PRINTER'S NO. 1586
No. 1355 Session of 2001
INTRODUCED BY BROWNE, MANN, BELFANTI, BOYES, CAPPELLI, CIVERA,
CORNELL, CORRIGAN, CREIGHTON, CURRY, DALLY, FEESE, FLICK,
FORCIER, FRANKEL, FREEMAN, GEORGE, GORDNER, GRUCELA, HARHAI,
HENNESSEY, HERMAN, HERSHEY, JAMES, JOSEPHS, KELLER, LAUGHLIN,
LEDERER, LEWIS, MYERS, ORIE, READSHAW, ROSS, RUBLEY,
SCHRODER, SCRIMENTI, SEMMEL, SHANER, SOLOBAY, SURRA,
E. Z. TAYLOR, THOMAS, TIGUE, TRELLO, WATSON, WILT AND
YUDICHAK, APRIL 17, 2001
REFERRED TO COMMITTEE ON INSURANCE, APRIL 17, 2001
AN ACT
1 Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
2 act relating to insurance; amending, revising, and
3 consolidating the law providing for the incorporation of
4 insurance companies, and the regulation, supervision, and
5 protection of home and foreign insurance companies, Lloyds
6 associations, reciprocal and inter-insurance exchanges, and
7 fire insurance rating bureaus, and the regulation and
8 supervision of insurance carried by such companies,
9 associations, and exchanges, including insurance carried by
10 the State Workmen's Insurance Fund; providing penalties; and
11 repealing existing laws," further providing for managed care
12 plans, for continuity of care, for utilization review, for
13 internal grievance process and for external grievance
14 process.
15 The General Assembly of the Commonwealth of Pennsylvania
16 hereby enacts as follows:
17 Section 1. The definition of "managed care plan" in section
18 2102 of the act of May 17, 1921 (P.L.682, No.284), known as The
19 Insurance Company Law of 1921, added June 17, 1998 (P.L.464,
20 No.68), is amended to read:
21 Section 2102. Definitions.--As used in this article, the
1 following words and phrases shall have the meanings given to
2 them in this section:
3 * * *
4 "Managed care plan." A health care plan that [uses a
5 gatekeeper to manage the utilization of health care services,]
6 integrates the financing and delivery of health care services to
7 enrollees by arrangements with health care providers selected to
8 participate on the basis of specific standards and provides
9 financial incentives for enrollees to use the participating
10 health care providers in accordance with procedures established
11 by the plan or which performs utilization review of any services
12 directly or through a subcontract. A managed care plan includes
13 health care arranged through an entity operating under any of
14 the following:
15 (1) Section 630.
16 (2) The act of December 29, 1972 (P.L.1701, No.364), known
17 as the "Health Maintenance Organization Act."
18 (3) The act of December 14, 1992 (P.L.835, No.134), known as
19 the "Fraternal Benefit Societies Code."
20 (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan
21 corporations).
22 (5) 40 Pa.C.S. Ch. 63 (relating to professional health
23 services plan corporations).
24 The term includes an entity, including a municipality, whether
25 licensed or unlicensed, that contracts with or functions as a
26 managed care plan to provide health care services to enrollees.
27 [The term does not include ancillary service plans or an
28 indemnity arrangement which is primarily fee for service.]
29 * * *
30 Section 2. Section 2117 of the act is amended by adding a
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1 subsection to read:
2 Section 2117. Continuity of Care.--* * *
3 (g) When a determination of referral for specialty is made,
4 a plan shall provide an enrollee with access to any
5 participating or nonparticipating specialist licensed to provide
6 the required service covered by the plan at the time the
7 services are required. When an enrollee accesses a
8 nonparticipating specialist, the plan shall reimburse the
9 enrollee for the covered service at a rate equal to at least
10 eighty per centum (80%) of the payment that the plan would have
11 paid had the covered service been provided by a participating
12 specialist. The following shall apply:
13 (1) In the case of a nonparticipating pharmacy, medical
14 equipment supplier or distributor of orthotics or prosthetics,
15 the minimum eighty per centum (80%) reimbursement provided for
16 in the section shall apply to the professional services or
17 dispensing fee, as distinct from reimbursement for the product
18 itself. Reimbursement for the product shall be made at the rate
19 that the plan normally reimburses participating providers.
20 (2) The plan shall provide to the enrollee intending to
21 access an out-of-network specialist information containing
22 adequate disclosure of coverage limitations and conditions
23 including the enrollees' liability for copayments. This
24 information shall also be provided to the nonparticipating
25 specialist upon written request as well as information regarding
26 the use of diagnostic and ancillary services and other
27 requirements or limitations on treatments, including selection
28 of treatment facilities.
29 (3) The enrollee and nonparticipating specialists shall be
30 informed of any certification requirements for nonemergency
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1 hospital admissions or treatment services.
2 (4) The plan shall provide claim forms and billing
3 information to the nonparticipating specialist. The plan shall
4 also provide the enrollee's primary care physician with claims
5 information concerning usage of a nonparticipating specialist so
6 that the primary care physician will be prepared to care for the
7 enrollee when the enrollee returns to the network.
8 (5) The plan shall pay nonparticipating specialists in
9 accordance with the procedures and within the time periods
10 established by the plan for participating specialists.
11 (6) Out-of-network access to licensed health care providers
12 for services covered by the plan shall be available at no extra
13 cost to enrollees when no network provider has offices within
14 twenty (20) minutes in urban areas or thirty (30) minutes in
15 rural areas, or no appointment is available within three (3)
16 weeks for nonurgent care or within twenty-four (24) hours for
17 urgent care. In such circumstances, the provider would be
18 reimbursed at the same rate as a network provider.
19 Section 3. Sections 2152 heading, (c) and (d), 2161(d) and
20 2162(c)(4) of the act, added June 17, 1998 (P.L.464, No.68), are
21 amended to read:
22 Section 2152. Operational Standards for Certification as a
23 Utilization Review Entity.--* * *
24 (c) Utilization review that results in a denial of payment
25 for a health care service shall be made by a licensed
26 physician[, except as provided in subsection (d).] or, in the
27 case of advance practice nurses, chiropractors, clinical social
28 workers, dentists, optometrists, pharmacists, physical
29 therapists, podiatrists or psychologists, a health care
30 practitioner licensed in the same profession as the attending
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1 health care practitioner. The use of these professionals to
2 perform utilization review shall be approved by the department
3 as part of the certification process under section 2151.
4 (d) A licensed psychologist may perform a utilization review
5 for behavioral health care services within the psychologist's
6 scope of practice if the psychologist's clinical experience
7 provides sufficient experience to review that specific
8 behavioral health care service. [The use of a licensed
9 psychologist to perform a utilization review of a behavioral
10 health care service shall be approved by the department as part
11 of the certification process under section 2151.] A licensed
12 psychologist shall not review the denial of payment for a health
13 care service involving inpatient care or a prescription drug.
14 Section 2161. Internal Grievance Process.--* * *
15 (d) Any initial review or second level review conducted
16 under this section shall include a licensed physician[, or,
17 where appropriate, an approved licensed psychologist,] in the
18 same or similar specialty that typically manages or consults on
19 the health care service[.] or, in the case of advance practice
20 nurses, chiropractors, dentists, clinical social workers,
21 optometrists, pharmacists, physical therapists, podiatrists or
22 psychologists, a health care practitioner licensed in the same
23 profession as the attending health care practitioner.
24 * * *
25 Section 2162. External Grievance Process.--* * *
26 (c) The external grievance process shall meet all of the
27 following requirements:
28 * * *
29 (4) An external grievance decision shall be made by:
30 (i) one or more licensed physicians [or approved licensed
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1 psychologists] or in the case of advance practice nurses,
2 chiropractors, clinical social workers, dentists, optometrists,
3 pharmacists, physical therapists, podiatrists or psychologists,
4 a health care practitioner licensed in the same profession as
5 the attending health care practitioner in active clinical
6 practice or in the same or similar specialty that typically
7 manages or recommends treatment for the health care service
8 being reviewed; or
9 (ii) if the health care provider is a physician, one or more
10 physicians currently certified by a board approved by the
11 American Board of Medical Specialists or the American Board of
12 Osteopathic Specialties in the same or similar specialty that
13 typically manages or recommends treatment for the health care
14 service being reviewed.
15 * * *
16 Section 4. This act shall take effect in 60 days.
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