PRINTER'S NO. 611
No. 585 Session of 1999
INTRODUCED BY BELAN, COSTA, STAPLETON, KASUNIC, WAGNER, BODACK,
STOUT AND BOSCOLA, MARCH 15, 1999
REFERRED TO BANKING AND INSURANCE, MARCH 15, 1999
AN ACT
1 Amending Title 42 (Judiciary and Judicial Procedure) of the
2 Pennsylvania Consolidated Statutes, providing for local
3 review boards and for the review of decisions by HMOs.
4 The General Assembly of the Commonwealth of Pennsylvania
5 hereby enacts as follows:
6 Section 1. Chapter 73 of Title 42 of the Pennsylvania
7 Consolidated Statutes is amended by adding a subchapter to read:
8 SUBCHAPTER D
9 LOCAL REVIEW BOARDS
10 Sec.
11 7371. Purpose.
12 7372. Definitions.
13 7373. Authority.
14 7374. Health Maintenance Organization Review Board.
15 7375. Filing, filing fees and hearing.
16 7376. Appeal.
17 7377. Special restricted account.
18 § 7371. Purpose.
1 There is hereby established a procedure for the immediate
2 review by local review boards of the insurance coverage denials
3 by health maintenance organizations.
4 § 7372. Definitions.
5 The following words and phrases when used in this subchapter
6 shall have the meanings given to them in this section unless the
7 context clearly indicates otherwise:
8 "Department." The Department of Health of the Commonwealth.
9 "Enrollee." Any person who enters a contract with a health
10 maintenance organization and is eligible for the delivery and
11 financing of health care services.
12 "Health maintenance organization" or "HMO." An organized
13 system which combines the delivery and financing of health care
14 and which provides basic health services to voluntarily enrolled
15 subscribers for a fixed prepaid fee.
16 § 7373. Authority.
17 The Supreme Court may require the courts of common pleas to
18 establish, by the adoption of local rules, a health maintenance
19 organization review board to review the decisions of an HMO
20 regarding the coverage, delivery, payment or reimbursement of
21 all or part of the cost of medical services, facilities,
22 appliances, medicines or supplies necessary for the examination,
23 treatment or rehabilitation of the enrollee or the enrolled
24 dependents.
25 § 7374. Health Maintenance Organization Review Board.
26 Members of a health maintenance organization review board
27 shall be appointed from a list of available candidates as
28 prescribed by local rule. However, the rules shall provide that
29 the board members be residents of the judicial district and be
30 comprised of three members. The three members shall be
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1 physicians licensed to practice in this Commonwealth,
2 physician's assistants licensed to practice in this
3 Commonwealth, registered nurses licensed to practice in this
4 Commonwealth or any combination of such persons.
5 § 7375. Filing, filing fees and hearing.
6 (a) Petition for review.--An enrollee shall have ten days
7 from the date of an HMO's decision to file a petition for
8 review. A reply shall be filed within ten days of the filing of
9 a petition for review. Filings shall be made with the
10 prothonotary of the court of common pleas unless otherwise
11 modified by local rule.
12 (b) Hearing.--The board shall be required to schedule a
13 hearing within ten days of the filing of the reply.
14 (c) Fee.--A $10 fee shall accompany the filing of both the
15 petition for review and the reply. However, the filing fee shall
16 be waived for enrollees seeking review in appropriate cases and
17 as provided by local rule.
18 § 7376. Appeal.
19 Any party to a matter filed under this subchapter shall have
20 the right to appeal for a trial de novo in the court of common
21 pleas. The party who takes the appeal shall pay such amount or
22 proportion of fees and costs and shall comply with such other
23 procedures as shall be prescribed by general rules. In the
24 absence of appeal the judgment entered by the board shall be
25 enforced as any other judgment of the court of common pleas.
26 § 7377. Special restricted account.
27 (a) Establishment.--There is hereby established within the
28 General Fund a restricted receipt account to be known as the
29 Health Maintenance Organization Review Board Account. Moneys
30 deposited into this account shall be used only for the initial
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1 establishment and ongoing operations of the health maintenance
2 organization review boards established by this subchapter. Any
3 funds appropriated by the General Assembly from the General Fund
4 for the establishment or ongoing operations of the health
5 maintenance organization review boards shall be repaid to the
6 General Fund from the Health Maintenance Organization Review
7 Board Account over a five-year period beginning 24 months after
8 the initial appropriation from the General Fund.
9 (b) Deposits into account.--Beginning January 1, 1998, and
10 annually thereafter, the Department of Health shall collect and
11 deposit into the Health Maintenance Organization Review Board
12 Account a health maintenance organization certification fee
13 which shall be provided by regulation of the department. The fee
14 shall be assessed by the department on any health maintenance
15 organization licensed pursuant to the act of December 29, 1972
16 (P.L.1701, No.364), known as the Health Maintenance Organization
17 Act.
18 (c) Disbursement from account.--Funds shall be disbursed to
19 the various courts of common pleas which have established health
20 maintenance organization review boards by appropriation of the
21 General Assembly only and pursuant to a formula developed by the
22 Supreme Court.
23 Section 2. This act shall take effect in 60 days.
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