Regular Session 2021-2022 Senate Bill 0225 P.N. 2004

HOUSE AMENDED

PRIOR PRINTER'S NOS. 453, 948, 1809,

1837, 1924

PRINTER'S NO. 2004

THE GENERAL ASSEMBLY OF PENNSYLVANIA

SENATE BILL

No.

225

Session of

2021

INTRODUCED BY PHILLIPS-HILL, MARTIN, J. WARD, MENSCH, COLLETT,

MUTH, KANE, STEFANO, AUMENT, CAPPELLETTI, BAKER, BROOKS,

BOSCOLA, HUTCHINSON, SABATINA, TOMLINSON, LAUGHLIN,

MASTRIANO, SANTARSIERO, KEARNEY, SCHWANK, DUSH, COMITTA,

FLYNN, L. WILLIAMS AND DILLON, MARCH 18, 2021

AS AMENDED ON SECOND CONSIDERATION, HOUSE OF REPRESENTATIVES,

OCTOBER 25, 2022

AN ACT

Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An

act relating to insurance; amending, revising, and

consolidating the law providing for the incorporation of

insurance companies, and the regulation, supervision, and

protection of home and foreign insurance companies, Lloyds

associations, reciprocal and inter-insurance exchanges, and

fire insurance rating bureaus, and the regulation and

supervision of insurance carried by such companies,

associations, and exchanges, including insurance carried by

the State Workmen's Insurance Fund; providing penalties; and

repealing existing laws," in quality health care

accountability and protection, further providing for

definitions, for responsibilities of managed care plans, for

financial incentives prohibition, for medical gag clause

prohibition, for emergency services, for continuity of care,

providing for medication assisted treatment, further

providing for procedures, for confidentiality, for required

disclosure, providing for medical policy and clinical review

criteria adopted by insurer, MCO or contractor, further

providing for internal complaint process, for appeal of

complaint, for complaint resolution, for certification, for

operational standards, providing for step therapy

considerations, for prior authorization review and for

provider portal, further providing for internal grievances

process, for records, for external grievance process, for

prompt payment of claims, for health care provider and

managed care plan, for departmental powers and duties, for

penalties and sanctions, for compliance with National

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Accrediting Standards; and making editorial changes. IN

QUALITY HEALTH CARE ACCOUNTABILITY AND PROTECTION, FURTHER

PROVIDING FOR DEFINITIONS, FOR RESPONSIBILITIES OF MANAGED

CARE PLANS, FOR FINANCIAL INCENTIVES PROHIBITION, FOR MEDICAL

GAG CLAUSE PROHIBITION, FOR EMERGENCY SERVICES, FOR

CONTINUITY OF CARE, FOR PROCEDURES, FOR CONFIDENTIALITY, FOR

REQUIRED DISCLOSURE AND FOR INTERNAL COMPLAINT PROCESS,

PROVIDING FOR INTERNAL COMPLAINT PROCESS FOR ENROLLEES,

FURTHER PROVIDING FOR APPEAL OF COMPLAINT, FOR COMPLAINT

RESOLUTION, FOR CERTIFICATION AND FOR OPERATIONAL STANDARDS,

PROVIDING FOR UTILIZATION REVIEW STANDARDS, FURTHER PROVIDING

FOR INTERNAL GRIEVANCE PROCESS, FOR EXTERNAL GRIEVANCE

PROCESS AND FOR RECORDS, PROVIDING FOR ADVERSE BENEFIT

DETERMINATIONS, FURTHER PROVIDING FOR PROMPT PAYMENT OF

CLAIMS, FOR HEALTH CARE PROVIDER AND MANAGED CARE PLAN

PROTECTION, FOR DEPARTMENTAL POWERS AND DUTIES, FOR

CONFIDENTIALITY AND FOR PENALTIES AND SANCTIONS, PROVIDING

FOR REGULATIONS AND FURTHER PROVIDING FOR COMPLIANCE WITH

NATIONAL ACCREDITING STANDARDS AND FOR EXCEPTIONS; MAKING

REPEALS; AND MAKING EDITORIAL CHANGES.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1. The definitions of "complaint," "drug formulary,"

"enrollee," "grievance," "health care service," "prospective

utilization review," "provider network," "retrospective

utilization review," "utilization review" and "utilization

review entity" in section 2102 of the act of May 17, 1921

(P.L.682, No.284), known as The Insurance Company Law of 1921,

are amended and the section is amended by adding definitions to

read:

Section 2102. Definitions.--As used in this article, the

following words and phrases shall have the meanings given to

them in this section:

* * *

"Administrative policy." A written document or collection of

documents reflecting the terms of the contractual or operating

relationship between an insurer, MCO, contractor and a health

care provider.

"Administrative denial." A denial of prior authorization,

coverage or payment based on a lack of eligibility, failure to

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submit complete information or other failure to comply with

written administrative standards for the administration of

benefits under a health insurance policy, MCO contract or CHIP

contract. The term does not include a denial based on medical

necessity.

"Adverse benefit determination." A determination by an

insurer, MCO, contractor or a utilization review entity

designated by the insurer, MCO or contractor that a health care

service has been reviewed and, based upon the information

provided, does not meet the insurer's, MCO's or contractor's

requirements for medical necessity, appropriateness, health care

setting, level of care or effectiveness and the requested

service or payment for the service is therefore denied, reduced

or terminated.

* * *

"Applicable governmental guidelines." Clinical practice and

associated guidelines issued under the authority of the United

States Department of Health and Human Services, United States

Food and Drug Administration, Centers for Disease Control and

Prevention, Department of Health or other similarly situated

Federal or State agency, department or subunit thereof focused

on the provision or regulation of medical care, prescription

drugs or public health within the United States.

"Children's Health Insurance Program" or "CHIP." The

children's health care program under Article XXIII-A.

"CHIP contract." The agreement between an insurer and the

Department of Human Services to provide for services to a CHIP

enrollee.

* * *

"Clinical review criteria." The set of written screening

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procedures, decision abstracts, clinical protocols and practice

guidelines used by an insurer, MCO or contractor to determine

the necessity and appropriateness of health care services.

"Closely related service." One or more health care services

subject to prior authorization that are closely related in

purpose, diagnostic utility or designated health care billing

code and provided on the same date of service such that a

prudent health care provider, acting within the scope of the

health care provider's license and expertise, might reasonably

be expected to perform such service in conjunction with or in

lieu of the originally authorized service in response to minor

differences in observed patient characteristics or needs for

diagnostic information that were not readily identifiable until

the health care provider was actually performing the originally

authorized service. The term does not include an order for or

administration of a prescription drug or any part of a series or

course of treatments.

"Complaint." A dispute or objection regarding a

participating health care provider or the coverage, operations

or management policies of [a managed care plan] an insurer, MCO

or contractor, which has not been resolved by the [managed care

plan] insurer, MCO or contractor and has been filed with the

[plan] insurer, MCO or contractor or with the Department of

Health or the Insurance Department of the Commonwealth. The term

does not include a grievance.

"Complete prior authorization request." A request for prior

authorization that meets an insurer's, MCO's or contractor's

administrative policy requirements for such a request and that

includes the specific clinical information necessary only to

evaluate the request under the terms of the applicable medical

20210SB0225PN2004 - 4 -

policy. To the extent a health care provider network agreement

requires medical records to be transmitted electronically, or a

health care provider is capable of transmitting medical records

electronically to support a complete prior authorization request

for a health care service, the health care provider shall ensure

the insurer , MCO or contractor has electronic access to,

including the ability to print, the medical records that have

been transmitted electronically, subject to any applicable law

and the health care provider's corporate policies. The inability

of a health care provider to provide such access shall not

constitute a reason to deny an authorization request.

* * *

"Contractor." An insurer awarded a contract under section

2304-A to provide health care services. The term includes an

entity and an entity's subsidiary which is established under

this act, the act of December 29, 1972 (P.L.1701, No.364), known

as the Health Maintenance Organization Act or 40 Pa.C.S. Ch. 61

(relating to hospital plan corporation) or 63 (relating to

professional health services plan corporations).

* * *

"Drug formulary." A listing of [managed care plan] insurer,

MCO or contractor preferred therapeutic drugs.

* * *

"Enrollee." Any policyholder, subscriber, covered person or

other individual who is entitled to receive health care services

under a [managed care plan] health insurance policy, MCO

contract or CHIP contract.

"Grievance." As provided in subdivision (i), a request by an

enrollee or a health care provider, with the written consent of

the enrollee, to have [a managed care plan] an insurer, MCO,

20210SB0225PN2004 - 5 -

contractor or utilization review entity reconsider a decision

solely concerning the medical necessity [and], appropriateness,

health care setting, level of care or effectiveness of a health

care service. If the [managed care plan] insurer, MCO or

contractor is unable to resolve the matter, a grievance may be

filed regarding the decision that:

(1) disapproves full or partial payment for a requested

health care service;

(2) approves the provision of a requested health care

service for a lesser scope or duration than requested; or

(3) disapproves payment for the provision of a requested

health care service but approves payment for the provision of an

alternative health care service.

The term does not include a complaint.

* * *

"Health care service." Any covered treatment, admission,

procedure, medical supplies and equipment or other services,

including behavioral health, prescribed or otherwise provided or

proposed to be provided by a health care provider to an enrollee

[under a managed care plan contract.]

"Health insurance policy." A policy, subscriber contract,

certificate or plan issued by an insurer that provides medical

or health care coverage. The term does not include any of the

following:

(1) An accident only policy.

(2) A credit only policy.

(3) A long-term care or disability income policy.

(4) A specified disease policy.

(5) A Medicare supplement policy.

(6) A TRICARE policy, including a Civilian Health and

20210SB0225PN2004 - 6 -

Medical Program of the Uniformed Services (CHAMPUS) supplement

policy.

(7) A fixed indemnity policy.

(8) A hospital indemnity policy.

(9) A dental only policy.

(10) A vision only policy.

(11) A workers' compensation policy.

(12) An automobile medical payment policy.

(13) A homeowners' insurance policy.

(14) A short-term limited duration policy.

(15) Any other similar policy providing for limited

benefits.

"Inpatient admission." Admission to a facility for purposes

of receiving a health care service at the inpatient level of

care.

"Insurer." An entity licensed by the department to issue a

health insurance policy, subscriber contract, certificate or

plan that provides medical or health care coverage that is

offered or governed under any of the following:

(1) Article XXIV, section 630 or any other provision of this

act.

(2) A provision of 40 Pa.C.S. Ch. 61 or 63.

* * *

"MCO contract." The agreement between a medical assistance

managed care organization or MCO and the Department of Human

Services to provide for services to a Medicaid enrollee.

"Medical assistance managed care organization" or "MCO." A

Medicaid managed care organization as defined in section 1903(m)

(1)(A) of the Social Security Act (49 Stat. 620, 42 U.S.C. §

1396b(m)(1)(A)) that is a party to a Medicaid managed care

20210SB0225PN2004 - 7 -

contract with the Department of Human Services. The term does

not include a behavioral health managed care organization that

is a party to a Medicaid managed care contract with the

Department of Human Services.

"Medical policy." A written document formally adopted,

maintained and applied by an insurer, MCO or contractor that

combines the clinical coverage criteria and any additional

administrative requirements, as applicable, necessary to

articulate the insurer's, MCO's or contractor's standards for

coverage of a given service or set of services under the terms

of a health insurance policy, MCO contract or CHIP contract.

"Medical or scientific evidence." Evidence found in any of

the following sources:

(1) A peer-reviewed scientific study published in or

accepted for publication by a medical journal that meets

nationally recognized requirements for scientific manuscripts

and which journal submits most of its published articles for

review by experts who are not part of the journal's editorial

staff.

(2) Peer-reviewed medical literature, including literature

relating to a therapy reviewed and approved by a qualified

institutional review board, biomedical compendia and other

medical literature that meet the criteria of the National

Institutes of Health's Library of Medicine for indexing in Index

Medicus (Medline) and Elsevier Science Limited for indexing in

Excerpta Medica (EMBASE).

(3) A medical journal recognized by the Secretary of Health

and Human Services under section 1861(t)(2) of the Social

Security Act (49 Stat. 620, 42 U.S.C. § 1395x(t)(2)).

(4) One of the following standard reference compendia:

20210SB0225PN2004 - 8 -

(i) The American Hospital Formulary Service-Drug

Information.

(ii) Drug Facts and Comparison.

(iii) The American Dental Association Accepted Dental

Therapeutics.

(iv) The United States Pharmacopoeia-Drug Information.

(5) Findings, studies or research conducted by or under the

auspices of a Federal Government agency or nationally recognized

Federal research institute, including:

(i) The Federal Agency for Healthcare Research and Quality.

(ii) The National Institute of Health.

(iii) The National Cancer Institute.

(iv) The National Academy of Sciences.

(v) The Centers for Medicare and Medicaid Services.

(vi) The Food and Drug Administration.

(vii) Any national board recognized by the National

Institutes of Health for the purpose of evaluating the medical

value of health care services.

(6) Other medical or scientific evidence that is comparable

to the sources specified in paragraphs (1), (2), (3), (4) and

(5).

"Medication assisted treatment." United States Food and Drug

Administration approved prescription drugs used in combination

with counseling and behavioral health therapies in the treatment

of opioid use disorders.

"Nationally recognized medical standards." Clinical

criteria, practice guidelines and related standards established

by national quality and accreditation entities generally

recognized in the United States health care industry.

"Participating provider." A health care provider that has

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entered into a contractual or operating relationship with an

insurer, MCO or contractor to participate in one or more

designated networks of the insurer, MCO or contractor and to

provide health care services to enrollees under the terms of the

insurer's, MCO's or contractor's administrative policy.

* * *

"Prior authorization." A review by an insurer, MCO,

contractor or by a utilization review entity acting on behalf of

an insurer, MCO or contractor of all reasonably necessary

supporting information that occurs prior to the delivery or

provision of a health care service and results in a decision to

approve or deny payment for the health care service. The term

includes step therapy and associated exceptions for prescription

drugs.

["Prospective utilization review." A review by a utilization

review entity of all reasonably necessary supporting information

that occurs prior to the delivery or provision of a health care

service and results in a decision to approve or deny payment for

the health care service.]

"Provider network." The health care providers designated by

[a managed care plan] an insurer, MCO or contractor to provide

health care services.

"Provider portal." A designated section or functional

software module accessible via an insurer's, MCO's or

contractor's publicly accessible Internet website that

facilitates health care provider submission of electronic prior

authorization requests.

* * *

"Retrospective utilization review." A review by [a] an

insurer, MCO, contractor or utilization review entity acting on

20210SB0225PN2004 - 10 -

behalf of an insurer, MCO or contractor of all reasonably

necessary supporting information which occurs following delivery

or provision of a health care service and results in a decision

to approve or deny payment for the health care service.

* * *

"Step therapy." A course of treatment where certain

designated drugs or treatment protocols must be either

contraindicated or used and found to be ineffective prior to

approval of coverage for other designated drugs. The term does

not include requests for coverage of nonformulary drugs.

"Urgent health care service." A covered health care service

subject to prior authorization that is delivered on an expedited

basis for the treatment of an acute condition with symptoms of

sufficient severity pursuant to a determination by a duly

licensed and board-certified treating physician, operating

within the individual's scope of practice and professional

expertise, that the absence of such significant medical

intervention is likely to result in serious, long-term health

complications or a material deterioration in the enrollee's

condition and prognosis.

"Utilization review." A system of [prospective, concurrent]

prior authorization, concurrent utilization review or

retrospective utilization review performed by [a] an insurer,

MCO, contractor or utilization review entity on behalf of an

insurer, MCO or contractor of the medical necessity [and],

appropriateness, health care setting and level of care or

effectiveness of health care services prescribed, provided or

proposed to be provided to an enrollee. The term does not

include any of the following:

(1) Requests for clarification of coverage, eligibility or

20210SB0225PN2004 - 11 -

health care service verification.

(2) A health care provider's internal quality assurance or

utilization review process unless the review results in denial

of payment for a health care service.

"Utilization review entity." Any entity certified pursuant

to subdivision (h) that performs utilization review on behalf of

[a managed care plan] an insurer, MCO or contractor.

Section 2. Subarticle (b) heading of Article XXI and

sections 2111, 2112 and 2113 of the act are amended to read:

(b) [Managed Care Plan] Insurer, MCO and Contractor

Requirements.

Section 2111. Responsibilities of [Managed Care Plans]

Insurer, MCOs and Contractors.--[A managed care plan] An

insurer, MCO or contractor shall do all of the following:

(1) Assure availability and accessibility of adequate health

care providers in a timely manner, which enables enrollees to

have access to quality care and continuity of health care

services.

(2) Consult with health care providers in active clinical

practice regarding professional qualifications and necessary

specialists to be included in the [plan] health insurance

policy, MCO contract or CHIP contract.

(3) Adopt and maintain a definition of medical necessity

used by the [plan] health insurance policy, MCO contract or CHIP

contract in determining health care services.

(4) Ensure that emergency services are provided twenty-four

(24) hours a day, seven (7) days a week and provide reasonable

payment or reimbursement for emergency services.

(5) Adopt and maintain procedures by which an enrollee can

obtain health care services outside the [plan's] health

20210SB0225PN2004 - 12 -

insurance policy's, MCO contract's or CHIP contract's service

area.

(6) Adopt and maintain procedures by which an enrollee with

a life-threatening, degenerative or disabling disease or

condition shall, upon request, receive an evaluation and, if the

[plan's] insurer's, MCO's or contractor's established standards

are met, be permitted to receive:

(i) a standing referral to a specialist with clinical

expertise in treating the disease or condition; or

(ii) the designation of a specialist to provide and

coordinate the enrollee's primary and specialty care.

The referral to or designation of a specialist shall be pursuant

to a treatment plan approved by the [managed care plan] insurer,

MCO or contractor in consultation with the primary care

provider, the enrollee and, as appropriate, the specialist. When

possible, the specialist must be a health care provider

participating in the [plan] health insurance policy, MCO

contract or CHIP contract.

(7) Provide direct access to obstetrical and gynecological

services by permitting an enrollee to select a health care

provider participating in the [plan] health insurance policy,

MCO contract or CHIP contract to obtain maternity and

gynecological care, including medically necessary and

appropriate follow-up care and referrals for diagnostic testing

related to maternity and gynecological care, without prior

approval from a primary care provider. The health care services

shall be within the scope of practice of the selected health

care provider. The selected health care provider shall inform

the enrollee's primary care provider of all health care services

provided.

20210SB0225PN2004 - 13 -

(8) Adopt and maintain a complaint process as set forth in

subdivision (g).

(9) Adopt and maintain a grievance process as set forth in

subdivision (i).

(10) Adopt and maintain credentialing standards for health

care providers as set forth in subdivision (d).

(11) Ensure that there are participating health care

providers that are physically accessible to people with

disabilities and can communicate with individuals with sensory

disabilities in accordance with Title III of the Americans with

Disabilities Act of 1990 (Public Law 101-336, 42 U.S.C. § 12181

et seq.).

(12) Provide a list of health care providers participating

in the [plan] health insurance policy, MCO contract or CHIP

contract to the department every two (2) years or as may

otherwise be required by the department. The list shall include

the extent to which [health care] participating providers [in

the plan] are accepting new enrollees.

(13) Report to the department and the Insurance Department

in accordance with the requirements of this article. Such

information shall include the number, type and disposition of

all complaints and grievances filed with the [plan] insurer, MCO

or contractor.

Section 2112. Financial Incentives Prohibition.--No [managed

care plan] insurer, MCO or contractor shall use any financial

incentive that compensates a health care provider for providing

less than medically necessary and appropriate care to an

enrollee. Nothing in this section shall be deemed to prohibit [a

managed care plan] an insurer, MCO or contractor from using a

capitated payment arrangement or other risk-sharing arrangement.

20210SB0225PN2004 - 14 -

Section 2113. Medical Gag Clause Prohibition.--(a) No

[managed care plan] insurer, MCO or contractor may penalize or

restrict a health care provider from discussing:

(1) the process that the [plan] insurer, MCO or contractor

or any entity contracting with the [plan] insurer, MCO or

contractor uses or proposes to use to deny payment for a health

care service;

(2) medically necessary and appropriate care with or on

behalf of an enrollee, including information regarding the

nature of treatment; risks of treatment; alternative treatments;

or the availability of alternate therapies, consultation or

tests; or

(3) the decision of any [managed care plan] insurer, MCO or

contractor to deny payment for a health care service.

(b) A provision to prohibit or restrict disclosure of

medically necessary and appropriate health care information

contained in a contract with a health care provider is contrary

to public policy and shall be void and unenforceable.

terminate the employment of or a contract with a health care

provider for any of the following:

(1) Advocating for medically necessary and appropriate

health care consistent with the degree of learning and skill

ordinarily possessed by a reputable health care provider

practicing according to the applicable legal standard of care.

(2) Filing a grievance pursuant to the procedures set forth

in this article.

(3) Protesting a decision, policy or practice that the

health care provider, consistent with the degree of learning and

skill ordinarily possessed by a reputable health care provider

20210SB0225PN2004 - 15 -

practicing according to the applicable legal standard of care,

reasonably believes interferes with the health care provider's

ability to provide medically necessary and appropriate health

care.

(d) Nothing in this section shall:

(1) Prohibit [a managed care plan] an insurer, MCO or

contractor from making a determination not to pay for a

particular medical treatment, supply or service, enforcing

reasonable peer review or utilization review protocols or making

a determination that a health care provider has or has not

complied with appropriate protocols.

(2) Be construed as requiring [a managed care plan] an

insurer, MCO or contractor to provide, reimburse for or cover

counseling, referral or other health care services if the [plan]

insurer, MCO or contractor:

(i) objects to the provision of that service on moral or

religious grounds; and

(ii) makes available information on its policies regarding

such health care services to enrollees and prospective

enrollees.

Section 3. Section 2116(a) and (b) of the act are amended

and the section is amended by adding a subsection to read:

Section 2116. Emergency Services.--(a) If an enrollee seeks

emergency services and the emergency health care provider

determines that emergency services are necessary, the emergency

health care provider shall initiate necessary intervention to

evaluate and, if necessary, stabilize the condition of the

enrollee without seeking or receiving authorization from the

[managed care plan. The managed care plan] insurer, MCO or

contractor. No insurer, MCO or contractor shall require a health

20210SB0225PN2004 - 16 -

care provider to submit a request for prior authorization for an

emergency service. The insurer, MCO or contractor shall pay all

reasonably necessary costs associated with emergency services

provided during the period of emergency, subject to all

copayments, coinsurances or deductibles[.], including testing

and other diagnostic services that are medically necessary to

evaluate or treat an emergency medical condition prior to the

point at which the condition is stabilized. When processing a

reimbursement claim for emergency services, [a managed care

plan] an insurer, MCO or contractor shall consider both the

presenting symptoms and the services provided. The [emergency]

health care provider shall notify the enrollee's [managed care

plan] insurer, MCO or contractor of the provision of emergency

services and the condition of the enrollee. If an enrollee's

condition has stabilized and the enrollee can be transported

without suffering detrimental consequences or aggravating the

enrollee's condition, the enrollee may be relocated to another

facility to receive continued care and treatment as necessary.

If an enrollee is admitted to inpatient care or placed in

observation immediately following receipt of a covered emergency

service, the inpatient facility shall have a minimum of twenty-

four (24) hours to notify the enrollee's insurer, MCO or

contractor of the admission or placement with such timeframe to

start at the later of:

(1) the time of the inpatient admission or placement; or

(2) in the case of an enrollee that is unconscious, comatose

or otherwise unable to effectively communicate pertinent

information, the time at which the inpatient facility knew or

reasonably should have known, through diligent efforts, the

identity of the enrollee's insurer, MCO or contractor.

20210SB0225PN2004 - 17 -

(b) For emergency services rendered by a licensed emergency

medical services agency, as defined in 35 Pa.C.S. § 8103

(relating to definitions), that has the ability to transport

patients or is providing and billing for emergency services

under an agreement with an emergency medical services agency

that has that ability, the [managed care plan] insurer, MCO or

contractor may not deny a claim for payment solely because the

enrollee did not require transport or refused to be transported.

* * *

(e) Nothing in this section shall require an insurer, MCO or

contractor to waive application of otherwise applicable clinical

review criteria.

Section 4. Section 2117 of the act is amended to read:

Section 2117. Continuity of Care.--(a) Except as provided

under subsection (b), if [a managed care plan] an insurer, MCO

or contractor initiates termination of its contract with a

participating health care provider, an enrollee may continue an

ongoing course of treatment with that health care provider at

the enrollee's option for a transitional period of up to sixty

(60) days from the date the enrollee was notified by the [plan]

insurer, MCO or contractor of the termination or pending

termination. The [managed care plan] insurer, MCO or contractor,

in consultation with the enrollee and the health care provider,

may extend the transitional period if determined to be

clinically appropriate. In the case of an enrollee in the second

or third trimester of pregnancy at the time of notice of the

termination or pending termination, the transitional period

shall extend through postpartum care related to the delivery.

Any health care service provided under this section shall be

covered by the [managed care plan] insurer, MCO or contractor

20210SB0225PN2004 - 18 -

under the same terms and conditions as applicable for

participating health care providers.

(b) If the [plan] insurer, MCO or contractor terminates the

contract of a participating health care provider for cause,

including breach of contract, fraud, criminal activity or posing

a danger to an enrollee or the health, safety or welfare of the

public as determined by the [plan] insurer, MCO or contractor,

the [plan] insurer, MCO or contractor shall not be responsible

for health care services provided to the enrollee following the

date of termination.

contract of a participating primary care provider, the [plan]

insurer, MCO or contractor shall notify every enrollee served by

that provider of the [plan's] insurer's, MCO's or contractor's

termination of its contract and shall request that the enrollee

select another primary care provider.

(d) A new enrollee may continue an ongoing course of

treatment with a nonparticipating health care provider for a

transitional period of up to sixty (60) days from the effective

date of enrollment in a [managed care plan] health insurance

policy, MCO contract or CHIP contract. The [managed care plan]

insurer, MCO or contractor, in consultation with the enrollee

and the health care provider, may extend this transitional

period if determined to be clinically appropriate. In the case

of a new enrollee in the second or third trimester of pregnancy

on the effective date of enrollment, the transitional period

shall extend through postpartum care related to the delivery.

Any health care service provided under this section shall be

covered by the [managed care plan] insurer, MCO or contractor

under the same terms and conditions as applicable for

20210SB0225PN2004 - 19 -

participating health care providers.

(e) [A plan] An insurer, MCO or contractor may require a

nonparticipating health care provider whose health care services

are covered under this section to meet the same terms and

conditions as a participating health care provider.

(f) Nothing in this section shall require [a managed care

plan] an insurer, MCO or contractor to provide health care

services that are not otherwise covered under the terms and

conditions of the [plan] health insurance policy, MCO contract

or CHIP contract.

Section 5. The act is amended by adding a section to read:

Section 2118. Medication assisted treatment.--(a) An

insurer, MCO or contractor shall make available without initial

prior authorization coverage of at least one United States Food

and Drug Administration approved prescription drug classified as

Medication Assisted Treatment.

(b) Nothing in this section shall prohibit an insurer, MCO

or contractor from designating preferred medications for the

relevant component of medication assisted treatment when

multiple medications are available, subject to applicable

requirements for documenting and posting any relevant medical

policy or prescription drug formulary information.

coverage, nothing in this section shall prohibit an insurer, MCO

or contractor from requiring prior authorization on subsequent

requests for medication assisted treatment to ensure adherence

with clinical guidelines.

Section 6. Sections 2121, 2131 and 2136 of the act are

amended to read:

Section 2121. Procedures.--(a) [A managed care plan] An

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