SENATE AMENDED
PRIOR PRINTER'S NOS. 369, 1754
PRINTER'S NO. 2259
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
347
Session of
2015
INTRODUCED BY O'NEILL, READSHAW, BAKER, BARRAR, CAUSER, COHEN,
D. COSTA, CUTLER, DAVIS, DAY, DEASY, DiGIROLAMO, DUSH,
GABLER, GILLEN, HARHART, HARPER, A. HARRIS, JAMES, KAUFFMAN,
M. K. KELLER, KORTZ, LAWRENCE, MALONEY, MARSHALL, MASSER,
MILLARD, MILNE, RADER, SONNEY, TALLMAN, TRUITT, WATSON,
WHEATLEY, FEE, MENTZER, MURT, ROZZI, FARRY, EVERETT, MOUL,
HEFFLEY, GIBBONS, M. DALEY, SANTARSIERO, MICCARELLI, ROAE,
BARBIN AND BURNS, FEBRUARY 5, 2015
SENATOR WHITE, BANKING AND INSURANCE, IN SENATE, AS AMENDED,
SEPTEMBER 30, 2015
AN ACT
Amending Title 35 (Health and Safety) of the Pennsylvania
Consolidated Statutes, in emergency medical services system,
providing for emergency service system billing.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Section 8103 of Title 35 of the Pennsylvania
Consolidated Statutes is amended by adding a definition to read:
§ 8103. Definitions.
The following words and phrases when used in this chapter
shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
* * *
"Insurer." As follows:
(1) An entity that is responsible for providing or
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paying for all or part of the cost of emergency medical
services covered by an insurance policy, contract or plan.
The term includes an entity subject to:
(i) SECTION 630, ARTICLE XXIV OR ANY OTHER PROVISION
OF the act of May 17, 1921 (P.L.682, No.284), known as
The Insurance Company Law of 1921;
(ii) the act of December 29, 1972 (P.L.1701,
No.364) , known as the Health Maintenance Organization
Act; or
(iii) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations) or 63 (relating to professional health
services plan corporations).
(2) The term does not include an entity that is
responsible for providing or paying under an insurance
policy, contract or plan which meets any of the following:
(i) Is a homeowner's insurance policy.
(ii) Provides any of the following types of
insurance:
(A) Accident only.
(B) Fixed indemnity.
(C) Limited benefit.
(D) Credit.
(E) Dental.
(F) Vision.
(G) Specified disease.
(H) Medicare supplement.
(I) Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS) supplement.
(J) Long-term care.
(K) Disability income.
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(L) Workers' compensation.
(M) Automobile medical payment insurance.
* * *
Section 2. Title 35 is amended by adding a section to read:
§ 8158 8143 . Billing.
(a) General rule.--When an EMS agency is dispatched by a
public safety answering point as defined in section 5302
(relating to definitions) OR AN EMS AGENCY DISPATCH CENTER UNDER
SECTION 8129(I) (RELATING TO EMERGENCY MEDICAL SERVICES
AGENCIES) FOR AN EMERGENCY and provides medically necessary
emergency care MEDICAL SERVICES , a payment made by an insurer
for a claim covered under and in accordance with a health
insurance policy for a service performed by the EMS agency
during the call shall be paid directly to the EMS agency.
(b) Reimbursement.--An insurer must reimburse a nonnetwork
EMS agency under the following conditions :
(1) The EMS agency has submitted a completed
standardized form to the department requesting nonnetwork
direct reimbursement from an insurer an EMS agency has
identified. The form must be submitted to the department
annually by October 15. The form shall declare the EMS
agency's intention to receive direct payment from an insurer
identified on the form for the next calendar year. The
department shall develop a standardized form, using an EMS
agency's assigned license number, to be used by an EMS agency
that meets the conditions established under this section.
The department shall develop and maintain a publicly
accessible ELECTRONIC registry that indicates which EMS
agency has requested nonnetwork direct reimbursement from an
insurer identified on the form.
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(2) An EMS agency has provided notification to the
insurer upon submitting a claim for reimbursement that the
EMS agency is registered with the department to receive
direct reimbursement as provided for under this section.
(c) Periodic audit.--An EMS agency may be subject to
periodic audits by an insurer to examine claims for direct
reimbursement under this chapter SECTION . If, through the audit,
the payer INSURER identifies an improper payment, the payer
INSURER may deduct the improper payment from future
reimbursements. The insurer must forward the insurer's findings
to the department.
(d) Insured.-- An EMS agency paid by an insurer under this
section WHERE AN INSURER HAS REIMBURSED A NONNETWORK EMS AGENCY
AT THE SAME RATE IT HAS ESTABLISHED FOR A NETWORK EMS AGENCY,
THE EMS AGENCY may not bill the insured directly or indirectly
or otherwise attempt to collect from the insured for the service
provided, except for a billing to recover a copayment,
coinsurance or deductible as specified in the health insurance
policy.
(e) Donations, etc.--
(1) An EMS agency that submits a form under this section
may solicit donations, memberships or conduct fundraising,
except that an EMS agency may not promise, suggest or infer
to donors that a donation will result in the donor not being
billed directly for any payment as provided under this
section. Notwithstanding this paragraph, an EMS agency may
bill in accordance with subsection (d).
(2) Material used for soliciting for donations or
memberships must state substantially that a donation or
membership may potentially limit out-of-pocket expenses. A
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violation of this section shall be considered a violation of
the act of December 17, 1968 (P.L.1224, No.387), known as the
Unfair Trade Practices and Consumer Protection Law.
(f) Clean claim.-- An insurer must remit payment of a clean
claim directly to the EMS agency in accordance with CLAIMS PAID
UNDER THIS SECTION SHALL BE SUBJECT TO section 2166 of the act
of May 17, 1921 (P.L.682, No.284), known as The Insurance
Company Law of 1921 . A payment to an insured shall not
constitute compliance with this section.
(g) Application.--This section shall apply only to an EMS
agency that is a nonnetwork provider and provides 911 emergency
care MEDICAL SERVICES .
Section 3. This act shall take effect January 1, 2016.
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