PRINTER'S NO. 1233
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No.
913
Session of
2017
INTRODUCED BY WARD, VULAKOVICH, BROWNE, YAW, STEFANO, KILLION
AND MENSCH, OCTOBER 5, 2017
REFERRED TO BANKING AND INSURANCE, OCTOBER 5, 2017
AN ACT
Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
act relating to insurance; amending, revising, and
consolidating the law providing for the incorporation of
insurance companies, and the regulation, supervision, and
protection of home and foreign insurance companies, Lloyds
associations, reciprocal and inter-insurance exchanges, and
fire insurance rating bureaus, and the regulation and
supervision of insurance carried by such companies,
associations, and exchanges, including insurance carried by
the State Workmen's Insurance Fund; providing penalties; and
repealing existing laws," in casualty insurance, providing
for prescription drug coverage; and providing for
Pennsylvania Health Care Payor Claims Database.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The act of May 17, 1921 (P.L.682, No.284), known
as The Insurance Company Law of 1921, is amended by adding a
section to read:
Section 631.2. Prescription Drug Coverage.--(a) Whenever a
health insurance policy provides coverage for prescription drugs
which have been approved by the United States Food and Drug
Administration for general use, the policy shall not impose cost
sharing for a prescribed drug that exceeds the average of all
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rebates and discounts negotiated among a health insurer,
pharmacy benefit manager and drug manufacturer. To ensure
compliance with this subsection, a health insurer shall report
the aggregate amount of rebates which the health insurer has
received from pharmacy benefit managers or drug manufacturers
for the preceding calendar year in the health insurer's annual
statement filed with the department.
(b) A health insurance policy that provides prescription
drug benefits through a pharmacy benefit manager may not
authorize any of the following actions:
(1) Requiring cost sharing for a covered prescription drug
or device that exceeds the retail price of the drug or device.
(2) Requiring a copayment for a thirty-day supply of a
covered drug that exceeds one-twelfth of the policy's annual
out-of-pocket spending limit.
(3) Prohibiting a pharmacist or pharmacy from providing an
insured individual information on the amount of the insured's
cost share for the insured's prescription drug and compared to
the current cash price. A pharmacy benefits manager may not
penalize a pharmacy or a pharmacist for disclosing this
information to an insured.
(4) Charging or collecting from an insured individual a
copayment that exceeds the total submitted charges by the
network pharmacy for which the pharmacy is paid.
(5) Charging or holding a pharmacist or pharmacy responsible
for a fee relating to the adjudication of a claim.
(6) Recouping funds from a pharmacy in connection with
claims for which the pharmacy has already been paid, unless the
recoupment is otherwise permitted or required by law.
(7) Penalizing or retaliating against a pharmacist or
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pharmacy for exercising rights.
(c) This section shall apply to those health insurance
policies issued or entered into or renewed on or after the
effective date of this section.
(d) As used in this section:
"Cost sharing" means the cost to an individual insured under
a health insurance policy according to a coverage limit,
copayment, coinsurance, deductible or other out-of-pocket
expense requirements imposed by the policy, contract or
agreement.
"Department" means the Insurance Department of the
Commonwealth.
"Health insurance policy" means:
(1) An individual or group health, sickness or accident
policy, or subscriber contract or certificate offered, issued or
renewed by an entity subject to one of the following:
(i) This act.
(ii) The act of December 29, 1972 (P.L.1701, No.364), known
as the "Health Maintenance Organization Act."
(iii) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations).
(iv) 40 Pa.C.S. Ch. 63 (relating to professional health
services plan corporations).
(2) The term does not include accident only, fixed
indemnity, limited benefit, credit, dental, vision, specified
disease, Medicare supplement, Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS) supplement, long-
term care or disability income, workers' compensation or
automobile medical payment insurance.
Section 2. The act is amended by adding an article to read:
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ARTICLE XXII
PENNSYLVANIA HEALTH CARE PAYOR CLAIMS DATABASE
Section 2201. Scope of article.
This article relates to the Pennsylvania Health Care Payor
Claims Database.
Section 2202. Legislative intent and purpose.
(a) Legislative intent.--The General Assembly finds that:
(1) The establishment of effective health care data
analysis and reporting initiatives is essential to improving
the quality and cost efficiency of health care, fostering
competition among health care providers and insurers and
increasing consumer choice regarding health care services in
this Commonwealth.
(2) Accurate and valuable health care data can best be
shown through actual claims paid by health care payors.
(b) Purpose.--To fulfill the legislative intent under
subsection (a), the department, in conjunction with the
Pennsylvania Health Care Cost Containment Council, shall
administer the health care data reporting initiatives
established under this article.
Section 2203. 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:
"Department." The Insurance Department of the Commonwealth.
"Health care insurer." As follows:
(1) A person, corporation or other entity that offers
administrative, indemnity or payment services for health care
in exchange for a premium or service charge under a program
of health care benefits, including, but not limited to, any
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of the following:
(i) An insurance company, association or exchange
issuing health insurance policies in this Commonwealth
governed by this act.
(ii) A hospital plan corporation as defined in 40
Pa.C.S. Ch. 61 (relating to hospital plan corporations).
(iii) A professional health service corporation as
defined in 40 Pa.C.S. Ch. 63 (relating to professional
health services plan corporations).
(iv) A health maintenance organization governed by
the act of December 29, 1972 (P.L.1701, No.364), known as
the Health Maintenance Organization Act.
(v) A third-party administrator governed by Article
X of the act of May 17, 1921 (P.L.789, No.285), known as
The Insurance Department Act of 1921.
(2) The term does not include employers, labor unions or
health and welfare funds jointly or separately administered
by employers or labor unions that purchase or self-fund a
program of health care benefits for their employees or
members and their dependents.
"Payor." A person or an entity, including, but not limited
to, health care insurers and purchasers, that make direct
payments to providers for covered services.
"Purchaser." As follows:
(1) Any of the following:
(i) A corporation, a labor organization or another
entity that purchases benefits which provide covered
services for its employees or members, either through a
health care insurer or by means of a self-funded program
of benefits.
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(ii) A certified bargaining representative that
represents a group or groups of employees for whom an
employer purchases a program of benefits which provides
covered services.
(2) The term does not include a health care insurer.
Section 2204. Database.
(a) Establishment.--The Pennsylvania Health Care Payor
Claims Database is established to:
(1) facilitate data driven, evidence-based improvements
in access, quality and cost of health care; and
(2) promote and improve health through the understanding
of health care expenditure patterns and operation and
performance of the health care system.
(b) Collection of data.--In coordination with the
Pennsylvania Health Care Cost Containment Council, the
department shall collect paid claims data for covered benefits
pursuant to a health care payor claims data submission manual as
described in subsection (c).
(c) Manual.--The following shall apply regarding a health
care payor claims data submission manual:
(1) The manual shall define the data elements needed to
establish and maintain a health care payor claims database
for all claims paid on behalf of patients receiving health
care in this Commonwealth.
(2) A health care payor shall comply with the manual to
submit data.
(3) The manual shall use and build upon existing data
collection standards and methods.
(4) For each claim, including each medical, dental and
pharmacy claim, the manual shall include, but not be limited
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to, the following data elements identified in the manual to
further the intent of this article:
(i) Additional patient and provider identifiers.
(ii) Patient demographic information.
(iii) Data necessary to identify the date and time
of service and the location and type of provider and
facility, such as a hospital, office or clinic.
(iv) Data describing the nature of health care
services provided to the patient, including diagnosis
codes.
(v) Other data relating to health care costs, prices
and utilization.
(d) Reporting.--
(1) The Health Care Cost Containment Council may not
require a health care insurer to report on data elements that
are not reported to nationally recognized accrediting
organizations or in quarterly or annual reports submitted to
the department, the Department of Health or the Department of
Human Services.
(2) The department may not require reporting by health
care insurers in different formats than are required for
reporting to nationally recognized accrediting organizations
or in quarterly or annual reports submitted to the
department, the Department of Health or the Department of
Human Services.
(3) The department may adopt the quality findings as
reported to nationally recognized accrediting organizations.
Additional quality data elements must be defined and released
for public comment prior to use.
(e) Availability of data.--Nothing in this article shall
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prohibit a purchaser from obtaining from its health care
insurer, nor relieve the health care insurer from the obligation
of providing to the purchaser, on terms consistent with past
practices, data previously provided or additional data not
currently provided to the purchaser by the health care insurer
pursuant to an existing or a future arrangement, agreement or
understanding.
Section 2205. Special studies and reports.
A Commonwealth agency, the Senate or the House of
Representatives may direct the department to publish, or
contract for publication, a special study, including, but not
limited to, a special study on diseases and the cost of health
care related to particular diseases in this Commonwealth. A
special study published under this subsection shall become a
public document.
Section 2206. Enforcement and penalty.
(a) Compliance enforcement.--The department shall have
standing to bring an action in law or equity to enforce
compliance with any provision of this article or any requirement
or appropriate request of the department made under this
article. The Attorney General shall bring an enforcement action
in aid of the department in a court of common pleas at the
request of the department and in the name of the Commonwealth.
(b) Penalty.--
(1) A person who fails to supply data under this article
may be assessed a civil penalty not to exceed $1,000 for each
day the data is not submitted.
(2) A person who knowingly submits inaccurate data under
this article commits a misdemeanor of the third degree and
shall, upon conviction, be sentenced to pay a fine of $1,000
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or to imprisonment for not more than one year, or both.
Section 3. This act shall take effect in 60 days.
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