PRINTER'S NO. 3734
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
2262
Session of
2015
INTRODUCED BY QUINN, ADOLPH, DUNBAR, GROVE, PHILLIPS-HILL,
MASSER, MILNE AND WARD, JULY 13, 2016
REFERRED TO COMMITTEE ON INSURANCE, JULY 13, 2016
AN ACT
Providing for an audit of dependent eligibility in group health
insurance plans for State employees.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Short title.
This act shall be known and may be cited as the State
Employee Group Health Plan Dependent Eligibility Act.
Section 2. 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:
"Dependent eligibility audit." An audit conducted to assess
and verify the eligibility of dependents to a health plan.
"Health plan." A group health insurance plan offered by a
health plan coordinator to an employee of the Commonwealth.
"Health plan coordinator." All of the following:
(1) The Pennsylvania Employee Benefit Trust Fund.
(2) The Senate Committee on Management Operations.
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(3) The Bipartisan Management Committee of the House of
Representatives.
(4) The Administrative Office of Pennsylvania Courts.
Section 3. Dependent eligibility audit.
(a) Request for proposals.--Each health plan coordinator
shall issue a request for proposals for performance of a
dependent eligibility audit. The request for proposals shall
require the lowest responsible bidder to:
(1) Conduct the dependent eligibility audit using a
document model for the health plan.
(2) Verify eligible dependents covered by the health
plan and report the findings to the health plan coordinator.
(3) Implement a process for ongoing eligibility
verification following the conclusion of the dependent
eligibility audit.
(4) Assign eligibility advocates to assist employees
through the verification process.
(b) Ineligibility.--A benefit consultant currently employed
by the health plan coordinator for a period in excess of two
years shall be ineligible to submit a proposal and may not be
awarded the contract.
(c) Contract.--Each health plan coordinator shall enter into
a contract with the lowest responsible bidder within one year of
the effective date of this section. The contract may incorporate
a flat fee per dependent or performance-based payment schedule
that compensates the contractor based on the amount of savings
generated by the services performed under the contract.
Section 4. Limitation of termination of dependent coverage.
No health plan coordinator may terminate the coverage of a
dependent in the health plan as a result of a failure to submit
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documentation required under the dependent eligibility audit
unless:
(1) At least 30 days before the proposed termination of
coverage, the health plan coordinator notifies the health
plan member by mail of:
(i) Each type of required documentation that has not
been submitted.
(ii) The name, telephone number and e-mail address
of a contact person of the health plan coordinator whom
the health plan member may contact regarding the
termination of the dependent's coverage.
(iii) The procedure the health plan member must
follow to appeal a finding that a dependent is ineligible
to continue coverage in the health plan.
(2) If a health plan member demonstrates that it is
impractical to submit the required documentation, the health
plan coordinator provides the health plan member an
alternative compliance method that the health plan
coordinator has determined is a reasonable manner of proving
eligible dependent status and the health plan member has not
submitted the necessary documents required under the
alternative method.
Section 5. Report to General Assembly.
Within 90 days of the completion of a dependent eligibility
audit conducted in accordance with this act, the health plan
coordinator shall submit a report to the Appropriations
Committee of the Senate and the Appropriations Committee of the
House of Representatives that includes a fiscal analysis and the
amount of savings realized to the Commonwealth as a result of
the dependent eligibility audit.
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Section 6. Effective date.
This act shall take effect in 60 days.
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