PRINTER'S NO. 2506
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
1688
Session of
2015
INTRODUCED BY DeLISSIO, THOMAS, HARKINS AND ROZZI,
NOVEMBER 9, 2015
REFERRED TO COMMITTEE ON HEALTH, NOVEMBER 9, 2015
AN ACT
Providing for a Statewide comprehensive health care system;
establishing the Pennsylvania Health Care Plan and providing
for eligibility, services, coverages, subrogation,
participating and nonparticipating providers, cost
containment, quality assurance and for transitional support
and training; establishing the Pennsylvania Health Care
Board, the Pennsylvania Health Care Agency, the Office of
Health Care Ombudsman and the Pennsylvania Health Care Trust
Fund; and imposing a payroll tax and an additional personal
income tax.
TABLE OF CONTENTS
Chapter 1. Preliminary Provisions
Section 101. Short title.
Section 102. Definitions.
Chapter 3. Administration of Pennsylvania Health Care Plan
Subchapter A. Pennsylvania Health Care Board
Section 301. Pennsylvania Health Care Board.
Section 302. Duties of board.
Section 303. Quality of care panels.
Subchapter B. Pennsylvania Health Care Agency
Section 321. Pennsylvania Health Care Agency.
Subchapter C. Office of Health Care Ombudsman
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Section 331. Office of Health Care Ombudsman.
Section 332. Duties of office.
Section 333. Funding of office.
Subchapter D. (Reserved).
Subchapter E. (Reserved).
Subchapter F. Immunity
Section 371. Immunity.
Chapter 5. Pennsylvania Health Care Plan
Section 501. Establishment of plan.
Section 502. Universal health care access eligibility.
Section 503. Covered services.
Section 504. Supplemental health insurance coverage.
Section 505. Duplicate coverage.
Section 506. Subrogation.
Section 507. Eligible participating providers and availability
of services.
Section 508. Rational cost containment.
Chapter 9. Pennsylvania Health Care Trust Fund
Section 901. Pennsylvania Health Care Trust Fund.
Section 902. Agency budget.
Section 903. Funding sources.
Section 904. Payroll tax.
Section 905. Additional personal income tax.
Chapter 11. Transitional Support
Section 1101. Definitions.
Section 1102. Transitional support and training for displaced
workers.
Chapter 45. Miscellaneous Provisions
Section 4501. Effective date.
The General Assembly of the Commonwealth of Pennsylvania
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hereby enacts as follows:
CHAPTER 1
PRELIMINARY PROVISIONS
Section 101. Short title.
This act shall be known and may be cited as the Pennsylvania
Health Care Plan Act.
Section 102. Definitions.
The following words and phrases when used in this act shall
have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Advisory committee." The advisory committee under section
301(b).
"Agency." The Pennsylvania Health Care Agency established
under section 321.
"Board." The Pennsylvania Health Care Board established
under section 301.
"Executive director." The executive director of the
Pennsylvania Health Care Agency.
"Fund." The Pennsylvania Health Care Trust Fund established
under section 901.
"Office." The Office of Health Care Ombudsman established
under section 331(a).
"Ombudsman." The health care ombudsman appointed under
section 331(b).
"Participant." An individual who is enrolled in the plan.
"Plan." The Pennsylvania Health Care Plan established under
section 501.
"Quality of care panels." The Health Professional Quality
Panel, Health Institution Quality Panel and Health Supplier
Quality Panel under section 303.
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CHAPTER 3
ADMINISTRATION OF PENNSYLVANIA HEALTH CARE PLAN
SUBCHAPTER A
PENNSYLVANIA HEALTH CARE BOARD
Section 301. Pennsylvania Health Care Board.
(a) Board established.--The Pennsylvania Health Care Board
is established as an independent administrative board. The board
shall be composed of the following members:
(1) A member appointed by the Governor who shall serve
as chairperson of the board.
(2) Two members from geographically diverse areas of
this Commonwealth who have frequent and direct contact with
the health care system and are knowledgeable about health
issues as follows:
(i) A caregiver of a child with a chronic illness or
developmental disability.
(ii) An adult with a chronic illness, physical
disability or mental illness.
(3) A physician.
(4) A dentist.
(5) An ophthalmologist or optometrist.
(6) A pharmacist.
(7) A hospital representative.
(8) A skilled nursing facility representative.
(9) An attorney with expertise in health care law and
policy.
(10) A mental health care professional.
(11) A representative of a business with fewer than 50
employees.
(12) A representative of a business with more than 50
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employees.
(13) An organized labor representative from the health
sector.
(14) A public health professional.
(b) Advisory committee.--
(1) Except for the gubernatorial appointee, the members
of the board shall be appointed by an advisory committee
comprised of the following:
(i) The President pro tempore of the Senate or a
designee.
(ii) The Minority Leader of the Senate or a
designee.
(iii) The Speaker of the House of Representatives or
a designee.
(iv) The Minority Leader of the House of
Representatives or a designee.
(v) The Secretary of Health or a designee.
(vi) The Secretary of Aging or a designee.
(vii) The Secretary of Human Services or a designee.
(viii) The Insurance Commissioner or a designee.
(ix) The Secretary of Labor and Industry or a
designee.
(2) All actions of the advisory committee shall be by
majority vote of the members present. A quorum shall be at
least one more than half the number of the advisory committee
members. Vacancies shall not be counted when calculating the
number needed for a quorum.
(3) The advisory committee shall elect a chair from
among its members. The advisory committee shall meet upon the
call of the chair of the advisory committee.
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(4) Advisory committee members shall not receive a
salary but shall be reimbursed for all necessary expenses
incurred in the performance of their duties.
(c) Terms.--
(1) Except as set forth in paragraph (2), the terms of
the members shall be four years from the date of appointment
or until a successor has been appointed.
(2) Of the initial members appointed by the advisory
committee:
(i) One-half of the members shall serve initial
terms of four years.
(ii) One-half of the members shall serve initial
terms of two years.
(iii) After the initial terms, individuals appointed
by the advisory committee shall serve for a term of four
years.
(d) Filling of vacancy.--Each vacancy on the board shall be
filled for the unexpired term by appointment in like manner as
in case of expiration of the term of a member of the board. A
vacancy shall be filled by a representative from the same
constituent group as the new member's predecessor.
(e) Board chairperson.--The Executive Board established by
section 204 of the act of April 9, 1929 (P.L.177, No.175), known
as The Administrative Code of 1929, shall determine the salary
to be paid to the chairperson of the board. The chairperson of
the board shall, when present, preside at all meetings and, if
absent, a member designated by the chairperson shall preside.
(f) Expenses.--Members of the board who are appointed by the
advisory committee shall be reimbursed only for necessary and
actual expenses incurred in the performance of their duties.
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(g) Meetings and conduct of business.--
(1) The chairperson of the board shall set the time,
place and date for the initial meeting of the board. The
initial meeting shall be scheduled not sooner than 30 days
nor later than 90 days after the appointment of the
chairperson. Subsequent meetings shall occur as determined by
the board but not less than six times annually. The
chairperson may call additional meetings.
(2) The board is subject to:
(i) The provisions of 65 Pa.C.S. Ch. 7 (relating to
open meetings).
(ii) The act of February 14, 2008 (P.L.6, No.3),
known as the Right-to-Know Law.
(3) A board member shall be deemed to have abandoned
office upon failure to attend at least 75% of the board
meetings in one year, without excuse approved by resolution
of the board.
(4) Decisions at meetings of the board shall be reached
by majority vote of those present in person and those present
by electronic or telephonic means which permit, at a minimum,
audio-video communication. Participation in a meeting
pursuant to this paragraph shall constitute presence at the
meeting. Absentee or proxy voting shall not be allowed.
(h) Quorum.--A quorum for the conducting of business at
meetings of the board shall be at least one more than half the
number of the board members. Vacancies shall not be counted when
calculating the number needed for a quorum.
(i) Prohibition.--No member of the board may hold any other
salaried public office, either elected or appointed, during the
member's tenure on the board.
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Section 302. Duties of board.
(a) General duties.--The board is responsible for directing
the agency in the performance of all duties, the exercise of all
powers and the assumption and discharge of all functions vested
in the agency. The board shall adopt and publish its policies
and procedures in the Pennsylvania Bulletin no later than 180
days after the first meeting of the board.
(b) Specific duties.--The board shall:
(1) Implement statutory eligibility standards for health
care benefits.
(2) Annually adopt a health care benefits package for
participants of the plan.
(3) Act directly or through one or more contractors as
the single payer administrator for all claims for health care
services provided under the plan.
(4) At least annually, review the appropriateness and
sufficiency of reimbursements for health care services
rendered and consider whether a charge is fair and reasonable
for its metropolitan statistical area.
(5) Provide for timely payments to participating
providers through a structure that is well organized and that
eliminates unnecessary administrative costs.
(6) Implement standardized claims and reporting methods
for use by the plan.
(7) Develop a system of centralized electronic claims
and payments accounting.
(8) Establish an enrollment system that will ensure that
eligible residents are knowledgeable and aware of their
rights to health care and are formally enrolled in the plan.
(9) Adopt bylaws for governing its operations.
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(10) Report annually to the General Assembly and to the
Governor, on or before the first day of October, on the
following:
(i) The performance of the plan.
(ii) The fiscal condition of the plan.
(iii) Recommendations for statutory changes.
(iv) The receipt of payments from the Federal
Government.
(v) Whether current year goals and priorities were
met.
(vi) Future goals and priorities.
(11) Obtain appropriate liability and other forms of
insurance to provide coverage for the plan, the board, the
agency and their employees and agents.
(12) Provide for oversight of the agency by taking the
following actions:
(i) Establishing standards and criteria for the
allocation of operating funds.
(ii) Meeting regularly to review the performance of
the agency and adopt and revise its policies.
(iii) Establishing goals for the health care
delivery system established pursuant to the plan in
measurable terms.
(iv) Supporting the development of an integrated
health care database for health care planning and quality
assurance.
(v) Implementing policies and developing mechanisms
and incentives to maximize efficacy across language and
cultural barriers.
(vi) Establishing rules and procedures for
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implementation and staffing of a no-fault compensation
system for iatrogenic injuries or complications of care
in cases where a patient's condition is made worse or an
opportunity for cure or improvement is lost due to the
health care or medication provided or appropriate care
not provided by participating providers under the plan.
(vii) Establishing standards and criteria for the
determination of appropriate transitional support and
training in accordance with Chapter 11 for residents of
this Commonwealth who are displaced from work.
(viii) Evaluating the state of the art in proven
technical innovations, medications and procedures and
adopting policies to expedite their introduction in this
Commonwealth.
(ix) Establishing methods for the recovery of costs
for health care services provided under the plan to a
participant who is also covered under the terms of a
policy of insurance, a health benefit plan or other
collateral source available to the participant under
which the participant has a right of action for
compensation. Receipt of health care services under the
plan shall be deemed an assignment by the participant of
any right to payment for services from a policy of
insurance, a health benefit plan or other source. The
other source of health care benefits shall pay to the
fund all amounts it is obligated to pay to, or on behalf
of, the participant for covered health care services. The
board may commence any action necessary to recover the
amounts due.
(13) Establish the quality of care panels in accordance
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with section 303.
(14) Establish a secure and centralized electronic
health record system wherein a participant's entire health
record can be readily and reliably accessed by authorized
persons with the objective of eliminating the errors and
expense associated with paper records and diagnostic films.
The system shall ensure the privacy of all health records it
contains.
(15) Establish, from the revenues received, a reserve
fund sufficient to provide a continuation of services during
periods of reduced or insufficient revenue due to economic
conditions or unforeseen emergency major health care needs.
(16) Adopt rules of ethics and definitions of
irreconcilable conflicts of interest that will determine
under what circumstances members must recuse themselves from
voting. The executive director and board members and their
immediate families are prohibited from having any pecuniary
interest in any business with a contract or in negotiation
for a contract with the agency. For purposes of this
paragraph, the term "immediate family member" includes a
spouse, child, stepchild, parent, stepparent, grandparent,
brother, stepbrother, sister, stepsister or like relative-in-
law.
(17) Establish procedures to identify, investigate and
resolve fraudulent practices in connection with the plan.
(18) Promulgate regulations and establish guidelines and
standards necessary to implement this act.
Section 303. Quality of care panels.
(a) Establishment.--The following quality of care panels
shall be established by the board upon recommendation of the
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advisory committee:
(1) The Health Professional Quality Panel.
(2) The Health Institution Quality Panel.
(3) The Health Supplier Quality Panel.
(b) Composition.--The quality of care panels shall be
comprised of persons who represent a cross section of the
medical and provider community as follows:
(1) Appointments shall be made by the board upon
recommendation of the advisory committee. The board shall
appoint a board member to serve as a nonvoting member and
chair of each quality of care panel.
(2) The Health Professional Quality Panel shall consist
of one representative of each of the following
constituencies:
(i) Primary care physicians.
(ii) Specialty care physicians.
(iii) Clinical psychologists.
(iv) Nurses.
(v) Social workers.
(vi) Midwives.
(vii) Nutritionists.
(viii) Pharmacists.
(ix) Optometrists.
(x) Podiatrists.
(xi) Hearing specialists.
(xii) Physical or occupational therapists.
(xiii) Dentists.
(xiv) Chiropractors.
(xv) Health educators.
(xvi) Acupuncturists.
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(xvii) Consumers.
(3) The Health Institution Quality Panel shall consist
of one representative of each of the following
constituencies:
(i) Academic medical centers.
(ii) Community hospitals.
(iii) Rehabilitation centers.
(iv) Trauma systems.
(v) Convenient care centers.
(vi) Hospice program.
(vii) Substance abuse centers.
(viii) Home health care services.
(ix) Skilled nursing facilities.
(x) Birth centers.
(xi) Consumers.
(4) The Health Supplier Quality Panel shall consist of
one representative of each of the following constituencies:
(i) Medical imaging facilities.
(ii) Medical laboratories.
(iii) Durable medical equipment suppliers.
(iv) Pharmaceutical suppliers.
(v) Medical suppliers other than durable medical
equipment suppliers.
(vi) Electronic medical records.
(vii) Consumers.
(c) Consumer representatives.--Each consumer representative
under subsection (b) must possess expertise in the area of
health care of the quality of care panel to which the consumer
representative is appointed.
(d) Duties.--Duties of the quality of care panels shall
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include:
(1) Making recommendations to the board on the
establishment of policy on medical issues, population-based
public health issues, research priorities, scope of services,
expansion of access to health care services and evaluation of
the performance of the plan in order to provide high quality
care for residents of this Commonwealth.
(2) Investigating proposals for innovative approaches to
the promotion of health, the prevention of disease and
injury, patient education, research and health care delivery.
(3) Advising the board on the establishment of standards
and criteria to evaluate requests from health care facilities
for capital improvements.
(4) Develop and recommend a schedule of reimbursement
rates for covered medical services.
(5) Evaluating and advising the board on requests from
providers or their representatives for adjustments to
reimbursements.
(6) Coordinating resources in order to minimize
duplication among providers, institutions and suppliers.
(7) Evaluating research in order to recommend products
or services.
(8) Presenting key recommendations in a report to the
board on improving quality of care. The quality of care
recommendations shall be presented in a formal report at
every board meeting.
(e) Compensation.--Voting members of the quality of care
panels shall be paid a per diem rate, established by the board,
for attendance at meetings and further be reimbursed for actual
and necessary expenses incurred in the performance of their
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duties.
(f) Meetings.--The quality of care panels shall meet
regularly as needed to create policies and recommendations to
deliver cost-effective, evidence-based, quality health care to
the residents of this Commonwealth.
(g) Staffing.--The board shall hire staff to work with the
agency on the development of quality of care recommendations.
(h) Report to board.--The chair of each quality of care
panel shall inform the board on progress or explain the lack of
progress in implementing key recommendations of the quality of
care panels.
SUBCHAPTER B
PENNSYLVANIA HEALTH CARE AGENCY
Section 321. Pennsylvania Health Care Agency.
(a) Establishment.--The Pennsylvania Health Care Agency is
established. The agency shall administer the plan and is the
sole agency authorized to accept Federal and State grants-in-
aid. The agency shall use Federal and State money received to
secure full compliance with applicable provisions of Federal and
State law and to carry out the purposes of this act. All grants-
in-aid accepted by the agency shall be deposited into the fund,
together with other revenues raised within this Commonwealth to
fund the plan.
(b) Executive director.--The executive director of the
agency shall be appointed by and shall serve at the pleasure of
the board. The executive director shall be the chief
administrator of the plan and is responsible for the
implementation of the plan. The executive director shall oversee
the operation of the agency and the agency's performance of any
duties assigned by the board.
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(c) Salary of executive director.--The salary of the
executive director shall not exceed the statutory salary of the
Governor. The executive director may not hold any other salaried
public office, either elected or appointed, during the executive
director's tenure with the agency.
(d) Personnel and employees.--The board shall employ and fix
the compensation of agency personnel. The employment of
personnel by the board is subject to the civil service laws of
this Commonwealth.
SUBCHAPTER C
OFFICE OF HEALTH CARE OMBUDSMAN
Section 331. Office of Health Care Ombudsman.
(a) Establishment.--The Office of Health Care Ombudsman is
established to represent the interests of plan participants and
prospective participants.
(b) Health care ombudsman.--The office shall be headed by
the health care ombudsman, who shall be appointed by the board
upon recommendation of the advisory committee. The ombudsman
shall serve at the pleasure of the board until a successor is
appointed and qualified. The ombudsman shall be a person who by
reason of training, experience and attainment is qualified to
represent the interest of participants and prospective
participants. The ombudsman shall devote full time to the
office.
(c) Employment restrictions.--No individual who serves as an
ombudsman shall, while serving in the position, engage in any
business, vocation or other employment, or have other interests,
that conflict with the official responsibilities of the
ombudsman during the tenure of the appointment.
(d) Political office restrictions.--Any individual who is
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appointed to the position of ombudsman shall not seek election
nor accept appointment to any political office during the tenure
as ombudsman.
(e) Staff.--The ombudsman shall appoint attorneys and
additional clerical, technical and professional staff as may be
appropriate and may contract for additional services as shall be
necessary for the performance of the functions of the office.
No employee shall, while employed by the office, engage in any
business, vocation or other employment, or have other interests,
that conflict with the official responsibilities of the
employee.
(f) Compensation.--The compensation of the ombudsman and the
attorneys and clerical, technical and professional staff of the
office shall be set by the Executive Board established by
section 204 of the act of April 9, 1929 (P.L.177, No.175), known
as The Administrative Code of 1929.
(g) Role of agency.--The agency shall have administrative
responsibilities for the office only and shall not be
responsible, in any manner, for the policies, procedures or
other substantive matters developed by the office in carrying
out its duties to represent the plan participants and
prospective participants.
Section 332. Duties of office.
(a) Duties of office.--In addition to any other duties
prescribed by this act, the office shall respond to questions,
complaints and problems related to implementation of the plan.
The office shall respond to an issue related to implementation
of the plan by acting directly or through one or more
contractors. The initial response of the office shall occur
within 24 hours following the office's notification of an issue.
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The office shall work with agency staff to provide information
when questions are presented and to identify permanent or
temporary resolutions to complaints and problems.
(b) Report.--The ombudsman shall prepare a report for each
board meeting summarizing major issues presented to the office
and recommendations for their resolution by the board.
Section 333. Funding of office.
The operating costs and expenses of the office shall be paid
from the money deposited in the fund.
SUBCHAPTER D
(Reserved)
SUBCHAPTER E
(Reserved)
SUBCHAPTER F
IMMUNITY
Section 371. Immunity.
In the absence of fraud or bad faith, the quality of care
panels, the board and agency and their respective members and
employees shall incur no liability in relation to the
performance of their duties and responsibilities under this act.
The Commonwealth shall incur no liability in relation to the
implementation and operation of the plan.
CHAPTER 5
PENNSYLVANIA HEALTH CARE PLAN
Section 501. Establishment of plan.
(a) Establishment of plan.--The Pennsylvania Health Care
Plan is established and shall be administered by the agency
under the direction of the board.
(b) Coverage.--The plan shall provide health care coverage
for residents of this Commonwealth in accordance with this act.
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The agency shall work simultaneously to:
(1) Control health care costs.
(2) Achieve measurable improvement in health care
outcomes.
(3) Promote a culture of health awareness.
(4) Develop an integrated health care database to
support health care planning and quality assurance.
(c) Implementation.--The board shall implement the plan
within one year of the effective date of this section.
Section 502. Universal health care access eligibility.
(a) Eligibility.--The following individuals may enroll as
participants in the plan:
(1) A resident of this Commonwealth who files a
Pennsylvania individual income tax return and any dependent
of the resident.
(2) Students from out-of-State who are attending school
in this Commonwealth and file a Pennsylvania individual
income tax return.
(3) Part-year residents who file a Pennsylvania
individual income tax return.
(b) Determination of residency status.--The agency shall
establish rules for use in making residency determinations. To
the extent applicable, the agency shall determine residency
using the rules of the Department of Revenue in its
administration of personal income taxes.
(c) Demonstration of eligibility.--The board shall establish
standards and a simple procedure for use in demonstrating proof
of eligibility.
(d) Enrollment.--Enrollment in the plan shall be established
by the board, and participants shall be provided with smart
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technology cards with appropriate proof of identity technology
and privacy protection.
(e) Outreach to eligible residents.--Residents of this
Commonwealth who are unable to file or pay their taxes because
of physical or mental disabilities may obtain assistance through
county assistance offices and other agencies identified by the
board.
(f) Waiver.--If a waiver is not granted from the medical
assistance or Medicare program operated under Title XVIII or XIX
of the Social Security Act (49 Stat. 620, 42 U.S.C. § 301 et
seq.), the medical assistance or Medicare program for which a
waiver is not granted shall act as the primary insurer for those
eligible for such coverage, and the plan shall serve as the
secondary or supplemental plan of health insurance coverage.
Until such time as a waiver is granted, the plan shall not pay
for services for persons otherwise eligible for the same health
care benefits under the medical assistance or Medicare program.
(g) Veterans.--The plan shall serve as the secondary or
supplemental plan of health insurance coverage for military
veterans except where reasonable and timely access, as defined
by the board, is denied or unavailable through the Department of
Veterans Affairs, in which instance the plan shall be the
primary insurer and shall seek reasonable reimbursement from the
Department of Veterans Affairs for the services provided to
veterans.
(h) Priority of plans.--A plan of employee health coverage
provided by an out-of-State employer to a resident of this
Commonwealth working outside of this Commonwealth shall serve as
the employee's primary plan of health coverage, and the plan
shall serve as the employee's secondary plan of health coverage.
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(i) Reimbursement.--The plan shall reimburse providers
practicing outside of this Commonwealth at plan rates. Services
provided to a participant outside this Commonwealth by other
than a participating provider shall be reimbursed to the
participant or to the provider at plan rates.
(j) Presumption of eligibility.--An individual who arrives
at a health care facility unconscious or otherwise unable to
document eligibility for coverage due to the individual's
medical condition shall be presumed to be eligible, and
emergency care shall be provided without delay occasioned by
issues of ability to pay.
(k) Rules.--The board shall adopt rules ensuring that a
participating provider who renders humanitarian emergency care,
urgent care or prevention or treatment for a communicable
disease or prenatal and delivery care within this Commonwealth
to a noneligible recipient shall be reimbursed by the plan for
the care provided. The rules shall reasonably limit the
frequency of reimbursement to protect the fiscal integrity of
the plan. The agency shall secure reimbursement for the costs
paid for the care provided from any appropriate third-party
funding source or from the individual to whom the services were
rendered.
Section 503. Covered services.
(a) Benefits package.--The board shall establish a single
health care benefits package within the plan that shall include,
but not be limited to, all of the following:
(1) All medically necessary inpatient and outpatient
care and treatment, both for primary and specialty care.
Medically necessary care and treatment shall be approved by
the quality of care panels and provided by licensed health
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care providers.
(2) Emergency services.
(3) Emergency and other medically necessary transport to
covered health services.
(4) Rehabilitation services, including speech,
occupational, physical and evidence-based alternative
therapy.
(5) Inpatient and outpatient mental health services and
substance abuse treatment.
(6) Hospice care.
(7) Prescription drugs and prescribed medical nutrition.
(8) Vision care, aids and equipment.
(9) Hearing care, hearing aids and equipment.
(10) Diagnostic medical tests, including laboratory
tests and imaging procedures.
(11) Medical supplies and prescribed medical equipment.
(12) Immunizations, preventive care, health maintenance
care and screening.
(13) Dental care.
(14) Home health care services.
(15) Chiropractic.
(16) Complementary and alternative modalities that have
been shown by the National Institute of Health's Division of
Complementary and Alternative Medicine to be safe and
effective for possible inclusion as covered benefits.
(b) Exclusions for preexisting conditions.--The plan shall
not exclude or limit coverage due to preexisting conditions.
(c) Copayments, deductibles and other charges.--Participants
are not subject to copayments, deductibles, point-of-service
charges or any other fee or charge for a service within the
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package and shall not be directly billed nor balance billed by
participating providers for covered benefits provided to the
participant. If a participant has directly paid for nonemergency
services of a nonparticipating provider, the participant may
submit a claim for reimbursement from the plan for the amount
the plan would have paid a participating provider for the same
service. If emergency services are rendered by a
nonparticipating provider, the participant shall receive
reimbursement of the full amount paid to the nonparticipating
provider, not to exceed the amount the plan would have paid a
participating provider for the same service.
(d) Exclusions of coverage.--
(1) The board may remove or exclude procedures and
treatments, equipment and prescription drugs from the plan
benefit package that the Food and Drug Administration or a
quality of care panel finds, on the basis of medical
evidence, unsafe or that add no therapeutic value.
(2) The board shall exclude coverage for any surgical,
orthodontic or other procedure or drug that the board
determines was or will be provided primarily for cosmetic
purposes unless required to correct a congenital defect, to
restore or correct disfigurements resulting from injury or
disease or that is certified to be medically necessary by a
licensed health care provider.
(e) Participant choice.--Participants shall normally be
granted freedom to choose participating providers, including
specialists, without preapprovals or referrals. However, the
board shall adopt procedures to restrict the freedom to choose
for those individuals who engage in patterns of wasteful or
abusive self-referrals to specialists. A specialist who provides
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primary care to a self-referred participant shall be reimbursed
at the board-approved primary care rate established for the
service in that community.
(f) Practice patterns.--Practice patterns of participating
providers shall be monitored. Practice patterns that reflect
overutilization or underutilization shall be reviewed. The board
may set policies addressing overutilization or underutilization
after reviewing practice patterns and recommendations from the
quality of care panels.
(g) Service.--No participating provider shall be compelled
to offer any particular service so long as the refusal is
consistent with the provider's practice.
(h) Discrimination.--The plan and participating providers
shall not discriminate on the basis of race, ethnicity, national
origin, sex, age, religion, sexual orientation, gender identity,
health status, mental or physical disability, employment status,
veteran status or occupation.
(i) Appeals.--A participant may appeal a decision relating
to covered services under the plan to the ombudsman.
Section 504. Supplemental health insurance coverage.
Subject to the regulations of the Insurance Commissioner and
all applicable laws, private health insurers shall be authorized
to offer coverage supplemental to the health benefits package
approved and provided under the plan.
Section 505. Duplicate coverage.
The agency is subrogated to and shall be deemed an assignee
of all rights of a participant who has received duplicate health
care benefits, or who has a right to such benefits, under any
other policy or contract of health care or under any government
program.
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Section 506. Subrogation.
The agency has no right of subrogation against a
participant's third-party claims for harm or losses not covered
under this act. A participant has no right to claim against a
third-party tortfeasor for the services provided or available to
the participant under this act. In all personal injury actions
accruing and prosecuted by a participant after the participant's
enrollment in the plan, the presiding judge shall advise any
jury that all health care expenses have been or will be paid
under the plan, and, therefore, no claim for past or future
health care benefits is pending before the court.
Section 507. Eligible participating providers and availability
of services.
(a) General rule.--Health care providers licensed,
registered or certified to practice and licensed health care
facilities are eligible to become a participating provider in
the plan in which instance they shall enjoy the rights and have
the duties as set forth in the plan as provided under this
section or as adopted by the board in accordance with this act.
Nonparticipating providers shall not enjoy the rights nor bear
the duties of participating providers.
(b) Required notice.--
(1) In advance of initially providing services to a
participant, nonparticipating providers shall advise the
participant at the time the appointment is made that the
person or entity is a nonparticipating provider and that the
recipient of the service initially will be personally
responsible for the entire cost of the service and ultimately
responsible for the cost in excess of any reimbursement
approved by the board for participating providers.
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(2) A form signed by the participant acknowledging that
the provider has disclosed to the participant whether the
provider participates or does not participate in the plan and
who is responsible for the cost of care shall be deemed
sufficient notice.
(3) Failure to make the required disclosure is deemed a
fraud on the participant and shall entitle the participant to
a refund from the provider equal to 200% of the amount paid
to the nonparticipating provider in excess of the board-
approved reimbursement for the services rendered, plus all
reasonable fees for collection. The burden of proof that the
disclosure was made shall be on the nonparticipating
provider.
(c) Plan by board.--The board shall assess the number of
primary care and specialty providers needed to supply adequate
health care services in this Commonwealth generally and in all
geographic areas and shall develop a plan to meet that need. The
board shall develop financial incentives for participating
providers in order to maintain and increase access to health
care services in underserved areas of this Commonwealth.
(d) Reimbursements.--Reimbursements shall be determined by
the board in such a fashion as to assure that a participating
provider receives compensation for services that fairly and
fully reflect the skill, training, outcomes, operating overhead
included in the costs of providing the service, capital costs of
facilities and equipment, cost of consumables and the expense of
safely discarding medical waste, plus a reasonable profit
sufficient to encourage talented individuals to enter the field
and for investors to make capital available for the construction
of state-of-the-art health care facilities in this Commonwealth.
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The plan shall review fee schedules and may offer reimbursement
mechanisms, including capitation, salary and bonuses.
(e) Adjustments to reimbursements.--Participating providers
shall have the right individually or collectively to petition
the board for adjustments to reimbursements believed to be too
low. Petitions shall be initially evaluated by the agency, with
input from the Health Professional Quality Panel. The agency
shall submit a report to the chairperson of the board within 30
days. Following receipt of the report, the chairperson shall
submit a recommendation to the board for action at the next
scheduled board meeting. Participating providers who remain
dissatisfied after the board has ruled may appeal the board's
determination to Commonwealth Court, which shall review the
action of the board on an abuse of discretion standard.
(f) Evaluation of access to care.--The board annually shall
evaluate access to trauma care, diagnostic imaging technology,
emergency transport and other vital urgent care requirements and
make recommendations as needed.
(g) Health care delivery models.--The board, with the
assistance of the quality of care panels, shall review best
practices in delivering high quality care. Those wellness
practices that can be adopted shall be funded with an increasing
emphasis on prevention and community-based care in order to
reduce the need for hospitalization and skilled nursing facility
care in the future.
(h) Performance reports.--The board, with the assistance of
the quality of care panels, shall define performance criteria
and goals for the plan and shall make a written report to the
General Assembly at least annually on the plan's performance.
Reports shall be made publicly available with the goal of total
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transparency and open self-analysis as a defining quality of the
agency. The board shall establish a system to monitor the
quality of health care and patient and provider satisfaction and
to adopt a system to devise improvements and efficiencies to the
provision of health care services.
(i) Data reporting.--Participating providers shall, in a
prompt and timely manner, provide information to the agency in
the form and manner requested by the agency.
(j) Coordination of services.--The agency shall coordinate
the provision of health care services with any other
Commonwealth and local agencies that provide health care
services directly to their charges or residents.
Section 508. Rational cost containment.
(a) Approval of expenditures.--As part of its cost
containment mission, the board, with the assistance of the
Health Institution Quality Panel, shall screen and approve or
disapprove private or public expenditures for new health care
facilities and other capital investments that may lead to
redundant and inefficient health care provider capacity.
Procedures shall be adopted for this purpose with an emphasis
upon efficiency, quality of delivery and a fair and open
consideration of all applications.
(b) Capital investments.--
(1) Capital investments of $1,000,000 or more require
the approval of the board. If a facility, an individual
acting on behalf of a facility or any other purchaser obtains
by lease or comparable arrangement any facility or part of a
facility, or any equipment for a facility, the market value
of which would have been a capital expenditure, the lease or
arrangement shall be considered a capital expenditure for
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purposes of this section.
(2) For purposes of this subsection, the term "capital
investments" includes the costs of studies, surveys, design
plans and working drawing specifications and other activities
essential to planning and execution of capital investment.
The term includes capital investments that change the bed
capacity of a health care facility by more than 10% over a
24-month period or that add a new service or license
category.
(c) Study.--An entity that intends to make capital
investments or acquisitions shall prepare a business case for
making each investment and acquisition. It shall include the
full-life-cycle costs of the investment or acquisition, an
environmental impact report that meets existing State standards
and a demonstration of how the investment or acquisition meets
the health care needs of the population it is intended to serve.
Acquisitions may include acquisitions of land, operational
property or administrative office space.
(d) Deemed approval.--Capital investment programs submitted
for approval shall be deemed approved by the board if not
disapproved by the board within 60 days from the date the
submissions are received by the chairperson of the board. A 60-
day extension may apply if the board requires additional
information.
(e) Recommendations.--Recommendations of the Health Care
Cost Containment Council and other public and private
authoritative bodies as shall be identified from time to time by
the board shall be received by the chairperson of the board and
submitted to the board with the chairperson's recommendation
regarding implementation of the recommended reforms. The board
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shall receive input from all interested parties and then shall
vote upon the recommendations within 60 days. If procedural or
protocol reforms are adopted, participating providers shall be
required to implement the designated best practices within the
next 60 days.
(f) Appeal.--A decision of the board may be appealed through
a uniform dispute resolution process that has been established
by unanimous approval of the board.
(g) Required investments.--The board, with the
recommendations of the Health Institution Quality Panel, may
adopt programs to assist participating providers in making
capital investments responsive to best practice recommendations.
CHAPTER 9
PENNSYLVANIA HEALTH CARE TRUST FUND
Section 901. Pennsylvania Health Care Trust Fund.
(a) Establishment.--The Pennsylvania Health Care Trust Fund
is established within the State Treasury. All money collected
and received by the plan shall be transmitted to the State
Treasurer for deposit into the fund and used exclusively to
finance the plan.
(b) State Treasurer.--The State Treasurer may invest the
principal and interest earned by the fund in any manner
authorized under law for the investment of Commonwealth money.
Any revenue or interest earned from the investments shall be
credited to the fund.
Section 902. Agency budget.
The agency budget shall comprise the cost of the agency,
services and benefits provided, administration, data gathering,
planning and other activities and revenues of the fund. The
board shall limit administrative costs, excluding start-up
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costs, to 5% of the agency budget. The board shall annually
evaluate methods to reduce administrative costs and publicly
report the results of that evaluation.
Section 903. Funding sources.
Revenues of the fund shall be obtained from the following
sources:
(1) Funds obtained through Federal health care programs.
(2) Funds from dedicated sources specified by the
General Assembly.
(3) Receipts from the tax under section 904.
(4) Receipts from the tax imposed under section 905.
Section 904. Payroll tax.
(a) Imposition.--Beginning July 1 of the calendar year
following the effective date of this section, a tax of 10% is
imposed on payroll amounts generated as a result of an employer
conducting business activity within this Commonwealth. For
purposes of the payroll tax imposed under this section, the
business activity shall be directly attributable to activity
within this Commonwealth. For purposes of computation of the
payroll tax, the payroll amount attributable to the Commonwealth
shall be determined by applying an apportionment factor to total
payroll expense based on that portion of payroll expense which
the total number of days an employee, partner, member,
shareholder or other individual works within this Commonwealth
bears to the total number of days the employee or person works
outside of this Commonwealth.
(b) Business activity.--For purposes of the payroll tax
assessed pursuant to this section, an employer is conducting
business within this Commonwealth if the employer engages,
hires, employs or contracts with one or more individuals as
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employees and, in addition, the employer does at least one of
the following:
(1) Maintains a fixed place of business within this
Commonwealth.
(2) Owns or leases real property within this
Commonwealth for purposes of a business.
(3) Maintains a stock of tangible personal property in
this Commonwealth for sale in the ordinary course of a
business.
(4) Conducts continuous solicitation within this
Commonwealth related to a business.
(5) Utilizes the highways of this Commonwealth in
connection with the operation of a business other than
transportation through this Commonwealth.
(c) Reports.--All employers in this Commonwealth shall file
returns and make payments as required by the Department of
Revenue. An employer making a return shall certify the
correctness of the return. The Department of Revenue may audit,
examine or inspect the books, records or accounts of all
employers subject to the tax imposed under this section.
(d) Regulations.--The Department of Revenue may promulgate
regulations necessary to implement this section.
(e) Deposit in fund.--All taxes, additions and penalties
collected pursuant to this section shall be transmitted to the
State Treasurer for deposit into the fund and used exclusively
for the purposes of this act.
(f) Offset prohibited.--An employer shall not offset the
amount of tax paid pursuant to this section by reducing
compensation or benefits paid to employees.
(g) Enforcement.--The Department of Revenue shall proceed to
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recover taxes due and unpaid under this section in accordance
with the applicable processes, remedies and procedures for the
collection of taxes provided by the act of March 4, 1971 (P.L.6,
No.2), known as the Tax Reform Code of 1971.
(h) Construction.--This section shall not be construed to
limit the Department of Revenue from recovering delinquent taxes
by any other means provided by law.
(i) Definitions.--As used in this section, the following
words and phrases shall have the meanings given to them in this
subsection unless the context clearly indicates otherwise:
"Employer." All persons conducting business activity within
this Commonwealth, including a governmental entity.
"Payroll amounts." All amounts paid by an employer as
salaries, wages, commissions, bonuses, net earnings and
incentive payments, whether based on profits or otherwise, fees
and similar remuneration for services rendered, whether directly
or through an agent and whether in cash, in property or the
right to receive property.
Section 905. Additional personal income tax imposed.
(a) Personal income tax.--Beginning July 1 of the calendar
year following the effective date of this section, there is
imposed an additional tax upon each class of income as defined
in Article III of the act of March 4, 1971 (P.L.6, No.2), known
as the Tax Reform Code of 1971. The tax shall be calculated,
collected and paid over to the Commonwealth in the same manner
as provided in Article III of the Tax Reform Code of 1971.
(b) Rate.--The tax imposed by subsection (a) shall be at the
rate of 3%.
(c) Deposit of tax proceeds.--The Department of Revenue
shall deposit taxes collected under this section in the fund.
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The amount shall be the sum of the taxes collected under this
section and Article III of the Tax Reform Code of 1971
multiplied by a fraction equal to the rate of tax under this
section divided by the sum of the rate of tax under this section
and the rate of tax under section 302 of the Tax Reform Code of
1971.
(d) Rules and regulations.--The rules and regulations of the
Department of Revenue promulgated under Article III of the Tax
Reform Code of 1971, or any other act, shall be applicable to
the tax imposed by this section to the extent that they are
applicable.
(e) Construction.--The tax imposed by this section shall be
in addition to any tax imposed under Article III of the Tax
Reform Code of 1971 or section 321(c) of the act of June 27,
2006 (1st Sp.Sess., P.L.1873, No.1), known as the Taxpayer
Relief Act. The provisions of Article III of the Tax Reform Code
of 1971 shall apply to the tax imposed by this section.
CHAPTER 11
TRANSITIONAL SUPPORT
Section 1101. 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:
"Displaced employee." A resident of this Commonwealth
employed by a health care insurer or other health care-related
business who loses employment within the first two years
following implementation of the plan as a direct result of the
implementation of the plan.
Section 1102. Transitional support and training for displaced
workers.
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(a) Agency duties.--The agency shall:
(1) Identify displaced employees.
(2) Determine the amount of monthly wages that each
displaced employee has lost due to the plan's implementation.
(3) Attempt to position the displaced employees in
comparable positions of employment or assist in the
retraining and placement of the displaced employees
elsewhere.
(b) Coordination of services.--The agency shall fully
coordinate activity with public and private services that are
available or actually participating in providing employment-
related assistance.
(c) Appeals.--Displaced employees who are dissatisfied with
the level of assistance they are receiving may appeal to the
ombudsman. A determination by the ombudsman shall be final and
not subject to appeal.
CHAPTER 45
MISCELLANEOUS PROVISIONS
Section 4501. Effective date.
This act shall take effect immediately.
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