PRINTER'S NO. 3998
No. 2789 Session of 2000
INTRODUCED BY SAMUELSON, BARRAR, BEBKO-JONES, BELARDI, BELFANTI,
BLAUM, CAPPABIANCA, M. COHEN, COSTA, COY, DeWEESE, EVANS,
GEORGE, GRUCELA, HARHAI, JOSEPHS, MANDERINO, MUNDY, PETRARCA,
ROONEY, STETLER, SURRA, VEON, WANSACZ, FREEMAN, GORDNER,
HALUSKA, HORSEY, LESCOVITZ, MANN, PESCI, PISTELLA, SOLOBAY,
STURLA, TRELLO AND YOUNGBLOOD, SEPTEMBER 27, 2000
REFERRED TO COMMITTEE ON INSURANCE, SEPTEMBER 27, 2000
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" for purposes of quality health care accountability and
13 protection; further providing for responsibilities of managed
14 care plans, for disclosure, for utilization review, for
15 complaints and grievances, for departmental powers and duties
16 and for penalties; and providing for comprehensive health
17 care for uninsured children.
18 The General Assembly of the Commonwealth of Pennsylvania
19 hereby enacts as follows:
20 Section 1. The definition of "managed care plan" in section
21 2102 of the act of May 17, 1921 (P.L.682, No.284), known as The
22 Insurance Company Law of 1921, added June 17, 1998 (P.L.464,
23 No.68), is amended to read:
1 Section 2102. Definitions.--As used in this article, the
2 following words and phrases shall have the meanings given to
3 them in this section:
4 * * *
5 "Managed care plan." A health care plan that uses a
6 gatekeeper to manage the utilization of health care services,
7 integrates the financing and delivery of health care services to
8 enrollees by arrangements with health care providers selected to
9 participate on the basis of specific standards [and] or provides
10 financial incentives for enrollees to use the participating
11 health care providers in accordance with procedures established
12 by the plan. A managed care plan includes health care arranged
13 through an entity operating under any of the following:
14 (1) Section 630.
15 (2) The act of December 29, 1972 (P.L.1701, No.364), known
16 as the "Health Maintenance Organization Act."
17 (3) The act of December 14, 1992 (P.L.835, No.134), known as
18 the "Fraternal Benefit Societies Code."
19 (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan
20 corporations).
21 (5) 40 Pa.C.S. Ch. 63 (relating to professional health
22 services plan corporations).
23 The term includes an entity, including a municipality, whether
24 licensed or unlicensed, that contracts with or functions as a
25 managed care plan to provide health care services to enrollees.
26 The term does not include ancillary service plans or an
27 indemnity arrangement which is primarily fee for service.
28 * * *
29 Section 2. Sections 2111, 2112, 2116 and 2131(a) of the act,
30 added June 17, 1998 (P.L.464, No.68), are amended to read:
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1 Section 2111. Responsibilities of Managed Care Plans.--(a)
2 A managed care plan shall do all of the following:
3 (1) Assure availability and accessibility of adequate health
4 care providers in a timely manner, which enables enrollees to
5 have access to quality care and continuity of health care
6 services. The Department of Health shall adopt by regulation
7 standards as to what constitutes a sufficient network, access to
8 service and reasonable consumer choice of provider.
9 (2) Consult with health care providers in active clinical
10 practice regarding professional qualifications and necessary
11 specialists to be included in the plan.
12 (3) Adopt and maintain a definition of medical necessity
13 used by the plan in determining health care services.
14 (4) Ensure that emergency services are provided twenty-four
15 (24) hours a day, seven (7) days a week and provide reasonable
16 payment or reimbursement for emergency services.
17 (5) Adopt and maintain procedures by which an enrollee can
18 obtain health care services outside the plan's service area.
19 (6) Adopt and maintain procedures by which an enrollee with
20 a life-threatening, degenerative or disabling disease or
21 condition shall, upon request, receive an evaluation and, if the
22 plan's established standards are met, be permitted to receive:
23 (i) a standing referral to a specialist with clinical
24 expertise in treating the disease or condition; or
25 (ii) the designation of a specialist to provide and
26 coordinate the enrollee's primary and specialty care.
27 The referral to or designation of a specialist shall be pursuant
28 to a treatment plan approved by the managed care plan in
29 consultation with the primary care provider, the enrollee and,
30 as appropriate, the specialist. When possible, the specialist
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1 must be a health care provider participating in the plan.
2 (7) Provide direct access to obstetrical and gynecological
3 services by permitting an enrollee to select a health care
4 provider participating in the plan to obtain routine and
5 nonroutine maternity and gynecological care, including medically
6 necessary and appropriate follow-up care and referrals for
7 diagnostic testing related to maternity and gynecological care,
8 without prior approval from a primary care provider. The health
9 care services shall be within the scope of practice of the
10 selected health care provider. The selected health care provider
11 shall inform the enrollee's primary care provider of all health
12 care services provided.
13 (8) Adopt and maintain a complaint process as set forth in
14 subdivision (g).
15 (9) Adopt and maintain a grievance process as set forth in
16 subdivision (i).
17 (10) Adopt and maintain credentialing standards for health
18 care providers as set forth in subdivision (d).
19 (11) Ensure that there are participating health care
20 providers that are physically accessible to people with
21 disabilities and can communicate with individuals with sensory
22 disabilities in accordance with Title III of the Americans with
23 Disabilities Act of 1990 (Public Law 101-336, 42 U.S.C. § 12181
24 et seq.).
25 (12) Provide a list of health care providers participating
26 in the plan to the department every two (2) years or as may
27 otherwise be required by the department. The list shall include
28 the extent to which health care providers in the plan are
29 accepting new enrollees.
30 (13) Report to the department and the Insurance Department
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1 in accordance with the requirements of this article. Such
2 information shall include the number, type and disposition of
3 all complaints and grievances filed with the plan.
4 (14) Offer every member the opportunity to seek treatment
5 from a licensed provider outside of the managed care plan
6 network. The managed care plan may cover the reasonable and
7 appropriate costs of such an option by raising the premium
8 charged for that member or implementing a requirement that the
9 member bear some percentage of the cost associated with
10 receiving treatment outside of the plan's network. Such a
11 requirement shall amount to not more than twenty per centum
12 (20%) of the provider's usual and customary rate for the service
13 provided and shall be subject to approval by the Insurance
14 Commissioner. The provider must offer services covered by the
15 plan.
16 (15) Ensure that there are participating health care
17 providers that are physically accessible to people with
18 disabilities and can communicate with individuals with sensory
19 disabilities in accordance with Title III of the Americans with
20 Disabilities Act of 1990 (Public Law 101-336, 42 U.S.C. § 12181
21 et seq.).
22 (16) Provide a list of health care providers participating
23 in the plan to the department at least every two (2) years or as
24 may otherwise be determined by the department. The list shall
25 identify the extent to which providers in the network are
26 accepting new patients.
27 (b) A managed care plan may adopt reasonable copayments for
28 services, but only after the department has reviewed each
29 proposed copayment to determine its impact on access to
30 services, continuity of care, quality of care and cost to the
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1 consumer.
2 Section 2112. Financial Incentives and Transfer of Liability
3 Prohibition.--(a) No managed care plan shall:
4 (1) use any financial incentive that compensates a health
5 care provider for providing less than medically necessary and
6 appropriate care to an enrollee[.]; or
7 (2) include any provision in a contract with a health care
8 provider that holds the plan harmless from liability for
9 treatment or payment of services or includes an indemnification
10 clause that transfers responsibility for indemnification or
11 otherwise transfers financial or medical liability relating to
12 the activities or omissions of the plan from the plan to that
13 provider.
14 (b) The plan shall disclose to members, prospective members
15 and participating providers any financial incentives provided or
16 offered to the plan medical director or any staff engaged in
17 utilization reviews.
18 (c) Nothing in this section shall be deemed to prohibit a
19 managed care plan from using a capitated payment arrangement or
20 other risk-sharing arrangement.
21 Section 2116. Emergency Services.--If an enrollee seeks
22 emergency services and the emergency health care provider
23 determines that emergency services are necessary, the emergency
24 health care provider shall initiate necessary intervention to
25 evaluate and, if necessary, stabilize the condition of the
26 enrollee without seeking or receiving authorization from the
27 managed care plan. The managed care plan shall pay all
28 reasonably necessary costs associated with the emergency
29 services provided during the period of the emergency, including
30 the costs of any medical assessment or test to determine if
20000H2789B3998 - 6 -
1 urgent care is required. When processing a reimbursement claim
2 for emergency services, a managed care plan shall consider both
3 the presenting symptoms and the services provided. The emergency
4 health care provider shall notify the enrollee's managed care
5 plan of the provision of emergency services and the condition of
6 the enrollee. If an enrollee's condition has stabilized and the
7 enrollee can be transported without suffering detrimental
8 consequences or aggravating the enrollee's condition, the
9 enrollee may be relocated to another facility to receive
10 continued care and treatment as necessary.
11 Section 2131. Confidentiality.--(a) (1) A managed care
12 plan and a utilization review entity shall adopt and maintain
13 procedures to ensure that all identifiable information regarding
14 enrollee health, diagnosis and treatment is adequately protected
15 and remains confidential in compliance with all applicable
16 Federal and State laws and regulations and professional ethical
17 standards.
18 (2) A managed care plan may not:
19 (i) Sell or transfer for any financial consideration the
20 names or any other patient-identifying information.
21 (ii) Release any patient-specific genetic information
22 without the written consent of that patient, the patient's legal
23 representative or legal guardian.
24 * * *
25 Section 3. Section 2136(a) of the act, added June 17, 1998
26 (P.L.464, No.68), is amended by adding paragraphs to read:
27 Section 2136. Required Disclosure.--(a) A managed care plan
28 shall supply each enrollee and, upon written request, each
29 prospective enrollee or health care provider with the following
30 written information. Such information shall be easily
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1 understandable by the layperson and shall include, but not be
2 limited to:
3 * * *
4 (16) Each enrolled member and each prospective member shall
5 be informed in writing that they have the right to:
6 (i) Obtain, without paying any financial penalty, specific
7 prescription drugs that are not included in that managed care
8 plan's drug formulary, when the patient is allergic to the
9 formulary medication, when the formulary medication may interact
10 with other medications the patient is taking or when the patient
11 has an intolerance for the formulary medication.
12 (ii) Be informed about alternative treatment options and the
13 consequences of each option.
14 (iii) Receive basic comparative information about the plan
15 in which they are enrolled or potentially could enroll.
16 (iv) Participate in and be covered for clinical trials and
17 experimental treatment so long as there is a meaningful
18 potential for a significant clinical benefit from that trial or
19 treatment.
20 (v) Receive a clear statement as to the charges and payments
21 for which that member is or may be liable and to the limitations
22 or other conditions that affect that member's ability to access
23 health care services.
24 (vi) File a grievance, authorize a provider to file a
25 grievance on his behalf and file a complaint and receive a
26 timely response.
27 (vii) Be informed about any special provider payment
28 procedures that could potentially impact on that member's
29 ability to access care.
30 (viii) Obtain a referral out-of-network when the network is
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1 insufficient to provide treatment required by that member.
2 (ix) Designate their own care coordinators or gatekeepers
3 from among the network of providers participating in that plan.
4 (x) For members who have been diagnosed and are in treatment
5 for a chronic illness or disability, select a specialist as
6 their primary care provider.
7 (xi) Seek treatment for a provider not in the plan provider
8 network, with a clear statement as to the additional cost to
9 that member for such service.
10 (xii) Receive accurate and complete information from any
11 physician treating that member about any diagnosis, treatment
12 option and prognosis.
13 (xiii) Request the name, professional status and function of
14 any individual providing health care services to that member.
15 (17) Each enrolled member and each prospective member shall
16 be informed in writing whenever a plan proposes to restrict
17 access to any member or group or class of members to any portion
18 or segment of its network.
19 * * *
20 Section 4. Section 2193 of the act is repealed.
21 Section 5. This act shall take effect immediately.
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