PRINTER'S NO. 4146
No. 2722 Session of 2006
INTRODUCED BY BEBKO-JONES, COHEN, OLIVER, LaGROTTA, BELFANTI, SIPTROTH, JOSEPHS, CAWLEY, YOUNGBLOOD, McGEEHAN, GEORGE, CALTAGIRONE, JAMES, PARKER, HANNA, FREEMAN, MANDERINO, SHANER AND ROEBUCK, JUNE 7, 2006
REFERRED TO COMMITTEE ON HEALTH AND HUMAN SERVICES, JUNE 7, 2006
AN ACT 1 Providing for a Statewide comprehensive health care system; 2 establishing the Pennsylvania Health Care Plan and providing 3 for eligibility, services, coverages, subrogation, 4 participating providers, cost containment, reduction of 5 errors, tort remedies, administrative remedies and 6 procedures, attorney fees, quality assurance, 7 nonparticipating providers, transitional support and 8 training; and establishing the Pennsylvania Health Care 9 Agency, the Employer Health Services Levy, the Individual 10 Wellness Tax and the Pennsylvania Health Care Board and 11 providing for their powers and duties. 12 WHEREAS, It is in the public interest to guarantee every 13 resident of this Commonwealth timely access to health care, to 14 assure a high quality of health services with adequate and 15 stable reimbursement for health care providers, and to apportion 16 rationally the costs of care; 17 WHEREAS, Health care providers and patients have lost 18 confidence in the existing system for resolving claims of 19 medical error and complications of treatment; 20 WHEREAS, The Commonwealth is dependent upon the volunteered 21 services of citizen firefighters, search and rescue teams, and
1 emergency medical technicians and there has been a substantial 2 loss of such volunteers as well as a general inability to 3 recruit replacement volunteers; 4 WHEREAS, A commitment to age-appropriate health awareness, 5 physical education, and first responder emergency training for 6 children through primary and secondary schools will enhance the 7 ability of our citizens to manage their health and the health 8 and safety of their families and communities; 9 WHEREAS, Our Commonwealth must embrace a culture of wellness 10 and illness prevention, rather than ever more expensive 11 interventions and treatments; 12 WHEREAS, A fair and scientific assessment of environmental 13 risks is key to identifying and abating such threats to the 14 health and safety of Pennsylvanians; 15 WHEREAS, The number of avoidable hospital-acquired injuries 16 and infections requires a renewed emphasis upon collection of 17 reliable data with the objective of analyzing the cause of such 18 events and developing and adopting effective protocols and 19 procedures to reduce their frequency; 20 WHEREAS, At least one million Pennsylvanians have no health 21 insurance at all and millions more have insurance that is 22 inadequate for their needs or risk; 23 WHEREAS, Providing financing for injuries incurred in the 24 course and scope of employment through workers' compensation 25 insurance is an increasingly expensive and inefficient approach 26 to managing the cost of industrial accident and disease and is 27 further creating an increasing burden on Commonwealth employers; 28 WHEREAS, Unacceptable health access disparities exist in this 29 Commonwealth by region, race, ethnicity, income and gender; 30 WHEREAS, The existing funding mechanism for health care in 20060H2722B4146 - 2 -
1 this Commonwealth is ill-suited to respond to a natural or man- 2 made catastrophe that could disrupt the availability of health 3 care in the affected regions while at the same time demanding 4 immediate flexibility in revenue sourcing to pay for the care of 5 the injured and reconstruction of health care infrastructure; 6 WHEREAS, Current availability of and funding for substance 7 abuse counseling and treatment is grossly inadequate to the need 8 resulting in lost productivity, domestic violence, vehicular and 9 workplace accidents and crime; 10 WHEREAS, Health care costs are a leading cause of personal 11 bankruptcy and the use of credit cards as a last means of 12 funding care for an individual or the individual's loved ones 13 only adds to the cost of such care through higher interest rates 14 associated with unsecured revolving credit; 15 WHEREAS, Pennsylvania spends significantly more per capita on 16 health care than many other states, putting our Commonwealth and 17 our businesses at a competitive disadvantage to other states and 18 to all the foreign countries where governments provide universal 19 health care; 20 WHEREAS, Unstable and unaffordable rate increases for health 21 insurance are causing significant economic hardship for 22 Commonwealth residents and their employers; 23 WHEREAS, The annual increases in the cost of private health 24 insurance are leading more Pennsylvania employers to shift costs 25 to workers or to discontinue insurance of employees and retirees 26 altogether; 27 WHEREAS, The escalating cost of insuring public employees is 28 increasing the taxpayer burden and preventing municipalities, 29 school boards and the Commonwealth itself from investing in 30 education, public works, human services, environmental 20060H2722B4146 - 3 -
1 protection and other projects needed for the public good; 2 WHEREAS, The Commonwealth has an inefficient concentration of 3 diagnostic and treatment facilities in some communities while 4 other areas are underserved; 5 WHEREAS, Technology exists to support a system of digital 6 medical records that would substantially reduce administrative 7 costs while also reducing medical errors and duplicative 8 treatments or diagnostic procedures caused by unavailable or 9 unreadable records and orders; 10 WHEREAS, The ever-increasing cost of prescription drugs is 11 depriving our citizens of medications that save lives and 12 prevent costly illness yet there currently exists no means 13 whereby our Commonwealth can leverage the purchasing power of 14 its 12,000,000 citizens to bargain for the same discounts 15 enjoyed by nations of even smaller populations; 16 WHEREAS, Needed community hospitals, long-term care 17 facilities, nursing homes and health care agencies within this 18 Commonwealth are threatened with financial failure due to 19 inadequate reimbursement for services and an increasing 20 percentage of unreimbursed care; 21 WHEREAS, Historically efforts to control health care costs 22 while maintaining the private health insurance market has 23 invariably led to diminished access and quality in health care; 24 WHEREAS, An unsustainable and ever-increasing percentage of 25 every Pennsylvania health care dollar goes to inefficient and 26 redundant administrative systems, marketing and underwriting 27 expenses; 28 WHEREAS, Through the adoption of a single-payer public health 29 insurance system, Pennsylvania could cover all residents and 30 better manage and control the future cost of health care; 20060H2722B4146 - 4 -
1 WHEREAS, By simplifying administration, eliminating marketing 2 and underwriting expenses, achieving bulk purchase discounts on 3 pharmaceuticals and medical equipment and reducing the use of 4 emergency facilities for primary care, Pennsylvania could 5 reallocate billions of dollars toward providing direct health 6 care and improved quality and access; 7 WHEREAS, Too many of our citizens have lost their focus on 8 the importance of a personal commitment to and responsibility 9 for health as the most effective means of controlling health 10 care costs; and 11 WHEREAS, Advances in medical technology are not available to 12 all Pennsylvania residents who need them while at the same time 13 some communities have an excess capacity of such technology 14 resulting in inefficient application of resources; 15 THEREFORE, The Commonwealth of Pennsylvania hereby finds it 16 necessary to enact this legislation. 17 TABLE 0F CONTENTS 18 Chapter 1. Preliminary Provisions 19 Section 101. Short title. 20 Section 102. Definitions. 21 Chapter 3. Administration and Oversight of the Pennsylvania 22 Health Care Plan 23 Subchapter A. Pennsylvania Health Care Board 24 Section 301. Organization. 25 Section 302. Duties of board. 26 Subchapter B. Pennsylvania Health Care Agency 27 Section 321. Pennsylvania Health Care Agency. 28 Section 322. Executive director duties. 29 Section 323. Administrator for planning, research and 30 development. 20060H2722B4146 - 5 -
1 Section 324. Administrator for consumer affairs and health 2 education. 3 Section 325. Administrator for quality assurance. 4 Section 326. Administrator for finance. 5 Section 327. Administrator for claims. 6 Section 328. Administrator for volunteer services. 7 Section 329. Administrator for provider coordination. 8 Section 330. Administrator for law. 9 Section 331. Administrator for transition services. 10 Section 332. Administrator for beneficiary advocate. 11 Subchapter C. (Reserved). 12 Subchapter D. (Reserved). 13 Subchapter E. (Reserved). 14 Subchapter F. Immunity 15 Section 371. Immunity. 16 Chapter 5. Pennsylvania Health Care Plan 17 Section 501. General provisions. 18 Section 502. Universal health care access eligibility. 19 Section 503. Covered services. 20 Section 504. Excess and collective bargaining agreement health 21 insurance coverage. 22 Section 505. Duplicate coverage. 23 Section 506. Subrogation. 24 Section 507. Eligible participating providers and availability 25 of services. 26 Section 508. Rational cost containment. 27 Chapter 7. No-Fault Administrative Remedies 28 Section 701. Rationalization of remedies for errors and 29 complications. 30 Section 702. Voluntary waiver of tort remedies and choice 20060H2722B4146 - 6 -
1 to retain 2 tort remedies. 3 Section 703. No-fault administrative remedies for those not 4 opting out. 5 Section 704. Administrative claims procedures. 6 Section 705. Beneficiary right to counsel. 7 Section 706. Quality assurance follow-up to claims. 8 Section 707. Surviving tort claims against participating 9 providers. 10 Section 708. Claims against nonparticipating providers. 11 Section 709. Parallel no-fault compensation for beneficiaries 12 injured by nonparticipating providers. 13 Chapter 9. Pennsylvania Health Care Trust Fund 14 Section 901. Pennsylvania Health Care Trust Fund. 15 Section 902. Rolling budget process. 16 Section 903. Limitation on administrative expense. 17 Section 904. Funding sources. 18 Chapter 11. Transitional Support and Training 19 for Displaced Workers 20 Section 1101. Transitional support and training for displaced 21 workers. 22 Chapter 13. Volunteer Emergency Responder Network 23 Section 1301. Preservation of volunteer emergency responder 24 network. 25 Section 1302. Eligibility certification. 26 Section 1303. Eligibility criteria. 27 Section 1304. Amount of tax credit. 28 Section 1305. Reimbursement of Department of Revenue. 29 Chapter 15. Miscellaneous Provisions 30 Section 1501. Effective date. 20060H2722B4146 - 7 -
1 The General Assembly of the Commonwealth of Pennsylvania 2 hereby enacts as follows: 3 CHAPTER 1 4 PRELIMINARY PROVISIONS 5 Section 101. Short title. 6 This act shall be known and may be cited as the Balanced and 7 Comprehensive Health Care Reform Act. 8 Section 102. Definitions. 9 The following words and phrases when used in this act shall 10 have the meanings given to them in this section unless the 11 context clearly indicates otherwise: 12 "Agency." The Pennsylvania Health Care Agency established 13 under this act. 14 "Board." The Pennsylvania Health Care Board established 15 under this act. 16 "Department." The Department of Health of the Commonwealth. 17 "Executive director." The Executive Director of the 18 Pennsylvania Health Care Board. 19 "Fund." The Pennsylvania Health Care Trust Fund established 20 under this act. 21 "Individual Wellness Tax" or "IWT" The Individual Wellness 22 Tax established under this act. 23 "Plan." The Pennsylvania Health Care Plan established under 24 this act. 25 "Tax." The Employer Health Services Levy established under 26 this act. 27 CHAPTER 3 28 ADMINISTRATION AND OVERSIGHT OF THE 29 PENNSYLVANIA HEALTH CARE PLAN 30 SUBCHAPTER A 20060H2722B4146 - 8 -
1 PENNSYLVANIA HEALTH CARE BOARD 2 Section 301. Organization. 3 (a) Composition.--The Pennsylvania Health Care Board shall 4 be composed of 11 voting members and shall be chaired by the 5 executive director. 6 (b) Appointments.-- 7 (1) The executive director shall be appointed by the 8 Governor. The members of the board shall be appointed by the 9 Governor, the President pro tempore of the Senate, and the 10 Speaker of the House of Representatives who collectively 11 shall make appointments of members from individuals 12 representative of each of the following constituencies: 13 (i) Hospitals. 14 (ii) Organized labor, private sector. 15 (iii) Consumers. 16 (iv) Business. 17 (v) Agriculture. 18 (vi) Physicians. 19 (vii) Public sector employees. 20 (viii) Nurses. 21 (ix) Pharmacists. 22 (x) Long-term care facilities. 23 (xi) Social workers. 24 (2) The Governor shall initially appoint the executive 25 director, who shall serve as chair of the board, appointments 26 of the members shall thereafter be made in a rotating fashion 27 beginning with the President pro tempore of the Senate, then 28 the Speaker of the House of Representatives and then the 29 Governor, with each in turn making an appointment from a 30 constituency category not previously filled. 20060H2722B4146 - 9 -
1 (c) Terms of members.--Each member appointed or reappointed 2 under this section shall hold office for three years, starting 3 on the first day of the first month following the member's 4 appointment. A serving member of the board shall continue to 5 serve following the expiration of the member's term until a 6 successor takes office or a period of 90 days has elapsed, 7 whichever occurs first. 8 (d) Midterm vacancies.--Midterm vacancies shall be filled by 9 the same appointer and the individual appointed to fill a 10 vacancy occurring prior to the expiration of the term for which 11 a member is appointed shall hold office for the remainder of the 12 predecessor's term. 13 (e) Compensation, benefits and expenses.--The executive 14 director and members of the board shall receive an annual 15 salary, benefits and expense reimbursement established by the 16 board, to be paid from the trust. The initial board shall 17 establish its own compensation. No increase or decrease in 18 salary or benefits adopted by the board for the executive 19 director or members shall become effective within the same 20 three-year term. 21 (f) Meetings.-- 22 (1) The executive director shall set the time, place and 23 date for the initial and subsequent meetings of the board and 24 shall preside over its meetings. The initial meeting shall be 25 set not sooner than 50 nor later than 100 days after the 26 appointment of the executive director. Subsequent meetings 27 shall occur at least monthly thereafter. 28 (2) All meetings of the board are open to the public 29 unless questions of patient confidentiality arise. The board 30 may go into closed executive session with regard to issues 20060H2722B4146 - 10 -
1 related to confidential patient information. 2 (g) Quorum.--Two-thirds of the appointed members of the 3 board shall constitute a quorum for the conducting of business 4 at meetings of the board. Decisions at ordinary meetings of the 5 board shall be reached by majority vote of those actually 6 present or, in the event of emergency meeting, those also 7 present by electronic or telephonic means. Where there is a tie 8 vote, the executive director shall be granted an additional vote 9 to break the tie. 10 (h) Ethics.--The executive director, the members and their 11 immediate families are prohibited from having any pecuniary 12 interest in any business with a contract or in negotiation for a 13 contract with the agency. The board shall also adopt rules of 14 ethics and definitions of irreconcilable conflicts of interest 15 that will determine under what circumstances members must recuse 16 themselves from voting. 17 (i) Prohibitions.--No member of the board, except for the 18 executive director, who shall receive no additional salary or 19 benefits by virtue of serving on the board, shall hold any other 20 salaried Commonwealth public position, either elected or 21 appointed, during the member's tenure on the board. 22 Section 302. Duties of board. 23 (a) General duties.--The board is responsible for directing 24 the agency in the performance of all duties, the exercise of all 25 powers, and the assumption and discharge of all functions vested 26 in the agency. The board shall adopt and publish its rules and 27 procedures in the Pennsylvania Bulletin no later than 180 days 28 after the first meeting of the board. 29 (b) Specific duties.--The duties and functions of the board 30 include, but are not limited to, the following: 20060H2722B4146 - 11 -
1 (1) Implementing statutory eligibility standards for 2 benefits. 3 (2) Annually adopting a benefits package for 4 participants of the plan. 5 (3) Acting directly or through one or more contractors 6 as the single payer administrator for all claims for health 7 care services made under the plan. 8 (4) At least annually reviewing the appropriateness and 9 sufficiency of reimbursements. 10 (5) Providing for timely payments to participating 11 providers through a structure that is well organized and that 12 eliminates unnecessary administrative costs. 13 (6) Implementing standardized claims and reporting 14 methods for use by the plan. 15 (7) Developing a system of centralized electronic claims 16 and payments accounting. 17 (8) Establishing an enrollment system that will ensure 18 that those who travel frequently and cannot read or speak 19 English are aware of their right to health care and are 20 formally enrolled in the plan. 21 (9) Reporting annually to the General Assembly and to 22 the Governor, on or before the first day of October, on the 23 performance of the plan, the fiscal condition of the plan, 24 recommendations for statutory changes, the receipt of 25 payments from the Federal Government, whether current year 26 goals and priorities were met, future goals and priorities, 27 and major new technology or prescription drugs that may 28 affect the cost of the health care services provided by the 29 plan. 30 (10) Administering the revenues of the trust. 20060H2722B4146 - 12 -
1 (11) Obtaining appropriate liability and other forms of 2 insurance to provide coverage for the plan, the board, the 3 agency and their employees and agents. 4 (12) Establishing, appointing and funding appropriate 5 staff, office space, equipment, training and administrative 6 support for the agency throughout this Commonwealth, all to 7 be paid from the trust. 8 (13) Administering aspects of the agency by taking 9 actions that include, but are not limited to, the following: 10 (i) Establishing standards and criteria for the 11 allocation of operating funds. 12 (ii) Meeting regularly to review the performance of 13 the agency and to adopt and revise its policies. 14 (iii) Establishing goals for the health care system 15 established pursuant to the plan in measurable terms. 16 (iv) Establishing Statewide health care databases to 17 support health care services planning. 18 (v) Implementing policies and developing mechanisms 19 and incentives to assure culturally and linguistically 20 sensitive care. 21 (vi) Establishing rules and procedures for 22 implementation and staffing of a no-fault compensation 23 system for iatrogenic injuries or complications of care 24 whereby a patient's condition is made worse or an 25 opportunity for cure or improvement is lost due to the 26 health care or medications provided or appropriate care 27 not provided by participating providers under the plan. 28 (vii) Establishing standards and criteria for the 29 determination of appropriate transitional support and 30 training for residents of this Commonwealth who are 20060H2722B4146 - 13 -
1 displaced from work during the first two years of the 2 implementation of the plan. 3 (viii) Evaluating the state of the art in proven 4 technical innovations, medications and procedures and 5 adopting policies to expedite the rapid introduction 6 thereof in this Commonwealth. 7 (ix) Establishing methods for the recovery of costs 8 for health care services provided pursuant to the plan to 9 a beneficiary who is also covered under the terms of a 10 policy of insurance, a health benefit plan or other 11 collateral source available to the participant under 12 which the participant has a right of action for 13 compensation. Receipt of health care services pursuant to 14 the plan shall be deemed an assignment by the participant 15 of any right to payment for services from any such 16 policy, plan or other source. The other source of health 17 care benefits shall pay to the trust all amounts it is 18 obligated to pay to, or on behalf of, the participant for 19 covered health care services. The board may commence any 20 action necessary to recover the amounts due. 21 (14) Recruiting the Health Advisory Panel of seven 22 members made up of a cross section of the medical and 23 provider community. The members of the advisory panel shall 24 be paid a per diem rate, established by the board, for 25 attendance at meetings and further be reimbursed for actual 26 and necessary expenses incurred in the performance of their 27 duties, which shall include: 28 (i) Advising the board on the establishment of 29 policy on medical issues, population-based public health 30 issues, research priorities, scope of services, expansion 20060H2722B4146 - 14 -
1 of access to health care services and evaluation of the 2 performance of the plan. 3 (ii) Investigating proposals for innovative 4 approaches to the promotion of health, the prevention of 5 disease and injury, patient education, research and 6 health care delivery. 7 (iii) Advising the board on the establishment of 8 standards and criteria to evaluate requests from health 9 care facilities for capital improvements. 10 (iv) Evaluating and advising the board on requests 11 from providers, or their representatives, for adjustments 12 to reimbursements. 13 (15) Establishing a secure and centralized electronic 14 health record system wherein a beneficiary's entire health 15 record can be readily and reliably accessed by authorized 16 persons with the objective of eliminating the errors and 17 expense associated with paper records and diagnostic films. 18 SUBCHAPTER B 19 PENNSYLVANIA HEALTH CARE AGENCY 20 Section 321. Pennsylvania Health Care Agency. 21 (a) Establishment of agency.--There is hereby established 22 the Pennsylvania Health Care Agency. The agency shall administer 23 the plan and is the sole agency authorized to accept applicable 24 grants-in-aid from the Federal Government and State government. 25 It shall use such funds in order to secure full compliance with 26 provisions of Federal and State law and to carry out the 27 purposes established under this act. All grants-in-aid accepted 28 by the agency shall be deposited into the Pennsylvania Health 29 Care Trust Fund established under this act, together with other 30 revenues raised within this Commonwealth to fund the plan. 20060H2722B4146 - 15 -
1 (b) Appointment of executive director.--The executive 2 director of the agency shall be appointed by the Governor for a 3 term of three years and is the chief administrator of the plan. 4 (c) Personnel and employees.--The board shall employ and fix 5 the compensation of agency personnel as needed by the agency to 6 properly discharge the agency's duties. The employment of 7 personnel by the board is subject to the civil service laws of 8 this Commonwealth. The board shall employ personnel including, 9 but not limited to, the following leadership positions, all of 10 whom will report to the executive director of the agency: 11 (1) Administrator for planning, research and 12 development. 13 (2) Administrator for finance. 14 (3) Administrator for quality assurance. 15 (4) Administrator for consumer affairs and health 16 education. 17 (5) Administrator of health claims. 18 (6) Administrator for volunteer services. 19 (7) Administrator for provider coordination. 20 (8) Administrator for law. 21 (9) Administrator of transition services until the 22 termination of this position on December 31, 2012. 23 (10) Beneficiary advocate. 24 Section 322. Executive director duties. 25 The executive director shall oversee the operation of the 26 agency and the agency's performance of any duties assigned by 27 the board. 28 Section 323. Administrator for planning, research and 29 development. 30 The executive director of the agency shall determine the 20060H2722B4146 - 16 -
1 duties of the administrator of planning, research and 2 development. Those duties shall include, but not be limited to, 3 the following: 4 (1) Establishing policy on medical issues, population- 5 based public health issues, research priorities, scope of 6 services, the expansion of participants' access to health 7 care services and the evaluation of the performance of the 8 plan. 9 (2) Investigating proposals for innovative approaches 10 for the promotion of health, the prevention of disease and 11 injury, patient education, research and the delivery of 12 health care services. 13 (3) Establishing standards and criteria for evaluating 14 applications from health care facilities for capital 15 improvements. 16 (4) Evaluating environmental risks and coordinating 17 agency policy with other governmental and nongovernmental 18 entities committed to assuring health by reducing 19 environmental hazards. 20 Section 324. Administrator for consumer affairs and health 21 education. 22 The executive director of the agency shall determine the 23 duties of the administrator for consumer affairs and health 24 education. Those duties shall include, but not be limited to, 25 the following: 26 (1) Developing educational and informational guides for 27 consumers that describe consumer rights and responsibilities 28 and that inform consumers of effective ways to exercise 29 consumer rights to obtain health care services. The guides 30 shall be easy to read and understand and available in English 20060H2722B4146 - 17 -
1 and in other languages. The agency shall make the guide 2 available to the public through public outreach and 3 educational programs and through the Internet website of the 4 agency. 5 (2) Establishing a toll-free telephone number to receive 6 questions and complaints regarding the agency and the 7 agency's services. The agency's Internet website shall 8 provide complaint forms and instructions online. 9 (3) Examining suggestions from the public. 10 (4) Making recommendations for improvements to the 11 board. 12 (5) Examining the extent to which individual health care 13 facilities in a region meet the needs of the community in 14 which they are located. 15 (6) Receiving, investigating and responding to all 16 consumer complaints about any aspect of the plan and, where 17 appropriate, referring the results of all investigations of 18 questioned care to the appropriate provider or health care 19 facility licensing board or, in cases of possible violation 20 of law, to a law enforcement agency. 21 (7) Publishing an annual report for the public, the 22 Governor and the General Assembly that contains a Statewide 23 evaluation of the agency. 24 (8) Holding public hearings in each congressional 25 district, at least annually, for public input. 26 Section 325. Administrator for quality assurance. 27 The executive director of the agency shall determine the 28 duties of the administrator of quality assurance. Those duties 29 shall include, but not be limited to, the following: 30 (1) Studying and reporting on the efficacy of health 20060H2722B4146 - 18 -
1 care treatments and medications for particular conditions. 2 (2) Identifying causes of medical errors and devising 3 procedures to reduce their frequency. 4 (3) Establishing an evidence-based formulary. 5 (4) Identifying treatments and medications that are 6 unsafe or have no proven value. 7 (5) Establishing a process for soliciting information on 8 medical standards from providers and consumers for purposes 9 of this section. 10 (6) Independently reviewing all claims submitted to the 11 administrator of health claims to determine if correctable 12 errors have occurred or whether there are patterns of errors 13 or complications which require closer investigation, 14 evaluation and correction, and then to assure all such 15 appropriate measures are recommended in writing to the 16 executive director. 17 Section 326. Administrator for finance. 18 The executive director of the agency shall determine the 19 duties of the administrator of finance. Those duties shall 20 include, but not be limited to, the following: 21 (1) Administering the trust. 22 (2) Making payments to participating providers within 23 five business days of submission and to other providers 24 within 30 days of submission. 25 (3) Developing a system of simplified, secure and 26 centralized electronic claims and payments employing the best 27 technology with assured backup and catastrophe recovery 28 contingencies and facilities. 29 (4) Communicating to the State Treasurer when funds are 30 needed from the trust for the operation of the plan. 20060H2722B4146 - 19 -
1 (5) Developing information systems for utilization 2 review. 3 (6) Investigating and recommending for appropriate civil 4 and/or criminal prosecution possible provider or consumer 5 fraud. 6 Section 327. Administrator for claims. 7 The executive director of the agency shall determine the 8 duties of the administrator of claims. Those duties shall 9 include, but not be limited to, the following: 10 (1) Establishing a system of administrative procedures, 11 health claim hearing officers and appeal panel for the 12 processing of patient claims. 13 (2) Supervising the health claims hearing officers to 14 assure swift and fair processing of claims. 15 (3) Reviewing all appeals from the determinations of the 16 health claims hearing officers, and then advising the 17 executive director who shall then make the final agency 18 determination. 19 (4) Supervising follow-up oversight of awarded claims to 20 determine when or if adjustments to the awarded compensation 21 is appropriate given improvement in the awardee's condition 22 and if so to initiate appropriate review procedures before 23 the health claims hearing officers. 24 Section 328. Administrator for volunteer services. 25 The executive director of the agency shall determine the 26 duties of the administrator for volunteer services. Those duties 27 shall include, but not be limited to, the following: 28 (1) Coordinating with the State Treasurer to establish 29 procedures necessary to implement the volunteer tax rebate 30 provisions of this act. 20060H2722B4146 - 20 -
1 (2) Investigating the status of volunteerism in this 2 Commonwealth in firefighting, search and rescue, emergency 3 response and otherwise as it pertains to the health of 4 Pennsylvanians and the means by which citizens can be 5 encouraged to volunteer. 6 (3) Developing programs to encourage blood and organ 7 donation in this Commonwealth. 8 (4) Making recommendations to the executive director and 9 the board for programs and initiatives that will best support 10 and encourage health-related volunteerism in this 11 Commonwealth. 12 Section 329. Administrator for provider coordination. 13 The executive director of the agency shall determine the 14 duties of the administrator for provider coordination. Those 15 duties shall include, but not be limited to, all of the 16 following: 17 (1) Processing all applications for participating 18 provider status. 19 (2) Assisting participating providers in their efforts 20 to meet the qualification requirements established by the 21 board. 22 (3) Establishing an inquiry office to assist 23 participating providers with regard to proper submission of 24 requests for reimbursements. 25 Section 330. Administrator for law. 26 The executive director of the agency shall determine the 27 duties of the administrator for law. Those duties shall include, 28 but not be limited to, the following: 29 (1) Establishing, supervising and maintaining a team of 30 legal professionals as necessary to support all of the legal 20060H2722B4146 - 21 -
1 representation needs of the agency. 2 (2) Defending the interests of the plan before the 3 health claims hearing officers and before the courts against 4 nonmeritorious claims. 5 (3) Representing the board in disciplinary actions 6 against participating providers. 7 (4) Serving as the principal ethics officer for the 8 agency. 9 Section 331. Administrator for transition services. 10 The executive director of the agency shall determine the 11 duties of the administrator of transition services. Those duties 12 shall include, but not be limited to, the following: 13 (1) Establishing procedures for identifying 14 Pennsylvanians whose livelihood will be detrimentally 15 affected by the passage of this act. 16 (2) Establishing procedures to most efficiently and 17 effectively transition such persons into positions with the 18 agency where appropriate or to other health-related fields 19 where the passage of this act will create an immediate need 20 for qualified employees. 21 (3) Reporting to the administrator of finance with 22 respect to the financial requirements to support the eligible 23 displaced citizens and to assist in the filing for 24 transitional wage replacement benefits approved by the board. 25 (4) Planning for the discontinuance of this division of 26 the board on December 31, 2012. 27 Section 332. Administrator for beneficiary advocate. 28 The executive director of the agency shall determine the 29 duties of the beneficiary advocate. Those duties shall include, 30 but not be limited to, the following: 20060H2722B4146 - 22 -
1 (1) Establishment of a readily accessible beneficiary 2 telephone and Internet website resource in instances where 3 they are having difficulties securing necessary care through 4 the plan. This office shall make immediate inquiries to 5 ascertain the nature of the difficulties and to resolve the 6 beneficiary's problem. 7 (2) Where a beneficiary seeks specialized care from 8 outside this Commonwealth and from other than a participating 9 provider, the beneficiary advocate shall assist in the proper 10 application for an extension of benefits on behalf of the 11 beneficiary. 12 (3) Management of death claim dependent trusts. 13 SUBCHAPTER C 14 (Reserved) 15 SUBCHAPTER D 16 (Reserved) 17 SUBCHAPTER E 18 (Reserved) 19 SUBCHAPTER F 20 IMMUNITY 21 Section 371. Immunity. 22 In the absence of fraud or bad faith, the advisory panel, the 23 board and agency and their respective members and employees 24 shall incur no liability in relation to the performance of their 25 duties and responsibilities under this act. The Commonwealth 26 shall incur no liability in relation to the implementation and 27 operation of the plan. 28 CHAPTER 5 29 PENNSYLVANIA HEALTH CARE PLAN 30 Section 501. General provisions. 20060H2722B4146 - 23 -
1 (a) Establishment of plan.--There is hereby established the 2 Pennsylvania Health Care Plan that shall be administered by the 3 independent Pennsylvania Health Care Agency under the direction 4 of the Pennsylvania Health Care Board. 5 (b) Coverage.--The plan shall provide health care coverage 6 for all citizens of this Commonwealth and for certain eligible 7 visitors. The agency shall work simultaneously to control health 8 care costs, achieve measurable improvement in health care 9 outcomes, promote a culture of health awareness, increase 10 satisfaction with the health care system, adopt an optional no- 11 fault administrative system to fairly compensate those whose 12 conditions are made worse by the treatments they receive or 13 through failures to receive appropriate care, implement policies 14 that strengthen and improve culturally sensitive care, and 15 develop an integrated health care database to support health 16 care planning and quality assurance. 17 (c) Reforms.--The board shall implement the reforms adopted 18 by the General Assembly hereby on January 1, 2008. 19 Section 502. Universal health care access eligibility. 20 (a) Eligibility.--All Pennsylvania citizens, including 21 documented aliens, full-time out-of-State students attending 22 school in this Commonwealth, homeless persons and migrant 23 agricultural workers and their accompanying families are 24 eligible beneficiaries under the plan. The board shall establish 25 standards and a simple procedure to demonstrate proof of 26 eligibility. 27 (b) Enrollment.--Enrollment in the plan shall be automatic 28 and beneficiaries shall be provided with access cards with 29 appropriate proof of identity technology and privacy protection. 30 Individuals covered under a collective bargaining agreement that 20060H2722B4146 - 24 -
1 provides health benefits at least as extensive as the plan, as 2 certified by the executive director, shall not be eligible for 3 plan benefits. 4 (c) Waivers.--If waivers are not obtained from the medical 5 assistance and/or Medicare programs operated under Title XVIII 6 or XIX of the Social Security Act (49 Stat. 620, 42 U.S.C. § 301 7 et seq.), the medical assistance and Medicare nonwaived programs 8 shall act as the primary insurers for those eligible for such 9 coverage, and the plan shall serve as the secondary or 10 supplemental plan of health coverage. Until such time as waivers 11 are obtained, the plan will not pay for services for persons 12 otherwise eligible for the same benefits under Medicare or 13 Medicaid. The plan shall also be secondary to benefits provided 14 to military veterans except where reasonable and timely access, 15 as defined by the board, is denied or unavailable through the 16 United States Veterans' Administration, in which instance the 17 plan will be primary and will seek reasonable reimbursement from 18 the United States Veterans' Administration for the services 19 provided to veterans. 20 (d) Priority of plans.--A plan of employee health coverage 21 provided by an out-of-State employer to a Pennsylvania resident 22 working outside of this Commonwealth shall serve as the 23 employee's primary plan of health coverage, and the plan shall 24 serve as the employee's secondary plan of health coverage. 25 (e) Reimbursement.--The plan shall reimburse participating 26 providers practicing outside of this Commonwealth at plan rates, 27 or reasonable locally prevailing rate, for health care services 28 rendered to a beneficiary while the beneficiary is out of this 29 Commonwealth. Services provided to a beneficiary out of this 30 Commonwealth by other than a participating provider shall be 20060H2722B4146 - 25 -
1 reimbursed to the beneficiary or to the provider at a fair and 2 reasonable rate for that location. 3 (f) Presumption of eligibility.--Any individual who arrives 4 at a health care facility unconscious or otherwise unable due to 5 their mental or physical condition to document eligibility for 6 coverage shall be presumed to be eligible, and emergency care 7 shall be provided without delay occasioned over issues of 8 ability to pay. 9 (g) Rules.--The board shall adopt rules assuring that any 10 participating provider who renders humanitarian emergency or 11 urgent care within this Commonwealth to a not actually eligible 12 recipient shall nevertheless be reimbursed for such care from 13 the plan subject to such rules as will reasonably limit the 14 frequency of such events to protect the fiscal integrity of the 15 plan. It shall be the agency's responsibility to secure 16 reimbursement for the costs paid for such care from any 17 appropriate third party funding source, or from the individual 18 to whom the services were rendered. 19 Section 503. Covered services. 20 (a) Benefits package.--The board shall establish a single 21 health benefits package within the plan that shall include, but 22 not be limited to, all of the following: 23 (1) Inpatient and outpatient care, both primary and 24 secondary. 25 (2) Emergency services. 26 (3) Emergency and other medically necessary transport to 27 covered health services. 28 (4) Rehabilitation services, including speech, 29 occupational and physical therapy. 30 (5) Inpatient and outpatient mental health services and 20060H2722B4146 - 26 -
1 substance abuse treatment. 2 (6) Hospice care. 3 (7) Prescription drugs and prescribed medical nutrition. 4 (8) Vision care, aids and equipment. 5 (9) Hearing care, hearing aids and equipment. 6 (10) Diagnostic medical tests, including laboratory 7 tests and imaging procedures. 8 (11) Medical supplies and prescribed medical equipment. 9 (12) Immunizations, preventive care, health maintenance 10 care and screening. 11 (13) Dental care. 12 (14) Home health care services. 13 (15) Chiropractic and massage therapy. 14 (16) Long-term care for those unable to care for 15 themselves independently and including assisted and skilled 16 care. 17 (b) Exclusions for preexisting conditions.--The plan shall 18 not exclude or limit coverage due to preexisting conditions. 19 (c) Copayments, deductibles, etc.--Beneficiaries of the plan 20 are not subject to copayments, deductibles, point-of-service 21 charges or any other fee or charge for a service within the 22 package and shall not be directly billed nor balance billed by 23 participating providers for covered benefits provided to the 24 beneficiary. Where a beneficiary has directly paid for 25 nonemergency services of a nonparticipating provider, the 26 beneficiary may submit a claim for reimbursement from the plan 27 for the amount the plan would have paid a participating provider 28 for the same service. Where emergency services are rendered by a 29 nonparticipating provider, the beneficiary shall receive 30 reimbursement of the full amount paid to such nonparticipating 20060H2722B4146 - 27 -
1 provider not to exceed 125% of the amount the plan would have 2 paid a participating provider for the same service. 3 (d) Exclusions of coverage.--The board shall remove or 4 exclude procedures and treatments, equipment and prescription 5 drugs from the plan benefit package that the board finds unsafe 6 or that add no therapeutic value. 7 (e) The board shall exclude coverage for any surgical, 8 orthodontic or other procedure or drug that the board determines 9 was or will be provided primarily for cosmetic purposes unless 10 required to correct a congenital defect, to restore or correct 11 disfigurements resulting from injury or disease or that is 12 certified to be medically necessary by a qualified, licensed 13 provider. 14 (f) Choice by beneficiary.--Beneficiaries shall normally be 15 granted free choice of the participating providers, including 16 specialists, without preapprovals or referrals. However, the 17 board shall adopt procedures to restrict such free choice for 18 those individuals who engage in patterns of wasteful or abusive 19 self-referrals to specialists. Specialists who provide primary 20 care to a self-referred beneficiary will be reimbursed at the 21 board-approved primary care rate established for the service in 22 that community. 23 (g) Service.--No participating provider shall be compelled 24 to offer any particular service so long as the refusal is 25 general, consistent and not discriminatory. 26 (h) Discrimination.--The plan and participating providers 27 shall not discriminate on the basis of race, ethnicity, national 28 origin, gender, age, religion, sexual orientation, health 29 status, mental or physical disability, employment status, 30 veteran status or occupation. 20060H2722B4146 - 28 -
1 Section 504. Excess and collective bargaining agreement health 2 insurance coverage. 3 Subject to the regulations of the Insurance Commissioner and 4 all applicable laws, private health insurers shall be authorized 5 to offer coverage supplemental to the package approved and 6 provided automatically under this act. Private insurers shall 7 also be authorized to offer programs to support the health care 8 terms of a collective bargaining agreement provided that such 9 benefits are at least as comprehensive as those provided under 10 the plan. 11 Section 505. Duplicate coverage. 12 The agency is subrogated to and shall be deemed an assignee 13 of all rights of a beneficiary who has received duplicate health 14 care benefits, or who has a right to such benefits, under any 15 other policy or contract of health care or under any government 16 program. 17 Section 506. Subrogation. 18 (a) General rule.--The agency shall have no right of 19 subrogation against a beneficiary's third-party claims for harm 20 or losses not covered under this act. Nor shall any beneficiary 21 under this act have a claim against a third-party tortfeasor for 22 the services provided or available to the beneficiary under this 23 act. In all personal injury actions accruing and prosecuted by a 24 beneficiary on or after January 1, 2008, the presiding judge 25 shall advise any jury that all health care expenses have been or 26 will be paid under the plan, and, therefore, no claim for past 27 or future health care benefits is pending before the court. 28 (b) Exception.--The exception to the general rule of no 29 subrogation shall be that the agency retains its equitable right 30 to subrogation to the recovery, including the recovery for 20060H2722B4146 - 29 -
1 noneconomic damages, of those persons opting out of the no-fault 2 administrative remedies adopted herein and who successfully 3 prosecute to verdict or settlement a claim for health care 4 professional or institutional negligence. The agency's right to 5 subrogation shall be absolute and shall not be subject to 6 reduction for attorney fees or costs of litigation. 7 Section 507. Eligible participating providers and availability 8 of services. 9 (a) General rule.--All licensed health care providers and 10 facilities are eligible to become a participating provider in 11 the plan in which instance they shall enjoy the rights and have 12 the duties as set forth in the plan as stated in this section or 13 as adopted by the board from time to time. Nonparticipating 14 providers shall not enjoy the rights nor bear the duties of 15 participating providers. 16 (b) Required notice.--In advance of initially providing 17 services to a beneficiary, nonparticipating providers shall 18 advise the beneficiary at the time the appointment is made that 19 the person or entity is a nonparticipating provider and that the 20 recipient of the service will be initially personally 21 responsible for the entire cost of the service and ultimately 22 responsible for the cost in excess of the reimbursement approved 23 by the board for participating providers. Failure to make such 24 financial disclosure will be deemed a fraud on the beneficiary 25 and entitle the beneficiary to a refund equal to 200% of the 26 amount paid to the nonparticipating provider in excess of the 27 board-approved reimbursement for the services rendered, plus all 28 reasonable fees for collection. The burden of proof that such 29 disclosure was made shall be on the nonparticipating provider. 30 (c) Plan by board.--The board shall assess the number of 20060H2722B4146 - 30 -
1 primary and specialty providers needed to supply adequate health 2 care services in this Commonwealth generally and in all 3 geographic areas and shall develop a plan to meet that need. The 4 board shall develop financial incentives for participating 5 providers in order to maintain and increase access to health 6 care services in underserved areas of this Commonwealth. 7 (d) Reimbursements.--Reimbursements shall be determined by 8 the board in such a fashion as to assure that a participating 9 provider receives compensation for services that fairly and 10 fully reflect the skill, training, operating overhead included 11 in the costs of providing the service, capital costs of 12 facilities and equipment, cost of consumables and the expense of 13 safely discarding medical waste, plus a reasonable profit 14 sufficient to encourage talented individuals to enter the field 15 and for investors to make capital available for the construction 16 of state-of-the-art health care facilities in this Commonwealth. 17 (e) Adjustments to reimbursements.--Participating providers 18 shall have the right alone or collectively to petition the board 19 for adjustments to reimbursements believed to be too low. Such 20 petitions shall be initially evaluated by the administrator of 21 provider services, with input from the Health Advisory Panel, 22 who shall submit a report to the executive director within 30 23 days. The executive director will then submit a recommendation 24 to the board for action at the next scheduled board meeting. 25 Participating providers who remain dissatisfied after the board 26 has ruled may appeal the board's determination to the Court of 27 Common Pleas of Dauphin County, which shall review the action of 28 the board on an abuse of discretion standard. 29 (f) Evaluation of access to care.--The board annually shall 30 evaluate access to trauma care, diagnostic imaging technology, 20060H2722B4146 - 31 -
1 emergency transport and other vital urgent care requirements and 2 shall establish measures to assure beneficiaries have equitable 3 and ready access to such resources regardless of where in this 4 Commonwealth they may be. 5 (g) Performance reports.--The board, with the assistance of 6 the Health Advisory Panel and the administrator of quality 7 assurance, shall define performance criteria and goals for the 8 plan and shall make a written report to the General Assembly at 9 least annually on the plan's performance. All such reports, 10 including the survey results obtained, shall be made publicly 11 available with the goal of total transparency and open self- 12 analysis as a defining quality of the agency. The board shall 13 establish a system to monitor the quality of health care and 14 patient and provider satisfaction and to adopt a system to 15 devise improvements and efficiencies to the provision of health 16 care services. 17 (h) Data reporting.--All participating providers shall 18 provide data to the agency promptly upon the request of the 19 executive director. 20 (i) Coordination of services.--The board shall coordinate 21 the provision of health care services with any other 22 Commonwealth and local agencies that provide health care 23 services directly to their charges or residents. 24 Section 508. Rational cost containment. 25 (a) Approval of expenditures.--As part of its cost 26 containment mission, the board shall screen and approve or 27 disapprove private or public expenditures for new health care 28 facilities and other capital investments that may lead to 29 redundant and inefficient health care provider capacity. 30 Procedures shall be adopted for this purpose with an emphasis 20060H2722B4146 - 32 -
1 upon efficiency and a fair and open consideration of all 2 applications. 3 (b) Capital investments.--All capital investments valued at 4 one million dollars or greater, including the costs of studies, 5 surveys, design plans and working drawing specifications, and 6 other activities essential to planning and execution of capital 7 investment and all capital investments that change the bed 8 capacity of a health care facility by more than 10% over a 24- 9 month period or that add a new service or license category shall 10 require the approval of the board. When a facility, an 11 individual acting on behalf of a facility or any other purchaser 12 obtains by lease or comparable arrangement any facility or part 13 of a facility, or any equipment for a facility, the market value 14 of which would have been a capital expenditure, the lease or 15 arrangement shall be considered a capital expenditure for 16 purposes of this section. 17 (c) Deemed approval.--Capital investment programs submitted 18 for approval shall be deemed approved unless specifically 19 rejected by the board within 60 days from the date the 20 submissions are received by the executive director. 21 (d) Recommendations.--Recommendations of the Pennsylvania 22 Heath Cost Containment Council, Pittsburgh Regional Health Care 23 Initiative and such other public and private authoritative 24 bodies as shall be identified from time to time by the board 25 shall be received by the executive director and submitted to the 26 board with the executive director's recommendation regarding 27 implementation of the recommended reforms. The board shall 28 receive input from all interested parties and then shall vote 29 upon all such recommendations within 60 days. Where procedural 30 or protocol reforms are adopted, participating providers will be 20060H2722B4146 - 33 -
1 required to implement such designated best practices within the 2 next 60 days. 3 (e) Required investments.--If mandated reforms require the 4 acquisition of additional equipment, participating providers 5 shall make such investments within one year, and, upon 6 application, the board shall provide financing for such mandated 7 equipment on reasonable terms. 8 (f) Sanctions.--Participating providers refusing to adopt 9 recommended reforms shall, after a reasonable opportunity to be 10 heard, be subject to such sanctions as the board shall deem 11 appropriate and necessary up to and including the suspension or 12 permanent decertification of the provider. 13 CHAPTER 7 14 NO-FAULT ADMINISTRATIVE REMEDIES 15 Section 701. Rationalization of remedies for errors and 16 complications. 17 A primary objective of the board shall be to reduce the 18 frequency of medical errors and complications and to establish a 19 no-fault administrative procedure for fair and expeditious 20 compensation to those who suffer injuries or complications 21 relating to their care. 22 Section 702. Voluntary waiver of tort remedies and choice to 23 retain tort remedies. 24 Beneficiaries under the plan shall be conclusively deemed to 25 have voluntarily waived all other common law and statutory tort 26 remedies against any participating provider for alleged 27 professional negligence, error of judgment or failure to secure 28 informed consent. Beneficiaries under the plan not willing to 29 waive such common law and statutory remedies may opt out of the 30 no-fault administrative remedies set forth in this act at any 20060H2722B4146 - 34 -
1 time prior to the events complained of. Nonparticipating 2 providers shall not fall within the protections of the waiver of 3 tort remedies. 4 Section 703. No-fault administrative remedies for those not 5 opting out. 6 (a) Compensation.--In exchange for the waiver of their 7 traditional tort remedies, beneficiaries who suffer a new injury 8 or complication directly related to the care provided by, or 9 medications or treatments prescribed by a participating provider 10 shall be entitled to expedited compensation without proof of 11 professional negligence or error of judgment. Where the 12 application for compensation does not arise from a new injury or 13 complication but rather asserts a failure of a participating 14 provider to properly intervene, and thus mitigate the natural 15 progress of a disease or injury, proof of a departure from the 16 standard of care must be demonstrated by a preponderance of the 17 credible evidence for the claimant to qualify for compensation. 18 Out-of-state patients seeking care in Pennsylvania from a 19 participating provider shall, prior to treatment unless 20 unconscious or other circumstances prevent it, be provided with 21 a form approved by the board on which the patient can opt in or 22 opt out of the no-fault administrative remedies. Where no 23 election is made, the patient shall be conclusively presumed to 24 have chosen to participate in the no-fault administrative 25 remedies should the occasion arise. 26 (b) Other compensation.--In further exchange for the waiver 27 of their traditional tort remedies, beneficiaries not opting out 28 of the no-fault administrative remedies and who assert that they 29 did not give their informed consent to an invasive procedure or 30 treatment, but who have not suffered a new injury or 20060H2722B4146 - 35 -
1 complication thereby, shall be entitled to compensation upon 2 proof of the failure of the participating provider, or the 3 provider's representative, to provide at least the level of 4 information required for the procedure at issue pursuant to 5 guidelines adopted by the board. 6 (c) Award of damages.--Eligible claimants not opting out of 7 the no-fault administrative remedies shall be entitled to awards 8 to be determined by the health claims hearing officers as 9 follows: 10 (1) For past and/or continuing lost earning capacity, up 11 to a maximum of $5,000 per month. 12 (2) For noneconomic harm, defined as past and/or 13 continuing pain, suffering, disfigurement and/or 14 inconvenience, up to a maximum of $5,000 per month. 15 (3) For a failure of informed consent, either alone or 16 in conjunction with an award for past and or continuing lost 17 earning capacity and/or noneconomic harm, a maximum single 18 lump-sum payment of $10,000. 19 (4) For death, and in addition to the lost earning 20 capacity and noneconomic harm endured prior to death, up to a 21 maximum of $10,000 per month for 120 months to be placed in 22 trust for the benefit of the decedent's dependents. The trust 23 shall be managed by the office of the beneficiary advocate 24 under guidelines adopted by the board. 25 (d) Adjustments of limits.--The board shall adjust the 26 limits of compensation annually to account for inflation, and 27 all awards for continuing lost earning capacity and/or 28 noneconomic damages shall be adjusted annually at the same rate 29 of inflation as determined by the board. 30 (e) Payment from trust.--The cost of all such compensation 20060H2722B4146 - 36 -
1 shall be paid from the trust. No participating provider shall be 2 held financially responsible for any portion of the compensation 3 award nor shall participating providers be required to fund the 4 cost of such awards collectively through any assessment or 5 premium. 6 Section 704. Administrative claims procedures. 7 (a) Application for compensation.--The board shall adopt 8 simplified procedures for the submission of applications for no- 9 fault compensation under this act to the administrator of health 10 claims. The procedures shall provide for the expeditious 11 handling and approval of any clearly qualifying claims. Where 12 fact-finding is required in whole or in part, such claims shall 13 be presented expeditiously to a health claims hearing officer 14 for findings. Administrative appeals to the executive director 15 shall be permitted, and, where a claimant has been denied 16 compensation or contests the sufficiency of the award, claimant 17 shall have an appeal to the Court of Common Pleas of Dauphin 18 County which will consider the adequacy of the compensation on a 19 de novo basis with the power to increase or decrease the amount 20 awarded administratively. However, such court shall not have the 21 power to award compensation in excess of the limits established 22 by this act. 23 (b) Attorney fees.--Where on appeal to the Court of Common 24 Pleas of Dauphin County a denied claim is approved or an 25 administrative award is increased by at least 25%, the court 26 shall also award a reasonable attorney fee of no more than 20% 27 and all reasonable litigation expenses including the cost of 28 expert witnesses and exhibits. 29 (c) Adjustment of awards.--The board shall further adopt 30 procedures whereby awards granted under this section for 20060H2722B4146 - 37 -
1 continuing harms shall be subject to increase, not to exceed the 2 limits, or decrease upon a showing of a material change in the 3 claimant's condition. Continuing benefits shall be contingent 4 upon the reasonable cooperation of the claimant with respect to 5 the rehabilitation and mitigation of the claimant's injury. 6 (d) Administrative procedure.--The board shall adopt 7 administrative procedure to review appeals of participating 8 providers with respect to denials or adjustment of reimbursement 9 which appeals must be filed within 90 days of the notice of a 10 denied or adjusted reimbursement. 11 Section 705. Beneficiary right to counsel. 12 (a) Choice of counsel.--Beneficiaries seeking to file a 13 claim for no-fault compensation under this act shall have the 14 right to be represented by legal counsel of their choice. 15 (b) Fee agreement.--Any contingent fee agreement entered 16 into between a beneficiary claimant and their legal counsel 17 shall be limited as follows: 18 (1) Five percent where the claim is administratively 19 approved without a hearing. 20 (2) Ten percent where the claim proceeds to a hearing. 21 (3) Twenty percent where the claim is resolved after 22 appeal. 23 Section 706. Quality assurance follow-up to claims. 24 (a) Investigations.--All claims of error, complication or 25 failure of informed consent shall simultaneously be submitted 26 for analysis and quality assurance investigation through the 27 office of the administrator for quality assurance. The 28 beneficiary submitting the claim shall be advised of the 29 progress of the inquiry and invited to present such information 30 or testimony as they deem necessary to the full and fair 20060H2722B4146 - 38 -
1 consideration of the matters reported. Beneficiaries may attend 2 and/or be represented during this process by counsel of their 3 choosing at their own expense or may request the assistance at 4 no cost of a qualified advocate from the office of the 5 administrator of consumer affairs. 6 (b) Representation of providers.--Participating providers 7 who are the subject of an inquiry initiated by a beneficiary 8 application for compensation may attend and/or be represented by 9 counsel of their choosing at their own expense or may request 10 the assistance at no cost of a qualified advocate from the 11 office of the administrator for provider coordination. 12 (c) Reports.--At the conclusion of the inquiry, the 13 administrator of quality assurance shall submit a report and 14 recommendations to the executive director who shall then take 15 such action as they deem necessary under the circumstances to 16 avoid a recurrence of any avoidable errors. A copy of the 17 recommendations shall be provided to the beneficiary who 18 initiated the claim and also to the participating provider 19 involved in the inquiry. The report will be forwarded to 20 appropriate licensing authorities for further action. 21 Section 707. Surviving tort claims against participating 22 providers. 23 (a) Optional remedies.--Otherwise eligible persons who have 24 opted out of the no-fault administrative remedies of the plan 25 shall retain their right to pursue traditional tort remedies 26 against participating providers through the courts of this 27 Commonwealth and, where jurisdictional requirements are 28 satisfied, through the courts of the United States. 29 (b) Legal counsel.--In all such cases participating 30 providers shall have the right to legal counsel of their choice 20060H2722B4146 - 39 -
1 the reasonable cost of which shall be paid by the plan as will 2 the reasonable cost of experts and other trial expenses. In the 3 event of a final award in favor of the persons filing the claim, 4 the plan shall further provide primary indemnification of up to 5 three million dollars per claim and six million dollars per 6 annual aggregate claims per participating provider. 7 (c) Excess liability coverage.--In the event the private 8 insurance market does not make excess coverage available to 9 participating providers at reasonable cost, the board shall 10 recommend to the General Assembly the establishment of an excess 11 liability insurance pool sponsored by the Commonwealth and 12 financed with premiums to be paid by those participating 13 providers who seek additional protection above and beyond the 14 protection provided in subsection (b). 15 Section 708. Claims against nonparticipating providers. 16 Health care providers opting out of the plan shall be 17 responsible for the cost of their legal defense and shall be 18 further responsible to the patient and/or the plan for any 19 settlement or award, if any. Where the plan has paid for health 20 care-related costs arising from an alleged failure of due care 21 by a nonparticipating provider and where the injured party has 22 otherwise been made whole, the plan shall be subrogated to the 23 claim to the extent of the medical expenses incurred or that 24 have been found will be incurred. 25 Section 709. Parallel no-fault compensation for beneficiaries 26 injured by nonparticipating providers. 27 Beneficiaries who have not opted out of the no-fault 28 administrative remedies pursuant to section 702, and who believe 29 they have been harmed by the negligence of a nonparticipating 30 provider, may elect, alone or in addition to pursuing 20060H2722B4146 - 40 -
1 traditional tort claims against the nonparticipating providers, 2 to submit a claim under section 704, in which instance the plan 3 shall be subrogated to and/or credited with the beneficiary's 4 recovery, net of reasonable attorney fees and expenses, from the 5 nonparticipating provider to the extent of economic, noneconomic 6 and/or failure of informed consent benefits paid to such 7 beneficiaries. 8 CHAPTER 9 9 PENNSYLVANIA HEALTH CARE TRUST FUND 10 Section 901. Pennsylvania Health Care Trust Fund. 11 (a) Establishment.--The Pennsylvania Health Care Trust Fund 12 is hereby established within the State Treasury. All moneys 13 collected and received by the plan shall be transmitted to the 14 State Treasurer for deposit into the fund, to be used 15 exclusively to finance the plan. 16 (b) State Treasurer.--The State Treasurer may invest the 17 principal and interest earned by the fund in any manner 18 authorized under law for the investment of Commonwealth moneys. 19 Any revenue or interest earned from the investments shall be 20 credited to the fund. 21 (c) Administrator of finance.--The administrator of finance 22 of the agency shall notify the board when the monthly 23 expenditures or anticipated future expenditures of the plan 24 appear to be in excess of the anticipated future revenues for 25 the same period. The board shall implement appropriate measures 26 upon such notification. Such measures shall include the 27 adjustment of the Wellness Tax as necessary to ensure the 28 solvency of the trust. 29 Section 902. Rolling budget process. 30 (a) Estimated annual budget.--The board shall prepare and 20060H2722B4146 - 41 -
1 recommend to the General Assembly an estimated annual budget for 2 health care, which budget specifies an estimated requirement for 3 health care provided under this act. The budget shall include 4 all of the following components: 5 (1) A system budget covering all expenditures for the 6 agency. 7 (2) A capital investment budget. 8 (3) A purchasing budget. 9 (4) A research and innovation budget. 10 (b) Budget projections.--In preparing the budget, the board 11 shall consider anticipated increased expenditures and savings, 12 including, but not limited to, projected increases in 13 expenditures due to improved access for underserved populations 14 and improved reimbursement for primary care, projected 15 administrative savings under the single-payer mechanism, 16 projected savings in prescription drug expenditures under 17 competitive bidding and a single buyer, and projected savings 18 due to provision of primary care rather than emergency room 19 treatment. 20 (c) Rolling budget.--The board shall operate on a rolling 21 budget whereby it will anticipate its funding needs 90 days in 22 advance and shall seek adjustments from the General Assembly to 23 The Employer Health Services Levy and/or The Individual Wellness 24 Tax to assure solvency of the plan and to avoid unnecessary cash 25 surpluses in the trust. 26 Section 903. Limitation on administrative expense. 27 The system budget referred to in this chapter shall comprise 28 the cost of the agency, services and benefits provided, 29 administration, data gathering, planning and other activities 30 and revenues deposited with the system account of the trust. The 20060H2722B4146 - 42 -
1 board shall limit administrative costs to 5% of the agency 2 budget and shall annually evaluate methods to reduce 3 administrative costs and publicly report the results of that 4 evaluation. 5 Section 904. Funding sources. 6 Funding of the plan shall be obtained from the following 7 dedicated sources: 8 (1) Funds obtained from existing or future Federal 9 health care programs. 10 (2) Funds from dedicated sources specified by the 11 General Assembly. 12 (3) Receipts from the tax of 10% of gross payroll, 13 including self-employment profits. One percent of the tax 14 shall become effective the date that shall be the first day 15 of a calendar month no less than 32 days after the effective 16 date of this act, and the tax shall become fully effective 17 November 1, 2007. Employers who are part of a collective 18 bargaining agreement whereby the health care benefits are no 19 less generous than those provided under the plan shall be 20 excused from paying 90% of the tax. 21 (4) Receipts from the Individual Wellness Tax of 3% of 22 personal earned, passive, pension and investment income. One- 23 half of one percent of the Individual Wellness Tax shall 24 become effective the date that shall be the first day of a 25 calendar month no less than 32 days after the effective date 26 of this act, and the IWC tax shall become fully effective 27 November 1, 2007. Employees who are part of a collective 28 bargaining agreement whereby the health care benefits are no 29 less generous than those provided under the plan shall be 30 excused from paying 90% of the Individual Wellness Tax. 20060H2722B4146 - 43 -
1 (5) In the event the General Assembly has not responded 2 to a request by the board for an increase in funding in 3 anticipation of projected expenses, the board is hereby 4 authorized to order a temporary increase, for no more than 90 5 days, in the Employer Health Services Tax and/or the 6 Individual Wellness Tax of no more than 250 basis points each 7 to respond to a threatened insolvency of the plan. 8 CHAPTER 11 9 TRANSITIONAL SUPPORT AND TRAINING FOR DISPLACED WORKERS 10 Section 1101. Transitional support and training for displaced 11 workers. 12 (a) Determination of administrator.--The administrator of 13 transition services shall determine which citizens of this 14 Commonwealth employed by a health care insurer, health insuring 15 corporation or other health care-related business have lost 16 their employment as a result of the implementation and operation 17 of the plan. The administrator also shall determine the amount 18 of monthly wages that the individual has lost due to the plan's 19 implementation. The department shall attempt to position these 20 displaced workers in comparable positions of employment or 21 assist in the retraining and placement of such displaced 22 employees elsewhere. 23 (b) Information.--The administrator of transition services 24 shall forward the information on the amount of monthly wages 25 lost by Commonwealth residents due to the implementation of the 26 plan to the board. The board shall determine the amount of 27 compensation required to assure income maintenance and training 28 that each displaced worker shall receive on a case-by-case basis 29 and shall submit a claim to the trust for payment. A displaced 30 worker, however, shall not receive compensation or training 20060H2722B4146 - 44 -
1 assistance from the trust in excess of $5,000 per month for two 2 years. Compensation paid to the displaced worker under this 3 section shall serve as a supplement to any compensation the 4 worker receives from any other source including unemployment 5 insurance. 6 (c) Coordination of services.--The administrator of 7 transition services shall fully coordinate activity with public 8 and private services also available or actually participating in 9 the assistance to the affected individuals. 10 (d) Appeals.--Persons dissatisfied with the level of 11 assistance they are receiving may appeal to the office of the 12 executive director whose determination shall be final and not 13 subject to appeal. 14 CHAPTER 13 15 VOLUNTEER EMERGENCY RESPONDER NETWORK 16 Section 1301. Preservation of volunteer emergency responder 17 network. 18 Because this Commonwealth is dependent upon the volunteered 19 services of firefighters, emergency medical technicians and 20 search and rescue workers, the board is further charged with 21 administering a Commonwealth income tax credit program for such 22 volunteers. 23 Section 1302. Eligibility certification. 24 Annually, in January, administrators of volunteer 25 firefighting and rescue departments, emergency medical 26 technicians and paramedics stations and similar volunteer 27 emergency entities shall certify the identity of Commonwealth 28 residents providing active services during the prior calendar 29 year. 30 Section 1303. Eligibility criteria. 20060H2722B4146 - 45 -
1 Active status shall require a minimum of 200 hours of service 2 during the preceding year and response to no less than 50% of 3 the emergency calls during at least three of the four calendar 4 quarters. 5 Section 1304. Amount of tax credit. 6 Each volunteer certified as active shall be granted a credit 7 equal to $1,000 toward their State income tax obligation under 8 Article III of the act of March 4, 1971 (P.L.6, No.2), known as 9 the Tax Reform Code of 1971. Any eligible volunteer who does not 10 incur $1,000 in annual State income tax liability shall 11 nevertheless be eligible for a refund equal to the amount the 12 credit exceeds that volunteer's tax obligation. 13 Section 1305. Reimbursement of Department of Revenue. 14 The State Treasury shall be reimbursed the value of such 15 volunteer credits from the fund. 16 CHAPTER 15 17 MISCELLANEOUS PROVISIONS 18 Section 1501. Effective date. 19 This act shall take effect immediately. D28L35RZ/20060H2722B4146 - 46 -