PRINTER'S NO. 71
No. 86 Session of 2001
INTRODUCED BY GEORGE, DeWEESE, MELIO, BELARDI, READSHAW,
CALTAGIRONE, BEBKO-JONES, HALUSKA, SOLOBAY, SHANER,
TRAVAGLIO, DeLUCA, LAUGHLIN, BELFANTI, MANN, TIGUE,
HENNESSEY, STABACK, BISHOP, PISTELLA, GRUCELA, SCRIMENTI,
HARHAI AND SATHER, JANUARY 23, 2001
REFERRED TO COMMITTEE ON INSURANCE, JANUARY 23, 2001
AN ACT
1 Providing for the ready access of managed care plan enrollees to
2 urgent care services.
3 The General Assembly of the Commonwealth of Pennsylvania
4 hereby enacts as follows:
5 Section 1. Short title.
6 This act shall be known and may be cited as the Patient
7 Access to Urgent Care Act.
8 Section 2. Declaration of policy.
9 The General Assembly finds and declares that while managed
10 care plans are essential to containing health care spending
11 within this Commonwealth, it is critical that plan enrollees
12 have ready access to emergency and urgent care services.
13 Section 3. Definitions.
14 The following words and phrases when used in this act shall
15 have the meanings given to them in this section unless the
16 context clearly indicates otherwise:
1 "Emergency care physician." Any individual who is licensed
2 as a physician, including an osteopathic physician, under the
3 laws of this Commonwealth and who provides emergency care
4 services.
5 "Emergency care provider." A hospital or facility licensed
6 under the laws of this Commonwealth that provides emergency care
7 services.
8 "Enrollee." An individual, including a policyholder,
9 subscriber or covered person, entitled to receive health care
10 benefits under a managed care plan.
11 "Managed care plan" or "plan." A health benefits plan that
12 integrates the financing and delivery of appropriate health care
13 services to enrollees by arrangements with participating
14 providers who are selected to participate on the basis of
15 explicit standards to furnish a comprehensive set of health care
16 services, including, but not limited to, behavioral health
17 services and financial incentives, for enrollees to use the
18 participating providers and procedures provided for in the plan.
19 A managed care plan includes health care arranged through an
20 entity or subcontractor thereof operating under any of the
21 following:
22 (1) Section 630 of the act of May 17, 1921 (P.L.682,
23 No.284), known as The Insurance Company Law of 1921.
24 (2) The act of December 29, 1972 (P.L.1701, No.364),
25 known as the Health Maintenance Organization Act.
26 (3) The act of December 14, 1992 (P.L.835, No.134),
27 known as the Fraternal Benefit Societies Code.
28 (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan
29 corporations).
30 (5) 40 Pa.C.S. Ch. 63 (relating to professional health
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1 services plan corporations).
2 (6) A contract with the Department of Public Welfare to
3 provide medical assistance benefits through a capitated plan.
4 "Nonparticipating provider." An emergency care provider not
5 under contract with an enrollee's managed care plan.
6 "Participating provider." An emergency care provider under
7 contract with an enrollee's managed care plan.
8 "Primary care physician." A licensed physician, including an
9 osteopathic physician, who supervises, coordinates and provides
10 initial and basic care to an enrollee on the basis of a
11 contractual relationship with the enrollee's managed care plan.
12 "Prior authorization." Prior approval, including approval
13 obtained through a payment authorization telephone call, from a
14 managed care plan or primary care physician that allows an
15 enrollee to receive services from a health care provider for
16 consultation, diagnosis or treatment of a medical condition, to
17 be covered as a benefit under the enrollee's managed care plan
18 contract.
19 "Urgent care services." Health care services provided by a
20 participating or nonparticipating emergency care provider for a
21 condition that:
22 (1) Is not an emergency care service.
23 (2) Requires prompt medical or clinical treatment.
24 (3) Poses a danger to a patient if not treated in a
25 timely manner, as defined by the State Board of Medicine in
26 consultation with the Pennsylvania College of Emergency
27 Physicians.
28 Section 4. Urgent care services.
29 (a) General rule.--If an enrollee presents to an emergency
30 care provider a condition for which an emergency care physician
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1 determines urgent care services are necessary, the emergency
2 care provider shall seek prior authorization.
3 (b) Time for decision.--In determining whether to grant
4 prior authorization, the managed care plan shall provide an
5 affirmative or negative answer with regard to prior
6 authorization within one-half hour. If more than one-half hour
7 has elapsed, the emergency care provider may render urgent care
8 services with guaranteed managed care plan reimbursement for all
9 usual and customary charges, including charges for consultation
10 with a licensed physician who has specialized training or board
11 certification and for follow-up care, certified to be necessary
12 by the emergency care physician.
13 (c) Postdenial contact.--If the preauthorization is denied,
14 the managed care plan shall ensure that the enrollee's primary
15 care physician contact the enrollee within 12 hours of the
16 denial to arrange for an appointment with the patient or to
17 provide consultation by telephone.
18 (d) Reimbursement.--When processing a claim for
19 reimbursement of urgent care services for which prior
20 authorization was given, a managed care plan shall pay all usual
21 and customary charges, including charges for consultation with
22 any licensed physician who has specialized training or board
23 certification and for follow-up care, associated with the urgent
24 care services certified to be necessary by the emergency care
25 physician.
26 Section 5. Effective date.
27 This act shall take effect in 60 days.
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