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| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
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| SENATE BILL |
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| INTRODUCED BY FERLO, TARTAGLIONE, FONTANA, SCHWANK, WASHINGTON, HUGHES, KITCHEN AND FARNESE, OCTOBER 12, 2011 |
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| REFERRED TO BANKING AND INSURANCE, OCTOBER 12, 2011 |
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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, the Pennsylvania Health Care Trust Fund and the |
11 | Pennsylvania Health Care Board and providing for their powers |
12 | and duties. |
13 | TABLE OF CONTENTS |
14 | Chapter 1. Preliminary Provisions |
15 | Section 101. Short title. |
16 | Section 102. Definitions. |
17 | Chapter 3. Administration and Oversight of the Pennsylvania |
18 | Health Care Plan |
19 | Subchapter A. Pennsylvania Health Care Board |
20 | Section 301. Organization. |
21 | Section 302. Duties of board. |
22 | Subchapter B. Pennsylvania Health Care Agency |
23 | Section 321. Pennsylvania Health Care Agency. |
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1 | |
2 | Subchapter C. (Reserved). |
3 | Subchapter D. (Reserved). |
4 | Subchapter E. (Reserved). |
5 | Subchapter F. Immunity |
6 | Section 371. Immunity. |
7 | Chapter 5. Pennsylvania Health Care Plan |
8 | Section 501. General provisions. |
9 | Section 502. Universal health care access eligibility. |
10 | Section 503. Covered services. |
11 | Section 504. Excess and collective bargaining agreement health |
12 | insurance coverage. |
13 | Section 505. Duplicate coverage. |
14 | Section 506. Subrogation. |
15 | Section 507. Eligible participating providers and availability |
16 | of services. |
17 | Section 508. Rational cost containment. |
18 | Chapter 9. Pennsylvania Health Care Trust Fund |
19 | Section 901. Pennsylvania Health Care Trust Fund. |
20 | Section 902. Limitation on administrative expense. |
21 | Section 903. Funding sources. |
22 | Chapter 11. Transitional Support and Training for Displaced |
23 | Workers |
24 | Section 1101. Transitional support and training for displaced |
25 | workers. |
26 | Chapter 13. Volunteer Emergency Responder Network |
27 | Section 1301. Preservation of volunteer emergency responder |
28 | network. |
29 | Section 1302. Eligibility certification. |
30 | Section 1303. Eligibility criteria. |
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1 | Section 1304. Amount of tax credit. |
2 | Section 1305. Reimbursement of Department of Revenue. |
3 | Chapter 45. Miscellaneous Provisions |
4 | Section 4501. Effective date. |
5 | The General Assembly of the Commonwealth of Pennsylvania |
6 | hereby enacts as follows: |
7 | CHAPTER 1 |
8 | PRELIMINARY PROVISIONS |
9 | Section 101. Short title. |
10 | This act shall be known and may be cited as the Family and |
11 | Business Healthcare Security Act. |
12 | Section 102. Definitions. |
13 | The following words and phrases when used in this act shall |
14 | have the meanings given to them in this section unless the |
15 | context clearly indicates otherwise: |
16 | "Agency." The Pennsylvania Health Care Agency established |
17 | under this act. |
18 | "Board." The Pennsylvania Health Care Board established |
19 | under this act. |
20 | "Certificate of need." A notice of approval issued by the |
21 | Department of Health under the provisions of the act of July 19, |
22 | 1979 (P.L.130, No.48), known as the Health Care |
23 | Facilities Act, including those notices of approval issued as an |
24 | amendment to an existing certificate of need. |
25 | "Chair." The Chair of the Pennsylvania Health Care Board. |
26 | "Department." The Department of Health of the Commonwealth. |
27 | "Executive director." The Executive Director of the |
28 | Pennsylvania Health Care Agency. |
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 | "Ombudsman." The Pennsylvania Health Care Ombudsman |
5 | established under this act. |
6 | "Plan." The Pennsylvania Health Care Plan established under |
7 | this act. |
8 | "Tax." The Employer Fair Share Health and Wellness Tax |
9 | established under this act. |
10 | CHAPTER 3 |
11 | ADMINISTRATION AND OVERSIGHT OF THE |
12 | PENNSYLVANIA HEALTH CARE PLAN |
13 | SUBCHAPTER A |
14 | PENNSYLVANIA HEALTH CARE BOARD |
15 | Section 301. Organization. |
16 | (a) Composition.--The Pennsylvania Health Care Board shall |
17 | be composed of 12 voting members. The chair shall preside over |
18 | the board and shall set the agenda but may vote only in the |
19 | event of a tie vote. |
20 | (b) Appointments.-- |
21 | (1) The board shall consist of 12 members to be |
22 | appointed by the Governor by and with the advice and consent |
23 | of a majority of all the members of the Senate from |
24 | individuals representative of each of the following |
25 | constituencies and reflective of the diversity of this |
26 | Commonwealth: |
27 | (i) Three patients or caregivers of patients who |
28 | experience the health care system daily. These members |
29 | must be geographically diverse, knowledgeable about |
30 | health issues and represent the following categories: |
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1 | (A) A caregiver of a child with a chronic |
2 | illness or developmental disability. |
3 | (B) An adult with a chronic illness or physical |
4 | disability. |
5 | (C) An adult with mental illness requiring |
6 | medications. |
7 | (ii) A physician. |
8 | (iii) A hospital representative. |
9 | (iv) A long-term care representative. |
10 | (v) A health care attorney. |
11 | (vi) Health care informatics. |
12 | (vii) A small business representative. |
13 | (viii) A large business representative. |
14 | (ix) An organized labor representative from the |
15 | health sector. |
16 | (x) Public health. |
17 | (2) Appointed board members shall take the oath of |
18 | office prior to serving on the board and may be removed only |
19 | for cause under subsection (j). |
20 | (b.1) Quality of care panels.-- |
21 | (1) In addition to the board, there shall be four |
22 | quality of care panels as follows: |
23 | (i) A health professional quality panel. |
24 | (ii) A health institution quality panel. |
25 | (iii) A health supplier quality panel. |
26 | (iv) The health care ombudsman panel. |
27 | (2) The quality of care panels shall meet regularly as |
28 | needed to create policies and recommendations to deliver |
29 | cost-effective, evidence-based, quality health care to the |
30 | residents of this Commonwealth. |
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1 | (3) The quality of care panels shall hire staff who will |
2 | work daily on quality of care recommendations with agency |
3 | staff. The quality of care recommendations shall be presented |
4 | in a formal report at every board meeting. |
5 | (4) The chair shall inform the board on progress or |
6 | explaining the lack of progress in implementing key |
7 | recommendations of the quality of care panels. |
8 | (c) Chairman.--The Governor shall designate one of the board |
9 | members as chairman, who shall serve in that position at the |
10 | pleasure of the Governor. The chairman shall, when present, |
11 | preside at all meetings, and in his absence a member designated |
12 | by the chairman shall preside. |
13 | (d) Midterm vacancies.--Midterm vacancies shall be filled by |
14 | a representative from the same constituent group required under |
15 | subsection (b) and the individual appointed to fill a vacancy |
16 | occurring prior to the expiration of the term for which a member |
17 | is appointed shall hold office for the remainder of the |
18 | predecessor's term. |
19 | (e) Compensation, benefits and expenses.--The chair shall |
20 | receive an annual salary, benefits and expense reimbursement |
21 | established by the board, to be paid from the fund, but the |
22 | salary may not exceed the salary of the Governor. The initial |
23 | board shall establish its own compensation per diem and, for |
24 | travel, reimbursement of expenses incurred on behalf of the |
25 | board and other necessary expenses. No increase or decrease in |
26 | salary or benefits adopted by the board for the chair or members |
27 | shall become effective within the same three-year term, except |
28 | for the first three initial years of the plan when readjustments |
29 | may be made. |
30 | (f) Meetings.-- |
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1 | (1) The chair shall set the time, place and date for the |
2 | initial and subsequent meetings of the board and shall |
3 | preside over its meetings. The initial meeting shall be set |
4 | not sooner than 50 nor later than 100 days after the |
5 | appointment of the chair. Subsequent meetings shall occur as |
6 | determined by the board but not less than six times annually. |
7 | (2) All meetings of the board are open to the public |
8 | unless questions of patient confidentiality arise. The board |
9 | may conduct closed executive session for issues relating to |
10 | confidential patient information, to evaluation of the chair |
11 | or to personnel matters. |
12 | (3) The board shall publish its rulings in the |
13 | Pennsylvania Bulletin with an opportunity for public comment |
14 | as determined by State law. |
15 | (4) The minutes of the board, except for executive |
16 | session deliberations, shall be public information. The media |
17 | shall be allowed access to all final public reports to ensure |
18 | full disclosure of decisions that impact the public. |
19 | (g) Quorum.--Two-thirds of the appointed members of the |
20 | board shall constitute a quorum for the conducting of business |
21 | at meetings of the board. Decisions at ordinary meetings of the |
22 | board shall be reached by majority vote of those actually |
23 | present or, in the event of an emergency meeting, those also |
24 | present by electronic or telephonic means. Where there is a tie |
25 | vote, the chair shall vote to break the tie. Except as otherwise |
26 | provided in this act, absentee or proxy voting shall not be |
27 | allowed. |
28 | (h) Ethics.--The executive director, the chair and other |
29 | board members and their immediate families are prohibited from |
30 | having any pecuniary interest in any business with a contract or |
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1 | in negotiation for a contract with the agency. The board shall |
2 | also adopt rules of ethics and definitions of irreconcilable |
3 | conflicts of interest that will determine under what |
4 | circumstances members must recuse themselves from voting. |
5 | (i) Prohibitions.-- |
6 | (1) No member of the board may receive any additional |
7 | salary or benefits by virtue of serving on the board. |
8 | (2) No member of the board may hold any other salaried |
9 | Commonwealth public position, either elected or appointed, |
10 | during the member's tenure on the board, including, but not |
11 | limited to, the position of State legislator or member of the |
12 | United States Congress. |
13 | (3) The executive director, chair and board members may |
14 | not be a State legislator or member of the United States |
15 | Congress. |
16 | (j) Dismissal.--Board members shall attend all meetings and |
17 | be prepared to discuss and vote on information presented. Board |
18 | members may be dismissed and positions refilled for any of the |
19 | following reasons: |
20 | (1) Failure to attend 75% of the meetings in one year. |
21 | (2) Inability to represent their constituency group. |
22 | (3) Clear conflict of interest. |
23 | (4) Fraud or criminal activity either present or in the |
24 | past. |
25 | Section 302. Duties of board. |
26 | (a) General duties.--The board is responsible for directing |
27 | the agency in the performance of all duties, the exercise of all |
28 | powers, and the assumption and discharge of all functions vested |
29 | in the agency. The board shall adopt and publish its rules and |
30 | procedures in the Pennsylvania Bulletin no later than 180 days |
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1 | after the first meeting of the board. |
2 | (b) Specific duties.--The duties and functions of the board |
3 | include, but are not limited to, the following: |
4 | (1) Implementing statutory eligibility standards for |
5 | benefits. |
6 | (2) Annually adopting a benefits package for |
7 | participants of the plan. |
8 | (3) Acting directly or through one or more contractors |
9 | as the single payer administrator for all claims for health |
10 | care services made under the plan. |
11 | (4) At least annually, reviewing the appropriateness and |
12 | sufficiency of reimbursements and considering whether a |
13 | charge is fair and reasonable for its geographic region or |
14 | location. |
15 | (5) Providing for timely payments to participating |
16 | providers through a structure that is well organized and that |
17 | eliminates unnecessary administrative costs. |
18 | (6) Implementing standardized claims and reporting |
19 | methods for use by the plan. |
20 | (7) Developing a system of centralized electronic claims |
21 | and payments accounting. |
22 | (8) Establishing an enrollment system that will ensure |
23 | that those who travel frequently and cannot read or speak |
24 | English are aware of their right to health care and are |
25 | formally enrolled in the plan. |
26 | (9) Reporting annually to the General Assembly and to |
27 | the Governor, on or before the first day of October, on the |
28 | performance of the plan, the fiscal condition of the plan, |
29 | recommendations for statutory changes, the receipt of |
30 | payments from the Federal Government, whether current year |
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1 | goals and priorities were met, future goals and priorities, |
2 | and major new technology or prescription drugs that may |
3 | affect the cost of the health care services provided by the |
4 | plan. |
5 | (10) Administering the revenues of the fund. |
6 | (11) Obtaining appropriate liability and other forms of |
7 | insurance to provide coverage for the plan, the board, the |
8 | agency and their employees and agents. |
9 | (12) Establishing, appointing and funding appropriate |
10 | staff, office space, equipment, training and administrative |
11 | support for the agency throughout this Commonwealth, all to |
12 | be paid from the fund. |
13 | (13) Administering aspects of the agency by taking |
14 | actions that include, but are not limited to, the following: |
15 | (i) Establishing standards and criteria for the |
16 | allocation of operating funds. |
17 | (ii) Meeting regularly to review the performance of |
18 | the agency and to adopt and revise its policies. |
19 | (iii) Establishing goals for the health care system |
20 | established pursuant to the plan in measurable terms. |
21 | (iv) Establishing Statewide health care databases to |
22 | support health care services planning. |
23 | (v) Implementing policies and developing mechanisms |
24 | and incentives to assure culturally and linguistically |
25 | sensitive care. |
26 | (vi) Establishing rules and procedures for |
27 | implementation and staffing of a no-fault compensation |
28 | system for iatrogenic injuries or complications of care |
29 | whereby a patient's condition is made worse or an |
30 | opportunity for cure or improvement is lost due to the |
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1 | health care or medications provided or appropriate care |
2 | not provided by participating providers under the plan. |
3 | (vii) Establishing standards and criteria for the |
4 | determination of appropriate transitional support and |
5 | training for residents of this Commonwealth who are |
6 | displaced from work during the first two years of the |
7 | implementation of the plan. |
8 | (viii) Evaluating the state of the art in proven |
9 | technical innovations, medications and procedures and |
10 | adopting policies to expedite the rapid introduction |
11 | thereof in this Commonwealth. |
12 | (ix) Establishing methods for the recovery of costs |
13 | for health care services provided pursuant to the plan to |
14 | a beneficiary who is also covered under the terms of a |
15 | policy of insurance, a health benefit plan or other |
16 | collateral source available to the participant under |
17 | which the participant has a right of action for |
18 | compensation. Receipt of health care services pursuant to |
19 | the plan shall be deemed an assignment by the participant |
20 | of any right to payment for services from any such |
21 | policy, plan or other source. The other source of health |
22 | care benefits shall pay to the trust all amounts it is |
23 | obligated to pay to, or on behalf of, the participant for |
24 | covered health care services. The board may commence any |
25 | action necessary to recover the amounts due. |
26 | (14) Establishing the Health Professional Quality Panel, |
27 | Health Institution Quality Panel and Health Supplier Quality |
28 | Panel, which panels shall be comprised of persons who |
29 | represent a cross section of the medical and provider |
30 | community as follows: |
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1 | (i) Appointments shall be nominated by the trade |
2 | organizations and in the event of multiple nominations, |
3 | made by the board. Each quality panel shall submit |
4 | recommendations for continual improvement in cost- |
5 | effective, quality health car. |
6 | (ii) The Health Professional Quality Panel shall |
7 | consist of one representative of the following |
8 | constituencies: |
9 | (A) Primary care physicians. |
10 | (B) Specialty care physicians. |
11 | (C) Clinical psychologists. |
12 | (D) Nurses. |
13 | (E) Social workers. |
14 | (F) Midwives. |
15 | (G) Nutritionists. |
16 | (H) Pharmacists. |
17 | (I) Optometrists. |
18 | (J) Podiatrists. |
19 | (K) Hearing specialists. |
20 | (L) Physical or occupational therapists. |
21 | (M) Dentists. |
22 | (N) Chiropractors. |
23 | (O) Health educators. |
24 | (P) Acupuncturists. |
25 | (iii) The Health Institution Quality Panel shall |
26 | consist of one representative of the following |
27 | constituencies: |
28 | (A) Academic medical centers. |
29 | (B) Community hospitals. |
30 | (C) Rehabilitation centers. |
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1 | (D) Trauma systems. |
2 | (E) Convenient care centers. |
3 | (F) Hospice program. |
4 | (G) Substance abuse centers. |
5 | (H) Home health care services. |
6 | (I) Long-term care facilities. |
7 | (iv) The Health Supplier Quality Panel shall consist |
8 | of one representative of the following constituencies: |
9 | (A) Medical imaging. |
10 | (B) Laboratory. |
11 | (C) Durable medical equipment suppliers. |
12 | (D) Pharmaceutical. |
13 | (E) Medical suppliers other than durable medical |
14 | equipment suppliers. |
15 | (v) The members of the quality panels shall be paid |
16 | a per diem rate, established by the board, for attendance |
17 | at meetings and further be reimbursed for actual and |
18 | necessary expenses incurred in the performance of their |
19 | duties, which shall include: |
20 | (A) Making recommendations to the agency on the |
21 | establishment of policy on medical issues, |
22 | population-based public health issues, research |
23 | priorities, scope of services, expansion of access to |
24 | health care services and evaluation of the |
25 | performance of the plan in order to provide high |
26 | quality care for Pennsylvania residents. |
27 | (B) Investigating proposals for innovative |
28 | approaches to the promotion of health, the prevention |
29 | of disease and injury, patient education, research |
30 | and health care delivery. |
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1 | (C) Advising the agency on the establishment of |
2 | standards and criteria to evaluate requests from |
3 | health care facilities for capital improvements. |
4 | (D) Evaluating and advising the board on |
5 | requests from providers or their representatives for |
6 | adjustments to reimbursements reflective of their |
7 | education and responsibilities. |
8 | (E) Coordinating resources in order to minimize |
9 | duplication among providers, institutions and |
10 | suppliers. |
11 | (F) Evaluating or conducting research in order |
12 | to recommend products or services. |
13 | (G) Presenting key recommendations in a report |
14 | to the board on improving quality of care. |
15 | (15) Establishing an Office of the Health Care |
16 | Ombudsman. Acting directly or through one or more |
17 | contractors, the ombudsman and staff shall expeditiously |
18 | resolve issues related to the implementation of the plan |
19 | within 24 hours. The office shall receive questions, |
20 | complaints or problems from the public and work with agency |
21 | staff in order to quickly find a permanent or temporary |
22 | resolution. The staff of the ombudsman shall be hired from |
23 | the funds deposited in the Pennsylvania Health Care Trust |
24 | Fund. The ombudsman shall prepare a report for every board |
25 | meeting summarizing the major issues and recommendations for |
26 | resolution by the board. |
27 | (16) Establishing a secure and centralized electronic |
28 | health record system wherein a beneficiary's entire health |
29 | record can be readily and reliably accessed by authorized |
30 | persons with the objective of eliminating the errors and |
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1 | expense associated with paper records and diagnostic films. |
2 | The system shall ensure the privacy of all health records it |
3 | contains. |
4 | (17) Establishing, from the revenues received, a reserve |
5 | fund sufficient to provide a continuation of services during |
6 | periods of reduced or insufficient revenue due to economic |
7 | conditions or unforeseen emergency major health care needs. |
8 | SUBCHAPTER B |
9 | PENNSYLVANIA HEALTH CARE AGENCY |
10 | Section 321. Pennsylvania Health Care Agency. |
11 | (a) Establishment.--The Pennsylvania Health Care Agency is |
12 | established. The agency shall administer the plan and is the |
13 | sole agency authorized to accept applicable grants-in-aid from |
14 | the Federal Government and State government. It shall use such |
15 | funds in order to secure full compliance with provisions of |
16 | Federal and State law and to carry out the purposes established |
17 | under this act. All grants-in-aid accepted by the agency shall |
18 | be deposited into the Pennsylvania Health Care Trust Fund |
19 | established under this act, together with other revenues raised |
20 | within this Commonwealth to fund the plan. |
21 | (b) Appointment of executive director.--The executive |
22 | director of the agency shall be appointed by the board and shall |
23 | be the chief administrator of the plan. The executive director |
24 | shall implement the plan and serve at the pleasure of the board. |
25 | The salary of the executive director shall not exceed the |
26 | statutory salary of the Governor. |
27 | (c) Personnel and employees.--The board shall employ and fix |
28 | the compensation of agency personnel as needed by the agency to |
29 | properly discharge the agency's duties. The employment of |
30 | personnel by the board is subject to the civil service laws of |
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1 | this Commonwealth. The executive director shall oversee the |
2 | operation of the agency and the agency's performance of any |
3 | duties assigned by the board. |
4 | SUBCHAPTER C |
5 | (Reserved) |
6 | SUBCHAPTER D |
7 | (Reserved) |
8 | SUBCHAPTER E |
9 | (Reserved) |
10 | SUBCHAPTER F |
11 | IMMUNITY |
12 | Section 371. Immunity. |
13 | In the absence of fraud or bad faith, the health quality |
14 | panels, the board and agency and their respective members and |
15 | employees shall incur no liability in relation to the |
16 | performance of their duties and responsibilities under this act. |
17 | The Commonwealth shall incur no liability in relation to the |
18 | implementation and operation of the plan. |
19 | CHAPTER 5 |
20 | PENNSYLVANIA HEALTH CARE PLAN |
21 | Section 501. General provisions. |
22 | (a) Establishment of plan.--There is hereby established the |
23 | Pennsylvania Health Care Plan that shall be administered by the |
24 | independent Pennsylvania Health Care Agency under the direction |
25 | of the Pennsylvania Health Care Board. |
26 | (b) Coverage.--The plan shall provide health care coverage |
27 | for all citizens of this Commonwealth. The agency shall work |
28 | simultaneously to control health care costs, achieve measurable |
29 | improvement in health care outcomes, promote a culture of health |
30 | awareness and develop an integrated health care database to |
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1 | support health care planning and quality assurance. |
2 | (c) Reforms.--The board shall implement the reforms adopted |
3 | by the General Assembly hereby within one year of the effective |
4 | date of the plan. |
5 | Section 502. Universal health care access eligibility. |
6 | (a) Eligibility.--All Pennsylvania residents, including |
7 | aliens or immigrants lawfully given admission to the United |
8 | States under the Immigration and Nationality Act (66 Stat. 163, |
9 | 8 U.S.C. § 1101 et seq.), homeless persons and migrant |
10 | agricultural workers and their accompanying families who reside |
11 | in this Commonwealth and are required to pay personal income tax |
12 | to the Commonwealth are eligible beneficiaries under the plan. |
13 | Health benefits shall be covered for the period when the |
14 | individual resided in Pennsylvania for tax purposes. When in |
15 | doubt, the definition of residency status shall follow the |
16 | definitions used by the Department of Revenue for paying |
17 | personal income taxes. The board shall establish standards and a |
18 | simple procedure to demonstrate proof of eligibility. Out-of- |
19 | State students who are not independent of their parents or |
20 | guardian attending school in this Commonwealth must obtain |
21 | health insurance. Part-year residents must obtain health |
22 | insurance for the period of time that they are not in State. |
23 | (b) Enrollment.--Enrollment in the plan shall be established |
24 | by the board and beneficiaries shall be provided with access |
25 | cards with appropriate proof of identity technology and privacy |
26 | protection. |
27 | (c) Outreach to eligible residents.--Pennsylvania residents |
28 | who are unable to pay their taxes because of physical or mental |
29 | disabilities may obtain assistance through county assistance |
30 | offices and other agencies identified by the board. |
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1 | (d) Waivers.--If waivers are not obtained from the medical |
2 | assistance and/or Medicare programs operated under Title XVIII |
3 | or XIX of the Social Security Act (49 Stat. 620, 42 U.S.C. § 301 |
4 | et seq.), the medical assistance and Medicare nonwaived programs |
5 | shall act as the primary insurers for those eligible for such |
6 | coverage, and the plan shall serve as the secondary or |
7 | supplemental plan of health coverage. Until such time as waivers |
8 | are obtained, the plan will not pay for services for persons |
9 | otherwise eligible for the same benefits under Medicare or |
10 | Medicaid. The plan shall also be secondary to benefits provided |
11 | to military veterans except where reasonable and timely access, |
12 | as defined by the board, is denied or unavailable through the |
13 | United States Veterans' Administration, in which instance the |
14 | plan will be primary and will seek reasonable reimbursement from |
15 | the United States Veterans' Administration for the services |
16 | provided to veterans. |
17 | (e) Priority of plans.--A plan of employee health coverage |
18 | provided by an out-of-State employer to a Pennsylvania resident |
19 | working outside of this Commonwealth shall serve as the |
20 | employee's primary plan of health coverage, and the plan shall |
21 | serve as the employee's secondary plan of health coverage. |
22 | (f) Reimbursement.--The plan shall reimburse providers |
23 | practicing outside of this Commonwealth at plan rates, or the |
24 | reasonable prevailing rate of the locale where the service is |
25 | provided, not to exceed 115% of the amount physicians in this |
26 | Commonwealth would have been paid for health care services |
27 | rendered to a beneficiary while the beneficiary is out of this |
28 | Commonwealth. Services provided to a beneficiary out of this |
29 | Commonwealth by other than a participating provider shall be |
30 | reimbursed to the beneficiary or to the provider at a fair and |
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1 | reasonable rate for that location. The plan may suggest |
2 | Pennsylvania providers for those who consistently use out-of- |
3 | State providers. |
4 | (g) Presumption of eligibility.--Any individual who arrives |
5 | at a health care facility unconscious or otherwise unable due to |
6 | their mental or physical condition to document eligibility for |
7 | coverage shall be presumed to be eligible, and emergency care |
8 | shall be provided without delay occasioned over issues of |
9 | ability to pay. |
10 | (h) Rules.--The board shall adopt rules assuring that any |
11 | participating provider who renders humanitarian emergency care, |
12 | urgent care or prevention or treatment for a communicable |
13 | disease or prenatal and delivery care within this Commonwealth |
14 | to a not actually eligible recipient shall nevertheless be |
15 | reimbursed for such care from the plan subject to such rules as |
16 | will reasonably limit the frequency of such events to protect |
17 | the fiscal integrity of the plan. It shall be the agency's |
18 | responsibility to secure reimbursement for the costs paid for |
19 | such care from any appropriate third party funding source, or |
20 | from the individual to whom the services were rendered. |
21 | Section 503. Covered services. |
22 | (a) Benefits package.--The board shall establish a single |
23 | health benefits package within the plan that shall include, but |
24 | not be limited to, all of the following: |
25 | (1) All medically necessary inpatient and outpatient |
26 | care and treatment, both primary and secondary. |
27 | (2) Emergency services. |
28 | (3) Emergency and other medically necessary transport to |
29 | covered health services. |
30 | (4) Rehabilitation services, including speech, |
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1 | occupational, physical and massage therapy. |
2 | (5) Inpatient and outpatient mental health services and |
3 | substance abuse treatment. |
4 | (6) Hospice care. |
5 | (7) Prescription drugs and prescribed medical nutrition. |
6 | (8) Vision care, aids and equipment. |
7 | (9) Hearing care, hearing aids and equipment. |
8 | (10) Diagnostic medical tests, including laboratory |
9 | tests and imaging procedures. |
10 | (11) Medical supplies and prescribed medical equipment. |
11 | (12) Immunizations, preventive care, health maintenance |
12 | care and screening. |
13 | (13) Dental care. |
14 | (14) Home health care services. |
15 | (15) Chiropractic and massage therapy. |
16 | (16) Complementary and alternative modalities that have |
17 | been shown by the National Institute of Health's Division of |
18 | Complementary and Alternative Medicine to be safe and |
19 | effective for possible inclusion as covered benefits. |
20 | (17) Long-term care for those unable to care for |
21 | themselves independently and including assisted and skilled |
22 | care. |
23 | (b) Exclusions for preexisting conditions.--The plan shall |
24 | not exclude or limit coverage due to preexisting conditions. |
25 | (c) Copayments, deductibles, etc.--Beneficiaries of the plan |
26 | are not subject to copayments, deductibles, point-of-service |
27 | charges or any other fee or charge for a service within the |
28 | package and shall not be directly billed nor balance billed by |
29 | participating providers for covered benefits provided to the |
30 | beneficiary. Where a beneficiary has directly paid for |
|
1 | nonemergency services of a nonparticipating provider, the |
2 | beneficiary may submit a claim for reimbursement from the plan |
3 | for the amount the plan would have paid a participating provider |
4 | for the same service. Where emergency services are rendered by a |
5 | nonparticipating provider, the beneficiary shall receive |
6 | reimbursement of the full amount paid to such nonparticipating |
7 | provider not to exceed 115% of the amount the plan would have |
8 | paid a participating provider for the same service. |
9 | (d) Exclusions of coverage.-- |
10 | (1) The board shall remove or exclude procedures and |
11 | treatments, equipment and prescription drugs from the plan |
12 | benefit package that the Food and Drug Administration or a |
13 | health quality panel finds unsafe or that add no therapeutic |
14 | value. |
15 | (2) The board shall exclude coverage for any surgical, |
16 | orthodontic or other procedure or drug that the board |
17 | determines was or will be provided primarily for cosmetic |
18 | purposes unless required to correct a congenital defect, to |
19 | restore or correct disfigurements resulting from injury or |
20 | disease or that is certified to be medically necessary by a |
21 | qualified, licensed provider. |
22 | (e) Choice by beneficiary.--Beneficiaries shall normally be |
23 | granted free choice of the participating providers, including |
24 | specialists, without preapprovals or referrals. However, the |
25 | board shall adopt procedures to restrict such free choice for |
26 | those individuals who engage in patterns of wasteful or abusive |
27 | self-referrals to specialists. Specialists who provide primary |
28 | care to a self-referred beneficiary will be reimbursed at the |
29 | board-approved primary care rate established for the service in |
30 | that community. |
|
1 | (f) Practice patterns.--Practice patterns of participating |
2 | providers shall be monitored. Outliers in terms of |
3 | overutilization or underutilization shall be reviewed by a panel |
4 | of peers and, if necessary, constructive feedback given. The |
5 | board may set outlier policies after reviewing practice patterns |
6 | and recommendations from the health quality panels. |
7 | (g) Service.--No participating provider shall be compelled |
8 | to offer any particular service so long as the refusal is |
9 | consistent with the provider's practice. |
10 | (h) Discrimination.--The plan and participating providers |
11 | shall not discriminate on the basis of race, ethnicity, national |
12 | origin, gender, age, religion, sexual orientation, health |
13 | status, mental or physical disability, employment status, |
14 | veteran status or occupation. |
15 | Section 504. Excess and collective bargaining agreement health |
16 | insurance coverage. |
17 | Subject to the regulations of the Insurance Commissioner and |
18 | all applicable laws, private health insurers shall be authorized |
19 | to offer coverage supplemental to the package approved and |
20 | provided automatically under this act. |
21 | Section 505. Duplicate coverage. |
22 | The agency is subrogated to and shall be deemed an assignee |
23 | of all rights of a beneficiary who has received duplicate health |
24 | care benefits, or who has a right to such benefits, under any |
25 | other policy or contract of health care or under any government |
26 | program. |
27 | Section 506. Subrogation. |
28 | The agency shall have no right of subrogation against a |
29 | beneficiary's third-party claims for harm or losses not covered |
30 | under this act. Nor shall any beneficiary under this act have a |
|
1 | claim against a third-party tortfeasor for the services provided |
2 | or available to the beneficiary under this act. In all personal |
3 | injury actions accruing and prosecuted by a beneficiary on or |
4 | after January 1, 2008, the presiding judge shall advise any jury |
5 | that all health care expenses have been or will be paid under |
6 | the plan, and, therefore, no claim for past or future health |
7 | care benefits is pending before the court. |
8 | Section 507. Eligible participating providers and availability |
9 | of services. |
10 | (a) General rule.--All licensed health care providers and |
11 | facilities are eligible to become a participating provider in |
12 | the plan in which instance they shall enjoy the rights and have |
13 | the duties as set forth in the plan as stated in this section or |
14 | as adopted by the board from time to time. Nonparticipating |
15 | providers shall not enjoy the rights nor bear the duties of |
16 | participating providers. |
17 | (b) Required notice.--In advance of initially providing |
18 | services to a beneficiary, nonparticipating providers shall |
19 | advise the beneficiary at the time the appointment is made that |
20 | the person or entity is a nonparticipating provider and that the |
21 | recipient of the service will be initially personally |
22 | responsible for the entire cost of the service and ultimately |
23 | responsible for the cost in excess of the reimbursement approved |
24 | by the board for participating providers. A sign at the point of |
25 | entry or reminder by the office staff disclosing whether the |
26 | provider accepts or does not accept the plan card and who covers |
27 | the cost of care shall be deemed sufficient notice. Failure to |
28 | make such financial disclosure will be deemed a fraud on the |
29 | beneficiary and entitle the beneficiary to a refund from the |
30 | provider equal to 200% of the amount paid to the |
|
1 | nonparticipating provider in excess of the board-approved |
2 | reimbursement for the services rendered, plus all reasonable |
3 | fees for collection. The burden of proof that such disclosure |
4 | was made shall be on the nonparticipating provider. |
5 | (c) Plan by board.--The board shall assess the number of |
6 | primary and specialty providers needed to supply adequate health |
7 | care services in this Commonwealth generally and in all |
8 | geographic areas and shall develop a plan to meet that need. The |
9 | board shall develop financial incentives for participating |
10 | providers in order to maintain and increase access to health |
11 | care services in underserved areas of this Commonwealth. |
12 | (d) Reimbursements.--Reimbursements shall be determined by |
13 | the board in such a fashion as to assure that a participating |
14 | provider receives compensation for services that fairly and |
15 | fully reflect the skill, training, operating overhead included |
16 | in the costs of providing the service, capital costs of |
17 | facilities and equipment, cost of consumables and the expense of |
18 | safely discarding medical waste, plus a reasonable profit |
19 | sufficient to encourage talented individuals to enter the field |
20 | and for investors to make capital available for the construction |
21 | of state-of-the-art health care facilities in this Commonwealth. |
22 | The plan shall review fee schedules and may offer alternative |
23 | reimbursement mechanisms, including capitation, salary and |
24 | bonuses. |
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 Professional |
30 | Quality Panel, who shall submit a report to the chair within 30 |
|
1 | days. The chair shall then submit a recommendation to the board |
2 | for action at the next scheduled board meeting. Participating |
3 | providers who remain dissatisfied after the board has ruled may |
4 | appeal the board's determination to Commonwealth Court, which |
5 | shall review the action of the board on an abuse of discretion |
6 | 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) Health care delivery models.--The board, with the |
14 | assistance of the health quality panels, shall review best |
15 | community practices in delivering high quality care. Those |
16 | wellness practices that can be adopted will be funded with an |
17 | increasing emphasis on prevention and community-based care in |
18 | order to reduce the need for hospitalization and nursing home |
19 | care in the future. |
20 | (h) Performance reports.--The board, with the assistance of |
21 | the Health Advisory Panel, shall define performance criteria and |
22 | goals for the plan and shall make a written report to the |
23 | General Assembly at least annually on the plan's performance. |
24 | All such reports, including the survey results obtained, shall |
25 | be made publicly available with the goal of total transparency |
26 | and open self-analysis as a defining quality of the agency. The |
27 | board shall establish a system to monitor the quality of health |
28 | care and patient and provider satisfaction and to adopt a system |
29 | to devise improvements and efficiencies to the provision of |
30 | health care services. |
|
1 | (i) Data reporting.--All participating providers shall, in a |
2 | prompt and timely manner, provide existing and ongoing data to |
3 | the agency upon its request. |
4 | (j) Coordination of services.--The agency shall coordinate |
5 | the provision of health care services with any other |
6 | Commonwealth and local agencies that provide health care |
7 | services directly to their charges or residents. |
8 | Section 508. Rational cost containment. |
9 | (a) Approval of expenditures.--As part of its cost |
10 | containment mission and based on the certificate of need, the |
11 | board, with the assistance of the Health Institution Quality |
12 | Panel, shall screen and approve or disapprove private or public |
13 | expenditures for new health care facilities and other capital |
14 | investments that may lead to redundant and inefficient health |
15 | care provider capacity. Procedures shall be adopted for this |
16 | purpose with an emphasis upon efficiency, quality of delivery |
17 | and a fair and open consideration of all applications. |
18 | (b) Capital investments.--Based on the certificate of need |
19 | all capital investments valued at $1,000,000 or greater, |
20 | including the costs of studies, surveys, design plans and |
21 | working drawing specifications, and other activities essential |
22 | to planning and execution of capital investment and all capital |
23 | investments that change the bed capacity of a health care |
24 | facility by more than 10% over a 24-month period or that add a |
25 | new service or license category shall require the approval of |
26 | the board. When a facility, an individual acting on behalf of a |
27 | facility or any other purchaser obtains by lease or comparable |
28 | arrangement any facility or part of a facility, or any equipment |
29 | for a facility, the market value of which would have been a |
30 | capital expenditure, the lease or arrangement shall be |
|
1 | considered a capital expenditure for purposes of this section. |
2 | (c) Study.--Those intending to make capital investments or |
3 | acquisitions shall prepare a business case for making each |
4 | investment and acquisition. It shall include the full-life-cycle |
5 | costs of the investment or acquisition, an environment impact |
6 | report that meets existing State standards and a demonstration |
7 | of how the investment or acquisition meets the health care needs |
8 | of the population it is intended to serve. Acquisitions may |
9 | include, but not be limited to, acquisitions of land, |
10 | operational property or administrative office space. |
11 | (d) Deemed approval.--Capital investment programs submitted |
12 | for approval shall be deemed approved by the board within 60 |
13 | days from the date the submissions are received by the chair. A |
14 | 60-day extension may apply if the board requires additional |
15 | information. |
16 | (e) Recommendations.--Recommendations of the Pennsylvania |
17 | Heath Cost Containment Council and such other public and private |
18 | authoritative bodies as shall be identified from time to time by |
19 | the board shall be received by the chair and submitted to the |
20 | board with the chair's recommendation regarding implementation |
21 | of the recommended reforms. The board shall receive input from |
22 | all interested parties and then shall vote upon all such |
23 | recommendations within 60 days. Where procedural or protocol |
24 | reforms are adopted, participating providers will be required to |
25 | implement such designated best practices within the next 60 |
26 | days. |
27 | (f) Appeal.--A decision of the board may be appealed through |
28 | a uniform dispute resolution process that has been established |
29 | by unanimous approval of the board. |
30 | (g) Required investments.--The board, with the |
|
1 | recommendations of the Health Institution Quality Panel, may |
2 | adopt programs to assist participating providers in making |
3 | capital investments responsive to best practice recommendations. |
4 | (h) Decertification.--Participating providers refusing to |
5 | adopt recommended reforms shall, after a reasonable opportunity |
6 | to be heard, be subject to such sanctions as the board shall |
7 | deem appropriate and necessary up to and including a |
8 | recommendation by the board to the Bureau of Professional and |
9 | Occupational Affairs or the Department of Health for the |
10 | suspension or permanent decertification of the participating |
11 | provider. |
12 | CHAPTER 9 |
13 | PENNSYLVANIA HEALTH CARE TRUST FUND |
14 | Section 901. Pennsylvania Health Care Trust Fund. |
15 | (a) Establishment.--The Pennsylvania Health Care Trust Fund |
16 | is hereby established within the State Treasury. All moneys |
17 | collected and received by the plan shall be transmitted to the |
18 | State Treasurer for deposit into the fund, to be used |
19 | exclusively to finance the plan. |
20 | (b) State Treasurer.--The State Treasurer may invest the |
21 | principal and interest earned by the fund in any manner |
22 | authorized under law for the investment of Commonwealth moneys. |
23 | Any revenue or interest earned from the investments shall be |
24 | credited to the fund. |
25 | Section 902. Limitation on administrative expense. |
26 | The system budget referred to in this chapter shall comprise |
27 | the cost of the agency, services and benefits provided, |
28 | administration, data gathering, planning and other activities |
29 | and revenues deposited with the system account of the fund. The |
30 | board shall limit ongoing administrative costs, excluding start- |
|
1 | up costs, to 5% of the agency budget and shall annually evaluate |
2 | methods to reduce administrative costs and publicly report the |
3 | results of that evaluation. |
4 | Section 903. Funding sources. |
5 | Funding of the plan shall be obtained from the following |
6 | dedicated sources: |
7 | (1) Funds obtained from existing or future Federal |
8 | health care programs. |
9 | (2) Funds from dedicated sources specified by the |
10 | General Assembly. |
11 | (3) Receipts from the tax of 10% of gross payroll, |
12 | including self-employment profits. One percent of the tax |
13 | shall become effective the date that shall be the first day |
14 | of a calendar month no less than 32 days after the effective |
15 | date of this act, and the tax shall become fully effective 60 |
16 | days before the plan takes effect. Employers who are part of |
17 | a collective bargaining agreement whereby the health care |
18 | benefits are no less generous than those provided under the |
19 | plan shall be excused from paying 90% of the tax. |
20 | (4) Receipts from the Individual Fair Share Health and |
21 | Wellness Tax of 3% on income as defined in sections 301 and |
22 | 303 of the act of March 4, 1971 (P.L.6, No.2), known as the |
23 | Tax Reform Code of 1971. One-half of one percent of the |
24 | Individual Fair Share Health and Wellness Tax shall become |
25 | effective the date that shall be the first day of a calendar |
26 | month no less than 32 days after the effective date of this |
27 | act, and the Individual Fair Share Health and Wellness tax |
28 | shall become fully effective 60 days before the plan takes |
29 | effect. |
30 | CHAPTER 11 |
|
1 | TRANSITIONAL SUPPORT AND TRAINING FOR DISPLACED WORKERS |
2 | Section 1101. Transitional support and training for displaced |
3 | workers. |
4 | (a) Determination of eligibility.--The plan shall determine |
5 | which citizens of this Commonwealth employed by a health care |
6 | insurer, health insuring corporation or other health care- |
7 | related business have lost their employment as a result of the |
8 | implementation and operation of the plan, including the amount |
9 | of monthly wages that the individual has lost due to the plan's |
10 | implementation. The plan shall attempt to position these |
11 | displaced workers in comparable positions of employment or |
12 | assist in the retraining and placement of such displaced |
13 | employees elsewhere. |
14 | (b) Compensation.--The plan shall forward the information on |
15 | the amount of monthly wages lost by Commonwealth residents due |
16 | to the implementation of the plan to the board. Compensation |
17 | shall be up to $5,000 each month but may not exceed the monthly |
18 | wages of the individual when he was displaced. Compensation will |
19 | cease upon reemployment or after two years, whichever comes |
20 | first. A displaced worker shall be eligible to receive |
21 | compensation, training assistance, or both, from the fund. |
22 | Training assistance may not exceed $20,000. |
23 | (c) Coordination of services.--The plan shall fully |
24 | coordinate activity with public and private services also |
25 | available or actually participating in the assistance to the |
26 | affected individuals. |
27 | (d) Appeals.--Persons dissatisfied with the level of |
28 | assistance they are receiving may appeal to the office of the |
29 | executive director whose determination shall be final and not |
30 | subject to appeal. |
|
1 | CHAPTER 13 |
2 | VOLUNTEER EMERGENCY RESPONDER NETWORK |
3 | Section 1301. Preservation of volunteer emergency responder |
4 | network. |
5 | Because this Commonwealth is dependent upon the volunteered |
6 | services of firefighters, emergency medical technicians and |
7 | search and rescue workers, the board is further charged with |
8 | administering a Commonwealth income tax credit program for such |
9 | volunteers. |
10 | Section 1302. Eligibility certification. |
11 | Annually, in January, administrators of volunteer |
12 | firefighting and rescue departments, emergency medical |
13 | technicians and paramedics stations and similar volunteer |
14 | emergency entities shall certify the identity of Commonwealth |
15 | residents providing active services during the prior calendar |
16 | year. |
17 | Section 1303. Eligibility criteria. |
18 | Active status shall require a minimum of 200 hours of service |
19 | during the preceding year and response to no less than 50% of |
20 | the emergency calls during at least three of the four calendar |
21 | quarters. |
22 | Section 1304. Amount of tax credit. |
23 | Each volunteer certified as active shall be granted a credit |
24 | equal to $1,000 toward the volunteer's State income tax |
25 | obligation under Article III of the act of March 4, 1971 (P.L.6, |
26 | No.2), known as the Tax Reform Code of 1971. Any eligible |
27 | volunteer who does not incur $1,000 in annual State income tax |
28 | liability shall nevertheless be eligible for a refund equal to |
29 | the amount the credit exceeds that volunteer's tax obligation. |
30 | Section 1305. Reimbursement. |
|
1 | The State Treasury shall be reimbursed the value of such |
2 | volunteer credits from the fund. |
3 | CHAPTER 45 |
4 | MISCELLANEOUS PROVISIONS |
5 | Section 4501. Effective date. |
6 | This act shall take effect immediately. |
|