PRINTER'S NO. 3962
No. 2803 Session of 1990
INTRODUCED BY KUKOVICH, RICHARDSON, PISTELLA, PRESSMANN,
BORTNER, JOSEPHS, KOSINSKI, J. L. WRIGHT, STUBAN, VAN HORNE,
STISH, MELIO, GIGLIOTTI, DeLUCA, TRICH, HARPER, LAUGHLIN,
PESCI, BELARDI, CAWLEY, WILLIAMS, McNALLY AND FREEMAN,
JULY 1, 1990
REFERRED TO COMMITTEE ON HEALTH AND WELFARE, JULY 1, 1990
AN ACT
1 Providing a comprehensive plan for health care for the indigent;
2 providing further duties of the Department of Health, the
3 Department of Public Welfare and the Department of Revenue;
4 providing for a hospital payment system and for certain
5 responsibilities under the Medicaid program; providing
6 primary health care programs for children and adults;
7 establishing the Pennsylvania Health Care Fund and the
8 Pennsylvania Health Insurance Partnership Trust Fund; making
9 certain assessments; imposing a tax; providing for certain
10 tax credits; providing for enforcement and civil penalties;
11 providing for certain health care studies; further providing
12 for eligibility for medical assistance; and making repeals.
13 TABLE OF CONTENTS
14 Chapter 1. General Provisions
15 Section 101. Short title.
16 Section 102. Legislative findings and intent.
17 Section 103. Definitions.
18 Chapter 3. Pennsylvania Hospital Fair Share Program
19 Section 301. Establishment and purpose.
20 Section 302. Computation.
21 Section 303. Disproportionate share hospital.
1 Section 304. Expenditures from fund.
2 Chapter 5. Medicaid Program
3 Section 501. Hospital responsibilities under Medicaid program.
4 Section 502. Medicaid outreach.
5 Chapter 7. Primary Health Care Programs
6 Section 701. Children's Health Care Plan.
7 Section 702. Uninsured workers and adults.
8 Section 703. Outreach and quality assurance.
9 Chapter 9. Pennsylvania Health Care Fund
10 Section 901. Establishment.
11 Section 902. Purpose.
12 Section 903. Administration.
13 Section 904. Assessment.
14 Section 905. Civil penalty.
15 Section 906. Financial provisions.
16 Chapter 11. Pennsylvania Health Insurance Partnership Trust
17 Fund
18 Section 1101. Establishment.
19 Section 1102. Purpose.
20 Section 1103. Administration.
21 Section 1104. Composition.
22 Section 1105. Trust for enrollees.
23 Section 1106. Miscellaneous provisions.
24 Chapter 13. Health Insurance Payroll Tax
25 Section 1301. Imposition.
26 Section 1302. Rate.
27 Section 1303. Tax credits.
28 Chapter 15. Small Business Health Insurance Tax Credit
29 Section 1501. Eligibility.
30 Section 1502. Calculation of credit.
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1 Section 1503. Rules and regulations.
2 Section 1504. Reports to General Assembly.
3 Chapter 17. Access to Health Care
4 Section 1701. Discrimination prohibited.
5 Section 1702. Health maintenance organizations.
6 Section 1703. Continuity on replacement of a group policy.
7 Section 1704. Continuity for individual who changes groups.
8 Section 1705. Limitations on exclusions and waiting periods.
9 Section 1706. Waiting period for preexisting conditions.
10 Section 1707. Enforcement.
11 Chapter 19. Studies and Hearings on Health Care
12 Section 1901. Hospital uncompensated charity care study.
13 Section 1902. Medicaid reimbursement.
14 Section 1903. Study of generic substitutes for brand name
15 prescriptions.
16 Chapter 31. Miscellaneous Provisions.
17 Section 3101. Persons eligible for medical assistance.
18 Section 3102. Group accident and sickness insurance.
19 Section 3103. Construction and application of Chapters 3 and 9.
20 Section 3104. Repeals.
21 Section 3105. Expiration of act.
22 Section 3106. Effective date.
23 The General Assembly of the Commonwealth of Pennsylvania
24 hereby enacts as follows:
25 CHAPTER 1
26 GENERAL PROVISIONS
27 Section 101. Short title.
28 This act shall be known and may be cited as the Health Care
29 Partnership Act.
30 Section 102. Legislative findings and intent.
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1 (a) Declaration.--The General Assembly finds and declares
2 that:
3 (1) All citizens of this Commonwealth have a right to
4 affordable and reasonably priced health care and to
5 nondiscriminatory treatment by health insurers and providers.
6 (2) The uninsured health care population of this
7 Commonwealth is over one million persons, and many thousands
8 more lack adequate insurance coverage. Approximately two-
9 thirds of the uninsured are employed or dependents of
10 employed persons.
11 (3) Over one-third of the uninsured health care
12 population are children. Uninsured children are of particular
13 concern because of their need for ongoing preventative and
14 primary care. Measures not taken to care for such children
15 now will result in higher human and financial costs later.
16 Access to timely and appropriate primary care is particularly
17 serious for women who receive late or no prenatal care which
18 increases the risk of low birth weights and infant mortality.
19 (4) The uninsured and underinsured lack access to timely
20 and appropriate primary and preventative care. As a result,
21 they often delay or forego health care, with the resulting
22 increased risk of developing more severe conditions, which
23 are more expensive to treat. This tendency of the medically
24 indigent to delay care and to seek ambulatory care in
25 hospital-based settings also causes inefficiencies in the
26 health care system.
27 (5) Health markets have been distorted through cost
28 shifts for the uncompensated health care costs of uninsured
29 citizens of this Commonwealth which has caused decreased
30 competitive capacity on the part of those health care
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1 providers who serve the poor, and increased costs of other
2 health care payors.
3 (6) Cost containment efforts and increased competition
4 have and will inhibit the traditional method of funding care
5 for uninsured citizens of this Commonwealth through cost
6 shifting. This will have an even greater negative impact on
7 the ability of uninsured citizens of this Commonwealth to
8 obtain needed health care.
9 (7) Not-for-profit hospitals which have been granted a
10 tax free status by the State vary greatly in the amount of
11 charitable uncompensated health care they provide and on
12 average provide less than the national average. There has
13 been no uniform definition to determine the amount of charity
14 care provided by these health care institutions.
15 (8) Although the proper implementation of spend-down
16 provisions under Medicaid should result in the provision of
17 the vast majority of all hospital care for the uninsured
18 through the Medicaid program, hospitals vary widely in their
19 willingness to allow patients to incur expenses so they can
20 qualify for Medicaid, and Department of Welfare regulations
21 which required hospitals to do so have recently been
22 rescinded.
23 (9) The professional health service plan corporation and
24 the hospital plan corporations which are granted an exemption
25 from the premium tax have varied greatly in the amount of
26 health services they provide to low-income citizens of this
27 Commonwealth and the manner in which they have targeted their
28 subsidies.
29 (10) Many health maintenance organizations have been
30 unwilling to reach an agreement with the Department of Public
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1 Welfare, to enroll as subscribers, individuals participating
2 in or eligible for Medicaid.
3 (11) No one sector can absorb the cost of providing
4 health care to all citizens of this Commonwealth who cannot
5 afford health care on their own. The cost is too large for
6 the public sector alone to bear and instead requires the
7 establishment of a public/private partnership to share the
8 costs in a manner economically feasible for all interests.
9 The magnitude of this need also requires that it be done on a
10 time-phased, cost-managed and planned basis.
11 (b) Intent.--It is the intent of the General Assembly and
12 the purpose of this act to:
13 (1) Ensure access to timely and appropriate health care
14 for all citizens of this Commonwealth by providing for a cost
15 effective, comprehensive health coverage for low-income
16 citizens of this Commonwealth who are unable to afford
17 coverage or obtain it through their employment.
18 (2) Provide incentives for employers to provide health
19 insurance coverage for their employees and their uninsured
20 dependents by providing for a more affordable group coverage.
21 (3) Promote the efficient use of health services by
22 assuring that care is provided in appropriate settings;
23 promoting care provided by efficient providers, consistent
24 with high quality care; and assuring that care is being
25 provided at an appropriate stage, soon enough to avert the
26 need for overly expensive treatment.
27 (4) Provide for a pooling of funds to finance the health
28 care by hospitals providing a disproportionate share of low-
29 income persons, which will insure continued access to needed
30 inpatient care by low-income, uninsured citizens of this
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1 Commonwealth and permit disproportionate share hospitals to
2 compete fairly in the marketplace.
3 (5) Assure equity among health providers and payors by
4 providing a mechanism for providers, employers, the public
5 sector and patients to share in financing indigent health
6 care.
7 Section 103. Definitions.
8 The following words and phrases when used in this act shall
9 have the meanings given to them in this section unless the
10 context clearly indicates otherwise:
11 "Average annual occupancy rate." The occupancy rate of a
12 hospital derived by dividing the total number of inpatient beds
13 for which the hospital is licensed times the number of days
14 between July 1 and June 30 of each year for which the beds were
15 licensed into the total days of inpatient care provided by the
16 hospital during the same period as follows: Total days of care
17 divided by the product of total licensed beds times total days
18 beds are licensed.
19 "Bad debt." The difference between the patient pay amount
20 due and the patient pay revenue received.
21 "Child." A person under 18 years of age.
22 "Department." The Department of Public Welfare of the
23 Commonwealth.
24 "Disproportionate share hospital." Each hospital, including
25 distinct parts, providing a number or percentage of inpatient
26 services paid through the medical assistance program during the
27 previous fiscal year in excess of one of the means of the
28 numbers or percentages of all hospitals, as described in Chapter
29 3.
30 "Fund" or "health care fund." The Pennsylvania Health Care
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1 Fund established in Chapter 9.
2 "Group." Any group for which a health insurance policy is
3 written in the Commonwealth of Pennsylvania.
4 "Health maintenance organization" or "HMO." An entity
5 organized and regulated under the act of December 29, 1972
6 (P.L.1701, No.364), known as the Health Maintenance Organization
7 Act.
8 "Hospital." An institution having an organized medical staff
9 which is engaged primarily in providing to inpatients, by or
10 under the supervision of physicians, diagnostic and therapeutic
11 services for the care of injured, disabled, pregnant, diseased
12 or sick or mentally ill persons. The term includes facilities
13 for the diagnosis and treatment of disorders within the scope of
14 specific medical specialties, including facilities which provide
15 care and treatment exclusively for the mentally ill and drug or
16 alcohol inpatient detoxification or rehabilitative care. The
17 term does not include inpatient nonhospital activity as
18 described in 28 Pa. Code § 701.1 (relating to general
19 definitions), publicly owned inpatient facilities or skilled or
20 intermediate care nursing facilities. The term also does not
21 include a facility which is operated by a religious organization
22 for the purpose of providing health care services exclusively to
23 clergymen or other persons in a religious profession who are
24 members of a religious denomination or a facility providing
25 treatment solely on the basis of prayer or spiritual means.
26 "Medical assistance." The State program of medical
27 assistance established under the act of June 13, 1967 (P.L.31,
28 No.21), known as the Public Welfare Code.
29 "Medicaid." The Federal medical assistance program
30 established under Title XIX of the Social Security Act (Public
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1 Law 74-271, 42 U.S.C. § 301 et seq.).
2 "Medically indigent." Families and individuals who lack
3 sufficient income or financial resources through insurance or
4 other means to pay for necessary health care services.
5 "Net inpatient revenue." The difference between a hospital's
6 total inpatient revenue and a hospital's total medical
7 assistance inpatient revenue.
8 "Nondisproportionate share hospital." A hospital, including
9 distinct parts, located within this Commonwealth which provided
10 a percentage of inpatient services paid through the medical
11 assistance program during the previous fiscal year below the
12 mean of the percentages of all hospitals, as described in
13 Chapter 3.
14 "Preexisting condition exclusion." An exclusion of benefits
15 for a specified or indefinite period of time on the basis of one
16 or more physical or mental conditions for which, before the
17 effective date of enrollment:
18 (1) a person experienced symptoms that would cause an
19 ordinarily prudent person to seek diagnosis, care or
20 treatment; or
21 (2) a provider of health care services recommended or
22 provided medical advice or treatment to the person.
23 "Specialty and supplemental health services." Services not
24 included as primary health services, such as hospital care, home
25 health services, rehabilitative services, mental health
26 services, drug and alcohol services and ambulatory surgical
27 services.
28 "Spend-down." The qualifying procedure for the Pennsylvania
29 Medical Assistance Program set forth in 55 Pa. Code, Chapter 181
30 (relating to income provisions for categorically needy nonmoney
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1 payment (NMP-MA) and medically needy only (MNO-MA) medical
2 assistance (MA)).
3 "Subgroup." An employer covered under a contract issued to a
4 multiple employer trust or to an association.
5 "Title XIX." Title XIX of the Social Security Act (Public
6 Law 74-271, 42 U.S.C. § 301 et seq.).
7 "Title XIX medical assistance." Only those aspects of the
8 medical assistance program established under Title XIX of the
9 Social Security Act (Public Law 74-271, 42 U.S.C. § 301 et
10 seq.), for which Federal financial participation is available.
11 "Waiting period." A period of time after the effective date
12 of enrollment during which a health insurance plan excludes
13 coverage for the diagnosis or treatment of one or more medical
14 conditions.
15 CHAPTER 3
16 PENNSYLVANIA HOSPITAL FAIR SHARE PROGRAM
17 Section 301. Establishment and purpose.
18 (a) Establishment.--The General Assembly hereby establishes
19 the Pennsylvania Hospital Fair Share Program, to be administered
20 by the department.
21 (b) Purpose.--The purpose of the program shall be to
22 identify those hospitals in this Commonwealth which provide a
23 disproportionate share of care to the medically indigent and to
24 compensate those hospitals for their services.
25 Section 302. Computation.
26 On or before the last day of January 1991, and each year
27 thereafter, the department shall:
28 (1) Determine the total number of inpatient hospital
29 days of care provided during the previous fiscal year by each
30 hospital which has entered into a medical assistance provider
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1 agreement.
2 (2) Determine the number of inpatient hospital days of
3 care provided by the hospital to all persons eligible for
4 medical assistance and paid through the medical assistance
5 program during the previous fiscal year.
6 (3) Determine the number of inpatient hospital days of
7 care provided by the hospital to persons eligible for Title
8 XIX medical assistance and paid through the medical
9 assistance program during the previous fiscal year.
10 (4) Using the information from paragraphs (1) through
11 (3), calculate the following for each hospital:
12 (i) the ratio of Title XIX medical assistance days
13 to total days;
14 (ii) the ratio of total medical assistance days to
15 total days;
16 (iii) the total number of Title XIX medical
17 assistance days; and
18 (iv) the total number of all medical assistance
19 days.
20 (5) Using the information from paragraph (4), for all
21 hospitals, determine:
22 (i) the mean ratio of Title XIX medical assistance
23 days to total days;
24 (ii) the mean ratio of total medical assistance days
25 to total days;
26 (iii) the mean of the total number of Title XIX
27 medical assistance days; and
28 (iv) the mean of the total number of all medical
29 assistance days.
30 Section 303. Disproportionate share hospital.
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1 A hospital is a disproportionate share hospital if any of its
2 hospital specific results determined under section 302(4) equals
3 or exceeds the corresponding mean Statewide result for all
4 hospitals determined under section 302(5). Disproportionate
5 share hospitals shall be ranked for payment purposes by the
6 ratio of Title XIX medical assistance days to total patient days
7 provided during the reporting period. The hospital with the
8 highest ratio of Title XIX medical assistance days to total
9 patient days provided during the reporting period shall be
10 assigned a numerical rank equal to the total number of
11 disproportionate share hospitals. The hospital with the lowest
12 ratio of Title XIX medical assistance days to total patient days
13 provided during the reporting period shall be assigned a rank
14 number of one. Each hospital shall be assigned a
15 disproportionate share rank weight equal to one plus the
16 quotient of its numerical rank divided by the total number of
17 disproportionate share hospitals.
18 Section 304. Expenditures from fund.
19 (a) Purpose.--Moneys deposited in the Pennsylvania Health
20 Care Fund shall be expended on programs established under this
21 act to provide care for the medically indigent, to provide all
22 hospitals with a medical assistance payment rate subsidy, to
23 provide a disproportionate share payment to all hospitals which
24 qualify for such payment, to provide a hold harmless payment to
25 all hospitals eligible to receive such payment, and to provide
26 for Medicaid expansion as set forth in section 3101.
27 (b) Medical assistance payment rate.--Amounts paid into the
28 fund shall be used to adjust medical assistance payment rates to
29 hospitals to the most recent rebased figures established by the
30 department. The department shall rebase the medical assistance
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1 payment rates at least every 24 months, to reflect current cost
2 data, but such rates shall not exceed the upper limits for
3 Medicaid payment rates established at 42 CFR 447.272 (relating
4 to application of upper payment limits).
5 (c) Disproportionate share payments.--Amounts paid into the
6 fund shall also be used to provide disproportionate share
7 payments to hospitals. Disproportionate share payments to
8 hospitals shall be in the form of a rate add-on. Hospitals which
9 qualify for disproportionate share payments shall receive the
10 payments at fixed intervals under the following formula:
11 (1) The department shall multiply each hospital's
12 assigned disproportionate share rank weight by its number of
13 medical assistance cases to obtain a weighted number of
14 medical assistance cases for each hospital.
15 (2) The department shall then divide the total amount of
16 money to be distributed through disproportionate share
17 payments by the total weighted number of medical assistance
18 cases for all hospitals to obtain a unit disproportionate
19 share payment weighted medical assistance case.
20 (3) The department shall then multiply each hospital's
21 weighted number of medical assistance cases by the unit
22 disproportionate share payment per weighted medical
23 assistance case to obtain a disproportionate share payment
24 for each qualifying hospital.
25 (d) Hold harmless payments.--Hold harmless payment shall be
26 made to each hospital which qualifies so that for any given
27 fiscal year no hospital receives payments from the Commonwealth
28 under subsections (b), (c) and (d) and payments of Federal funds
29 earned under this section totaling less than 1.05 times the
30 amount the hospital paid into the fund for that year, except as
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1 provided in subsections (g) and (h).
2 (e) Funding for expansion of the Pennsylvania Medical
3 Assistance Program.--Payments from the fund may be made for the
4 additional costs due to the expansion of the Pennsylvania
5 Medical Assistance Program as is provided for in this act.
6 (f) Total payments.--The amount to be paid to each hospital
7 under this section shall be set so that the total amounts paid
8 do not exceed the total amount deposited into the fund.
9 (g) Medical assistance program.--No payment from this fund
10 shall be made to any hospital that does not ensure that all
11 staff and admitting physicians are enrolled and actively
12 participating in the Pennsylvania Medical Assistance Program. As
13 a condition of receiving payments from the fund, each hospital
14 must establish a physician referral service to assist medical
15 assistance recipients with referrals to primary care and
16 specialist physicians on an equitable, rotating basis.
17 (h) Charity care.--Commencing with the calendar year
18 beginning January 1, 1992, no payment from this fund shall be
19 made to any hospital that does not provide for the year an
20 amount of uncompensated charity care, as described in section
21 1901, equal to at least 2% of their total revenue for that year.
22 CHAPTER 5
23 MEDICAID PROGRAM
24 Section 501. Hospital responsibilities under Medicaid program.
25 (a) Necessary care.--Each licensed acute care hospital shall
26 not deny necessary and timely health care due to a person's
27 inability to pay in advance from current income or resources for
28 all or part of that care.
29 (b) Installment agreements.--Hospitals shall enter into
30 reasonable installment agreements to cover the spend-down cost
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1 of the care necessary for the person to qualify for medical
2 assistance coverage or insurance. Within six months of the
3 effective date of this act, the department shall issue
4 guidelines to ensure uniformity of this provision and compliance
5 with Federal and State requirements.
6 (c) Prohibitions.--It is unlawful for any hospital licensed
7 by the Commonwealth:
8 (1) to require, as a condition of admission or
9 treatment, assurance from the patient or any other person
10 that the patient is not eligible for or will not apply for
11 medical assistance;
12 (2) to deny or delay admission or treatment of a person
13 because of his current or possible future status as a medical
14 assistance recipient;
15 (3) to transfer a patient to another health care
16 provider because of his current or possible status as a
17 medical assistance recipient;
18 (4) to discharge a patient from care because of his
19 current or possible future status as a medical assistance
20 recipient;
21 (5) to charge any amounts in excess of the medical
22 assistance rate for any services covered or which could have
23 been covered by the medical assistance program; or
24 (6) to discourage any person who would be eligible for
25 the medical assistance program from applying or seeking
26 needed health care or needed admission to a health care
27 facility because of his inability to pay for that care.
28 (d) Application for medical assistance.--Each hospital shall
29 provide to each prospective uninsured or underinsured patient,
30 assistance in completing an application for medical assistance,
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1 within one business day of the prospective patient's first
2 request to be admitted to the hospital.
3 (e) Access to all services.--Each hospital shall ensure that
4 all Medicaid beneficiaries have full access to all available
5 services, physician specialists and any department of the
6 facility. If necessary, hospitals shall make enrollment and
7 participation in the Pennsylvania Medical Assistance Program a
8 condition of obtaining or renewing staff privileges.
9 Section 502. Medicaid outreach.
10 The department shall establish and administer an outreach
11 program to enroll people who are eligible for Medicaid but have
12 not enrolled. This shall include:
13 (1) Placing caseworkers in hospitals which serve a large
14 Medicaid population to take on-site applications for
15 Medicaid.
16 (2) Providing Statewide training to hospital staff on
17 Medicaid spend-down and other eligibility procedures.
18 (3) Developing a program of public service announcements
19 to be aired on television and radio on a regular Statewide
20 basis, advising citizens of:
21 (i) expanded Medicaid eligibility for pregnant
22 women, infants, the elderly, the disabled, persons with
23 acquired immune deficiency syndrome (AIDS); and
24 (ii) general eligibility requirements, spend-down,
25 expedited issuance of medical assistance cards, and how
26 and where to apply.
27 (4) Developing pamphlets and informational services for
28 Medicaid providers to help providers inform patients about
29 medical assistance options and eligibility.
30 (5) Providing the General Assembly and the public an
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1 annual report for each fiscal year, detailing the outreach
2 and enrollment efforts taken by each county assistance
3 office, and reporting by county on the number of citizens
4 enrolled in the Medicaid and the projected Medicaid eligible
5 population of each county.
6 CHAPTER 7
7 PRIMARY HEALTH CARE PROGRAMS
8 Section 701. Children's Health Care Plan.
9 (a) Development.--The professional health services plan
10 corporation and each hospital plan corporation shall jointly
11 develop for operation no later than January 1, 1992, a Statewide
12 primary health care insurance plan for all children of this
13 Commonwealth who are not otherwise eligible for, or covered by,
14 a health insurance plan, a self-insurance health plan or the
15 medical assistance program.
16 (b) Department of Health.--The Children's Health Care Plan
17 shall be regulated by the Department of Health as to quality of
18 care and scope of services, but at a minimum shall provide
19 preventive care, including routine physical examinations, eye
20 and ear examinations to determine the need for vision and
21 hearing correction, and immunizations, physician office visits
22 when a child is sick, emergency care, diagnostic tests,
23 outpatient surgery, availability of 24-hours-a-day, 7-days-a-
24 week-access, integration with EPSDT, WIC, MIC Programs,
25 specialist referral requirements and prescription drugs.
26 (c) Contracts with providers.--To the fullest extent
27 practicable, the Children's Health Care Plan shall contract with
28 providers to provide primary health care services for enrollees
29 on a basis best calculated to manage costs of the program,
30 including, but not limited to, purchasing health care services
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1 on a capitated basis, using managed health care techniques,
2 using generic drugs where appropriate or other cost management
3 methods.
4 (d) Eligibility for enrollment.--
5 (1) To the extent funds permit, any parent, guardian or
6 other legal representative of a child residing in this
7 Commonwealth who is not eligible for or covered by a health
8 insurance plan, a self-insurance health plan or the medical
9 assistance program shall be eligible for enrollment of their
10 child in the Children's Health Care Plan. However, the plan
11 may permit enrollment by children who are eligible for a
12 health insurance plan or self-insurance health plan or
13 medical assistance program but who refuse to accept such
14 coverage if:
15 (i) the premium payment required for such coverage
16 for the child is so expensive relative to the income of
17 that family that it would constitute a severe economic
18 hardship if the family accepted such coverage for the
19 child;
20 (ii) the refusal to accept such coverage was made in
21 good faith; and
22 (iii) providing coverage would be consistent with
23 the purposes of this section.
24 (2) Coverage shall not be denied on the basis of a
25 preexisting medical condition.
26 (e) Inpatient care.--Inpatient hospital care shall be
27 provided through the Medicaid program, with primary care
28 physicians making the necessary arrangements for admission to
29 the hospital and necessary specialty care.
30 (f) Uninsured children.--The plan shall be free to all
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1 uninsured children whose family income is less than or up to
2 150% of the Federal poverty level, and shall be available on a
3 sliding fee basis to children whose family income is more than
4 150% but less than 200% of the Federal poverty level. Those over
5 200% of the Federal poverty level may purchase coverage for
6 children under the plan at cost. There shall be no copayments or
7 deductibles.
8 (g) Children temporarily without coverage.--The plan shall
9 provide for participation in the program by children who are
10 temporarily without coverage by a health insurance plan, self-
11 insurance health plan or medical assistance.
12 (h) Contracts.--The plan shall have a contractual
13 arrangement with the Department of Public Welfare to receive
14 Federal and State funding under Title XIX for persons who are
15 eligible for medical assistance, and contract with providers who
16 agree to accept the fee established for provision of primary
17 health care to medical assistance recipients as payment in full.
18 (i) Funding.--The plan shall be financed by the professional
19 health service corporations as defined in 40 Pa.C.S. (relating
20 to insurance) in partial fulfillment of their obligation to
21 serve low-income subscribers. The expenses of the plan shall be
22 financed by each professional health service corporation in
23 proportion to the percentage of premiums of that professional
24 health service corporation to the total premiums for all the
25 Commonwealth professional health service corporation premiums,
26 but shall not exceed 2% of any professional health service
27 corporation's total annual premiums, excluding administrative
28 costs. Administrative expenses of the plan shall be donated by
29 the respective professional health service corporations.
30 (j) Insurance cards.--The plan shall provide Blue Cross/Blue
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1 Shield cards to those children covered under the plan which
2 shall not specially identify them as low income.
3 (k) Physicians.--The plan shall ensure that there are
4 adequate primary care physicians throughout this Commonwealth to
5 ensure some choice of physicians, availability within a
6 reasonable and convenient travel distance and Statewide
7 coverage.
8 (l) Contracts with providers.--The plan shall contract with
9 any qualified, cost-effective provider, including hospital
10 outpatient departments, HMOs, clinics, group practices and
11 individual practitioners.
12 Section 702. Uninsured workers and adults.
13 (a) Development.--The professional health service plan
14 corporation and the hospital plan corporations shall
15 concurrently develop a primary health care insurance plan for
16 adults, equivalent to the Children's Primary Health Care Plan
17 set forth in section 701 for purchase at cost by January 1,
18 1992. The plan for adults shall make affordable primary health
19 care available to individual Commonwealth residents whose income
20 exceeds Medicaid eligibility guidelines but who are without
21 sufficient means to purchase other health care insurance to
22 cover the costs of health care.
23 (b) Rates.--The Insurance Commissioner shall review the
24 rates for the Primary Health Care Plan for adults and shall
25 ensure that the premium covers all appropriate costs, reserves
26 and administrative costs of the professional health service
27 corporation.
28 (c) Cost data.--The professional health service plan and the
29 hospital plan corporations shall keep detailed actuarial data on
30 the costs of the adult plan in preparation for its expansion in
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1 1993 pursuant to Chapter 11.
2 (d) Premiums.--The professional health service plan and the
3 hospital plan corporations shall establish a premium structure
4 for enrollment effective January 1, 1993, which shall be
5 adjusted to reflect the incomes of persons seeking to become
6 enrollees in the program and shall be structured so that
7 individuals whose incomes are insufficient to pay the full
8 premium can participate in the program.
9 (e) Payment by Pennsylvania Health Insurance Partnership
10 Trust Fund.--Effective June 30, 1993, for uninsured employed
11 persons whose income is less than or equal to 200% of the
12 Federal poverty level, the premium shall be paid for qualified
13 persons by the Pennsylvania Health Insurance Partnership Trust
14 Fund, at no expense to the individual. The Insurance Department
15 shall, prior to the commencement of the program, determine a
16 sliding rate schedule for qualified persons whose income exceeds
17 200% of the Federal poverty level.
18 Section 703. Outreach and quality assurance.
19 (a) Public information.--The professional health service
20 plan and the hospital plan corporations shall actively publicize
21 both the children's and adults' primary care health plans and
22 shall solicit the assistance of the Commonwealth, health care
23 providers and others in bringing the program to the attention of
24 prospective enrollees.
25 (b) Quality assurance.--The children's and adults' plans
26 shall have an ongoing quality assurance program for its
27 services, as required by the Department of Health and shall have
28 organizational arrangements for referral to supplemental health
29 care and acute hospital care, as required by the Department of
30 Health.
19900H2803B3962 - 21 -
1 (c) Enrollment information.--Commencing January 1, 1993, all
2 employers who do not provide qualifying health care insurance as
3 defined by this act shall provide their employees with
4 enrollment information concerning the Primary Health Care Plan
5 for Adults.
6 CHAPTER 9
7 PENNSYLVANIA HEALTH CARE FUND
8 Section 901. Establishment.
9 There is hereby established in the State Treasury a separate
10 account, to be known as the Pennsylvania Health Care Fund.
11 Section 902. Purpose.
12 Moneys deposited in the fund shall be expended for programs,
13 goods and services which support the provisions of this act for
14 which Federal matching funds are available through Title XIX.
15 Section 903. Administration.
16 The fund shall be administered by the Department of Revenue.
17 The Department of Revenue shall:
18 (1) Collect and distribute the moneys of the fund
19 pursuant to this act.
20 (2) Promulgate rules and regulations for the collection
21 of data and the determination of deposit amounts for the fund
22 and the distribution thereof, as set forth in Chapter 3.
23 Section 904. Assessment.
24 Every hospital is hereby assessed an amount for the fund,
25 payable at the rate provided in this section. On the last day of
26 September, December, March and June, every hospital shall
27 forward to the Department of Revenue for deposit in the fund an
28 amount equal to one-fourth of one and one-half percent of the
29 hospital's net inpatient revenue for the preceding quarter.
30 Section 905. Civil penalty.
19900H2803B3962 - 22 -
1 Any hospital that fails to comply with section 904 shall be
2 liable for a civil penalty of $1,000 per day for each day after
3 the due date that the funds are not deposited. The Secretary of
4 Revenue may waive this penalty for a period not to exceed 30
5 days. In addition, no hospital shall be eligible to receive
6 funds under the Pennsylvania Hospital Fair Share Program until
7 the requirements of this section are met and penalties, if
8 applicable, are paid. Interest on the penalty and the amounts
9 due under section 904 may be applied in accordance with the
10 regulations of the Department of Revenue.
11 Section 906. Financial provisions.
12 (a) Appropriations.--All moneys in the fund are hereby
13 appropriated to the Department of Public Welfare on a continuing
14 basis to carry out the purposes of the fund as described in this
15 act. Federal funds earned as the result of payments under this
16 chapter are likewise appropriated to the Department of Public
17 Welfare on a continuing basis.
18 (b) Reconciliation of payments.--The Department of Public
19 Welfare shall reconcile payments to hospitals made under section
20 304(d), as are necessary on an annual basis.
21 (c) Fund administration.--For the purpose of the orderly
22 administration of payments under this act, in any year in which
23 obligations exceed the balance in the fund, the payment of
24 obligations may be carried forward to the following fiscal year.
25 In addition, any funds not expended during a fiscal year shall
26 be retained in the fund and be made available for use during the
27 following fiscal year.
28 CHAPTER 11
29 PENNSYLVANIA HEALTH INSURANCE
30 PARTNERSHIP TRUST FUND
19900H2803B3962 - 23 -
1 Section 1101. Establishment.
2 There is hereby established in the State Treasury a separate
3 account to be known as the Pennsylvania Health Insurance
4 Partnership Trust Fund.
5 Section 1102. Purpose.
6 Moneys deposited in the fund shall be expended for the
7 primary health care program for adults set forth in Chapter 7
8 for uninsured workers and their spouses for whom their employers
9 have paid the tax specified in Chapter 13, but have not received
10 a tax credit pursuant to that chapter.
11 Section 1103. Administration.
12 The fund shall be administered by the Department of Health
13 without liability on the part of the Commonwealth beyond the
14 amounts appropriated or dedicated to the fund and amounts earned
15 by the fund.
16 Section 1104. Composition.
17 The fund shall consist of all taxes collected pursuant to
18 Chapter 13 and all premiums, fees, contributions and other
19 moneys paid into the State Treasury and credited to the fund as
20 is provided in this act; all property and securities acquired by
21 and through the use of moneys belonging to the fund and all
22 interest thereon; less withdrawals from the fund for payments to
23 health care providers for health care services, for
24 administrative expenses, for other expenses authorized under
25 this act and for deposits into the General Fund to reimburse the
26 fund for credits granted under Chapter 13.
27 Section 1105. Trust for enrollees.
28 Moneys deposited in the fund are imposed with a trust for the
29 benefit of the enrollees of any insurance plan administered by
30 the Pennsylvania health insurance partnership and are not
19900H2803B3962 - 24 -
1 subject to appropriation.
2 Section 1106. Miscellaneous provisions.
3 (a) Reserve.--A prudent level of reserve funds shall be
4 maintained to protect the solvency of the trust fund, as shall
5 be determined by the Insurance Commissioner.
6 (b) Separate accounts.--The Department of Health shall
7 maintain separate accounts and segregate funds for the trust.
8 (c) Payment of certain premiums.--Commencing on June 30,
9 1993, all uninsured workers and their spouses who qualify for
10 benefits under the primary health care plan for adults shall be
11 enrolled in the plan with premiums paid for by this fund.
12 (d) Certain Medicaid costs.--The fund shall also pay for all
13 State Medicaid acute hospital costs associated with payment for
14 any qualifying uninsured worker.
15 (e) Eligible employees.--The Department of Health shall
16 determine the hours per week and the length of employment
17 required to qualify for health care and the payroll tax
18 requirements under this act.
19 CHAPTER 13
20 HEALTH INSURANCE PAYROLL TAX
21 Section 1301. Imposition.
22 A payroll tax is imposed on wages in this Commonwealth paid
23 by an employer, other than a governmental unit, to each employee
24 for each taxable year commencing with 1993. A tax is imposed on
25 net earnings in this Commonwealth from self-employment for each
26 taxable year commencing with 1993.
27 Section 1302. Rate.
28 The rate of the tax shall be based on the amount necessary to
29 finance the primary health care for adults in the primary health
30 care plan described in Chapter 11 and the State Medicaid costs
19900H2803B3962 - 25 -
1 for inpatient hospital care for uninsured workers and their
2 spouses receiving primary health care under the plan.
3 Section 1303. Tax credits.
4 (a) Employers.--Commencing in 1993, an employer may take a
5 credit against the tax imposed by section 1301 for each employee
6 who is covered by a qualifying health insurance plan, self-
7 insurance plan or medical assistance program as defined in this
8 act. The credit shall be equal to the tax paid under this
9 chapter for wages paid by the employer to that employee for any
10 period during which the employee has such qualifying alternative
11 health insurance coverage.
12 (b) Self-employed persons.--Commencing in 1993, a self-
13 employed person who throughout any taxable year is covered by a
14 qualifying health insurance plan, self-insurance health plan or
15 medical assistance program may take a credit in an amount equal
16 to the tax specified in this chapter for his net earnings from
17 self-employment against the tax imposed under section 1301.
18 (c) Regulations.--The Department of Health shall promulgate
19 regulations which define the requirements for a qualifying
20 health insurance plan for this section within six months of the
21 effective date of this act and after a full public hearing.
22 CHAPTER 15
23 SMALL BUSINESS HEALTH INSURANCE TAX CREDIT
24 Section 1501. Eligibility.
25 An employer shall be eligible for a tax credit against any
26 tax due under Article II, III, IV, or VI of the act of March 4,
27 1971 (P.L.6, No.2), known as the Tax Reform Code of 1971, and
28 against any payment of estimated tax or payment of tentative tax
29 due on account of said taxes if all of the following conditions
30 are met:
19900H2803B3962 - 26 -
1 (1) The employer has a payroll of nine or fewer
2 employees.
3 (2) When seeking credit for the cost of providing
4 employee health care coverage, the employer has not provided
5 at least 50% of the cost of a health insurance plan which
6 would have met standards established by the Insurance
7 Commissioner for any of the employees of the enterprise in
8 any of the preceding three years, or where seeking credit for
9 the cost of providing dependent coverage, the employer has
10 not provided at least 50% of the cost of a health insurance
11 plan for any of the employees' uninsured dependents in any of
12 the preceding three years.
13 (3) The employer provides health care insurance for the
14 employees, or the employees and their uninsured dependents or
15 the uninsured dependents of the employees.
16 (4) The employer provides a health care benefit plan
17 that meets minimum standards established by the Insurance
18 Commissioner.
19 (5) The employer's health insurance expenditure for the
20 coverage for which credit is sought equals at least 50% of
21 the total cost of the health insurance coverage.
22 (6) The health insurance plan is made available to all
23 of the employees specified by the Department of Health under
24 section 1106(e).
25 Section 1502. Calculation of credit.
26 (a) Beneficiaries.--An eligible employer shall receive a tax
27 credit of a portion of the amount of employers' expenditure for
28 health insurance costs initiated or expanded coverage only for
29 the following beneficiaries:
30 (1) Employees whose average annualized wage is less than
19900H2803B3962 - 27 -
1 150% of the Federal poverty level for a family of four, as
2 published by the United States Department of Health and Human
3 Services.
4 (2) Employees whose average annualized wage is less than
5 150% of the Federal poverty level and their uninsured
6 dependents.
7 (3) Uninsured dependents of employees whose average
8 annualized wage is less than 150% of the Federal poverty
9 level, when coverage previously included only the employees.
10 (b) Credit schedule.--The credit may be claimed in
11 accordance with the following schedule:
12 Percentage of amount Tax year in which
13 of employer's such expenditure was made,
14 expenditure for and for which the tax
15 health insurance credit is claimed
16 costs
17 40% The tax year commencing on
18 or after January 1, 1991.
19 30% The tax year commencing on
20 or after January 1, 1992.
21 20% The tax year commencing on
22 or after January 1, 1993.
23 (c) Availability of credit.--Tax credits shall be available
24 in years following the first year in which coverage is initiated
25 or expanded, only if the employer continues to offer it in the
26 following two years. No employer shall be eligible for a tax
27 credit for more than the three tax years specified in subsection
28 (b).
29 Section 1503. Rules and regulations.
30 The Department of Revenue and the Insurance Department shall:
19900H2803B3962 - 28 -
1 (1) Promulgate any rules and regulations which may be
2 required to implement this chapter.
3 (2) Publish as a notice in the Pennsylvania Bulletin, no
4 later than January 1, of the year following the effective
5 date of this act, forms upon which taxpayers may apply for
6 the tax credit authorized by this chapter.
7 Section 1504. Reports to General Assembly.
8 Within five months after the close of any tax year for which
9 tax credits granted pursuant to this chapter were used, the
10 Insurance Department and the Department of Revenue shall furnish
11 to the General Assembly a report providing the number of
12 employers who used credits during the preceding tax year, the
13 number of employees and dependents receiving new health care
14 coverage and the amount of tax credits granted.
15 CHAPTER 17
16 ACCESS TO HEALTH CARE
17 Section 1701. Discrimination prohibited.
18 (a) General rule.--No health care provider in this
19 Commonwealth shall discriminate against any person based on that
20 person's enrollment in or eligibility for medical assistance, or
21 otherwise based upon a person's source of payment for health
22 care.
23 (b) Definition.--For purposes of this section,
24 "discriminate" shall include, but not be limited to, the
25 following actions:
26 (1) The refusal to provide health or medical care or
27 services, diagnosis or treatment which the health care
28 provider is qualified to provide.
29 (2) The segregation of medical assistance patients from
30 other patients with respect to office or health service
19900H2803B3962 - 29 -
1 facilities.
2 (3) The rendering of inferior medical or health care
3 services.
4 Section 1702. Health maintenance organizations.
5 (a) Fair share of medical assistance subscribers.--Within
6 six months of the effective date of this act, each health
7 maintenance organization shall enter into an agreement with the
8 department to enroll as subscribers individuals who are eligible
9 to receive medical assistance benefits. A health maintenance
10 organization that receives its certificate of authority after
11 the effective date of this act shall enter into an agreement
12 with the department under this section before the end of the
13 health maintenance organization's second year of operation in
14 this Commonwealth. All health maintenance organizations shall
15 agree to accept as enrollees a fair share of medical assistance
16 recipients. A "fair share" of medical assistance subscribers for
17 purposes of this section shall be defined as the same ratio of
18 medical assistance recipients to general population in the
19 health maintenance organization's service area as enrolled
20 medical assistance subscribers to the total health maintenance
21 organization enrollment or 25%, whichever is less. Within three
22 years of the effective date of the contract between the
23 department and the health maintenance organization, the health
24 maintenance organization shall have enrolled or have attempted
25 to enroll its fair share of medical assistance subscribers.
26 (b) County percentages.--The department shall publish
27 annually in the Pennsylvania Bulletin notice of the county
28 percentage of medical assistance recipients for each county and
29 shall assist health maintenance organizations in determining the
30 number of medical assistance subscribers necessary to constitute
19900H2803B3962 - 30 -
1 its fair share.
2 (c) Approval of capitated rate.--The capitated rate
3 contained in the agreement between the health maintenance
4 organization and the department is subject to the approval of
5 the Insurance Commissioner in accordance with section 10 of the
6 act of December 29, 1972 (P.L.1701, No.364), known as the Health
7 Maintenance Organization Act. The rate shall not exceed 100% of
8 the fee-for-service medical assistance cost in each county
9 served by the health maintenance organization. In the event the
10 Insurance Commissioner finds that the proposed rate is
11 insufficient to meet the costs of the health maintenance
12 organization, the Secretary of Public Welfare shall waive the
13 limit on the capitation rate, renegotiate the agreement with the
14 health maintenance organization to address the concerns of the
15 Insurance Commissioner or grant an exception to the health
16 maintenance organization from the fair share requirements of
17 this act.
18 (d) Separate systems.--Unless authorized by the department,
19 after consultation with the Medical Assistance Advisory
20 Committee, a health maintenance organization shall not establish
21 separate systems of care for its medical assistance subscribers.
22 (e) Waiver of requirements.--The department may grant a
23 waiver of the requirements of this section if it finds that the
24 health maintenance organization has made and continues to make a
25 good faith effort to obtain a fair share of medical assistance
26 subscribers, but is unable to reach or maintain that percentage.
27 Section 1703. Continuity on replacement of a group policy.
28 (a) Policies subject to this section.--This section applies
29 to all group health insurance policies, except group long-term
30 care policies or group long-term disability policies, issued by
19900H2803B3962 - 31 -
1 insurers or health maintenance organizations doing business in
2 this Commonwealth to policyholders who are obtaining coverage to
3 replace coverage under a different contract or policy.
4 (b) Continuity of coverage.--The replacement policy issued
5 to replace the prior contract or policy shall provide continuity
6 of coverage to all persons who were covered under the replaced
7 contract or policy at any time during the 90 days before the
8 discontinuance of the replaced contract or policy.
9 (c) Prohibition against discontinuity.--In a replacement
10 policy subject to this section, an insurer or health maintenance
11 organization may not, for any person described in section 1704:
12 (1) request that the person provide or otherwise seek to
13 obtain evidence of insurability;
14 (2) decline to enroll the person on the basis of
15 evidence of insurability if the person is otherwise eligible
16 for coverage; or
17 (3) impose a preexisting condition exclusion period or
18 waiting period on that person, except as provided in the
19 section.
20 (d) Person covered for fewer than 90 continuous days.--
21 Notwithstanding subsection (c), a person who was covered under
22 the replaced contract or policy for fewer than 90 continuous
23 days may be subject to a preexisting condition exclusion or
24 waiting period in the replacement policy, provided the period is
25 not longer than 90 days, and credit is given for satisfaction or
26 partial satisfaction of the same or similar provisions under the
27 replaced contract or policy.
28 (e) Liability after discontinuance.--The entity, insurer or
29 health maintenance organization that issued the replaced
30 contract or policy is liable after discontinuance of that
19900H2803B3962 - 32 -
1 contract or policy only to the extent of its accrued liabilities
2 and extensions of benefits.
3 Section 1704. Continuity for individual who changes groups.
4 (a) Application.--This section applies to all group health
5 policies issued by insurers or health maintenance organizations,
6 except group long-term care policies and group disability
7 coverage.
8 (b) Persons provided continuity of coverage.--This section
9 provides continuity of coverage for a person who seeks coverage
10 under a group insurance or health maintenance organization
11 policy if:
12 (1) That person was covered under an individual or group
13 contract or policy issued by an insurer, health maintenance
14 organization, or governmental program such as Medicaid or
15 Medicare.
16 (2) Coverage under the prior contract or policy
17 terminated within three months before the date the person
18 enrolls or is eligible to enroll in the succeeding policy. A
19 period of ineligibility for any health plan imposed by terms
20 of employment may not be considered in determining whether
21 the coverage ended within three months of the date the person
22 enrolls or would otherwise be eligible to enroll.
23 (c) Prohibition against discontinuity.--Except as provided
24 in this section, in a group policy subject to this section, an
25 insurer or health maintenance organization must, for any person
26 described in subsection (b), waive any medical underwriting or
27 preexisting conditions exclusion to the extent that benefits
28 would have been payable under a prior contract or policy if the
29 prior contract or policy were still in effect. The succeeding
30 policy is not required to duplicate any benefits covered by the
19900H2803B3962 - 33 -
1 prior contract or policy.
2 (d) Determination of benefits.--When a determination of
3 benefit under the prior contract or policy is required, the
4 issuer of the prior contract or policy shall, at the request of
5 the issuer of the succeeding policy, furnish a statement of
6 benefits available or pertinent information sufficient to permit
7 verification of the benefit determination or the determination
8 itself by the issuer of the succeeding policy. For purposes of
9 this section, benefits of the prior contract or policy are
10 determined in accordance with the definitions, conditions and
11 covered expense provisions of that contract or policy rather
12 than those of the succeeding policy. The benefit determination
13 must be made as if coverage had not been replaced.
14 Section 1705. Limitations on exclusions and waiting periods.
15 (a) Application.--This section applies to any individual or
16 group health insurance policy or contract either with an insurer
17 or health maintenance organization, except long-term care
18 policies or long-term disability policies.
19 (b) Exclusions for certain factors.--No group or individual
20 health insurance policy written in this Commonwealth may exclude
21 or use waivers or riders of any kind to exclude, limit or reduce
22 coverage or benefits for a specifically named or described
23 preexisting disease or physical condition, beyond the waiting
24 period defined in this act.
25 (c) Preexisting conditions.--No group health policy,
26 contract or certificate shall exclude a member of that group who
27 has applied for coverage, except that coverage can be denied for
28 a preexisting condition within the waiting period for new
29 enrollees, as is defined in section 1706, for those not
30 qualifying for continuity of benefits under this act.
19900H2803B3962 - 34 -
1 (d) Permitted exclusion.--An individual policy issued by an
2 insurer may not impose a preexisting condition exclusion or
3 waiting period except as defined in section 1706.
4 Section 1706. Waiting period for preexisting conditions.
5 No group or individual health policy, certificate or contract
6 may deny coverage for an enrollee for a preexisting condition
7 except as follows:
8 (1) Preexisting medical conditions occurring within
9 three months of the effective date of coverage or enrollment
10 in the group.
11 (2) Preexisting medical conditions for which the
12 enrollee has received treatment within three months of the
13 effective date of coverage on the enrollee or enrollment in
14 the group.
15 (3) In no event may there be an exclusion of coverage
16 for a group or individual enrollee for any condition or
17 disease covered by the policy, certificate or contract after
18 that enrollee or insured has been enrolled or insured for 12
19 continuous months.
20 Section 1707. Enforcement.
21 (a) Authority of department.--The department shall exercise
22 all powers necessary and appropriate to enforce this chapter,
23 including, but not limited to, the following powers:
24 (1) To require health care providers to enter into
25 provider agreements with the department.
26 (2) To monitor and enforce health care provider
27 participation in the medical assistance program.
28 (3) To recommend to the appropriate licensing authority
29 the suspension or revocation of a health care provider's
30 license for violations of this act.
19900H2803B3962 - 35 -
1 (b) Penalties.--
2 (1) Any individual alleging discrimination under this
3 chapter may file a civil cause of action in a court of
4 competent jurisdiction against a health care provider alleged
5 to be in violation of this chapter. If the health care
6 provider is found to have violated this chapter the court may
7 assess attorney fees, cost and penalties against the health
8 care provider in addition to any monetary compensation to the
9 plaintiff. A judgment against a health care provider shall be
10 referred by the court to the appropriate professional
11 licensing authority or regulatory agency.
12 (2) (i) Any health maintenance organization that
13 violates the provisions of this chapter shall be subject
14 to a civil penalty equal to 2% of the annual premiums of
15 the HMO or the HMO's average rate per member multiplied
16 by the number of individuals that the HMO has failed to
17 enroll under the fair share provisions of this chapter,
18 whichever is greater. This penalty shall be deposited in
19 the Pennsylvania Health Care Fund. The penalty shall be
20 levied by the department, annually, when it concludes
21 that the HMO did not make a good faith effort to enroll
22 the minimum number of medical assistance subscribers
23 required by this chapter.
24 (ii) Any HMO found to have violated the provisions
25 of this chapter shall have the right to appeal such a
26 determination to the Secretary of Public Welfare in the
27 manner provided in Title 2 of the Pennsylvania
28 Consolidated Statutes (relating to administrative law and
29 procedure).
30 (3) Any individual alleging discrimination under this
19900H2803B3962 - 36 -
1 chapter may file a civil cause of action in a court of
2 competent jurisdiction against a health maintenance
3 organization or group insurers alleged to be in violation of
4 this chapter. If the health maintenance organization or group
5 insurers is found to have violated this chapter the court may
6 assess attorney fees, cost and penalties against the health
7 maintenance organization or group insurers in addition to any
8 monetary compensation to the plaintiff. A judgment against a
9 health maintenance organization or group insurers shall be
10 referred by the court to the appropriate professional
11 licensing authority or regulatory agency.
12 CHAPTER 19
13 STUDIES AND HEARINGS ON HEALTH CARE
14 Section 1901. Hospital uncompensated charity care study.
15 (a) Charity care data.--The Department of Health shall
16 collect each year commencing with the calendar year beginning
17 January 1, 1991, the following charity care data from all acute
18 care hospitals licensed in this Commonwealth:
19 (1) Catastrophic inpatient and outpatient costs which
20 are defined as the allowable audited costs of services
21 provided to persons above 150% of the poverty level, with an
22 unpaid personal liability greater than annual family income,
23 less an amount equivalent to 150% of the Federal poverty
24 level. Such amount must be net, following reasonable
25 collection procedures, consistently applied, and may not
26 include any costs or services for which reimbursement could
27 have been secured from the medical assistance or Medicare
28 program.
29 (2) Medical assistance which is defined as the inpatient
30 and outpatient patient-pay amount for medical assistance
19900H2803B3962 - 37 -
1 recipients which has been unable to be collected following
2 reasonable collection procedures, consistently applied.
3 (3) Underinsured inpatient charity care which is defined
4 as the allowable audited cost of services provided to
5 uninsured persons below 150% of the Federal poverty level,
6 following reasonable collection procedures, consistently
7 applied. Such amount may not include payment for goods or
8 services which could have been reimbursed under the Medicaid
9 or Medicare program.
10 (4) Uninsured inpatient charity care which is defined as
11 the allowable audited cost of services provided to persons
12 without public or private insurance coverage, with income
13 below 150% of the poverty level, following reasonable
14 collection procedures, consistently applied. Such amount may
15 not include payment for goods or services which could have
16 been reimbursed under the Medicaid or Medicare program.
17 (b) Recommendations to General Assembly.--Commencing March
18 1, 1992, and every March 1 thereafter, the Department of Health
19 shall submit recommendations to the Governor and the General
20 Assembly as to whether a source of funding is required for
21 uncompensated charity care provided by acute care hospitals in
22 this Commonwealth. These recommendations shall be based on data
23 collection for uncompensated charity care as defined in this
24 section for the preceding calendar year.
25 (c) Annual hearings of the General Assembly.--The Health and
26 Welfare Committee of the House of Representatives and the Public
27 Health and Welfare Committee of the Senate shall hold annual
28 joint public hearings in each region to review the Health Care
29 Cost Containment Council's recommendations for the level of
30 funding required for charity care.
19900H2803B3962 - 38 -
1 Section 1902. Medicaid reimbursement.
2 (a) Joint hearings.--The Health and Welfare Committee of the
3 House of Representatives and the Public Health and Welfare
4 Committee of the Senate shall hold joint public hearings in each
5 region of this Commonwealth to review the adequacy of payments
6 to providers under the medical assistance program.
7 (b) Reports.--Each committee shall issue a report by
8 December 31, 1991, and the General Assembly shall enact
9 legislation, if necessary, to adjust medical assistance provider
10 reimbursement to comply with Federal requirements.
11 Section 1903. Study of generic substitutes for brand name
12 prescriptions.
13 The Department of Health shall study the cost and
14 effectiveness of generic substitutes for brand name
15 prescriptions and determine what legislative, administrative and
16 regulatory measures can be taken to increase the appropriate use
17 of those substitutes. The Department of Health shall file the
18 report of this study with the General Assembly and the Governor
19 no later than 180 days after the effective date of this act.
20 CHAPTER 31
21 MISCELLANEOUS PROVISIONS
22 Section 3101. Persons eligible for medical assistance.
23 (a) General rule.--In addition to those persons described in
24 section 441.1(1) and (2) of the act of June 13, 1967 (P.L.31,
25 No.21), known as the Public Welfare Code, the following persons
26 shall also be eligible for medical assistance under that act:
27 (1) Medically needy persons, whose income eligibility
28 levels shall be no lower than 133.3% of the highest Aid To
29 Families with Dependent Children grant paid in the State.
30 (2) Pregnant women and infants whose family income is at
19900H2803B3962 - 39 -
1 or less than 185% of the Federal determined poverty level.
2 (3) Children under eight years of age whose family
3 income is less than 100% of the Federally-determined poverty
4 level.
5 (b) Additional eligibility.--For purposes of this section
6 and section 441.1 of the Public Welfare Code, all recipients
7 (including medically needy recipients) and recipients of the
8 State blind pension shall be entitled to all the medical
9 assistance benefits available to persons deemed categorically
10 needy as provided for in section 441.1(1) of the Public Welfare
11 Code except dental care. The Healthy Horizon resource level
12 shall be increased to the maximum permitted under Federal law.
13 Section 3102. Group accident and sickness insurance.
14 In addition to the provisions of section 621.2(a)(3) of the
15 act of May 17, 1921 (P.L.682, No.284), known as The Insurance
16 Company Law of 1921, group accident and sickness insurance shall
17 also include insurance under policies issued to the trustees of
18 a fund established by any two or more employers or by an insurer
19 licensed in this Commonwealth.
20 Section 3103. Construction and application of Chapters 3 and 9.
21 (a) Construction of chapters.--
22 (1) Chapters 3 and 9 shall not be construed to create
23 any legally enforceable right or entitlement to payment for
24 services on the part of any medically indigent person or any
25 right of entitlement to payment of any particular rate by any
26 hospital, other provider of medical services or other person.
27 (2) Chapters 3 and 9 shall not be construed to relieve
28 any hospital of its obligations under the Hill-Burton Act (60
29 Stat. 1040, 42 U.S.C. § 291 et seq.) or under any other
30 similar Federal or State law or agreement to provide
19900H2803B3962 - 40 -
1 unreimbursed care to medically indigent persons.
2 (b) Application of chapters.--Chapters 3 and 9 shall apply
3 only upon publication of notice in the Pennsylvania Bulletin by
4 the Secretary of Public Welfare that the United States
5 Department of Health and Human Services has approved the
6 amendment of Pennsylvania's State Plan for Medical Assistance as
7 set forth by the provisions of this act.
8 Section 3104. Repeals.
9 (a) Specific repeal.--Section 441.1(3) of the act of June
10 13, 1967 (P.L.31, No.21), known as the Public Welfare Code, is
11 repealed.
12 (b) General repeals.--All other acts and parts of acts are
13 repealed insofar as they are inconsistent with this act.
14 Section 3105. Expiration of act.
15 This act shall expire December 31, 1999, unless reenacted by
16 the General Assembly.
17 Section 3106. Effective date.
18 This act shall take effect in 60 days.
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