PRINTER'S NO. 2189
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
1638
Session of
2017
INTRODUCED BY ORTITAY, GROVE, A. HARRIS, PHILLIPS-HILL,
KAUFFMAN, MENTZER, RADER, WHEELAND AND ZIMMERMAN,
JUNE 29, 2017
REFERRED TO COMMITTEE ON HEALTH, JUNE 29, 2017
AN ACT
Amending the act of June 13, 1967 (P.L.31, No.21), entitled "An
act to consolidate, editorially revise, and codify the public
welfare laws of the Commonwealth," providing for patient-
centered health care reform; and establishing the Keystone
Care Fund.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The act of June 13, 1967 (P.L.31, No.21), known
as the Human Services Code, is amended by adding an article to
read:
ARTICLE IV-A
PATIENT-CENTERED HEALTH CARE REFORM
Section 401-A. Definitions.
The following words and phrases when used in this article
shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Account." The enrollee's personal responsibility and
wellness account established under section 406-A.
"CHIP." The children's health care program under Article
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
XXIII-A of the act of May 17, 1921 (P.L.682, No.284), known as
The Insurance Company Law of 1921.
"Enrollee." An individual enrolled in the plan.
"Fund." The Keystone Care Fund established under section
415-A.
"Medicaid." The Federal program established under Title XIX
of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1396 et
seq.).
"Medicare." The Federal program established under Title
XVIII of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1395
et seq.).
"Plan." The Keystone Care Plan established under section
402-A to administer Medicaid programs.
"Preventive care services." Care that is provided to an
individual to prevent disease, diagnose disease or promote good
health.
Section 402-A. Establishment of plan.
(a) Waiver application.--Upon the effective date of this
article, the secretary shall apply to the Centers for Medicare
and Medicaid Services of the United States Department of Health
and Human Services for a waiver under section 1315 of the Social
Security Act (49 Stat. 620, 42 U.S.C. § 1315) to establish the
plan, to be known as the Keystone Care Plan.
(b) Purpose.--The plan shall focus on achieving the
following goals:
(1) Improving health care outcomes for enrollees.
(2) Providing greater accountability and flexibility for
enrollees regarding medical decisions.
(3) Providing incentives for enrollees to use preventive
care services to improve health outcomes and curtail the use
20170HB1638PN2189 - 2 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
of more costly medical treatment and procedures that become
necessary in the absence of preventive care services.
(c) Standards and costs.--Following the grant of the waiver
application under subsection (a) and implementation of the plan,
the secretary shall ensure that:
(1) the plan meets the goals under subsection (b); and
(2) the total cost of administering the plan does not
exceed the cost of administering the State plan under Title
XIX of the Social Security Act (49 Stat. 620, 42 U.S.C. §
1396 et seq.) which was in effect prior to the plan for each
of the immediately prior two fiscal years.
Section 403-A. Administration of plan.
(a) Coordination.--For the purpose of administering the
plan, the department shall coordinate with the Insurance
Department to provide oversight of the marketing practices of
the plan.
(b) Promotion.--The department shall promote the plan and
provide information to potential enrollees who live in medically
underserved areas of this Commonwealth.
(c) Enrollment distribution.--To the extent possible, the
department shall ensure that enrollment in the plan is
distributed throughout this Commonwealth in proportion to the
number of individuals who are eligible for participation in the
plan.
(d) Standards.--The department shall establish standards for
consumer protection regarding the plan, including, but not
limited to, the following:
(1) Standards to ensure quality of care.
(2) A uniform process for enrollee grievances and
appeals.
20170HB1638PN2189 - 3 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
(3) Standardized reporting concerning provider
performance, consumer experiences and costs.
(e) Participation.--A health care provider that provides
care to an individual who received health insurance coverage
under the State plan under Title XIX of the Social Security Act
(49 Stat. 620, 42 U.S.C. § 1396 et seq.) which was in effect
prior to the plan shall participate in the plan.
(f) Referrals.--The department may refer an individual to
the Insurance Department for information regarding insurance
coverage and other insurance services if the individual:
(1) has applied for health insurance coverage under the
plan; and
(2) is at high risk of chronic disease.
Section 404-A. Applicability.
The following do not apply to the plan:
(1) Section 403.1.
(2) Section 436.
(3) Section 443.1.
(4) Section 443.2.
(5) Section 454.
(6) Section 455.
(7) Section 456.
(8) Section 457.
(9) Section 458.
(10) Section 460.
(11) Section 460.1.
(12) Article VIII-I.
Section 405-A. Coverage under plan.
(a) Options set by department.--To the extent that the
department determines, the plan shall provide enrollees options
20170HB1638PN2189 - 4 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
for the following:
(1) Mental health care services.
(2) Inpatient hospital services.
(3) Prescription drug coverage.
(4) Emergency room services.
(5) Physician office services.
(6) Diagnostic services.
(7) Outpatient services, including therapy services.
(8) Comprehensive disease management services.
(9) Home health services, including case management
services.
(10) Urgent care center services.
(11) Preventive care services.
(12) Family planning services which:
(i) shall include contraceptives and sexually
transmitted disease testing under Medicaid; and
(ii) shall not include abortion services or
abortifacients.
(13) Hospice services.
(14) Substance abuse services.
(b) Components.--The plan shall:
(1) Offer coverage for dental services and vision
services to enrollees. The following apply:
(i) Vision services offered by the plan must include
services provided by an optometrist.
(ii) The plan shall pay at least 50% of the premium
cost of coverage for dental services and vision services.
(iii) An enrollee who receives coverage for dental
services and vision services shall pay an amount
determined by the department for the coverage. The amount
20170HB1638PN2189 - 5 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
shall not be less than 1% nor more than 5% of the
enrollee's annual household income.
(iv) Payment required under this subsection shall be
in addition to the payment required under the plan into
the account.
(2) Comply with coverage requirements that apply to an
accident and health insurance policy issued in this
Commonwealth.
(3) Not permit treatment limitations or financial
requirements on the coverage of mental health care services
or substance abuse services if similar limitations or
requirements are not imposed on the coverage of services for
other medical or surgical conditions.
Section 406-A. Personal responsibility and wellness account.
(a) Establishment.--As part of the enrollment in the plan,
an enrollee shall establish an account, to be known as a
personal responsibility and wellness account, into which money
may be deposited for the enrollee's expenses under the plan.
(b) Source of deposits.--Deposits into an account on behalf
of an enrollee shall only be made by the following:
(1) The enrollee.
(2) An employer of the enrollee.
(3) The Commonwealth.
(c) Minimum funding amount.--The minimum funding amount for
an account shall be as specified under section 407-A.
(d) Purpose.--An account shall be used to pay the enrollee's
deductibles for health care services provided under the plan.
(e) Deposit procedure.--A person under subsection (b) may
make deposits into an account as follows:
(1) At the request of an enrollee, an enrollee's
20170HB1638PN2189 - 6 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
employer shall withhold or cause to be withheld from the
enrollee's wages or salary, after taxes are deducted from the
wages or salary, contributions to the account, which shall be
distributed equally throughout the calendar year. Submission
of the enrollee's contributions to the account shall be made
through the department, which shall immediately deposit the
money in the account or otherwise credit the account and
provide the enrollee with notification of the deposit or
credit.
(2) An enrollee may submit a contribution to the account
through the department, which shall immediately deposit the
money into the account or otherwise credit the account and
provide the enrollee with notification of the deposit or
credit.
(3) As determined by the department.
(f) Employer payments.--An enrollee's employer may make
required payments to an account from funds not payable by the
employer to the enrollee. The amount of the payments shall not
exceed 50% of the enrollee's required payment to the account.
Section 407-A. Contributions into account.
(a) Commencement.--An individual becomes an enrollee upon an
initial payment into the account.
(b) Limitation.--An enrollee's required payment to the plan
may not exceed 1/12 of the annual payment required under this
section.
(c) Application.--To participate in the plan, an individual
shall apply for the plan on a form prescribed by the department.
The department may develop and allow a joint application for a
household.
(d) Amounts.--Following approval by the department for an
20170HB1638PN2189 - 7 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
individual to participate in the plan, the individual as
enrollee shall contribute into the account the lesser of the
following as determined by the department:
(1) One thousand one hundred dollars per year, less any
amounts paid by the enrollee under Medicaid, Medicare or
CHIP. The Commonwealth shall contribute to the account the
difference between the amount paid by the enrollee and $1,100
if the enrollee's payment is less than $1,100 per year.
(2) Not more than the following applicable percentage of
the enrollee's annual household income per year, less any
amounts paid by the enrollee under Medicaid, Medicare or CHIP
as determined by the department:
(i) two percent of the enrollee's annual household
income per year if the enrollee's annual household income
is at or below 100% of the Federal poverty limit;
(ii) three percent of the enrollee's annual
household income per year if the enrollee's annual
household income is above 100% of the Federal poverty
level and is at or below 125% of the Federal poverty
limit;
(iii) four percent of the enrollee's annual
household income per year if the enrollee's annual
household income is above 125% of the Federal poverty
level and is at or below 150% of the Federal poverty
limit; or
(iv) five percent of the enrollee's annual household
income per year if the enrollee's annual household income
is above 150% of the Federal poverty limit and is at or
below 200% of the Federal poverty limit.
(e) Termination for nonpayment.--If an enrollee's required
20170HB1638PN2189 - 8 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
payment to the account is not made within 60 days after the
required payment date, the enrollee may be terminated from
participation in the plan. The following shall apply:
(1) The enrollee must receive written notice before
being terminated from the plan.
(2) After an individual is terminated from the plan, the
individual may not reapply to participate in the plan for 12
months.
Section 408-A. Incentives for using preventive services.
(a) List of health care services.--The department shall
provide to each enrollee a list of health care services that
qualify as preventive care services for the age, gender and
preexisting conditions of the enrollee. The department shall
consult with the Centers for Disease Control and Prevention for
a list of recommended preventive care services.
(b) Amount.--At no cost to an enrollee, the plan shall
provide payment for not more than $500 of qualifying preventive
care services per year for the enrollee. Additional preventive
care services covered under the plan and received by the
enrollee during the year shall be subject to the deductible and
payment requirements of the plan.
Section 409-A. Coverage limitations.
The plan shall have the following per enrollee coverage
limitations:
(1) An annual individual maximum coverage limitation of
$300,000.
(2) A lifetime individual maximum coverage limitation of
$1,000,000.
Section 410-A. Funding requirements for plan.
(a) Limitations.--The following requirements shall apply to
20170HB1638PN2189 - 9 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
money appropriated by the General Assembly for the plan:
(1) At least 85% of the appropriated money shall be used
for payments regarding health care services.
(2) The secretary shall determine the amount necessary
for the following:
(i) Administrative costs associated with
implementing this article.
(ii) Profits due to an insurer or a health
maintenance organization under a contract with the
department to provide health insurance coverage under the
plan. The amount determined under this subparagraph shall
not exceed 15% of the appropriated money.
(b) Status of plan.--Nothing in this article shall be
construed to classify the plan as an entitlement program. The
maximum enrollment of enrollees shall be dependent on money
appropriated for the plan.
Section 411-A. Eligibility for enrollment in plan.
(a) Eligible individuals.--Subject to subsection (c), an
individual is eligible to become an enrollee if the individual:
(1) is 18 years of age or older but less than 65 years
of age;
(2) is a citizen of the United States;
(3) has resided in this Commonwealth for at least 12
months;
(4) has an annual household income of less than 200% of
the Federal poverty limit;
(5) is not eligible for health insurance coverage
through the individual's employer; and
(6) has not had health insurance coverage for at least
six months.
20170HB1638PN2189 - 10 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
(b) Ineligible individuals.--An individual is not eligible
to become an enrollee if the individual:
(1) participates in Medicare; or
(2) is eligible for Medicaid as a person with a
disability.
(c) Approval by Federal Government.--The eligibility
requirements under subsection (a) are subject to approval for
Federal financial participation by the United States Department
of Health and Human Services as part of the waiver under section
1315 of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1315
et seq.).
(d) Eligibility period.--
(1) An individual who is approved as an enrollee shall
be eligible for a 12-month plan period.
(2) An enrollee may not be refused renewal to
participate in the plan based solely on the reason that the
plan has reached the plan's maximum enrollment.
(e) Renewal.--If an enrollee chooses to renew participation
in the plan, the enrollee shall complete a renewal application
and any necessary documentation and submit the application and
documentation to the department on a form prescribed by the
department.
(f) Nonrenewal.--If an enrollee chooses not to renew
participation in the plan, the enrollee may allow the enrollment
to lapse but may not reapply to participate in the plan for at
least 12 months after the date that the enrollee's participation
has lapsed.
Section 412-A. Money in account.
(a) Money in account upon renewal.--If an enrollee renews
participation in the plan at the end of the enrollee's 12-month
20170HB1638PN2189 - 11 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
period, money remaining in the account shall remain in the
account and count against the enrollee's payments for the
subsequent plan period. If, during the plan period, the enrollee
did not receive all qualified preventive services recommended
under this article, the State's contribution to the account may
not be used to reduce the enrollee's payments for the subsequent
plan period.
(b) Refund.--If an enrollee does not renew participation in
the plan, is no longer eligible for the plan or is terminated
from the plan for nonpayment of a required payment, the
department shall, not more than 60 days after the last date of
the enrollee's participation in the plan, refund to the enrollee
the amount of money remaining in the account as determined by
the department and subject to the following:
(1) For an enrollee who does not renew participation or
who is no longer eligible for the plan, the refund to the
enrollee shall be the amount of money in the account
personally deposited by the enrollee divided by the amount of
money in the account deposited from all other sources, with
that quotient then multiplied by the total amount of money
remaining in the account.
(2) For an enrollee who was terminated from the plan for
nonpayment of a required payment, the refund to the enrollee
shall be the amount determined under paragraph (1) multiplied
by 0.75.
Section 413-A. Use of emergency services for nonemergency care.
(a) General rule.--Except as provided in subsection (b) and
to the appeal procedures to the department, an enrollee may be
held liable under the plan for receiving nonemergency services
in an emergency room setting, including prohibiting the enrollee
20170HB1638PN2189 - 12 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
from using funds in the account to pay for the nonemergency
services.
(b) Exception.--An enrollee may not be prohibited from using
money in the account to pay for nonemergency services provided
in an emergency room setting for a medical condition that arises
suddenly and unexpectedly and manifests itself by acute symptoms
of such severity, including severe pain, that the absence of
immediate medical attention could reasonably be expected by a
prudent individual who possesses an average knowledge of health
and medicine to:
(1) place an individual's health in serious jeopardy;
(2) result in serious impairment to the individual's
bodily functions; or
(3) result in serious dysfunction of a bodily organ or
part of the individual.
Section 414-A. Processing claims under plan.
(a) Reimbursement and coverage.--An insurer or a health
maintenance organization that contracts with the department to
provide health insurance coverage, dental coverage or vision
coverage to an enrollee shall be responsible for the claim
processing for the enrollee's coverage and:
(1) shall reimburse providers at a reimbursement rate of
not less than the Medicare reimbursement rate for the service
provided or at a rate of 130% of the Medicaid reimbursement
rate for a service that does not have a Medicare
reimbursement rate; and
(2) may not deny coverage to an enrollee, unless the
enrollee has met the coverage limitations described in this
article.
(b) Cultural competency standards.--An insurer or a health
20170HB1638PN2189 - 13 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
maintenance organization that contracts with the department to
provide health insurance coverage under the plan shall
incorporate cultural competency standards established by the
department. The standards must include standards for non-
English-speaking individuals, minority individuals and
individuals with disabilities.
(c) Coverage for specific individuals.--An insurer or a
health maintenance organization that contracts with the
department to provide health insurance coverage under the plan
or an affiliate of an insurer or a health maintenance
organization that contracts with the department to provide
health insurance coverage under the plan shall offer to provide
the same health insurance coverage to an individual who:
(1) has not had health insurance coverage during the
previous six months; and
(2) either:
(i) meets the eligibility requirements for
participation in the plan but is not enrolled because the
plan has reached maximum enrollment; or
(ii) does not meet the eligibility requirements for
participation in the plan.
(d) Underwriting and rating practices.--The insurance
underwriting and rating practices applied to health insurance
coverage offered under subsection (c) shall not be different
from underwriting and rating practices used for the health
insurance coverage provided under the plan. Standard individual
or small group insurance underwriting and rating practices may
be applied to the health insurance coverage.
(e) Prohibition.--The Commonwealth may not appropriate or
otherwise provide money for health insurance coverage received
20170HB1638PN2189 - 14 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
under this section.
Section 415-A. Keystone Care Fund.
(a) Establishment.--A restricted account is established in
the Treasury Department to be known as the Keystone Care Fund.
(b) Purposes.--The fund shall:
(1) Administer the plan.
(2) Provide copayments, preventive care services and
premiums for enrollees.
(c) Administration.--The secretary shall administer the
fund.
(d) Expenses.--The expenses of administering the fund shall
be paid from encumbered funds of the department.
(e) Composition.--The fund shall consist of the following:
(1) Tax revenue specified by the General Assembly.
(2) Other funds transferred or designated by the General
Assembly to be part of the fund.
(3) Federal funds available for the purposes of the
fund.
(4) Gifts or donations to the fund.
(5) Money appropriated by the General Assembly to
administer the plan.
(f) Investments.--The State Treasurer shall:
(1) Invest the money in the fund not currently needed to
meet the obligations of the fund in the same manner as other
public money may be invested.
(2) Provide semiannual updates on investments regarding
the fund to the following:
(i) The Secretary of the Budget.
(ii) The secretary.
(iii) The chairperson and minority chairperson of
20170HB1638PN2189 - 15 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
the Appropriations Committee of the Senate.
(iv) The chairperson and minority chairperson of the
Appropriations Committee of the House of Representatives.
(g) Appropriation requirement.--An appropriation must be
made before money from the fund is available for use.
(h) No reversion.--Money in the fund shall not revert to the
General Fund at the end of a fiscal year.
(i) Restrictions.--Money may not be transferred, assigned or
otherwise removed from the fund by or for any department,
agency, board, commission, authority, office or other entity of
the Commonwealth without prior authorization from the General
Assembly.
Section 416-A. Limitations on department.
The department may not operate the plan in a manner that
would obligate the Commonwealth to financial participation
beyond the level of State appropriations authorized for the plan
by the General Assembly.
Section 417-A. Implementation of plan.
(a) Rules and regulations.--The department shall promulgate
rules and regulations necessary to implement this article.
(b) Denial by Federal Government.--A denial of a waiver
under section 402-A or a denial of Federal financial
participation that applies to a provision of this article does
not prohibit the department from implementing any other
provision of this article that:
(1) is approved for Federal financial participation; or
(2) does not require Federal approval or Federal
financial participation.
Section 2. This act shall take effect in 60 days.
20170HB1638PN2189 - 16 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29