PRINTER'S NO. 2212
No. 1804 Session of 1999
INTRODUCED BY SOLOBAY, MANN, COSTA, YUDICHAK, VEON, HARHAI,
GEORGE, RUFFING, BELARDI, OLIVER, TRICH, READSHAW, HALUSKA,
WOJNAROSKI, TRELLO, WALKO, YOUNGBLOOD, GIGLIOTTI, FRANKEL,
GRUCELA, CURRY, BEBKO-JONES, VAN HORNE, MANDERINO, MUNDY,
SHANER, STABACK, SURRA, MELIO AND DeWEESE, AUGUST 23, 1999
REFERRED TO COMMITTEE ON INSURANCE, AUGUST 23, 1999
AN ACT
1 Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
2 act relating to insurance; amending, revising, and
3 consolidating the law providing for the incorporation of
4 insurance companies, and the regulation, supervision, and
5 protection of home and foreign insurance companies, Lloyds
6 associations, reciprocal and inter-insurance exchanges, and
7 fire insurance rating bureaus, and the regulation and
8 supervision of insurance carried by such companies,
9 associations, and exchanges, including insurance carried by
10 the State Workmen's Insurance Fund; providing penalties; and
11 repealing existing laws," further defining "emergency
12 service"; further providing for responsibilities of managed
13 care plans; and repealing provisions relating to preemption.
14 The General Assembly of the Commonwealth of Pennsylvania
15 hereby enacts as follows:
16 Section 1. The definition of "emergency service" in section
17 2102 of the act of May 17, 1921 (P.L.682, No.284), known as The
18 Insurance Company Law of 1921, added June 17, 1998 (P.L.464,
19 No.68), is amended to read:
20 Section 2102. Definitions.--As used in this article, the
21 following words and phrases shall have the meanings given to
22 them in this section:
1 * * *
2 "Emergency service." Any health care service provided to an
3 enrollee after the sudden onset of a medical condition that
4 manifests itself by acute symptoms of sufficient severity or
5 severe pain such that a prudent layperson who possesses an
6 average knowledge of health and medicine could reasonably expect
7 the absence of immediate medical attention to result in:
8 (1) placing the health of the enrollee or, with respect to a
9 pregnant woman, the health of the woman or her unborn child in
10 serious jeopardy;
11 (2) serious impairment to bodily functions; or
12 (3) serious dysfunction of any bodily organ or part.
13 Emergency transportation and related emergency service provided
14 by a licensed ambulance service shall constitute an emergency
15 service. The term also includes screening used to determine if a
16 medical emergency exists.
17 * * *
18 Section 2. Section 2111 of the act, added June 17, 1998
19 (P.L.464, No.68), is amended to read:
20 Section 2111. Responsibilities of Managed Care Plans.--A
21 managed care plan shall do all of the following:
22 (1) Assure availability and accessibility of adequate health
23 care providers in a timely manner, which enables enrollees to
24 have access to quality care and continuity of health care
25 services.
26 (2) Consult with health care providers in active clinical
27 practice regarding professional qualifications and necessary
28 specialists to be included in the plan.
29 (3) Adopt and maintain a definition of medical necessity
30 used by the plan in determining health care services.
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1 (4) Ensure that emergency services are provided twenty-four
2 (24) hours a day, seven (7) days a week and provide reasonable
3 payment or reimbursement for emergency services.
4 (4.1) Pay for medical emergency assessments, as required
5 under Federal law, whether or not it is later determined that a
6 medical emergency did not exist.
7 (4.2) Cover emergency services regardless of whether the
8 enrollee or the provider obtained prior authorization and the
9 costs of emergency care at an out-of-network hospital if such
10 services are necessitated by the enrollee's condition.
11 (4.3) Provide coverage for trauma services at any designated
12 level I or level II trauma center as medically necessary. Such
13 coverage must continue until the attending physician determines
14 that the patient is medically stable, no longer requires
15 critical care and can safely be transported.
16 (5) Adopt and maintain procedures by which an enrollee can
17 obtain health care services outside the plan's service area.
18 (6) Adopt and maintain procedures by which an enrollee with
19 a life-threatening, degenerative or disabling disease or
20 condition shall, upon request, receive an evaluation and, if the
21 plan's established standards are met, be permitted to receive:
22 (i) a standing referral to a specialist with clinical
23 expertise in treating the disease or condition; or
24 (ii) the designation of a specialist to provide and
25 coordinate the enrollee's primary and specialty care.
26 The referral to or designation of a specialist shall be pursuant
27 to a treatment plan approved by the managed care plan in
28 consultation with the primary care provider, the enrollee and,
29 as appropriate, the specialist. When possible, the specialist
30 must be a health care provider participating in the plan.
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1 (7) Provide direct access to obstetrical and gynecological
2 services by permitting an enrollee to select a health care
3 provider participating in the plan to obtain maternity and
4 gynecological care, including medically necessary and
5 appropriate follow-up care and referrals for diagnostic testing
6 related to maternity and gynecological care, without prior
7 approval from a primary care provider. The health care services
8 shall be within the scope of practice of the selected health
9 care provider. The selected health care provider shall inform
10 the enrollee's primary care provider of all health care services
11 provided.
12 (8) Adopt and maintain a complaint process as set forth in
13 subdivision (g).
14 (9) Adopt and maintain a grievance process as set forth in
15 subdivision (i).
16 (10) Adopt and maintain credentialing standards for health
17 care providers as set forth in subdivision (d).
18 (11) Ensure that there are participating health care
19 providers that are physically accessible to people with
20 disabilities and can communicate with individuals with sensory
21 disabilities in accordance with Title III of the Americans with
22 Disabilities Act of 1990 (Public Law 101-336, 42 U.S.C. § 12181
23 et seq.).
24 (12) Provide a list of health care providers participating
25 in the plan to the department every two (2) years or as may
26 otherwise be required by the department. The list shall include
27 the extent to which health care providers in the plan are
28 accepting new enrollees.
29 (13) Report to the department and the Insurance Department
30 in accordance with the requirements of this article. Such
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1 information shall include the number, type and disposition of
2 all complaints and grievances filed with the plan.
3 Section 3. Section 2193 of the act is repealed.
4 Section 4. This act shall take effect immediately.
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