THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE BILL

INTRODUCED BY PAYTON, McGEEHAN, V. BROWN, CALTAGIRONE, MYERS, PASHINSKI, SCHMOTZER, WATERS, WILLIAMS AND YOUNGBLOOD, JULY 17, 2012

REFERRED TO COMMITTEE ON HEALTH, JULY 17, 2012  

AN ACT

Providing for a Statewide comprehensive health care system;

establishing the Pennsylvania Health Care Plan and providing

for eligibility, services, coverages, subrogation,

participating providers, cost containment, reduction of

errors, tort remedies, administrative remedies and

procedures, attorney fees, quality assurance,

nonparticipating providers, transitional support and

training; and establishing the Pennsylvania Health Care

Agency, the Employer Health Services Levy, the Individual

Wellness Tax, the Pennsylvania Health Care Trust Fund and the

Pennsylvania Health Care Board and providing for their powers

and duties.

TABLE OF CONTENTS

Chapter 1.  Preliminary Provisions

Section 101.  Short title.

Section 102.  Definitions.

Chapter 3.  Administration and Oversight of the Pennsylvania

Health Care Plan

Subchapter A.  Pennsylvania Health Care Board

Section 301.  Organization.

Section 302.  Duties of board.

Subchapter B.  Pennsylvania Health Care Agency

Section 321.  Pennsylvania Health Care Agency.

Subchapter C.  (Reserved).

Subchapter D.  (Reserved).

Subchapter E.  (Reserved).

Subchapter F.  Immunity

Section 371.  Immunity.

Chapter 5.  Pennsylvania Health Care Plan

Section 501.  General provisions.

Section 502.  Universal health care access eligibility.

Section 503.  Covered services.

Section 504.  Excess and collective bargaining agreement health

insurance coverage.

Section 505.  Duplicate coverage.

Section 506.  Subrogation.

Section 507.  Eligible participating providers and availability

of services.

Section 508.  Rational cost containment.

Chapter 9.  Pennsylvania Health Care Trust Fund

Section 901.  Pennsylvania Health Care Trust Fund.

Section 902.  Limitation on administrative expense.

Section 903.  Funding sources.

Chapter 11.  Transitional Support and Training for Displaced

Workers

Section 1101.  Transitional support and training for displaced

workers.

Chapter 13.  Volunteer Emergency Responder Network

Section 1301.  Preservation of volunteer emergency responder

network.

Section 1302.  Eligibility certification.

Section 1303.  Eligibility criteria.

Section 1304.  Amount of tax credit.

Section 1305.  Reimbursement of Department of Revenue.

Chapter 45.  Miscellaneous Provisions

Section 4501.  Effective date.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

CHAPTER 1

PRELIMINARY PROVISIONS

Section 101.  Short title.

This act shall be known and may be cited as the Family and

Business Healthcare Security Act.

Section 102.  Definitions.

The following words and phrases when used in this act shall

have the meanings given to them in this section unless the

context clearly indicates otherwise:

"Agency."  The Pennsylvania Health Care Agency established

under this act.

"Board."  The Pennsylvania Health Care Board established

under this act.

"Certificate of need."  A notice of approval issued by the

Department of Health under the provisions of the act of July 19,

1979 (P.L.130, No.48), known as the Health Care

Facilities Act, including those notices of approval issued as an

amendment to an existing certificate of need.

"Chair."  The Chair of the Pennsylvania Health Care Board.

"Department."  The Department of Health of the Commonwealth.

"Executive director."  The Executive Director of the

Pennsylvania Health Care Agency.

"Fund."  The Pennsylvania Health Care Trust Fund established

under this act.

"Individual Fair Share Health and Wellness Tax."  The

Individual Fair Share Health and Wellness Tax established under

this act.

"Ombudsman."  The Pennsylvania Health Care Ombudsman

established under this act.

"Plan."  The Pennsylvania Health Care Plan established under

this act.

"Tax."  The Employer Fair Share Health and Wellness Tax

established under this act.

CHAPTER 3

ADMINISTRATION AND OVERSIGHT OF THE

PENNSYLVANIA HEALTH CARE PLAN

SUBCHAPTER A

PENNSYLVANIA HEALTH CARE BOARD

Section 301.  Organization.

(a)  Composition.--The Pennsylvania Health Care Board shall

be composed of 11 voting members. The chair shall preside over

the board and shall set the agenda but may vote only in the

event of a tie vote.

(b)  Appointments.--

(1)  The board shall consist of 11 members, the Chair of

which shall be appointed by the Governor. Three of the

remaining members shall be appointed by the Majority Leader

of the Senate, three of the remaining members shall be

appointed by the Majority Leader of the House of

Representatives, two of the remaining members shall be

appointed by the Minority Leader of the Senate and two of the

remaining members shall be appointed by the Minority Leader

of the House of Representatives. The board shall be composed

of individuals representative of each of the following

constituencies and reflective of the diversity of this

Commonwealth:

(i)  Two patients or caregivers of patients who

experience the health care system daily. These members

must be geographically diverse, knowledgeable about

health issues and represent the following categories:

(A)  A caregiver of a child with a chronic

illness or developmental disability.

(B)  An adult with a chronic illness, physical

disability or mental illness requiring medications.

(ii)  A physician.

(iii)  A hospital representative.

(iv)  A long-term care representative.

(v)  A health care attorney.

(vi)  Health care informatics.

(vii)  A small business representative.

(viii)  A large business representative.

(ix)  An organized labor representative from the

health sector.

(x)  Public health.

(2)  Appointed board members shall take the oath of

office prior to serving on the board and may be removed only

for cause under subsection (j).

(b.1)  Quality of care panels.--

(1)  In addition to the board, there shall be four

quality of care panels as follows:

(i)  A health professional quality panel.

(ii)  A health institution quality panel.

(iii)  A health supplier quality panel.

(iv)  The health care ombudsman panel.

(2)  The quality of care panels shall meet regularly as

needed to create policies and recommendations to deliver

cost-effective, evidence-based, quality health care to the

residents of this Commonwealth.

(3)  The quality of care panels shall hire staff who will

work daily on quality of care recommendations with agency

staff. The quality of care recommendations shall be presented

in a formal report at every board meeting.

(4)  The chair shall inform the board on progress or

explaining the lack of progress in implementing key

recommendations of the quality of care panels.

(c)  Chairman.--The Governor shall designate one of the board

members as chairman, who shall serve in that position at the

pleasure of the Governor. The chairman shall, when present,

preside at all meetings, and in his absence a member designated

by the chairman shall preside.

(d)  Midterm vacancies.--Midterm vacancies shall be filled by

a representative from the same constituent group required under

subsection (b) and the individual appointed to fill a vacancy

occurring prior to the expiration of the term for which a member

is appointed shall hold office for the remainder of the

predecessor's term.

(e)  Compensation, benefits and expenses.--The chair shall

receive an annual salary, benefits and expense reimbursement

established by the board, to be paid from the fund, but the

salary may not exceed the salary of the Governor. The initial

board shall establish its own compensation per diem and, for

travel, reimbursement of expenses incurred on behalf of the

board and other necessary expenses. No increase or decrease in

salary or benefits adopted by the board for the chair or members

shall become effective within the same three-year term, except

for the first three initial years of the plan when readjustments

may be made.

(f)  Meetings.--

(1)  The chair shall set the time, place and date for the

initial and subsequent meetings of the board and shall

preside over its meetings. The initial meeting shall be set

not sooner than 50 nor later than 100 days after the

appointment of the chair. Subsequent meetings shall occur as

determined by the board but not less than six times annually.

(2)  All meetings of the board are open to the public

unless questions of patient confidentiality arise. The board

may conduct closed executive session for issues relating to

confidential patient information, to evaluation of the chair

or to personnel matters.

(3)  The board shall publish its rulings in the

Pennsylvania Bulletin with an opportunity for public comment

as determined by State law.

(4)  The minutes of the board, except for executive

session deliberations, shall be public information. The media

shall be allowed access to all final public reports to ensure

full disclosure of decisions that impact the public.

(g)  Quorum.--Two-thirds of the appointed members of the

board shall constitute a quorum for the conducting of business

at meetings of the board. Decisions at ordinary meetings of the

board shall be reached by majority vote of those actually

present or, in the event of an emergency meeting, those also

present by electronic or telephonic means. Where there is a tie

vote, the chair shall vote to break the tie. Except as otherwise

provided in this act, absentee or proxy voting shall not be

allowed.

(h)  Ethics.--The executive director, the chair and other

board members and their immediate families are prohibited from

having any pecuniary interest in any business with a contract or

in negotiation for a contract with the agency. The board shall

also adopt rules of ethics and definitions of irreconcilable

conflicts of interest that will determine under what

circumstances members must recuse themselves from voting.

(i)  Prohibitions.--

(1)  No member of the board may receive any additional

salary or benefits by virtue of serving on the board.

(2)  No member of the board may hold any other salaried

Commonwealth public position, either elected or appointed,

during the member's tenure on the board, including, but not

limited to, the position of State legislator or member of the

United States Congress.

(3)  The executive director, chair and board members may

not be a State legislator or member of the United States

Congress.

(j)  Dismissal.--Board members shall attend all meetings and

be prepared to discuss and vote on information presented. Board

members may be dismissed and positions refilled for any of the

following reasons:

(1)  Failure to attend 75% of the meetings in one year.

(2)  Inability to represent their constituency group.

(3)  Clear conflict of interest.

(4)  Fraud or criminal activity either present or in the

past.

Section 302.  Duties of board.

(a)  General duties.--The board is responsible for directing

the agency in the performance of all duties, the exercise of all

powers, and the assumption and discharge of all functions vested

in the agency. The board shall adopt and publish its rules and

procedures in the Pennsylvania Bulletin no later than 180 days

after the first meeting of the board.

(b)  Specific duties.--The duties and functions of the board

include, but are not limited to, the following:

(1)  Implementing statutory eligibility standards for

benefits.

(2)  Annually adopting a benefits package for

participants of the plan.

(3)  Acting directly or through one or more contractors

as the single payer administrator for all claims for health

care services made under the plan.

(4)  At least annually, reviewing the appropriateness and

sufficiency of reimbursements and considering whether a

charge is fair and reasonable for its geographic region or

location.

(5)  Providing for timely payments to participating

providers through a structure that is well organized and that

eliminates unnecessary administrative costs.

(6)  Implementing standardized claims and reporting

methods for use by the plan.

(7)  Developing a system of centralized electronic claims

and payments accounting.

(8)  Establishing an enrollment system that will ensure

that those who travel frequently and cannot read or speak

English are aware of their right to health care and are

formally enrolled in the plan.

(9)  Reporting annually to the General Assembly and to

the Governor, on or before the first day of October, on the

performance of the plan, the fiscal condition of the plan,

recommendations for statutory changes, the receipt of

payments from the Federal Government, whether current year

goals and priorities were met, future goals and priorities,

and major new technology or prescription drugs that may

affect the cost of the health care services provided by the

plan.

(10)  Administering the revenues of the fund.

(11)  Obtaining appropriate liability and other forms of

insurance to provide coverage for the plan, the board, the

agency and their employees and agents.

(12)  Establishing, appointing and funding appropriate

staff, office space, equipment, training and administrative

support for the agency throughout this Commonwealth, all to

be paid from the fund.

(13)  Administering aspects of the agency by taking

actions that include, but are not limited to, the following:

(i)  Establishing standards and criteria for the

allocation of operating funds.

(ii)  Meeting regularly to review the performance of

the agency and to adopt and revise its policies.

(iii)  Establishing goals for the health care system

established pursuant to the plan in measurable terms.

(iv)  Establishing Statewide health care databases to

support health care services planning.

(v)  Implementing policies and developing mechanisms

and incentives to assure culturally and linguistically

sensitive care.

(vi)  Establishing rules and procedures for

implementation and staffing of a no-fault compensation

system for iatrogenic injuries or complications of care

whereby a patient's condition is made worse or an

opportunity for cure or improvement is lost due to the

health care or medications provided or appropriate care

not provided by participating providers under the plan.

(vii)  Establishing standards and criteria for the

determination of appropriate transitional support and

training for residents of this Commonwealth who are

displaced from work during the first two years of the

implementation of the plan.

(viii)  Evaluating the state of the art in proven

technical innovations, medications and procedures and

adopting policies to expedite the rapid introduction

thereof in this Commonwealth.

(ix)  Establishing methods for the recovery of costs

for health care services provided pursuant to the plan to

a beneficiary who is also covered under the terms of a

policy of insurance, a health benefit plan or other

collateral source available to the participant under

which the participant has a right of action for

compensation. Receipt of health care services pursuant to

the plan shall be deemed an assignment by the participant

of any right to payment for services from any such

policy, plan or other source. The other source of health

care benefits shall pay to the trust all amounts it is

obligated to pay to, or on behalf of, the participant for

covered health care services. The board may commence any

action necessary to recover the amounts due.

(14)  Establishing the Health Professional Quality Panel,

Health Institution Quality Panel and Health Supplier Quality

Panel, which panels shall be comprised of persons who

represent a cross section of the medical and provider

community as follows:

(i)  Appointments shall be nominated by the trade

organizations and in the event of multiple nominations,

made by the board. Each quality panel shall submit

recommendations for continual improvement in cost-

effective, quality health care.

(ii)  The Health Professional Quality Panel shall

consist of one representative of the following

constituencies:

(A)  Primary care physicians.

(B)  Specialty care physicians.

(C)  Clinical psychologists.

(D)  Nurses.

(E)  Social workers.

(F)  Midwives.

(G)  Nutritionists.

(H)  Pharmacists.

(I)  Optometrists.

(J)  Podiatrists.

(K)  Hearing specialists.

(L)  Physical or occupational therapists.

(M)  Dentists.

(N)  Chiropractors.

(O)  Health educators.

(P)  Acupuncturists.

(iii)  The Health Institution Quality Panel shall

consist of one representative of the following

constituencies:

(A)  Academic medical centers.

(B)  Community hospitals.

(C)  Rehabilitation centers.

(D)  Trauma systems.

(E)  Convenient care centers.

(F)  Hospice program.

(G)  Substance abuse centers.

(H)  Home health care services.

(I)  Long-term care facilities.

(iv)  The Health Supplier Quality Panel shall consist

of one representative of the following constituencies:

(A)  Medical imaging.

(B)  Laboratory.

(C)  Durable medical equipment suppliers.

(D)  Pharmaceutical.

(E)  Medical suppliers other than durable medical

equipment suppliers.

(v)  The members of the quality panels shall be paid

a per diem rate, established by the board, for attendance

at meetings and further be reimbursed for actual and

necessary expenses incurred in the performance of their

duties, which shall include:

(A)  Making recommendations to the agency on the

establishment of policy on medical issues,

population-based public health issues, research

priorities, scope of services, expansion of access to

health care services and evaluation of the

performance of the plan in order to provide high

quality care for Pennsylvania residents.

(B)  Investigating proposals for innovative

approaches to the promotion of health, the prevention

of disease and injury, patient education, research

and health care delivery.

(C)  Advising the agency on the establishment of

standards and criteria to evaluate requests from

health care facilities for capital improvements.

(D)  Evaluating and advising the board on

requests from providers or their representatives for

adjustments to reimbursements reflective of their

education and responsibilities.

(E)  Coordinating resources in order to minimize

duplication among providers, institutions and

suppliers.

(F)  Evaluating or conducting research in order

to recommend products or services.

(G)  Presenting key recommendations in a report

to the board on improving quality of care.

(15)  Establishing an Office of the Health Care

Ombudsman. Acting directly or through one or more

contractors, the ombudsman and staff shall expeditiously

resolve issues related to the implementation of the plan

within 24 hours. The office shall receive questions,

complaints or problems from the public and work with agency

staff in order to quickly find a permanent or temporary

resolution. The staff of the ombudsman shall be hired from

the funds deposited in the Pennsylvania Health Care Trust

Fund. The ombudsman shall prepare a report for every board

meeting summarizing the major issues and recommendations for

resolution by the board.

(16)  Establishing a secure and centralized electronic

health record system wherein a beneficiary's entire health

record can be readily and reliably accessed by authorized

persons with the objective of eliminating the errors and

expense associated with paper records and diagnostic films.

The system shall ensure the privacy of all health records it

contains.

(17)  Establishing, from the revenues received, a reserve

fund sufficient to provide a continuation of services during

periods of reduced or insufficient revenue due to economic

conditions or unforeseen emergency major health care needs.

SUBCHAPTER B

PENNSYLVANIA HEALTH CARE AGENCY

Section 321.  Pennsylvania Health Care Agency.

(a)  Establishment.--The Pennsylvania Health Care Agency is

established. The agency shall administer the plan and is the

sole agency authorized to accept applicable grants-in-aid from

the Federal Government and State government. It shall use such

funds in order to secure full compliance with provisions of

Federal and State law and to carry out the purposes established

under this act. All grants-in-aid accepted by the agency shall

be deposited into the Pennsylvania Health Care Trust Fund

established under this act, together with other revenues raised

within this Commonwealth to fund the plan.

(b)  Appointment of executive director.--The executive

director of the agency shall be appointed by the board and shall

be the chief administrator of the plan. The executive director

shall implement the plan and serve at the pleasure of the board.

The salary of the executive director shall not exceed the

statutory salary of the Governor.

(c)  Personnel and employees.--The board shall employ and fix

the compensation of agency personnel as needed by the agency to

properly discharge the agency's duties. The employment of

personnel by the board is subject to the civil service laws of

this Commonwealth. The executive director shall oversee the

operation of the agency and the agency's performance of any

duties assigned by the board.

SUBCHAPTER C

(Reserved)

SUBCHAPTER D

(Reserved)

SUBCHAPTER E

(Reserved)

SUBCHAPTER F

IMMUNITY

Section 371.  Immunity.

In the absence of fraud or bad faith, the health quality

panels, the board and agency and their respective members and

employees shall incur no liability in relation to the

performance of their duties and responsibilities under this act.

The Commonwealth shall incur no liability in relation to the

implementation and operation of the plan.

CHAPTER 5

PENNSYLVANIA HEALTH CARE PLAN

Section 501.  General provisions.

(a)  Establishment of plan.--There is hereby established the

Pennsylvania Health Care Plan that shall be administered by the

independent Pennsylvania Health Care Agency under the direction

of the Pennsylvania Health Care Board.

(b)  Coverage.--The plan shall provide health care coverage

for all citizens of this Commonwealth. The agency shall work

simultaneously to control health care costs, achieve measurable

improvement in health care outcomes, promote a culture of health

awareness and develop an integrated health care database to

support health care planning and quality assurance.

(c)  Reforms.--The board shall implement the reforms adopted

by the General Assembly hereby within one year of the effective

date of the plan.

Section 502.  Universal health care access eligibility.

(a)  Eligibility.--All Pennsylvania residents, including

aliens or immigrants lawfully given admission to the United

States under the Immigration and Nationality Act (66 Stat. 163,

8 U.S.C. § 1101 et seq.), homeless persons and migrant

agricultural workers and their accompanying families who reside

in this Commonwealth and are required to pay personal income tax

to the Commonwealth are eligible beneficiaries under the plan.

Health benefits shall be covered for the period when the

individual resided in Pennsylvania for tax purposes. When in

doubt, the definition of residency status shall follow the

definitions used by the Department of Revenue for paying

personal income taxes. The board shall establish standards and a

simple procedure to demonstrate proof of eligibility. Out-of-

State students who are not independent of their parents or

guardian attending school in this Commonwealth must obtain

health insurance. Part-year residents must obtain health

insurance for the period of time that they are not in State.

(b)  Enrollment.--Enrollment in the plan shall be established

by the board and beneficiaries shall be provided with access

cards with appropriate proof of identity technology and privacy

protection.

(c)  Outreach to eligible residents.--Pennsylvania residents

who are unable to pay their taxes because of physical or mental

disabilities may obtain assistance through county assistance

offices and other agencies identified by the board.

(d)  Waivers.--If waivers are not obtained from the medical

assistance and/or Medicare programs operated under Title XVIII

or XIX of the Social Security Act (49 Stat. 620, 42 U.S.C. § 301 

et seq.), the medical assistance and Medicare nonwaived programs

shall act as the primary insurers for those eligible for such

coverage, and the plan shall serve as the secondary or

supplemental plan of health coverage. Until such time as waivers

are obtained, the plan will not pay for services for persons

otherwise eligible for the same benefits under Medicare or

Medicaid. The plan shall also be secondary to benefits provided

to military veterans except where reasonable and timely access,

as defined by the board, is denied or unavailable through the

United States Veterans' Administration, in which instance the

plan will be primary and will seek reasonable reimbursement from

the United States Veterans' Administration for the services

provided to veterans.

(e)  Priority of plans.--A plan of employee health coverage

provided by an out-of-State employer to a Pennsylvania resident

working outside of this Commonwealth shall serve as the

employee's primary plan of health coverage, and the plan shall

serve as the employee's secondary plan of health coverage.

(f)  Reimbursement.--The plan shall reimburse providers

practicing outside of this Commonwealth at plan rates, or the

reasonable prevailing rate of the locale where the service is

provided, not to exceed 115% of the amount physicians in this

Commonwealth would have been paid for health care services

rendered to a beneficiary while the beneficiary is out of this

Commonwealth. Services provided to a beneficiary out of this

Commonwealth by other than a participating provider shall be

reimbursed to the beneficiary or to the provider at a fair and

reasonable rate for that location. The plan may suggest

Pennsylvania providers for those who consistently use out-of-

State providers.

(g)  Presumption of eligibility.--Any individual who arrives

at a health care facility unconscious or otherwise unable due to

their mental or physical condition to document eligibility for

coverage shall be presumed to be eligible, and emergency care

shall be provided without delay occasioned over issues of

ability to pay.

(h)  Rules.--The board shall adopt rules assuring that any

participating provider who renders humanitarian emergency care,

urgent care or prevention or treatment for a communicable

disease or prenatal and delivery care within this Commonwealth

to a not actually eligible recipient shall nevertheless be

reimbursed for such care from the plan subject to such rules as

will reasonably limit the frequency of such events to protect

the fiscal integrity of the plan. It shall be the agency's

responsibility to secure reimbursement for the costs paid for

such care from any appropriate third party funding source, or

from the individual to whom the services were rendered.

Section 503.  Covered services.

(a)  Benefits package.--The board shall establish a single

health benefits package within the plan that shall include, but

not be limited to, all of the following:

(1)  All medically necessary inpatient and outpatient

care and treatment, both primary and secondary.

(2)  Emergency services.

(3)  Emergency and other medically necessary transport to

covered health services.

(4)  Rehabilitation services, including speech,

occupational, physical and massage therapy.

(5)  Inpatient and outpatient mental health services and

substance abuse treatment.

(6)  Hospice care.

(7)  Prescription drugs and prescribed medical nutrition.

(8)  Vision care, aids and equipment.

(9)  Hearing care, hearing aids and equipment.

(10)  Diagnostic medical tests, including laboratory

tests and imaging procedures.

(11)  Medical supplies and prescribed medical equipment.

(12)  Immunizations, preventive care, health maintenance

care and screening.

(13)  Dental care.

(14)  Home health care services.

(15)  Chiropractic and massage therapy.

(16)  Complementary and alternative modalities that have

been shown by the National Institute of Health's Division of

Complementary and Alternative Medicine to be safe and

effective for possible inclusion as covered benefits.

(17)  Long-term care for those unable to care for

themselves independently and including assisted and skilled

care.

(b)  Exclusions for preexisting conditions.--The plan shall

not exclude or limit coverage due to preexisting conditions.

(c)  Copayments, deductibles, etc.--Beneficiaries of the plan

are not subject to copayments, deductibles, point-of-service

charges or any other fee or charge for a service within the

package and shall not be directly billed nor balance billed by

participating providers for covered benefits provided to the

beneficiary. Where a beneficiary has directly paid for

nonemergency services of a nonparticipating provider, the

beneficiary may submit a claim for reimbursement from the plan

for the amount the plan would have paid a participating provider

for the same service. Where emergency services are rendered by a

nonparticipating provider, the beneficiary shall receive

reimbursement of the full amount paid to such nonparticipating

provider not to exceed 115% of the amount the plan would have

paid a participating provider for the same service.

(d)  Exclusions of coverage.--

(1)  The board shall remove or exclude procedures and

treatments, equipment and prescription drugs from the plan

benefit package that the Food and Drug Administration or a

health quality panel finds unsafe or that add no therapeutic

value.

(2)  The board shall exclude coverage for any surgical,

orthodontic or other procedure or drug that the board

determines was or will be provided primarily for cosmetic

purposes unless required to correct a congenital defect, to

restore or correct disfigurements resulting from injury or

disease or that is certified to be medically necessary by a

qualified, licensed provider.

(e)  Choice by beneficiary.--Beneficiaries shall normally be

granted free choice of the participating providers, including

specialists, without preapprovals or referrals. However, the

board shall adopt procedures to restrict such free choice for

those individuals who engage in patterns of wasteful or abusive

self-referrals to specialists. Specialists who provide primary

care to a self-referred beneficiary will be reimbursed at the

board-approved primary care rate established for the service in

that community.

(f)  Practice patterns.--Practice patterns of participating

providers shall be monitored. Outliers in terms of

overutilization or underutilization shall be reviewed by a panel

of peers and, if necessary, constructive feedback given. The

board may set outlier policies after reviewing practice patterns

and recommendations from the health quality panels.

(g)  Service.--No participating provider shall be compelled

to offer any particular service so long as the refusal is

consistent with the provider's practice.

(h)  Discrimination.--The plan and participating providers

shall not discriminate on the basis of race, ethnicity, national

origin, gender, age, religion, sexual orientation, health

status, mental or physical disability, employment status,

veteran status or occupation.

Section 504.  Excess and collective bargaining agreement health

insurance coverage.

Subject to the regulations of the Insurance Commissioner and

all applicable laws, private health insurers shall be authorized

to offer coverage supplemental to the package approved and

provided automatically under this act.

Section 505.  Duplicate coverage.

The agency is subrogated to and shall be deemed an assignee

of all rights of a beneficiary who has received duplicate health

care benefits, or who has a right to such benefits, under any

other policy or contract of health care or under any government

program.

Section 506.  Subrogation.

The agency shall have no right of subrogation against a

beneficiary's third-party claims for harm or losses not covered

under this act. Nor shall any beneficiary under this act have a

claim against a third-party tortfeasor for the services provided

or available to the beneficiary under this act. In all personal

injury actions accruing and prosecuted by a beneficiary on or

after January 1, 2008, the presiding judge shall advise any jury

that all health care expenses have been or will be paid under

the plan, and, therefore, no claim for past or future health

care benefits is pending before the court.

Section 507.  Eligible participating providers and availability

of services.

(a)  General rule.--All licensed health care providers and

facilities are eligible to become a participating provider in

the plan in which instance they shall enjoy the rights and have

the duties as set forth in the plan as stated in this section or

as adopted by the board from time to time. Nonparticipating

providers shall not enjoy the rights nor bear the duties of

participating providers.

(b)  Required notice.--In advance of initially providing

services to a beneficiary, nonparticipating providers shall

advise the beneficiary at the time the appointment is made that

the person or entity is a nonparticipating provider and that the

recipient of the service will be initially personally

responsible for the entire cost of the service and ultimately

responsible for the cost in excess of the reimbursement approved

by the board for participating providers. A sign at the point of

entry or reminder by the office staff disclosing whether the

provider accepts or does not accept the plan card and who covers

the cost of care shall be deemed sufficient notice. Failure to

make such financial disclosure will be deemed a fraud on the

beneficiary and entitle the beneficiary to a refund from the

provider equal to 200% of the amount paid to the

nonparticipating provider in excess of the board-approved

reimbursement for the services rendered, plus all reasonable

fees for collection. The burden of proof that such disclosure

was made shall be on the nonparticipating provider.

(c)  Plan by board.--The board shall assess the number of

primary and specialty providers needed to supply adequate health

care services in this Commonwealth generally and in all

geographic areas and shall develop a plan to meet that need. The

board shall develop financial incentives for participating

providers in order to maintain and increase access to health

care services in underserved areas of this Commonwealth.

(d)  Reimbursements.--Reimbursements shall be determined by

the board in such a fashion as to assure that a participating

provider receives compensation for services that fairly and

fully reflect the skill, training, operating overhead included

in the costs of providing the service, capital costs of

facilities and equipment, cost of consumables and the expense of

safely discarding medical waste, plus a reasonable profit

sufficient to encourage talented individuals to enter the field

and for investors to make capital available for the construction

of state-of-the-art health care facilities in this Commonwealth.

The plan shall review fee schedules and may offer alternative

reimbursement mechanisms, including capitation, salary and

bonuses.

(e)  Adjustments to reimbursements.--Participating providers

shall have the right alone or collectively to petition the board

for adjustments to reimbursements believed to be too low. Such

petitions shall be initially evaluated by the administrator of

provider services, with input from the Health Professional

Quality Panel, who shall submit a report to the chair within 30

days. The chair shall then submit a recommendation to the board

for action at the next scheduled board meeting. Participating

providers who remain dissatisfied after the board has ruled may

appeal the board's determination to Commonwealth Court, which

shall review the action of the board on an abuse of discretion

standard.

(f)  Evaluation of access to care.--The board annually shall

evaluate access to trauma care, diagnostic imaging technology,

emergency transport and other vital urgent care requirements and

shall establish measures to assure beneficiaries have equitable

and ready access to such resources regardless of where in this

Commonwealth they may be.

(g)  Health care delivery models.--The board, with the

assistance of the health quality panels, shall review best

community practices in delivering high quality care. Those

wellness practices that can be adopted will be funded with an

increasing emphasis on prevention and community-based care in

order to reduce the need for hospitalization and nursing home

care in the future.

(h)  Performance reports.--The board, with the assistance of

the Health Advisory Panel, shall define performance criteria and

goals for the plan and shall make a written report to the

General Assembly at least annually on the plan's performance.

All such reports, including the survey results obtained, shall

be made publicly available with the goal of total transparency

and open self-analysis as a defining quality of the agency. The

board shall establish a system to monitor the quality of health

care and patient and provider satisfaction and to adopt a system

to devise improvements and efficiencies to the provision of

health care services.

(i)  Data reporting.--All participating providers shall, in a

prompt and timely manner, provide existing and ongoing data to

the agency upon its request.

(j)  Coordination of services.--The agency shall coordinate

the provision of health care services with any other

Commonwealth and local agencies that provide health care

services directly to their charges or residents.

Section 508.  Rational cost containment.

(a)  Approval of expenditures.--As part of its cost

containment mission and based on the certificate of need, the

board, with the assistance of the Health Institution Quality

Panel, shall screen and approve or disapprove private or public

expenditures for new health care facilities and other capital

investments that may lead to redundant and inefficient health

care provider capacity. Procedures shall be adopted for this

purpose with an emphasis upon efficiency, quality of delivery

and a fair and open consideration of all applications.

(b)  Capital investments.--Based on the certificate of need

all capital investments valued at $1,000,000 or greater,

including the costs of studies, surveys, design plans and

working drawing specifications, and other activities essential

to planning and execution of capital investment and all capital

investments that change the bed capacity of a health care

facility by more than 10% over a 24-month period or that add a

new service or license category shall require the approval of

the board. When a facility, an individual acting on behalf of a

facility or any other purchaser obtains by lease or comparable

arrangement any facility or part of a facility, or any equipment

for a facility, the market value of which would have been a

capital expenditure, the lease or arrangement shall be

considered a capital expenditure for purposes of this section.

(c)  Study.--Those intending to make capital investments or

acquisitions shall prepare a business case for making each

investment and acquisition. It shall include the full-life-cycle

costs of the investment or acquisition, an environment impact

report that meets existing State standards and a demonstration

of how the investment or acquisition meets the health care needs

of the population it is intended to serve. Acquisitions may

include, but not be limited to, acquisitions of land,

operational property or administrative office space.

(d)  Deemed approval.--Capital investment programs submitted

for approval shall be deemed approved by the board within 60

days from the date the submissions are received by the chair. A

60-day extension may apply if the board requires additional

information.

(e)  Recommendations.--Recommendations of the Pennsylvania

Heath Cost Containment Council and such other public and private

authoritative bodies as shall be identified from time to time by

the board shall be received by the chair and submitted to the

board with the chair's recommendation regarding implementation

of the recommended reforms. The board shall receive input from

all interested parties and then shall vote upon all such

recommendations within 60 days. Where procedural or protocol

reforms are adopted, participating providers will be required to

implement such designated best practices within the next 60

days.

(f)  Appeal.--A decision of the board may be appealed through

a uniform dispute resolution process that has been established

by unanimous approval of the board.

(g)  Required investments.--The board, with the

recommendations of the Health Institution Quality Panel, may

adopt programs to assist participating providers in making

capital investments responsive to best practice recommendations.

(h)  Decertification.--Participating providers refusing to

adopt recommended reforms shall, after a reasonable opportunity

to be heard, be subject to such sanctions as the board shall

deem appropriate and necessary up to and including a

recommendation by the board to the Bureau of Professional and

Occupational Affairs or the Department of Health for the

suspension or permanent decertification of the participating

provider.

CHAPTER 9

PENNSYLVANIA HEALTH CARE TRUST FUND

Section 901.  Pennsylvania Health Care Trust Fund.

(a)  Establishment.--The Pennsylvania Health Care Trust Fund

is hereby established within the State Treasury. All moneys

collected and received by the plan shall be transmitted to the

State Treasurer for deposit into the fund, to be used

exclusively to finance the plan.

(b)  State Treasurer.--The State Treasurer may invest the

principal and interest earned by the fund in any manner

authorized under law for the investment of Commonwealth moneys.

Any revenue or interest earned from the investments shall be

credited to the fund.

Section 902.  Limitation on administrative expense.

The system budget referred to in this chapter shall comprise

the cost of the agency, services and benefits provided,

administration, data gathering, planning and other activities

and revenues deposited with the system account of the fund. The

board shall limit ongoing administrative costs, excluding start-

up costs, to 5% of the agency budget and shall annually evaluate

methods to reduce administrative costs and publicly report the

results of that evaluation.

Section 903.  Funding sources.

Funding of the plan shall be obtained from the following

dedicated sources:

(1)  Funds obtained from existing or future Federal

health care programs.

(2)  Funds from dedicated sources specified by the

General Assembly.

(3)  Receipts from the tax of 10% of gross payroll,

including self-employment profits. One percent of the tax

shall become effective the date that shall be the first day

of a calendar month no less than 32 days after the effective

date of this act, and the tax shall become fully effective 60

days before the plan takes effect. Employers who are part of

a collective bargaining agreement whereby the health care

benefits are no less generous than those provided under the

plan shall be excused from paying 90% of the tax.

(4)  Receipts from the Individual Fair Share Health and

Wellness Tax of 3% on income as defined in sections 301 and

303 of the act of March 4, 1971 (P.L.6, No.2), known as the

Tax Reform Code of 1971. One-half of one percent of the

Individual Fair Share Health and Wellness Tax shall become

effective the date that shall be the first day of a calendar

month no less than 32 days after the effective date of this

act, and the Individual Fair Share Health and Wellness tax

shall become fully effective 60 days before the plan takes

effect.

CHAPTER 11

TRANSITIONAL SUPPORT AND TRAINING FOR DISPLACED WORKERS

Section 1101.  Transitional support and training for displaced

workers.

(a)  Determination of eligibility.--The plan shall determine

which citizens of this Commonwealth employed by a health care

insurer, health insuring corporation or other health care-

related business have lost their employment as a result of the

implementation and operation of the plan, including the amount

of monthly wages that the individual has lost due to the plan's

implementation. The plan shall attempt to position these

displaced workers in comparable positions of employment or

assist in the retraining and placement of such displaced

employees elsewhere.

(b)  Compensation.--The plan shall forward the information on

the amount of monthly wages lost by Commonwealth residents due

to the implementation of the plan to the board. Compensation

shall be up to $5,000 each month but may not exceed the monthly

wages of the individual when he was displaced. Compensation will

cease upon reemployment or after two years, whichever comes

first. A displaced worker shall be eligible to receive

compensation, training assistance, or both, from the fund.

Training assistance may not exceed $20,000.

(c)  Coordination of services.--The plan shall fully

coordinate activity with public and private services also

available or actually participating in the assistance to the

affected individuals.

(d)  Appeals.--Persons dissatisfied with the level of

assistance they are receiving may appeal to the office of the

executive director whose determination shall be final and not

subject to appeal.

CHAPTER 13

VOLUNTEER EMERGENCY RESPONDER NETWORK

Section 1301.  Preservation of volunteer emergency responder

network.

Because this Commonwealth is dependent upon the volunteered

services of firefighters, emergency medical technicians and

search and rescue workers, the board is further charged with

administering a Commonwealth income tax credit program for such

volunteers.

Section 1302.  Eligibility certification.

Annually, in January, administrators of volunteer

firefighting and rescue departments, emergency medical

technicians and paramedics stations and similar volunteer

emergency entities shall certify the identity of Commonwealth

residents providing active services during the prior calendar

year.

Section 1303.  Eligibility criteria.

Active status shall require a minimum of 200 hours of service

during the preceding year and response to no less than 50% of

the emergency calls during at least three of the four calendar

quarters.

Section 1304.  Amount of tax credit.

Each volunteer certified as active shall be granted a credit

equal to $1,000 toward the volunteer's State income tax

obligation under Article III of the act of March 4, 1971 (P.L.6,

No.2), known as the Tax Reform Code of 1971. Any eligible

volunteer who does not incur $1,000 in annual State income tax

liability shall nevertheless be eligible for a refund equal to

the amount the credit exceeds that volunteer's tax obligation.

Section 1305.  Reimbursement.

The State Treasury shall be reimbursed the value of such

volunteer credits from the fund.

CHAPTER 45

MISCELLANEOUS PROVISIONS

Section 4501.  Effective date.

This act shall take effect immediately.