.--The board shall adopt rules assuring that any |
24 | participating provider who renders humanitarian emergency or |
25 | urgent care within this Commonwealth to a not actually eligible |
26 | recipient shall nevertheless be reimbursed for such care from |
27 | the plan subject to such rules as will reasonably limit the |
28 | frequency of such events to protect the fiscal integrity of the |
29 | plan. It shall be the agency's responsibility to secure |
30 | reimbursement for the costs paid for such care from any |
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1 | appropriate third party funding source, or from the individual |
2 | to whom the services were rendered. |
3 | Section 503. Covered services. |
4 | (a) Benefits package.--The board shall establish a single |
5 | health benefits package within the plan that shall include, but |
6 | not be limited to, all of the following: |
7 | (1) All medically necessary inpatient and outpatient |
8 | care and treatment, both primary and secondary. |
9 | (2) Emergency services. |
10 | (3) Emergency and other medically necessary transport to |
11 | covered health services. |
12 | (4) Rehabilitation services, including speech, |
13 | occupational, physical and massage therapy. |
14 | (5) Inpatient and outpatient mental health services and |
15 | substance abuse treatment. |
16 | (6) Hospice care. |
17 | (7) Prescription drugs and prescribed medical nutrition. |
18 | (8) Vision care, aids and equipment. |
19 | (9) Hearing care, hearing aids and equipment. |
20 | (10) Diagnostic medical tests, including laboratory |
21 | tests and imaging procedures. |
22 | (11) Medical supplies and prescribed medical equipment. |
23 | (12) Immunizations, preventive care, health maintenance |
24 | care and screening. |
25 | (13) Dental care. |
26 | (14) Home health care services. |
27 | (15) Chiropractic and massage therapy. |
28 | (16) Complementary and alternative modalities that have |
29 | been shown by the National Institute of Health's Division of |
30 | Complementary and Alternative Medicine to be safe and |
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1 | effective for possible inclusion as covered benefits. |
2 | (17) Long-term care for those unable to care for |
3 | themselves independently and including assisted and skilled |
4 | care. |
5 | (b) Exclusions for preexisting conditions.--The plan shall |
6 | not exclude or limit coverage due to preexisting conditions. |
7 | (c) Copayments, deductibles, etc.--Beneficiaries of the plan |
8 | are not subject to copayments, deductibles, point-of-service |
9 | charges or any other fee or charge for a service within the |
10 | package and shall not be directly billed nor balance billed by |
11 | participating providers for covered benefits provided to the |
12 | beneficiary. Where a beneficiary has directly paid for |
13 | nonemergency services of a nonparticipating provider, the |
14 | beneficiary may submit a claim for reimbursement from the plan |
15 | for the amount the plan would have paid a participating provider |
16 | for the same service. Where emergency services are rendered by a |
17 | nonparticipating provider, the beneficiary shall receive |
18 | reimbursement of the full amount paid to such nonparticipating |
19 | provider not to exceed 125% of the amount the plan would have |
20 | paid a participating provider for the same service. |
21 | (d) Exclusions of coverage.-- |
22 | (1) The board shall remove or exclude procedures and |
23 | treatments, equipment and prescription drugs from the plan |
24 | benefit package that the board finds unsafe or that add no |
25 | therapeutic value. |
26 | (2) The board shall exclude coverage for any surgical, |
27 | orthodontic or other procedure or drug that the board |
28 | determines was or will be provided primarily for cosmetic |
29 | purposes unless required to correct a congenital defect, to |
30 | restore or correct disfigurements resulting from injury or |
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1 | disease or that is certified to be medically necessary by a |
2 | qualified, licensed provider. |
3 | (e) Choice by beneficiary.--Beneficiaries shall normally be |
4 | granted free choice of the participating providers, including |
5 | specialists, without preapprovals or referrals. However, the |
6 | board shall adopt procedures to restrict such free choice for |
7 | those individuals who engage in patterns of wasteful or abusive |
8 | self-referrals to specialists. Specialists who provide primary |
9 | care to a self-referred beneficiary will be reimbursed at the |
10 | board-approved primary care rate established for the service in |
11 | that community. |
12 | (f) Service.--No participating provider shall be compelled |
13 | to offer any particular service so long as the refusal is |
14 | consistent with the provider's practice and is in no way |
15 | discriminatory. |
16 | (g) Discrimination.--The plan and participating providers |
17 | shall not discriminate on the basis of race, ethnicity, national |
18 | origin, gender, age, religion, sexual orientation, health |
19 | status, mental or physical disability, employment status, |
20 | veteran status or occupation. |
21 | Section 504. Excess and collective bargaining agreement health |
22 | insurance coverage. |
23 | Subject to the regulations of the Insurance Commissioner and |
24 | all applicable laws, private health insurers shall be authorized |
25 | to offer coverage supplemental to the package approved and |
26 | provided automatically under this act. |
27 | Section 505. Duplicate coverage. |
28 | The agency is subrogated to and shall be deemed an assignee |
29 | of all rights of a beneficiary who has received duplicate health |
30 | care benefits, or who has a right to such benefits, under any |
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1 | other policy or contract of health care or under any government |
2 | program. |
3 | Section 506. Subrogation. |
4 | The agency shall have no right of subrogation against a |
5 | beneficiary's third-party claims for harm or losses not covered |
6 | under this act. Nor shall any beneficiary under this act have a |
7 | claim against a third-party tortfeasor for the services provided |
8 | or available to the beneficiary under this act. In all personal |
9 | injury actions accruing and prosecuted by a beneficiary on or |
10 | after January 1, 2008, the presiding judge shall advise any jury |
11 | that all health care expenses have been or will be paid under |
12 | the plan, and, therefore, no claim for past or future health |
13 | care benefits is pending before the court. |
14 | Section 507. Eligible participating providers and availability |
15 | of services. |
16 | (a) General rule.--All licensed health care providers and |
17 | facilities are eligible to become a participating provider in |
18 | the plan in which instance they shall enjoy the rights and have |
19 | the duties as set forth in the plan as stated in this section or |
20 | as adopted by the board from time to time. Nonparticipating |
21 | providers shall not enjoy the rights nor bear the duties of |
22 | participating providers. |
23 | (b) Required notice.--In advance of initially providing |
24 | services to a beneficiary, nonparticipating providers shall |
25 | advise the beneficiary at the time the appointment is made that |
26 | the person or entity is a nonparticipating provider and that the |
27 | recipient of the service will be initially personally |
28 | responsible for the entire cost of the service and ultimately |
29 | responsible for the cost in excess of the reimbursement approved |
30 | by the board for participating providers. Failure to make such |
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1 | financial disclosure will be deemed a fraud on the beneficiary |
2 | and entitle the beneficiary to a refund from the provider equal |
3 | to 200% of the amount paid to the nonparticipating provider in |
4 | excess of the board-approved reimbursement for the services |
5 | rendered, plus all reasonable fees for collection. The burden of |
6 | proof that such disclosure was made shall be on the |
7 | nonparticipating provider. |
8 | (c) Plan by board.--The board shall assess the number of |
9 | primary and specialty providers needed to supply adequate health |
10 | care services in this Commonwealth generally and in all |
11 | geographic areas and shall develop a plan to meet that need. The |
12 | board shall develop financial incentives for participating |
13 | providers in order to maintain and increase access to health |
14 | care services in underserved areas of this Commonwealth. |
15 | (d) Reimbursements.--Reimbursements shall be determined by |
16 | the board in such a fashion as to assure that a participating |
17 | provider receives compensation for services that fairly and |
18 | fully reflect the skill, training, operating overhead included |
19 | in the costs of providing the service, capital costs of |
20 | facilities and equipment, cost of consumables and the expense of |
21 | safely discarding medical waste, plus a reasonable profit |
22 | sufficient to encourage talented individuals to enter the field |
23 | and for investors to make capital available for the construction |
24 | of state-of-the-art health care facilities in this Commonwealth. |
25 | (e) Adjustments to reimbursements.--Participating providers |
26 | shall have the right alone or collectively to petition the board |
27 | for adjustments to reimbursements believed to be too low. Such |
28 | petitions shall be initially evaluated by the administrator of |
29 | provider services, with input from the Health Advisory Panel, |
30 | who shall submit a report to the executive director within 30 |
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1 | days. The executive director will then submit a recommendation |
2 | to the board for action at the next scheduled board meeting. |
3 | Participating providers who remain dissatisfied after the board |
4 | has ruled may appeal the board's determination to Commonwealth |
5 | Court, which shall review the action of the board on an abuse of |
6 | discretion standard. |
7 | (f) Evaluation of access to care.--The board annually shall |
8 | evaluate access to trauma care, diagnostic imaging technology, |
9 | emergency transport and other vital urgent care requirements and |
10 | shall establish measures to assure beneficiaries have equitable |
11 | and ready access to such resources regardless of where in this |
12 | Commonwealth they may be. |
13 | (g) Performance reports.--The board, with the assistance of |
14 | the Health Advisory Panel, shall define performance criteria and |
15 | goals for the plan and shall make a written report to the |
16 | General Assembly at least annually on the plan's performance. |
17 | All such reports, including the survey results obtained, shall |
18 | be made publicly available with the goal of total transparency |
19 | and open self-analysis as a defining quality of the agency. The |
20 | board shall establish a system to monitor the quality of health |
21 | care and patient and provider satisfaction and to adopt a system |
22 | to devise improvements and efficiencies to the provision of |
23 | health care services. |
24 | (h) Data reporting.--All participating providers shall, in a |
25 | prompt and timely manner, provide existing and ongoing data to |
26 | the agency upon its request. |
27 | (i) Coordination of services.--The board shall coordinate |
28 | the provision of health care services with any other |
29 | Commonwealth and local agencies that provide health care |
30 | services directly to their charges or residents. |
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1 | Section 508. Rational cost containment. |
2 | (a) Approval of expenditures.--As part of its cost |
3 | containment mission and based on the certificate of need, the |
4 | board shall screen and approve or disapprove private or public |
5 | expenditures for new health care facilities and other capital |
6 | investments that may lead to redundant and inefficient health |
7 | care provider capacity. Procedures shall be adopted for this |
8 | purpose with an emphasis upon efficiency, quality of delivery |
9 | and a fair and open consideration of all applications. |
10 | (b) Capital investments.--Based on the certificate of need |
11 | all capital investments valued at $1,000,000 or greater, |
12 | including the costs of studies, surveys, design plans and |
13 | working drawing specifications, and other activities essential |
14 | to planning and execution of capital investment and all capital |
15 | investments that change the bed capacity of a health care |
16 | facility by more than 10% over a 24-month period or that add a |
17 | new service or license category shall require the approval of |
18 | the board. When a facility, an individual acting on behalf of a |
19 | facility or any other purchaser obtains by lease or comparable |
20 | arrangement any facility or part of a facility, or any equipment |
21 | for a facility, the market value of which would have been a |
22 | capital expenditure, the lease or arrangement shall be |
23 | considered a capital expenditure for purposes of this section. |
24 | (c) Study.--Those intending to make capital investments or |
25 | acquisitions shall prepare a business case for making each |
26 | investment and acquisition. It shall include the full-life-cycle |
27 | costs of the investment or acquisition, an environment impact |
28 | report that meets existing State standards and a demonstration |
29 | of how the investment or acquisition meets the health care needs |
30 | of the population it is intended to serve. Acquisitions may |
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1 | include, but not be limited to, acquisitions of land, |
2 | operational property or administrative office space. |
3 | (d) Deemed approval.--Capital investment programs submitted |
4 | for approval shall be deemed approved by the board within 60 |
5 | days from the date the submissions are received by the executive |
6 | director. A 60-day extension may apply if the board requires |
7 | additional information. |
8 | (e) Recommendations.--Recommendations of the Pennsylvania |
9 | Heath Cost Containment Council and such other public and private |
10 | authoritative bodies as shall be identified from time to time by |
11 | the board shall be received by the executive director and |
12 | submitted to the board with the executive director's |
13 | recommendation regarding implementation of the recommended |
14 | reforms. The board shall receive input from all interested |
15 | parties and then shall vote upon all such recommendations within |
16 | 60 days. Where procedural or protocol reforms are adopted, |
17 | participating providers will be required to implement such |
18 | designated best practices within the next 60 days. |
19 | (f) Appeal.--A decision of the board may be appealed through |
20 | a uniform dispute resolution process that has been established |
21 | by unanimous approval of the board. |
22 | (g) Required investments.--The board is authorized to adopt |
23 | programs to assist participating providers in making capital |
24 | investments responsive to best practice recommendations. |
25 | (h) Decertification.--Participating providers refusing to |
26 | adopt recommended reforms shall, after a reasonable opportunity |
27 | to be heard, be subject to such sanctions as the board shall |
28 | deem appropriate and necessary up to and including the |
29 | suspension or permanent decertification of the participating |
30 | provider. |
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1 | CHAPTER 9 |
2 | PENNSYLVANIA HEALTH CARE TRUST FUND |
3 | Section 901. Pennsylvania Health Care Trust Fund. |
4 | (a) Establishment.--The Pennsylvania Health Care Trust Fund |
5 | is hereby established within the State Treasury. All moneys |
6 | collected and received by the plan shall be transmitted to the |
7 | State Treasurer for deposit into the fund, to be used |
8 | exclusively to finance the plan. |
9 | (b) State Treasurer.--The State Treasurer may invest the |
10 | principal and interest earned by the fund in any manner |
11 | authorized under law for the investment of Commonwealth moneys. |
12 | Any revenue or interest earned from the investments shall be |
13 | credited to the fund. |
14 | Section 902. Limitation on administrative expense. |
15 | The system budget referred to in this chapter shall comprise |
16 | the cost of the agency, services and benefits provided, |
17 | administration, data gathering, planning and other activities |
18 | and revenues deposited with the system account of the fund. The |
19 | board shall limit ongoing administrative costs, excluding start- |
20 | up costs, to 5% of the agency budget and shall annually evaluate |
21 | methods to reduce administrative costs and publicly report the |
22 | results of that evaluation. |
23 | Section 903. Funding sources. |
24 | Funding of the plan shall be obtained from the following |
25 | dedicated sources: |
26 | (1) Funds obtained from existing or future Federal |
27 | health care programs. |
28 | (2) Funds from dedicated sources specified by the |
29 | General Assembly. |
30 | (3) Receipts from the tax of 10% of gross payroll, |
|
1 | including self-employment profits. One percent of the tax |
2 | shall become effective the date that shall be the first day |
3 | of a calendar month no less than 32 days after the effective |
4 | date of this act, and the tax shall become fully effective 60 |
5 | days before the plan takes effect. Employers who are part of |
6 | a collective bargaining agreement whereby the health care |
7 | benefits are no less generous than those provided under the |
8 | plan shall be excused from paying 90% of the tax. |
9 | (4) Receipts from the Individual Fair Share Health and |
10 | Wellness Tax of 3% on income as defined in sections 301 and |
11 | 303 of the act of March 4, 1971 (P.L.6, No.2), known as the |
12 | Tax Reform Code of 1971. One-half of one percent of the |
13 | Individual Fair Share Health and Wellness Tax shall become |
14 | effective the date that shall be the first day of a calendar |
15 | month no less than 32 days after the effective date of this |
16 | act, and the Individual Fair Share Health and Wellness tax |
17 | shall become fully effective 60 days before the plan takes |
18 | effect. |
19 | (5) In the event the General Assembly has not responded |
20 | to a request by the board for an increase in funding in |
21 | anticipation of projected expenses, the board is hereby |
22 | authorized to order a temporary increase, for no more than 90 |
23 | days, in the tax and/or the Individual Fair Share Health and |
24 | Wellness Tax of not more than 250 basis points each to |
25 | respond to a threatened insolvency of the plan. |
26 | CHAPTER 11 |
27 | TRANSITIONAL SUPPORT AND TRAINING FOR DISPLACED WORKERS |
28 | Section 1101. Transitional support and training for displaced |
29 | workers. |
30 | (a) Determination of eligibility.--The plan shall determine |
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1 | which citizens of this Commonwealth employed by a health care |
2 | insurer, health insuring corporation or other health care- |
3 | related business have lost their employment as a result of the |
4 | implementation and operation of the plan, including the amount |
5 | of monthly wages that the individual has lost due to the plan's |
6 | implementation. The plan shall attempt to position these |
7 | displaced workers in comparable positions of employment or |
8 | assist in the retraining and placement of such displaced |
9 | employees elsewhere. |
10 | (b) Compensation.--The plan shall forward the information on |
11 | the amount of monthly wages lost by Commonwealth residents due |
12 | to the implementation of the plan to the board. Compensation |
13 | shall be up to $5,000 each month but may not exceed the monthly |
14 | wages of the individual when he was displaced. Compensation will |
15 | cease upon reemployment or after two years, whichever comes |
16 | first. A displaced worker shall be eligible to receive |
17 | compensation, training assistance, or both, from the fund. |
18 | Training assistance may not exceed $20,000. |
19 | (c) Coordination of services.--The plan shall fully |
20 | coordinate activity with public and private services also |
21 | available or actually participating in the assistance to the |
22 | affected individuals. |
23 | (d) Appeals.--Persons dissatisfied with the level of |
24 | assistance they are receiving may appeal to the office of the |
25 | executive director whose determination shall be final and not |
26 | subject to appeal. |
27 | CHAPTER 13 |
28 | VOLUNTEER EMERGENCY RESPONDER NETWORK |
29 | Section 1301. Preservation of volunteer emergency responder |
30 | network. |
|
1 | Because this Commonwealth is dependent upon the volunteered |
2 | services of firefighters, emergency medical technicians and |
3 | search and rescue workers, the board is further charged with |
4 | administering a Commonwealth income tax credit program for such |
5 | volunteers. |
6 | Section 1302. Eligibility certification. |
7 | Annually, in January, administrators of volunteer |
8 | firefighting and rescue departments, emergency medical |
9 | technicians and paramedics stations and similar volunteer |
10 | emergency entities shall certify the identity of Commonwealth |
11 | residents providing active services during the prior calendar |
12 | year. |
13 | Section 1303. Eligibility criteria. |
14 | Active status shall require a minimum of 200 hours of service |
15 | during the preceding year and response to no less than 50% of |
16 | the emergency calls during at least three of the four calendar |
17 | quarters. |
18 | Section 1304. Amount of tax credit. |
19 | Each volunteer certified as active shall be granted a credit |
20 | equal to $1,000 toward their State income tax obligation under |
21 | Article III of the act of March 4, 1971 (P.L.6, No.2), known as |
22 | the Tax Reform Code of 1971. Any eligible volunteer who does not |
23 | incur $1,000 in annual State income tax liability shall |
24 | nevertheless be eligible for a refund equal to the amount the |
25 | credit exceeds that volunteer's tax obligation. |
26 | Section 1305. Reimbursement. |
27 | The State Treasury shall be reimbursed the value of such |
28 | volunteer credits from the fund. |
29 | CHAPTER 45 |
30 | MISCELLANEOUS PROVISIONS |
|
1 | Section 4501. Effective date. |
2 | This act shall take effect immediately. |
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