| |
|
| |
| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
| |
| HOUSE BILL |
|
| |
| |
| INTRODUCED BY BOYD, AUMENT, CLYMER, CUTLER, EVERETT, HARHART, KILLION AND WATSON, MAY 21, 2012 |
| |
| |
| REFERRED TO COMMITTEE ON INSURANCE, MAY 21, 2012 |
| |
| |
| |
| AN ACT |
| |
1 | Establishing the Commonwealth Health Insurance Interchange. |
2 | The General Assembly of the Commonwealth of Pennsylvania |
3 | hereby enacts as follows: |
4 | Section 1. Short title. |
5 | This act shall be known and may be cited as the Commonwealth |
6 | Health Insurance Interchange Act (CHIIA). |
7 | Section 2. Definitions. |
8 | The following words and phrases when used in this act shall |
9 | have the meanings given to them in this section unless the |
10 | context clearly indicates otherwise: |
11 | "Basic care." A health insurance plan, available to |
12 | individuals and small employers, as set forth in this act. |
13 | "Department." The Insurance Department of the Commonwealth. |
14 | "Health care payment." An amount established by the employer |
15 | to contribute to the employee's health benefits. |
16 | "Health insurer." A company or health insurance entity |
17 | licensed in this Commonwealth to issue any individual or group |
|
1 | health, sickness or accident policy or subscriber contract or |
2 | certificate or plan that provides medical or health care |
3 | coverage by a health care facility or licensed health care |
4 | provider that is offered or governed under any of the following: |
5 | (1) The act of May 17, 1921 (P.L.682, No.284), known as |
6 | The Insurance Company Law of 1921. |
7 | (2) The act of December 29, 1972 (P.L.1701, No.364), |
8 | known as the Health Maintenance Organization Act. |
9 | (3) The act of May 18, 1976 (P.L.123, No.54), known as |
10 | the Individual Accident and Sickness Insurance Minimum |
11 | Standards Act. |
12 | (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan |
13 | corporations) or 63 (relating to professional health services |
14 | plan corporations). |
15 | "Health plan." A plan, other than basic care, as provided |
16 | for in this act. The term shall not include any of the |
17 | following: |
18 | (1) An accident-only policy. |
19 | (2) A credit-only policy. |
20 | (3) A long-term care or disability income policy. |
21 | (4) A specified-disease policy. |
22 | (5) A Medicare supplemental policy. |
23 | (6) The Civilian Health and Medical Program of the |
24 | Uniformed Services (CHAMPUS) supplemental policy. |
25 | (7) A fixed-indemnity policy. |
26 | (8) A dental-only policy. |
27 | (9) A vision-only policy. |
28 | (10) A workers' compensation policy. |
29 | (11) An automobile medical payment policy under 75 |
30 | Pa.C.S. (relating to vehicles). |
|
1 | (12) A short-term medical insurance policy for an |
2 | eligible individual who is temporarily without health |
3 | insurance, such as an individual between jobs, a student or a |
4 | new employee waiting for coverage to begin. |
5 | (13) Medical assistance. |
6 | (14) The Children's Health Insurance Program established |
7 | under Article XXIII of the act of May 17, 1921 (P.L.682, |
8 | No.284), known as The Insurance Company Act of 1921. |
9 | (15) Other limited benefit plans as recognized by the |
10 | department as exempted from this act. |
11 | "Interchange." The Commonwealth Health Insurance Interchange |
12 | Act (CHIIA). |
13 | "Licensed health insurance producer." An entity licensed |
14 | under Article VI-A of the act of May 17, 1921 (P.L.789, No.285), |
15 | known as The Insurance Department Act of 1921. |
16 | "Medical service fee." An amount charged to the patient by a |
17 | health care provider for services rendered. |
18 | "Rate band." A limit on the amount that insurers may vary |
19 | premiums based on health status. |
20 | "Small employer." An employer that employed an average of |
21 | not more than 50 employees during the preceding calendar year, |
22 | as defined in section 301 of the act of December 18, 1996 |
23 | (P.L.1066, No.159), known as the Accident and Health Filing |
24 | Reform Act, under the definition of "small group." |
25 | Section 3. Commonwealth Health Insurance Interchange Act. |
26 | (a) Establishment.--The Commonwealth Health Insurance |
27 | Interchange (CHIIA) is established within the department. |
28 | (b) Function.--The interchange shall: |
29 | (1) Facilitate the purchase and sale of basic care as |
30 | provided for in this act. |
|
1 | (2) Meet the requirements of this act and any |
2 | regulations implemented under this act. |
3 | (c) Contracts.--The interchange may facilitate a contract |
4 | with an eligible third party for any of its functions described |
5 | in this act. |
6 | (d) Information.--The interchange shall enter into |
7 | information–sharing agreements with Federal and State agencies |
8 | to carry out its responsibilities under this act, provided that |
9 | such agreements include adequate protections with respect to the |
10 | confidentiality of the information to be shared and comply with |
11 | all Federal and State regulations. |
12 | Section 4. General requirements. |
13 | (a) Website.--The interchange shall maintain an Internet |
14 | website through which individuals and small employers may do all |
15 | of the following: |
16 | (1) Obtain information on basic care as provided for in |
17 | this act. |
18 | (2) Do various premium comparisons of basic care in a |
19 | particular zip code. |
20 | (3) Complete a preliminary application for enrollment in |
21 | basic care. |
22 | (4) Provide for the purchase of basic care by the |
23 | applicant. |
24 | (b) Updates.--The website shall be updated at least monthly. |
25 | (c) Contact information.--The interchange shall provide for |
26 | the operation of a toll-free telephone hotline to respond to |
27 | requests for assistance. |
28 | (d) Links for research.--The interchange shall provide links |
29 | to health insurance companies so individuals and small employers |
30 | may chose which company they want to research. This link shall |
|
1 | provide a health insurance company insurance producer locator by |
2 | zip code so that the consumer using the interchange site is |
3 | connected to a licensed health insurance producer who may sell, |
4 | solicit and negotiate placement of basic care and other health |
5 | care plans. Nothing in this section shall restrict a consumer |
6 | from enrolling in the interchange through any health insurance |
7 | company or a licensed health insurance producer that is |
8 | authorized by the department to participate in the interchange |
9 | or that is entitled to receive compensation from the health |
10 | insurance company chosen to issue the policy. |
11 | (e) Other links.--The interchange shall provide linkage to |
12 | other interactive Internet systems including portals providing |
13 | access to medical assistance and the Children's Health Insurance |
14 | Program eligibility. It shall also provide a link to department |
15 | health insurance consumer educational materials and supply a |
16 | form where eligible individuals and small employers may make an |
17 | inquiry or register a complaint or concern. |
18 | (f) Applications.--The interchange shall develop a uniform |
19 | application with health insurance companies for use by |
20 | individuals and small employers. |
21 | (g) Expanded coverage.--Every licensed health insurance |
22 | company may offer additional coverages to provide broader |
23 | benefits. An individual or small employer shall be charged for |
24 | any additional coverages added to basic care by endorsement. |
25 | (h) Changes in premiums.--A change in the premium shall only |
26 | be effective for basic care on the annual renewal date for that |
27 | policy or for new policies purchased after the effective date of |
28 | the rate change period. Every insurer offering basic care shall |
29 | develop a base rate for department approval; this base rate |
30 | shall not be excessive, inadequate or unfairly discriminatory. |
|
1 | (i) Limits on increases and decreases.--A proposed rate band |
2 | premium adjustment to the base rate for basic care shall |
3 | increase no more than 20% or decrease no more than 15% from the |
4 | current approved base rate. The insurer may not, without prior |
5 | approval of the department, use rating characteristics when |
6 | determining a rate band premium adjustment for basic care other |
7 | than: |
8 | (1) Age of each applicant. |
9 | (2) Tobacco use. |
10 | (3) The geographic area/zip code for the applicant's |
11 | residency. |
12 | (j) Preexisting condition.-- |
13 | (1) A preexisting condition shall not be considered by |
14 | the insurer when an eligible individual or small employer |
15 | initially enrolls in or renews basic care coverage. |
16 | (2) However, if basic care lapses or is terminated, |
17 | reenrollment in basic care shall consider preexisting |
18 | conditions for rating purposes according to the rules of the |
19 | Health Insurance Portability and Accountability Act of 1996 |
20 | (Public Law 104-191, 110 Stat. 1936). |
21 | Section 5. Payments to employees for the purchase of basic |
22 | care. |
23 | A small employer may, in lieu of providing health care |
24 | coverage, provide an employee with a health care payment for the |
25 | purpose of paying all or a portion of the basic care that is |
26 | independently purchased by an employee. This payment shall not |
27 | be considered compensation for the employee as defined under |
28 | section 301 of the act of March 4, 1971 (P.L.6, No.2), known as |
29 | the Tax Reform Code of 1971. |
30 | Section 6. Funding. |
|
1 | The General Assembly shall appropriate funds for startup |
2 | costs to implement the interchange. Within 60 days of the |
3 | effective date of this act, the department shall determine a |
4 | cost estimate to administer the interchange. |
5 | Section 7. Basic care. |
6 | (a) Required offering.--An insurer licensed in this |
7 | Commonwealth to sell health insurance and has at least 1% of the |
8 | health insurance market Statewide shall offer basic care. |
9 | (b) Service fee.--All eligible benefits may be subject to a |
10 | medical service fee. A medical service fee shall not exceed 10% |
11 | of the health care provider's approved fee schedule, as provided |
12 | for in section 8. The additional medical service fee shall be |
13 | limited to $1,000 maximum per health care provider per calendar |
14 | year and shall be paid to the provider rendering services. |
15 | (c) Benefits.--Basic care benefits include all of the |
16 | following: |
17 | (1) Twenty-one days of inpatient surgical and medical |
18 | coverage per policy year. |
19 | (2) Eight office visits for primary health care |
20 | services. |
21 | (3) Surgery and anesthesia. |
22 | (4) Emergency accident and medical treatment. |
23 | (5) Diagnostic services up to $2,500 for each policy |
24 | year. |
25 | (6) Chemotherapy and radiation treatment. |
26 | (7) Maternity care. |
27 | (8) Newborn care up to 31 days following birth. |
28 | (9) Prescription drugs as provided for in a formulary of |
29 | commonly dispensed medications covered under basic care to be |
30 | established by the department with assistance from the |
|
1 | Department of Health. |
2 | Section 8. Health care provider fee schedule. |
3 | (a) General fees.--Except as provided for in section 7(b), a |
4 | health care provider or institution providing treatment, |
5 | accommodations, products or services to a patient for a benefit |
6 | covered by basic care shall not require, request or accept |
7 | payment for treatment, accommodations, products or services in |
8 | excess of any of the following: |
9 | (1) One hundred twenty percent of the prevailing charge |
10 | at the 75th percentile. |
11 | (2) One hundred twenty percent of the applicable fee |
12 | schedule, the recommended fee or the inflation index charge. |
13 | (3) One hundred twenty percent of the diagnostic-related |
14 | groups (DRG) payment, whichever pertains to the specialty |
15 | service involved, determined to be applicable in this |
16 | Commonwealth under the Medicare program for comparable |
17 | services at the time the services were rendered or the |
18 | provider's usual and customary charge, whichever is less. |
19 | (b) Calculating payments.--The reimbursement allowances |
20 | applicable in this Commonwealth under the Medicare program are |
21 | an appropriate basis for the department and health care insurers |
22 | to calculate payment for treatments, accommodations, products or |
23 | services. |
24 | (c) Subsequent fee schedules.--Future changes or additions |
25 | to Medicare allowances are applicable under this section. |
26 | (d) Unreasonable fees.--If the department determines that an |
27 | allowance under the Medicare program is not reasonable, the |
28 | Insurance Commissioner may adopt a different allowance by |
29 | regulation, which allowance shall be applied against the |
30 | percentage limitation in this subsection. |
|
1 | (e) Other charges.--If a prevailing charge, fee schedule, |
2 | recommended fee, inflation index charge or DRG payment has not |
3 | been calculated under the Medicare program for a particular |
4 | treatment, accommodation, product or service, the amount of the |
5 | payment may not exceed 80% of the provider's usual and customary |
6 | charge. |
7 | (f) Emergency treatment.--If acute care is provided in an |
8 | acute care facility to a patient with an immediately |
9 | life-threatening or urgent injury by a Level I or Level II |
10 | trauma center accredited by the Pennsylvania Trauma Systems |
11 | Foundation under 35 Pa.C.S. § 8107 (relating to Pennsylvania |
12 | Trauma Systems Foundation) or to a major burn injury patient by |
13 | a burn facility which meets all the service standards of the |
14 | American Burn Association, the amount of payment may not exceed |
15 | the usual and customary charge. |
16 | (g) Billing.--Providers subject to this section may not bill |
17 | the insured directly but must bill the insurer for a |
18 | determination of the amount payable. |
19 | Section 9. Advisory committee. |
20 | (a) Establishment.--An advisory committee is formed to |
21 | assist in overseeing the provisions of this act. |
22 | (b) Members.--The advisory committee shall be comprised of |
23 | the following members: |
24 | (1) The Insurance Commissioner or a department designee |
25 | who will serve as chairperson. |
26 | (2) Two members of the Senate appointed by the President |
27 | pro tempore, one of whom shall be a member of the minority |
28 | party. |
29 | (3) Two members of the House of Representatives |
30 | appointed by the Speaker, one of whom shall be a member of |
|
1 | the minority party. |
2 | (4) Two representatives of hospitals selected by the |
3 | Governor from a list of five individuals supplied by an |
4 | association whose membership consists primarily of hospitals. |
5 | (5) Two primary health care practitioners selected by |
6 | the Governor from a list of five individuals supplied by an |
7 | association whose membership consists of medical care |
8 | practitioners. |
9 | (6) One individual appointed by the Governor and |
10 | employed by a for-profit insurance carrier licensed to |
11 | provide health insurance from a list supplied by an |
12 | association whose membership consists of for-profit insurers. |
13 | (7) One individual employed by a nonprofit health |
14 | insurer appointed by the Governor. |
15 | (8) Two members of the general public appointed by the |
16 | Governor. |
17 | (9) Two insurance producers licensed to sell health |
18 | insurance in this Commonwealth appointed by the Governor from |
19 | a list of five individuals submitted by an association whose |
20 | members consist of insurance producers licensed to sell |
21 | health insurance. |
22 | (10) One actuary who is not an employee of this |
23 | Commonwealth appointed by the department. |
24 | (c) Legislative terms.--Legislative members shall serve so |
25 | long as they remain in office. |
26 | (d) Other terms.--All other members of the advisory |
27 | committee shall serve for a two-year term, not to exceed two |
28 | terms. |
29 | (e) Compensation.--No member of the advisory committee shall |
30 | be eligible to receive financial reimbursement, except for |
|
1 | travel. |
2 | (f) Duties.--The advisory committee shall have the following |
3 | responsibilities: |
4 | (1) Assist the Insurance Commissioner in preparing the |
5 | interchange annual report as specified in subsection (g). |
6 | (2) Provide expertise to the Insurance Commissioner. |
7 | (3) Assist the department in reviewing the Internet |
8 | website for accuracy and clarity in communication to |
9 | individuals and small employers. |
10 | (g) Report.--A report shall be submitted to the General |
11 | Assembly by March 1 of each calendar year, to include a summary |
12 | of the previous year's interchange data. |
13 | Section 10. Effective date. |
14 | This act shall take effect in 180 days. |
|