PRINTER'S NO. 2390
No. 1926 Session of 1999
INTRODUCED BY WALKO, DeWEESE, GEORGE, BELARDI, GORDNER, FRANKEL,
MANN, SOLOBAY, MANDERINO, MUNDY, DeLUCA, VAN HORNE, SHANER,
CORRIGAN, EVANS, FREEMAN, DALEY, LAUGHLIN, PETRARCA, GRUCELA,
SCRIMENTI, WOJNAROSKI, STABACK, SURRA, McCALL, COSTA, BEBKO-
JONES, TRELLO, YUDICHAK, YOUNGBLOOD, HARHAI, TRAVAGLIO, VEON,
MELIO, RAMOS, STEELMAN AND CAPPABIANCA, OCTOBER 5, 1999
REFERRED TO COMMITTEE ON INSURANCE, OCTOBER 5, 1999
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 defining "managed care
12 plan"; further providing for duties of managed care plans and
13 for required disclosure; and providing for duties of the
14 Health Care Cost Containment Council.
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 and the section is amended by adding a
21 definition to read:
22 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 "Council." The Health Care Cost Containment Council created
5 by the act of July 8, 1986 (P.L.408, No.89), known as the
6 "Health Care Cost Containment Act."
7 * * *
8 "Managed care plan." A health care plan that uses a
9 gatekeeper to manage the utilization of health care services,
10 integrates the financing and delivery of health care services to
11 enrollees by arrangements with health care providers selected to
12 participate on the basis of specific standards [and] or provides
13 financial incentives for enrollees to use the participating
14 health care providers in accordance with procedures established
15 by the plan. A managed care plan includes health care arranged
16 through an entity operating under any of the following:
17 (1) Section 630.
18 (2) The act of December 29, 1972 (P.L.1701, No.364), known
19 as the "Health Maintenance Organization Act."
20 (3) The act of December 14, 1992 (P.L.835, No.134), known as
21 the "Fraternal Benefit Societies Code."
22 (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan
23 corporations).
24 (5) 40 Pa.C.S. Ch. 63 (relating to professional health
25 services plan corporations).
26 The term includes an entity, including a municipality, whether
27 licensed or unlicensed, that contracts with or functions as a
28 managed care plan to provide health care services to enrollees.
29 The term does not include ancillary service plans or an
30 indemnity arrangement which is primarily fee for service.
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1 * * *
2 Section 2. Sections 2111 and 2136(a) of the act are amended
3 by adding paragraphs to read:
4 Section 2111. Responsibilities of Managed Care Plans.--A
5 managed care plan shall do all of the following:
6 * * *
7 (14) Provide the council and the department with the
8 following information in such form and according to such
9 schedule as the department shall determine:
10 (i) The results of a consumer satisfaction survey
11 implemented and based on a protocol established by the
12 department. The protocol shall include standard questions
13 developed by the department, a survey instrument approved by the
14 department and a survey technique endorsed by the department. At
15 a minimum, the survey shall involve the following areas:
16 (A) Information and enrollee communication.
17 (B) Patient treatment.
18 (C) Preventative care.
19 (D) Access to and adequacy of network.
20 (E) Services for individuals with special needs.
21 (F) Referrals.
22 (G) Denials of care.
23 (H) Options available to patients.
24 (I) In the case of former enrollees, the reason for their
25 disenrollment.
26 (ii) Quality service indicators as developed by the council.
27 At a minimum these quality indicators shall include the
28 following:
29 (A) The indicators used by the National Commission on
30 Quality Assurance HEDIS system.
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1 (B) The indicators used by the Department of Public Welfare
2 to monitor Medicaid managed care contractors.
3 (C) Indicators used by the Foundation for Accountability.
4 (D) Indicators developed by the department after
5 consultation with representatives of managed care plans,
6 providers, patients, consumer advocates and academic experts.
7 Section 2136. Required Disclosure.--(a) A managed care plan
8 shall supply each enrollee and, upon written request, each
9 prospective enrollee or health care provider with the following
10 written information. Such information shall be easily
11 understandable by the layperson and shall include, but not be
12 limited to:
13 * * *
14 (16) Each managed care plan shall annually provide each
15 member, and shall include with enrollment materials for
16 prospective members, a guide, written in plain English, in a
17 format approved by the department, indicating how that managed
18 care plan compares with other managed care plans in terms of the
19 quality of care rendered, based on data supplied to the
20 department under this article.
21 * * *
22 Section 3. Section 2193 of the act is repealed.
23 Section 4. The act is amended by adding a section to read:
24 Section 2194. Powers and Duties of the Health Care Cost
25 Containment Council.--The council shall have the following
26 powers and its duties shall be:
27 (1) To have access without charge to the materials submitted
28 to the department pursuant to section 2111(14).
29 (2) To issue annually reports comparing the performance of
30 health maintenance organizations in the following areas:
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1 (i) Consumer satisfaction as provided for in section
2 2111(14)(i).
3 (ii) Indicators of plan performance and quality as provided
4 for in section 2111(14)(ii).
5 (iii) Medical loss ratio for the prior year.
6 (iv) Denials of coverage or payment for emergency room
7 claims for the prior year.
8 (v) The percentage of children who have received
9 immunizations pursuant to the schedule adopted by the American
10 Academy of Pediatricians for the prior year.
11 (vi) The percentage of pregnant women who received prenatal
12 care in their first trimester and the number of low-birth babies
13 as a percentage of all live births for the prior year.
14 (vii) The percentage of all enrollees who had a physical
15 examination and a well patient visit over the prior year.
16 (viii) The availability and appropriateness of services and
17 treatment provided to enrollees, including preventative care and
18 services for enrollees with chronic or severe medical conditions
19 or other special needs.
20 (3) To issue special reports comparing the performance of
21 managed care organizations in the following areas:
22 (i) Adult diabetes, including the incidence of retinal exams
23 within the past twenty-four (24) months, hospitalization for
24 inpatient diabetes-related treatment and other indicators of
25 treatment for diabetes and diabetes-related illnesses.
26 (ii) Juvenile asthma, including the incidence of inpatient
27 hospitalization for asthma and asthma-related illnesses.
28 (iii) Breast cancer, including incidence of annual
29 mammograms for women forty-five (45) through sixty-nine (69)
30 years of age, the percentage of breast cancer patients detected
19990H1926B2390 - 5 -
1 in stage 0 or stage 1; the incidence of radical mastectomies and
2 breast conserving surgeries and other indicators related to the
3 diagnosis and treatment of breast cancer.
4 (iv) Other reports comparing the performance of managed care
5 organizations in addressing ambulatory sensitive conditions and
6 elective surgery, including the treatment of prostate cancer,
7 coronary artery bypass grafting, knee and hip replacement and
8 Cesarean sections.
9 Section 5. This act shall take effect immediately.
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