A01943
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 AND FEE, FEBRUARY 5, 2015
REFERRED TO COMMITTEE ON VETERANS AFFAIRS AND EMERGENCY
PREPAREDNESS, FEBRUARY 5, 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:
ยง 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
paying for all or part of the cost of emergency medical
services covered by an insurance policy, contract or plan.
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The term includes an entity subject to:
(i) 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.
(L) Workers' compensation.
(M) Automobile medical payment insurance.
* * *
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Section 2. Title 35 is amended by adding a section to read:
ยง 8158. Billing.
(a) General rule.--When an emergency medical services EMS
agency is properly dispatched by a public safety answering point
as defined in section 5302 (relating to definitions) and
provides medically necessary emergency care, 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 emergency
medical services EMS agency during the call shall be paid
directly to the emergency medical services EMS agency.
(b) Application.--This section shall be construed to apply
only to emergency medical services agencies that are nonnetwork
providers.
(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 registry that indicates which EMS agency has
requested nonnetwork direct reimbursement from an insurer
identified on the form.
(2) An EMS agency has provided notification to the
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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. If, through the audit, the
payer identifies an improper payment, the payer 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 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
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
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claim directly to the EMS agency in accordance with 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.
Section 3. This act shall take effect in 60 days January 1,
2016.
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