1Providing for a Statewide comprehensive health care system;
2establishing the Pennsylvania Health Care Plan and providing
3for eligibility, services, coverages, subrogation,
4participating providers, cost containment, reduction of
5errors, tort remedies, administrative remedies and
6procedures, attorney fees, quality assurance,
7nonparticipating providers, transitional support and
8training; and establishing the Pennsylvania Health Care
9Agency, the Employer Health Services Levy, the Individual
10Wellness Tax, the Pennsylvania Health Care Trust Fund and the
11Pennsylvania Health Care Board and providing for their powers
12and duties.

13TABLE OF CONTENTS

14Chapter 1. Preliminary Provisions

15Section 101. Short title.

16Section 102. Definitions.

17Chapter 3. Administration and Oversight of the Pennsylvania
18Health Care Plan

19Subchapter A. Pennsylvania Health Care Board

20Section 301. Organization.

21Section 302. Duties of board.

22Subchapter B. Pennsylvania Health Care Agency

23Section 321. Pennsylvania Health Care Agency.

1Subchapter C. (Reserved)

2Subchapter D. (Reserved)

3Subchapter E. (Reserved)

4Subchapter F. Immunity

5Section 371. Immunity.

6Chapter 5. Pennsylvania Health Care Plan

7Section 501. General provisions.

8Section 502. Universal health care access eligibility.

9Section 503. Covered services.

10Section 504. Excess and collective bargaining agreement health
11insurance coverage.

12Section 505. Duplicate coverage.

13Section 506. Subrogation.

14Section 507. Eligible participating providers and availability
15of services.

16Section 508. Rational cost containment.

17Chapter 9. Pennsylvania Health Care Trust Fund

18Section 901. Pennsylvania Health Care Trust Fund.

19Section 902. Limitation on administrative expense.

20Section 903. Funding sources.

21Chapter 11. Transitional Support and Training for Displaced
22Workers

23Section 1101. Transitional support and training for displaced
24workers.

25Chapter 13. Volunteer Emergency Responder Network

26Section 1301. Preservation of volunteer emergency responder
27network.

28Section 1302. Eligibility certification.

29Section 1303. Eligibility criteria.

30Section 1304. Amount of tax credit.

1Section 1305. Reimbursement of Department of Revenue.

2Chapter 45. Miscellaneous Provisions

3Section 4501. Effective date.

4The General Assembly of the Commonwealth of Pennsylvania
5hereby enacts as follows:

6CHAPTER 1

7PRELIMINARY PROVISIONS

8Section 101. Short title.

9This act shall be known and may be cited as the Family and
10Business Healthcare Security Act.

11Section 102. Definitions.

12The following words and phrases when used in this act shall
13have the meanings given to them in this section unless the
14context clearly indicates otherwise:

15"Agency." The Pennsylvania Health Care Agency established
16under this act.

17"Board." The Pennsylvania Health Care Board established
18under this act.

19"Certificate of need." A notice of approval issued by the 
20Department of Health under the provisions of the act of July 19, 
211979 (P.L.130, No.48), known as the Health Care Facilities Act,
22including those notices of approval issued as an amendment to an
23existing certificate of need.

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

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

26"Executive director." The Executive Director of the
27Pennsylvania Health Care Agency.

28"Fund." The Pennsylvania Health Care Trust Fund established
29under this act.

30"Individual Fair Share Health and Wellness Tax." The

1Individual Fair Share Health and Wellness Tax established under
2this act.

3"Ombudsman." The Pennsylvania Health Care Ombudsman
4established under this act.

5"Plan." The Pennsylvania Health Care Plan established under
6this act.

7"Tax." The Employer Fair Share Health and Wellness Tax
8established under this act.

9CHAPTER 3

10ADMINISTRATION AND OVERSIGHT OF THE

11PENNSYLVANIA HEALTH CARE PLAN

12SUBCHAPTER A

13PENNSYLVANIA HEALTH CARE BOARD

14Section 301. Organization.

15(a) Composition.--The Pennsylvania Health Care Board shall
16be composed of 12 voting members. The chair shall preside over
17the board and shall set the agenda but may vote only in the
18event of a tie vote.

19(b) Appointments.--

20(1) The board shall consist of 12 members to be
21appointed by the Governor by and with the advice and consent
22of a majority of all the members of the Senate from
23individuals representative of each of the following
24constituencies and reflective of the diversity of this
25Commonwealth:

26(i) Three patients or caregivers of patients who
27experience the health care system daily. These members
28must be geographically diverse, knowledgeable about
29health issues and represent the following categories:

30(A) A caregiver of a child with a chronic

1illness or developmental disability.

2(B) An adult with a chronic illness or physical
3disability.

4(C) An adult with mental illness requiring
5medications.

6(ii) A physician.

7(iii) A hospital representative.

8(iv) A long-term care representative.

9(v) A health care attorney.

10(vi) A health care informatics representative.

11(vii) A small business representative.

12(viii) A large business representative.

13(ix) An organized labor representative from the
14health sector.

15(x) A public health representative.

16(2) Appointed board members shall take the oath of
17office prior to serving on the board and may be removed only
18for cause under subsection (j).

19(b.1) Quality of care panels.--

20(1) In addition to the board, there shall be four
21quality of care panels as follows:

22(i) A health professional quality panel.

23(ii) A health institution quality panel.

24(iii) A health supplier quality panel.

25(iv) The health care ombudsman panel.

26(2) The quality of care panels shall meet regularly as
27needed to create policies and recommendations to deliver
28cost-effective, evidence-based, quality health care to the
29residents of this Commonwealth.

30(3) The quality of care panels shall hire staff who will

1work daily on quality of care recommendations with agency
2staff. The quality of care recommendations shall be presented
3in a formal report at every board meeting.

4(4) The chair shall inform the board on progress or
5explaining the lack of progress in implementing key
6recommendations of the quality of care panels.

7(c) Chairman.--The Governor shall designate one of the board
8members as chairman, who shall serve in that position at the
9pleasure of the Governor. The chairman shall, when present,
10preside at all meetings, and in his absence a member designated
11by the chairman shall preside.

12(d) Midterm vacancies.--Midterm vacancies shall be filled by
13a representative from the same constituent group required under
14subsection (b) and the individual appointed to fill a vacancy
15occurring prior to the expiration of the term for which a member
16is appointed shall hold office for the remainder of the
17predecessor's term.

18(e) Compensation, benefits and expenses.--The chair shall
19receive an annual salary, benefits and expense reimbursement
20established by the board, to be paid from the fund, but the
21salary may not exceed the salary of the Governor. The initial
22board shall establish its own compensation per diem and, for
23travel, reimbursement of expenses incurred on behalf of the
24board and other necessary expenses. No increase or decrease in
25salary or benefits adopted by the board for the chair or members
26shall become effective within the same three-year term, except
27for the first three initial years of the plan when readjustments
28may be made.

29(f) Meetings.--

30(1) The chair shall set the time, place and date for the

1initial and subsequent meetings of the board and shall
2preside over its meetings. The initial meeting shall be set
3not sooner than 50 nor later than 100 days after the
4appointment of the chair. Subsequent meetings shall occur as
5determined by the board but not less than six times annually.

6(2) All meetings of the board are open to the public
7unless questions of patient confidentiality arise. The board
8may conduct closed executive session for issues relating to
9confidential patient information, to evaluation of the chair
10or to personnel matters.

11(3) The board shall publish its rulings in the
12Pennsylvania Bulletin with an opportunity for public comment
13as determined by State law.

14(4) The minutes of the board, except for executive
15session deliberations, shall be public information. The media
16shall be allowed access to all final public reports to ensure
17full disclosure of decisions that impact the public.

18(g) Quorum.--Two-thirds of the appointed members of the
19board shall constitute a quorum for the conducting of business
20at meetings of the board. Decisions at ordinary meetings of the
21board shall be reached by majority vote of those actually
22present or, in the event of an emergency meeting, those also
23present by electronic or telephonic means. Where there is a tie
24vote, the chair shall vote to break the tie. Except as otherwise
25provided in this act, absentee or proxy voting may not be
26allowed.

27(h) Ethics.--The executive director, the chair and other
28board members and their immediate families are prohibited from
29having any pecuniary interest in any business with a contract or
30in negotiation for a contract with the agency. The board shall

1also adopt rules of ethics and definitions of irreconcilable
2conflicts of interest that will determine under what
3circumstances members must recuse themselves from voting.

4(i) Prohibitions.--

5(1) No member of the board may receive any additional
6salary or benefits by virtue of serving on the board.

7(2) No member of the board may hold any other salaried
8Commonwealth public position, either elected or appointed,
9during the member's tenure on the board, including, but not
10limited to, the position of State legislator or member of the
11United States Congress.

12(3) The executive director, chair and board members may
13not be a State legislator or member of the United States
14Congress.

15(j) Dismissal.--Board members shall attend all meetings and
16be prepared to discuss and vote on information presented. Board
17members may be dismissed and positions refilled for any of the
18following reasons:

19(1) Failure to attend 75% of the meetings in one year.

20(2) Inability to represent their constituency group.

21(3) Clear conflict of interest.

22(4) Fraud or criminal activity either present or in the
23past.

24Section 302. Duties of board.

25(a) General duties.--The board is responsible for directing
26the agency in the performance of all duties, the exercise of all
27powers, and the assumption and discharge of all functions vested
28in the agency. The board shall adopt and publish its rules and
29procedures in the Pennsylvania Bulletin no later than 180 days
30after the first meeting of the board.

1(b) Specific duties.--The duties and functions of the board
2include, but are not limited to, the following:

3(1) Implementing statutory eligibility standards for
4benefits.

5(2) Annually adopting a benefits package for
6participants of the plan.

7(3) Acting directly or through one or more contractors
8as the single payer administrator for all claims for health
9care services made under the plan.

10(4) At least annually, reviewing the appropriateness and
11sufficiency of reimbursements and considering whether a
12charge is fair and reasonable for its geographic region or
13location.

14(5) Providing for timely payments to participating
15providers through a structure that is well organized and that
16eliminates unnecessary administrative costs.

17(6) Implementing standardized claims and reporting
18methods for use by the plan.

19(7) Developing a system of centralized electronic claims
20and payments accounting.

21(8) Establishing an enrollment system that will ensure
22that those who travel frequently and cannot read or speak
23English are aware of their right to health care and are
24formally enrolled in the plan.

25(9) Reporting annually to the General Assembly and to
26the Governor, on or before the first day of October, on the
27performance of the plan, the fiscal condition of the plan,
28recommendations for statutory changes, the receipt of
29payments from the Federal Government, whether current year
30goals and priorities were met, future goals and priorities,

1and major new technology or prescription drugs that may
2affect the cost of the health care services provided by the
3plan.

4(10) Administering the revenues of the fund.

5(11) Obtaining appropriate liability and other forms of
6insurance to provide coverage for the plan, the board, the
7agency and their employees and agents.

8(12) Establishing, appointing and funding appropriate
9staff, office space, equipment, training and administrative
10support for the agency throughout this Commonwealth, all to
11be paid from the fund.

12(13) Administering aspects of the agency by taking
13actions that include, but are not limited to, the following:

14(i) Establishing standards and criteria for the
15allocation of operating funds.

16(ii) Meeting regularly to review the performance of
17the agency and to adopt and revise its policies.

18(iii) Establishing goals for the health care system
19established pursuant to the plan in measurable terms.

20(iv) Establishing Statewide health care databases to
21support health care services planning.

22(v) Implementing policies and developing mechanisms
23and incentives to assure culturally and linguistically
24sensitive care.

25(vi) Establishing rules and procedures for
26implementation and staffing of a no-fault compensation
27system for iatrogenic injuries or complications of care
28whereby a patient's condition is made worse or an
29opportunity for cure or improvement is lost due to the
30health care or medications provided or appropriate care

1not provided by participating providers under the plan.

2(vii) Establishing standards and criteria for the
3determination of appropriate transitional support and
4training for residents of this Commonwealth who are
5displaced from work during the first two years of the
6implementation of the plan.

7(viii) Evaluating the state of the art in proven
8technical innovations, medications and procedures and
9adopting policies to expedite the rapid introduction
10thereof in this Commonwealth.

11(ix) Establishing methods for the recovery of costs
12for health care services provided pursuant to the plan to
13a beneficiary who is also covered under the terms of a
14policy of insurance, a health benefit plan or other
15collateral source available to the participant under
16which the participant has a right of action for
17compensation. Receipt of health care services pursuant to
18the plan shall be deemed an assignment by the participant
19of any right to payment for services from the policy,
20plan or other source. The other source of health care
21benefits shall pay to the trust all amounts it is
22obligated to pay to, or on behalf of, the participant for
23covered health care services. The board may commence any
24action necessary to recover the amounts due.

25(14) Establishing the Health Professional Quality Panel,
26Health Institution Quality Panel and Health Supplier Quality
27Panel, which panels shall be comprised of persons who
28represent a cross section of the medical and provider
29community as follows:

30(i) Appointments shall be nominated by the trade

1organizations and in the event of multiple nominations,
2made by the board. Each quality panel shall submit
3recommendations for continual improvement in cost-
4effective, quality health care.

5(ii) The Health Professional Quality Panel shall
6consist of one representative of the following
7constituencies:

8(A) Primary care physicians.

9(B) Specialty care physicians.

10(C) Clinical psychologists.

11(D) Nurses.

12(E) Social workers.

13(F) Midwives.

14(G) Nutritionists.

15(H) Pharmacists.

16(I) Optometrists.

17(J) Podiatrists.

18(K) Hearing specialists.

19(L) Physical or occupational therapists.

20(M) Dentists.

21(N) Chiropractors.

22(O) Health educators.

23(P) Acupuncturists.

24(iii) The Health Institution Quality Panel shall
25consist of one representative of the following
26constituencies:

27(A) Academic medical centers.

28(B) Community hospitals.

29(C) Rehabilitation centers.

30(D) Trauma systems.

1(E) Convenient care centers.

2(F) Hospice programs.

3(G) Substance abuse centers.

4(H) Home health care services.

5(I) Long-term care facilities.

6(iv) The Health Supplier Quality Panel shall consist
7of one representative of the following constituencies:

8(A) Medical imaging.

9(B) Laboratory.

10(C) Durable medical equipment suppliers.

11(D) Pharmaceutical.

12(E) Medical suppliers other than durable medical
13equipment suppliers.

14(v) The members of the quality panels shall be paid
15a per diem rate, established by the board, for attendance
16at meetings and further be reimbursed for actual and
17necessary expenses incurred in the performance of their
18duties, which shall include:

19(A) Making recommendations to the agency on the
20establishment of policy on medical issues,
21population-based public health issues, research
22priorities, scope of services, expansion of access to
23health care services and evaluation of the
24performance of the plan in order to provide high
25quality care for Pennsylvania residents.

26(B) Investigating proposals for innovative
27approaches to the promotion of health, the prevention
28of disease and injury, patient education, research
29and health care delivery.

30(C) Advising the agency on the establishment of

1standards and criteria to evaluate requests from
2health care facilities for capital improvements.

3(D) Evaluating and advising the board on
4requests from providers or their representatives for
5adjustments to reimbursements reflective of their
6education and responsibilities.

7(E) Coordinating resources in order to minimize
8duplication among providers, institutions and
9suppliers.

10(F) Evaluating or conducting research in order
11to recommend products or services.

12(G) Presenting key recommendations in a report
13to the board on improving quality of care.

14(15) Establishing an Office of the Health Care
15Ombudsman. Acting directly or through one or more
16contractors, the ombudsman and staff shall expeditiously
17resolve issues related to the implementation of the plan
18within 24 hours. The office shall receive questions,
19complaints or problems from the public and work with agency
20staff in order to quickly find a permanent or temporary
21resolution. The staff of the ombudsman shall be hired from
22the funds deposited in the Pennsylvania Health Care Trust
23Fund. The ombudsman shall prepare a report for every board
24meeting summarizing the major issues and recommendations for
25resolution by the board.

26(16) Establishing a secure and centralized electronic
27health record system that provides for a beneficiary's entire
28health record to be readily and reliably accessed by
29authorized persons with the objective of eliminating the
30errors and expense associated with paper records and

1diagnostic films. The system shall ensure the privacy of all
2health records it contains.

3(17) Establishing, from the revenues received, a reserve
4fund sufficient to provide a continuation of services during
5periods of reduced or insufficient revenue due to economic
6conditions or unforeseen emergency major health care needs.

7SUBCHAPTER B

8PENNSYLVANIA HEALTH CARE AGENCY

9Section 321. Pennsylvania Health Care Agency.

10(a) Establishment.--The Pennsylvania Health Care Agency is
11established. The agency shall administer the plan and is the
12sole agency authorized to accept applicable grants-in-aid from
13the Federal Government and State government. It shall use the
14funds in order to secure full compliance with provisions of
15Federal and State law and to carry out the purposes established
16under this act. All grants-in-aid accepted by the agency shall
17be deposited into the Pennsylvania Health Care Trust Fund
18established under this act, together with other revenues raised
19within this Commonwealth to fund the plan.

20(b) Appointment of executive director.--The executive
21director of the agency shall be appointed by the board and shall
22be the chief administrator of the plan. The executive director
23shall implement the plan and serve at the pleasure of the board.
24The salary of the executive director shall not exceed the
25statutory salary of the Governor.

26(c) Personnel and employees.--The board shall employ and fix
27the compensation of agency personnel as needed by the agency to
28properly discharge the agency's duties. The employment of
29personnel by the board is subject to the civil service laws of
30this Commonwealth. The executive director shall oversee the

1operation of the agency and the agency's performance of any
2duties assigned by the board.

3SUBCHAPTER C

4(Reserved)

5SUBCHAPTER D

6(Reserved)

7SUBCHAPTER E

8(Reserved)

9SUBCHAPTER F

10IMMUNITY

11Section 371. Immunity.

12In the absence of fraud or bad faith, the health quality
13panels, the board and agency and their respective members and
14employees shall incur no liability in relation to the
15performance of their duties and responsibilities under this act.
16The Commonwealth shall incur no liability in relation to the
17implementation and operation of the plan.

18CHAPTER 5

19PENNSYLVANIA HEALTH CARE PLAN

20Section 501. General provisions.

21(a) Establishment of plan.--There is hereby established the
22Pennsylvania Health Care Plan that shall be administered by the
23independent Pennsylvania Health Care Agency under the direction
24of the Pennsylvania Health Care Board.

25(b) Coverage.--The plan shall provide health care coverage
26for all citizens of this Commonwealth. The agency shall work
27simultaneously to control health care costs, achieve measurable
28improvement in health care outcomes, promote a culture of health
29awareness and develop an integrated health care database to
30support health care planning and quality assurance.

1(c) Reforms.--The board shall implement the reforms adopted
2by the General Assembly under this act within one year of the
3effective date of the plan.

4Section 502. Universal health care access eligibility.

5(a) Eligibility.--All Pennsylvania residents, including
6aliens or immigrants lawfully given admission to the United
7States under the Immigration and Nationality Act (66 Stat. 163,
88 U.S.C. § 1101 et seq.), homeless persons and migrant
9agricultural workers and their accompanying families who reside
10in this Commonwealth and are required to pay personal income tax
11to the Commonwealth are eligible beneficiaries under the plan.
12Health benefits shall be covered for the period when the
13individual resided in Pennsylvania for tax purposes. When in
14doubt, the definition of residency status shall follow the
15definitions used by the Department of Revenue for paying
16personal income taxes. The board shall establish standards and a
17simple procedure to demonstrate proof of eligibility. Out-of-
18State students who are not independent of their parents or
19guardian attending school in this Commonwealth must obtain
20health insurance. Part-year residents must obtain health
21insurance for the period of time that they are not in State.

22(b) Enrollment.--Enrollment in the plan shall be established
23by the board, and beneficiaries shall be provided with access
24cards with appropriate proof of identity technology and privacy
25protection.

26(c) Outreach to eligible residents.--A resident of this
27Commonwealth who is unable to pay taxes because of physical or
28mental disabilities may obtain assistance through county
29assistance offices and other agencies identified by the board.

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

1assistance and/or Medicare programs operated under Title XVIII
2or XIX of the Social Security Act (49 Stat. 620, 42 U.S.C. § 301
3et seq.), the medical assistance and Medicare nonwaived programs
4shall act as the primary insurers for those eligible for such
5coverage, and the plan shall serve as the secondary or
6supplemental plan of health coverage. Until such time as waivers
7are obtained, the plan will not pay for services for persons
8otherwise eligible for the same benefits under Medicare or
9Medicaid. The plan shall also be secondary to benefits provided
10to military veterans except where reasonable and timely access,
11as defined by the board, is denied or unavailable through the
12United States Veterans' Administration, in which instance the
13plan will be primary and will seek reasonable reimbursement from
14the United States Veterans' Administration for the services
15provided to veterans.

16(e) Priority of plans.--A plan of employee health coverage
17provided by an out-of-State employer to a Pennsylvania resident
18working outside of this Commonwealth shall serve as the
19employee's primary plan of health coverage, and the plan shall
20serve as the employee's secondary plan of health coverage.

21(f) Reimbursement.--The plan shall reimburse providers
22practicing outside of this Commonwealth at plan rates, or the
23reasonable prevailing rate of the locale where the service is
24provided, not to exceed 115% of the amount physicians in this
25Commonwealth would have been paid for health care services
26rendered to a beneficiary while the beneficiary is out of this
27Commonwealth. Services provided to a beneficiary out of this
28Commonwealth by other than a participating provider shall be
29reimbursed to the beneficiary or to the provider at a fair and
30reasonable rate for that location. The plan may suggest

1Pennsylvania providers for those who consistently use out-of-
2State providers.

3(g) Presumption of eligibility.--An individual who arrives
4at a health care facility unconscious or otherwise unable due to
5their mental or physical condition to document eligibility for
6coverage shall be presumed to be eligible, and emergency care
7shall be provided without delay occasioned over issues of
8ability to pay.

9(h) Rules.--The board shall adopt rules assuring that a
10participating provider who renders humanitarian emergency care,
11urgent care or prevention or treatment for a communicable
12disease or prenatal and delivery care within this Commonwealth
13to a not actually eligible recipient shall nevertheless be
14reimbursed for that care from the plan subject to such rules as
15will reasonably limit the frequency of those events to protect
16the fiscal integrity of the plan. It shall be the agency's
17responsibility to secure reimbursement for the costs paid for
18that care from any appropriate third party funding source, or
19from the individual to whom the services were rendered.

20Section 503. Covered services.

21(a) Benefits package.--The board shall establish a single
22health benefits package within the plan that shall include, but
23not be limited to, all of the following:

24(1) All medically necessary inpatient and outpatient
25care and treatment, both primary and secondary.

26(2) Emergency services.

27(3) Emergency and other medically necessary transport to
28covered health services.

29(4) Rehabilitation services, including speech,
30occupational, physical and massage therapy.

1(5) Inpatient and outpatient mental health services and
2substance abuse treatment.

3(6) Hospice care.

4(7) Prescription drugs and prescribed medical nutrition.

5(8) Vision care, aids and equipment.

6(9) Hearing care, hearing aids and equipment.

7(10) Diagnostic medical tests, including laboratory
8tests and imaging procedures.

9(11) Medical supplies and prescribed medical equipment.

10(12) Immunizations, preventive care, health maintenance
11care and screening.

12(13) Dental care.

13(14) Home health care services.

14(15) Chiropractic and massage therapy.

15(16) Complementary and alternative modalities that have
16been shown by the National Institute of Health's Division of
17Complementary and Alternative Medicine to be safe and
18effective for possible inclusion as covered benefits.

19(17) Long-term care for those unable to care for
20themselves independently and including assisted and skilled
21care.

22(b) Exclusions for preexisting conditions.--The plan shall
23not exclude or limit coverage due to preexisting conditions.

24(c) Copayments, deductibles, etc.--Beneficiaries of the plan
25may not be subject to copayments, deductibles, point-of-service
26charges or any other fee or charge for a service within the
27package and may not be directly billed nor balance billed by
28participating providers for covered benefits provided to the
29beneficiary. Where a beneficiary has directly paid for
30nonemergency services of a nonparticipating provider, the

1beneficiary may submit a claim for reimbursement from the plan
2for the amount the plan would have paid a participating provider
3for the same service. Where emergency services are rendered by a
4nonparticipating provider, the beneficiary shall receive
5reimbursement of the full amount paid to the nonparticipating
6provider not to exceed 115% of the amount the plan would have
7paid a participating provider for the same service.

8(d) Exclusions of coverage.--

9(1) The board shall remove or exclude procedures and
10treatments, equipment and prescription drugs from the plan
11benefit package that the Food and Drug Administration or a
12health quality panel finds unsafe or that add no therapeutic
13value.

14(2) The board shall exclude coverage for any surgical,
15orthodontic or other procedure or drug that the board
16determines was or will be provided primarily for cosmetic
17purposes unless required to correct a congenital defect, to
18restore or correct disfigurements resulting from injury or
19disease or that is certified to be medically necessary by a
20qualified, licensed provider.

21(e) Choice by beneficiary.--Beneficiaries shall normally be
22granted free choice of the participating providers, including
23specialists, without preapprovals or referrals. However, the
24board shall adopt procedures to restrict the free choice for
25those individuals who engage in patterns of wasteful or abusive
26self-referrals to specialists. Specialists who provide primary
27care to a self-referred beneficiary will be reimbursed at the
28board-approved primary care rate established for the service in
29that community.

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

1providers shall be monitored. Outliers in terms of
2overutilization or underutilization shall be reviewed by a panel
3of peers and, if necessary, constructive feedback given. The
4board may set outlier policies after reviewing practice patterns
5and recommendations from the health quality panels.

6(g) Service.--No participating provider may be compelled to
7offer a particular service so long as the refusal is consistent
8with the provider's practice.

9(h) Discrimination.--The plan and participating providers
10may not discriminate on the basis of race, ethnicity, national
11origin, gender, age, religion, sexual orientation, health
12status, mental or physical disability, employment status,
13veteran status or occupation.

14Section 504. Excess and collective bargaining agreement health
15insurance coverage.

16Subject to the regulations of the Insurance Commissioner and
17all applicable laws, private health insurers shall be authorized
18to offer coverage supplemental to the package approved and
19provided automatically under this act.

20Section 505. Duplicate coverage.

21The agency is subrogated to and shall be deemed an assignee
22of all rights of a beneficiary who has received duplicate health
23care benefits, or who has a right to those benefits, under any
24other policy or contract of health care or under any government
25program.

26Section 506. Subrogation.

27The agency shall have no right of subrogation against a
28beneficiary's third-party claims for harm or losses not covered
29under this act. A beneficiary under this act may not make a
30claim against a third-party tortfeasor for the services provided

1or available to the beneficiary under this act. In all personal
2injury actions accruing and prosecuted by a beneficiary on or
3after January 1, 2008, the presiding judge shall advise any jury
4that all health care expenses have been or will be paid under
5the plan, and, therefore, no claim for past or future health
6care benefits is pending before the court.

7Section 507. Eligible participating providers and availability
8of services.

9(a) General rule.--All licensed health care providers and
10facilities are eligible to become a participating provider in
11the plan in which instance they shall enjoy the rights and have
12the duties as set forth in the plan as stated in this section or
13as adopted by the board from time to time. Nonparticipating
14providers may not enjoy the rights nor bear the duties of
15participating providers.

16(b) Required notice.--In advance of initially providing
17services to a beneficiary, nonparticipating providers shall
18advise the beneficiary at the time the appointment is made that
19the person or entity is a nonparticipating provider and that the
20recipient of the service will be initially personally
21responsible for the entire cost of the service and ultimately
22responsible for the cost in excess of the reimbursement approved
23by the board for participating providers. A sign at the point of
24entry or reminder by the office staff disclosing whether the
25provider accepts or does not accept the plan card and who covers
26the cost of care shall be deemed sufficient notice. Failure to
27make the financial disclosure will be deemed a fraud on the
28beneficiary and entitle the beneficiary to a refund from the
29provider equal to 200% of the amount paid to the
30nonparticipating provider in excess of the board-approved

1reimbursement for the services rendered, plus all reasonable
2fees for collection. The burden of proof that the disclosure was
3made shall be on the nonparticipating provider.

4(c) Plan by board.--The board shall assess the number of
5primary and specialty providers needed to supply adequate health
6care services in this Commonwealth generally and in all
7geographic areas and shall develop a plan to meet that need. The
8board shall develop financial incentives for participating
9providers in order to maintain and increase access to health
10care services in underserved areas of this Commonwealth.

11(d) Reimbursements.--Reimbursements shall be determined by
12the board in such a fashion as to assure that a participating
13provider receives compensation for services that fairly and
14fully reflect the skill, training, operating overhead included
15in the costs of providing the service, capital costs of
16facilities and equipment, cost of consumables and the expense of
17safely discarding medical waste, plus a reasonable profit
18sufficient to encourage talented individuals to enter the field
19and for investors to make capital available for the construction
20of state-of-the-art health care facilities in this Commonwealth.
21The plan shall review fee schedules and may offer alternative
22reimbursement mechanisms, including capitation, salary and
23bonuses.

24(e) Adjustments to reimbursements.--Participating providers
25shall have the right alone or collectively to petition the board
26for adjustments to reimbursements believed to be too low. A
27petition shall be initially evaluated by the administrator of
28provider services, with input from the Health Professional
29Quality Panel, who shall submit a report to the chair within 30
30days. The chair shall then submit a recommendation to the board

1for action at the next scheduled board meeting. Participating
2providers who remain dissatisfied after the board has ruled may
3appeal the board's determination to Commonwealth Court, which
4shall review the action of the board on an abuse of discretion
5standard.

6(f) Evaluation of access to care.--The board annually shall
7evaluate access to trauma care, diagnostic imaging technology,
8emergency transport and other vital urgent care requirements and
9shall establish measures to assure beneficiaries have equitable
10and ready access to those resources regardless of where in this
11Commonwealth they may be.

12(g) Health care delivery models.--The board, with the
13assistance of the health quality panels, shall review best
14community practices in delivering high quality care. Those
15wellness practices that can be adopted will be funded with an
16increasing emphasis on prevention and community-based care in
17order to reduce the need for hospitalization and nursing home
18care in the future.

19(h) Performance reports.--The board, with the assistance of
20the Health Advisory Panel, shall define performance criteria and
21goals for the plan and shall make a written report to the
22General Assembly at least annually on the plan's performance.
23The reports, including the survey results obtained, shall be
24made publicly available with the goal of total transparency and
25open self-analysis as a defining quality of the agency. The
26board shall establish a system to monitor the quality of health
27care and patient and provider satisfaction and to adopt a system
28to devise improvements and efficiencies to the provision of
29health care services.

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

1prompt and timely manner, provide existing and ongoing data to
2the agency upon its request.

3(j) Coordination of services.--The agency shall coordinate
4the provision of health care services with any other
5Commonwealth and local agencies that provide health care
6services directly to their charges or residents.

7Section 508. Rational cost containment.

8(a) Approval of expenditures.--As part of its cost
9containment mission and based on the certificate of need, the
10board, with the assistance of the Health Institution Quality
11Panel, shall screen and approve or disapprove private or public
12expenditures for new health care facilities and other capital
13investments that may lead to redundant and inefficient health
14care provider capacity. Procedures shall be adopted for this
15purpose with an emphasis upon efficiency, quality of delivery
16and a fair and open consideration of all applications.

17(b) Capital investments.--Based on the certificate of need
18all capital investments valued at $1,000,000 or greater,
19including the costs of studies, surveys, design plans and
20working drawing specifications and other activities essential to
21planning and execution of capital investment, and all capital
22investments that change the bed capacity of a health care
23facility by more than 10% over a 24-month period or that add a
24new service or license category shall require the approval of
25the board. When a facility, an individual acting on behalf of a
26facility or any other purchaser obtains by lease or comparable
27arrangement any facility or part of a facility, or any equipment
28for a facility, the market value of which would have been a
29capital expenditure, the lease or arrangement shall be
30considered a capital expenditure for purposes of this section.

1(c) Study.--A person intending to make capital investments
2or acquisitions shall prepare a business case for making each
3investment and acquisition. The business case shall include the
4full-life-cycle costs of the investment or acquisition, an
5environment impact report that meets existing State standards
6and a demonstration of how the investment or acquisition meets
7the health care needs of the population it is intended to serve.
8Acquisitions may include, but not be limited to, acquisitions of
9land, operational property or administrative office space.

10(d) Deemed approval.--Capital investment programs submitted
11for approval shall be deemed approved by the board within 60
12days from the date the submissions are received by the chair. A
1360-day extension may apply if the board requires additional
14information.

15(e) Recommendations.--Recommendations of the Pennsylvania
16Heath Cost Containment Council and such other public and private
17authoritative bodies as shall be identified from time to time by
18the board shall be received by the chair and submitted to the
19board with the chair's recommendation regarding implementation
20of the recommended reforms. The board shall receive input from
21all interested parties and then shall vote upon the
22recommendations within 60 days. Where procedural or protocol
23reforms are adopted, participating providers must implement the
24designated best practices within 60 days of adoption.

25(f) Appeal.--A decision of the board may be appealed through
26a uniform dispute resolution process that has been established
27by unanimous approval of the board.

28(g) Required investments.--The board, with the
29recommendations of the Health Institution Quality Panel, may
30adopt programs to assist participating providers in making

1capital investments responsive to best practice recommendations.

2(h) Decertification.--Participating providers refusing to
3adopt recommended reforms shall, after a reasonable opportunity
4to be heard, be subject to such sanctions as the board shall
5deem appropriate and necessary up to and including a
6recommendation by the board to the Bureau of Professional and
7Occupational Affairs or the Department of Health for the
8suspension or permanent decertification of the participating
9provider.

10CHAPTER 9

11PENNSYLVANIA HEALTH CARE TRUST FUND

12Section 901. Pennsylvania Health Care Trust Fund.

13(a) Establishment.--The Pennsylvania Health Care Trust Fund
14is hereby established within the State Treasury. All moneys
15collected and received by the plan shall be transmitted to the
16State Treasurer for deposit into the fund, to be used
17exclusively to finance the plan.

18(b) State Treasurer.--The State Treasurer may invest the
19principal and interest earned by the fund in any manner
20authorized under law for the investment of Commonwealth moneys.
21Any revenue or interest earned from the investments shall be
22credited to the fund.

23Section 902. Limitation on administrative expense.

24The system budget referred to in this chapter shall be
25comprised of the cost of the agency, services and benefits
26provided, administration, data gathering, planning and other
27activities and revenues deposited with the system account of the
28fund. The board shall limit ongoing administrative costs,
29excluding start-up costs, to 5% of the agency budget and shall
30annually evaluate methods to reduce administrative costs and

1publicly report the results of that evaluation.

2Section 903. Funding sources.

3Funding of the plan shall be obtained from the following
4dedicated sources:

5(1) Funds obtained from existing or future Federal
6health care programs.

7(2) Funds from dedicated sources specified by the
8General Assembly.

9(3) Receipts from the tax of 10% of gross payroll,
10including self-employment profits. One percent of the tax
11shall become effective the date that shall be the first day
12of a calendar month no less than 32 days after the effective
13date of this act, and the tax shall become fully effective 60
14days before the plan takes effect. Employers who are part of
15a collective bargaining agreement whereby the health care
16benefits are no less generous than those provided under the
17plan shall be excused from paying 90% of the tax.

18(4) Receipts from the Individual Fair Share Health and
19Wellness Tax of 3% on income as defined in sections 301 and
20303 of the act of March 4, 1971 (P.L.6, No.2), known as the
21Tax Reform Code of 1971. One-half of one percent of the
22Individual Fair Share Health and Wellness Tax shall become
23effective the date that shall be the first day of a calendar
24month no less than 32 days after the effective date of this
25act, and the Individual Fair Share Health and Wellness tax
26shall become fully effective 60 days before the plan takes
27effect.

28CHAPTER 11

29TRANSITIONAL SUPPORT AND TRAINING FOR DISPLACED WORKERS

30Section 1101. Transitional support and training for displaced

1workers.

2(a) Determination of eligibility.--The plan shall determine
3which citizens of this Commonwealth employed by a health care
4insurer, health insuring corporation or other health care-
5related business have lost their employment as a result of the
6implementation and operation of the plan, including the amount
7of monthly wages that the individual has lost due to the plan's
8implementation. The plan shall attempt to position these
9displaced workers in comparable positions of employment or
10assist in the retraining and placement of the displaced
11employees elsewhere.

12(b) Compensation.--The plan shall forward the information on
13the amount of monthly wages lost by Commonwealth residents due
14to the implementation of the plan to the board. A displaced
15worker shall be eligible to receive compensation, training
16assistance, or both, from the fund. Compensation shall be up to
17$5,000 each month but may not exceed the monthly wages of the
18individual when the individual was displaced. Compensation will
19cease upon reemployment or after two years, whichever comes
20first. Training assistance may not exceed $20,000.

21(c) Coordination of services.--The plan shall fully
22coordinate activity with public and private services also
23available or actually participating in the assistance to the
24affected individuals.

25(d) Appeals.--A displaced employee who is dissatisfied with
26the level of assistance the employee is receiving may appeal to
27the office of the executive director whose determination shall
28be final and not subject to appeal.

29CHAPTER 13

30VOLUNTEER EMERGENCY RESPONDER NETWORK

1Section 1301. Preservation of volunteer emergency responder
2network.

3Because this Commonwealth is dependent upon the volunteered
4services of firefighters, emergency medical technicians and
5search and rescue workers, the board is further charged with
6administering a Commonwealth income tax credit program for those
7volunteers.

8Section 1302. Eligibility certification.

9Annually, in January, administrators of volunteer
10firefighting and rescue departments, emergency medical
11technicians and paramedics stations and similar volunteer
12emergency entities shall certify the identity of Commonwealth
13residents providing active services during the prior calendar
14year.

15Section 1303. Eligibility criteria.

16Active status shall require a minimum of 200 hours of service
17during the preceding year and response to no less than 50% of
18the emergency calls during at least three of the four calendar
19quarters.

20Section 1304. Amount of tax credit.

21Each volunteer certified as active shall be granted a credit
22equal to $1,000 toward the volunteer's State income tax
23obligation under Article III of the act of March 4, 1971 (P.L.6, 
24No.2), known as the Tax Reform Code of 1971. An eligible
25volunteer who does not incur $1,000 in annual State income tax
26liability shall nevertheless be eligible for a refund equal to
27the amount the credit exceeds that volunteer's tax obligation.

28Section 1305. Reimbursement.

29The State Treasury shall be reimbursed the value of the
30volunteer credits from the fund.

1CHAPTER 45

2MISCELLANEOUS PROVISIONS

3Section 4501. Effective date.

4This act shall take effect immediately.