PRINTER'S NO. 2195
No. 1660 Session of 2007
INTRODUCED BY MANDERINO, McILVAINE SMITH, BELFANTI, BISHOP, BLACKWELL, BRENNAN, CALTAGIRONE, CURRY, FREEMAN, GALLOWAY, GIBBONS, HANNA, HARKINS, JAMES, MAHONEY, McGEEHAN, MYERS, M. O'BRIEN, OLIVER, PARKER, PETRONE, ROEBUCK, SIPTROTH, STEIL, TANGRETTI, WALKO, WOJNAROSKI, YOUNGBLOOD, CRUZ AND THOMAS, JULY 3, 2007
REFERRED TO COMMITTEE ON HEALTH AND HUMAN SERVICES, JULY 3, 2007
AN ACT 1 Providing for a Statewide comprehensive health care system; 2 establishing the Pennsylvania Health Care Plan and providing 3 for eligibility, services, coverages, subrogation, 4 participating providers, cost containment, reduction of 5 errors, tort remedies, administrative remedies and 6 procedures, attorney fees, quality assurance, 7 nonparticipating providers, transitional support and 8 training; and establishing the Pennsylvania Health Care 9 Agency, the Employer Health Services Levy, the Individual 10 Wellness Tax and the Pennsylvania Health Care Board and 11 providing for their powers and duties. 12 TABLE OF CONTENTS 13 Chapter 1. Preliminary Provisions 14 Section 101. Short title. 15 Section 102. Definitions. 16 Chapter 3. Administration and Oversight of the Pennsylvania 17 Health Care Plan 18 Subchapter A. Pennsylvania Health Care Board 19 Section 301. Organization. 20 Section 302. Duties of board.
1 Subchapter B. Pennsylvania Health Care Agency 2 Section 321. Pennsylvania Health Care Agency. 3 Section 322. Executive director duties. 4 Section 323. Administrator for planning, research and 5 development. 6 Section 324. Administrator for consumer affairs and health 7 education. 8 Section 325. Administrator for quality assurance. 9 Section 326. Administrator for finance. 10 Section 327. Administrator for claims. 11 Section 328. Administrator for volunteer services. 12 Section 329. Administrator for provider coordination. 13 Section 330. Administrator for law. 14 Section 331. Administrator for transition services. 15 Section 332. Administrator for beneficiary advocate. 16 Subchapter C. (Reserved). 17 Subchapter D. (Reserved). 18 Subchapter E. (Reserved). 19 Subchapter F. Immunity 20 Section 371. Immunity. 21 Chapter 5. Pennsylvania Health Care Plan 22 Section 501. General provisions. 23 Section 502. Universal health care access eligibility. 24 Section 503. Covered services. 25 Section 504. Excess and collective bargaining agreement health 26 insurance coverage. 27 Section 505. Duplicate coverage. 28 Section 506. Subrogation. 29 Section 507. Eligible participating providers and availability 30 of services. 20070H1660B2195 - 2 -
1 Section 508. Rational cost containment. 2 Chapter 7. No-Fault Administrative Remedies 3 Section 701. Rationalization of remedies for errors and 4 complications. 5 Section 702. Voluntary waiver of tort remedies and choice 6 to retain tort remedies. 7 Section 703. No-fault administrative remedies for those not 8 opting out. 9 Section 704. Administrative claims procedures. 10 Section 705. Beneficiary right to counsel. 11 Section 706. Quality assurance follow-up to claims. 12 Section 707. Surviving tort claims against participating 13 providers. 14 Section 708. Claims against nonparticipating providers. 15 Section 709. Parallel no-fault compensation for beneficiaries 16 injured by nonparticipating providers. 17 Chapter 9. Pennsylvania Health Care Trust Fund 18 Section 901. Pennsylvania Health Care Trust Fund. 19 Section 902. Rolling budget process. 20 Section 903. Limitation on administrative expense. 21 Section 904. Funding sources. 22 Chapter 11. Transitional Support and Training for Displaced 23 Workers 24 Section 1101. Transitional support and training for displaced 25 workers. 26 Chapter 13. Volunteer Emergency Responder Network 27 Section 1301. Preservation of volunteer emergency responder 28 network. 29 Section 1302. Eligibility certification. 30 Section 1303. Eligibility criteria. 20070H1660B2195 - 3 -
1 Section 1304. Amount of tax credit. 2 Section 1305. Reimbursement of Department of Revenue. 3 Chapter 15. Miscellaneous Provisions 4 Section 1501. Effective date. 5 The General Assembly of the Commonwealth of Pennsylvania 6 hereby enacts as follows: 7 CHAPTER 1 8 PRELIMINARY PROVISIONS 9 Section 101. Short title. 10 This act shall be known and may be cited as the Family and 11 Business Healthcare Security Act. 12 Section 102. Definitions. 13 The following words and phrases when used in this act shall 14 have the meanings given to them in this section unless the 15 context clearly indicates otherwise: 16 "Agency." The Pennsylvania Health Care Agency established 17 under this act. 18 "Board." The Pennsylvania Health Care Board established 19 under this act. 20 "Department." The Department of Health of the Commonwealth. 21 "Executive director." The Executive Director of the 22 Pennsylvania Health Care Board. 23 "Fund." The Pennsylvania Health Care Trust Fund established 24 under this act. 25 "Individual Wellness Tax" or "IWT." The Individual Wellness 26 Tax established under this act. 27 "Plan." The Pennsylvania Health Care Plan established under 28 this act. 29 "Tax." The Employer Health Services Levy established under 30 this act. 20070H1660B2195 - 4 -
1 CHAPTER 3 2 ADMINISTRATION AND OVERSIGHT OF THE 3 PENNSYLVANIA HEALTH CARE PLAN 4 SUBCHAPTER A 5 PENNSYLVANIA HEALTH CARE BOARD 6 Section 301. Organization. 7 (a) Composition.--The Pennsylvania Health Care Board shall 8 be composed of 11 voting members and shall be chaired by the 9 executive director. 10 (b) Appointments.-- 11 (1) The executive director shall be appointed by the 12 Governor. The members of the board shall be appointed by the 13 Governor, the President pro tempore of the Senate, and the 14 Speaker of the House of Representatives who collectively 15 shall make appointments of members from individuals 16 representative of each of the following constituencies: 17 (i) Hospitals. 18 (ii) Organized labor, private sector. 19 (iii) Consumers. 20 (iv) Business. 21 (v) Agriculture. 22 (vi) Physicians. 23 (vii) Public sector employees. 24 (viii) Nurses. 25 (ix) Pharmacists. 26 (x) Long-term care facilities. 27 (xi) Social workers. 28 (2) The Governor shall initially appoint the executive 29 director, who shall serve as chair of the board, appointments 30 of the members shall thereafter be made in a rotating fashion 20070H1660B2195 - 5 -
1 beginning with the President pro tempore of the Senate, then 2 the Speaker of the House of Representatives and then the 3 Governor, with each in turn making an appointment from a 4 constituency category not previously filled. 5 (c) Terms of members.--Each member appointed or reappointed 6 under this section shall hold office for three years, starting 7 on the first day of the first month following the member's 8 appointment. A serving member of the board shall continue to 9 serve following the expiration of the member's term until a 10 successor takes office or a period of 90 days has elapsed, 11 whichever occurs first. 12 (d) Midterm vacancies.--Midterm vacancies shall be filled by 13 the same appointer and the individual appointed to fill a 14 vacancy occurring prior to the expiration of the term for which 15 a member is appointed shall hold office for the remainder of the 16 predecessor's term. 17 (e) Compensation, benefits and expenses.--The executive 18 director and members of the board shall receive an annual 19 salary, benefits and expense reimbursement established by the 20 board, to be paid from the trust. The initial board shall 21 establish its own compensation. No increase or decrease in 22 salary or benefits adopted by the board for the executive 23 director or members shall become effective within the same 24 three-year term. 25 (f) Meetings.-- 26 (1) The executive director shall set the time, place and 27 date for the initial and subsequent meetings of the board and 28 shall preside over its meetings. The initial meeting shall be 29 set not sooner than 50 nor later than 100 days after the 30 appointment of the executive director. Subsequent meetings 20070H1660B2195 - 6 -
1 shall occur at least monthly thereafter. 2 (2) All meetings of the board are open to the public 3 unless questions of patient confidentiality arise. The board 4 may go into closed executive session with regard to issues 5 related to confidential patient information. 6 (g) Quorum.--Two-thirds of the appointed members of the 7 board shall constitute a quorum for the conducting of business 8 at meetings of the board. Decisions at ordinary meetings of the 9 board shall be reached by majority vote of those actually 10 present or, in the event of emergency meeting, those also 11 present by electronic or telephonic means. Where there is a tie 12 vote, the executive director shall be granted an additional vote 13 to break the tie. 14 (h) Ethics.--The executive director, the members and their 15 immediate families are prohibited from having any pecuniary 16 interest in any business with a contract or in negotiation for a 17 contract with the agency. The board shall also adopt rules of 18 ethics and definitions of irreconcilable conflicts of interest 19 that will determine under what circumstances members must recuse 20 themselves from voting. 21 (i) Prohibitions.--No member of the board, except for the 22 executive director, who shall receive no additional salary or 23 benefits by virtue of serving on the board, shall hold any other 24 salaried Commonwealth public position, either elected or 25 appointed, during the member's tenure on the board. 26 Section 302. Duties of board. 27 (a) General duties.--The board is responsible for directing 28 the agency in the performance of all duties, the exercise of all 29 powers, and the assumption and discharge of all functions vested 30 in the agency. The board shall adopt and publish its rules and 20070H1660B2195 - 7 -
1 procedures in the Pennsylvania Bulletin no later than 180 days 2 after the first meeting of the board. 3 (b) Specific duties.--The duties and functions of the board 4 include, but are not limited to, the following: 5 (1) Implementing statutory eligibility standards for 6 benefits. 7 (2) Annually adopting a benefits package for 8 participants of the plan. 9 (3) Acting directly or through one or more contractors 10 as the single payer administrator for all claims for health 11 care services made under the plan. 12 (4) At least annually reviewing the appropriateness and 13 sufficiency of reimbursements. 14 (5) Providing for timely payments to participating 15 providers through a structure that is well organized and that 16 eliminates unnecessary administrative costs. 17 (6) Implementing standardized claims and reporting 18 methods for use by the plan. 19 (7) Developing a system of centralized electronic claims 20 and payments accounting. 21 (8) Establishing an enrollment system that will ensure 22 that those who travel frequently and cannot read or speak 23 English are aware of their right to health care and are 24 formally enrolled in the plan. 25 (9) Reporting annually to the General Assembly and to 26 the Governor, on or before the first day of October, on the 27 performance of the plan, the fiscal condition of the plan, 28 recommendations for statutory changes, the receipt of 29 payments from the Federal Government, whether current year 30 goals and priorities were met, future goals and priorities, 20070H1660B2195 - 8 -
1 and major new technology or prescription drugs that may 2 affect the cost of the health care services provided by the 3 plan. 4 (10) Administering the revenues of the trust. 5 (11) Obtaining appropriate liability and other forms of 6 insurance to provide coverage for the plan, the board, the 7 agency and their employees and agents. 8 (12) Establishing, appointing and funding appropriate 9 staff, office space, equipment, training and administrative 10 support for the agency throughout this Commonwealth, all to 11 be paid from the trust. 12 (13) Administering aspects of the agency by taking 13 actions that include, but are not limited to, the following: 14 (i) Establishing standards and criteria for the 15 allocation of operating funds. 16 (ii) Meeting regularly to review the performance of 17 the agency and to adopt and revise its policies. 18 (iii) Establishing goals for the health care system 19 established pursuant to the plan in measurable terms. 20 (iv) Establishing Statewide health care databases to 21 support health care services planning. 22 (v) Implementing policies and developing mechanisms 23 and incentives to assure culturally and linguistically 24 sensitive care. 25 (vi) Establishing rules and procedures for 26 implementation and staffing of a no-fault compensation 27 system for iatrogenic injuries or complications of care 28 whereby a patient's condition is made worse or an 29 opportunity for cure or improvement is lost due to the 30 health care or medications provided or appropriate care 20070H1660B2195 - 9 -
1 not provided by participating providers under the plan. 2 (vii) Establishing standards and criteria for the 3 determination of appropriate transitional support and 4 training for residents of this Commonwealth who are 5 displaced from work during the first two years of the 6 implementation of the plan. 7 (viii) Evaluating the state of the art in proven 8 technical innovations, medications and procedures and 9 adopting policies to expedite the rapid introduction 10 thereof in this Commonwealth. 11 (ix) Establishing methods for the recovery of costs 12 for health care services provided pursuant to the plan to 13 a beneficiary who is also covered under the terms of a 14 policy of insurance, a health benefit plan or other 15 collateral source available to the participant under 16 which the participant has a right of action for 17 compensation. Receipt of health care services pursuant to 18 the plan shall be deemed an assignment by the participant 19 of any right to payment for services from any such 20 policy, plan or other source. The other source of health 21 care benefits shall pay to the trust all amounts it is 22 obligated to pay to, or on behalf of, the participant for 23 covered health care services. The board may commence any 24 action necessary to recover the amounts due. 25 (14) Recruiting the Health Advisory Panel of seven 26 members made up of a cross section of the medical and 27 provider community. The members of the advisory panel shall 28 be paid a per diem rate, established by the board, for 29 attendance at meetings and further be reimbursed for actual 30 and necessary expenses incurred in the performance of their 20070H1660B2195 - 10 -
1 duties, which shall include: 2 (i) Advising the board on the establishment of 3 policy on medical issues, population-based public health 4 issues, research priorities, scope of services, expansion 5 of access to health care services and evaluation of the 6 performance of the plan. 7 (ii) Investigating proposals for innovative 8 approaches to the promotion of health, the prevention of 9 disease and injury, patient education, research and 10 health care delivery. 11 (iii) Advising the board on the establishment of 12 standards and criteria to evaluate requests from health 13 care facilities for capital improvements. 14 (iv) Evaluating and advising the board on requests 15 from providers, or their representatives, for adjustments 16 to reimbursements. 17 (15) Establishing a secure and centralized electronic 18 health record system wherein a beneficiary's entire health 19 record can be readily and reliably accessed by authorized 20 persons with the objective of eliminating the errors and 21 expense associated with paper records and diagnostic films. 22 SUBCHAPTER B 23 PENNSYLVANIA HEALTH CARE AGENCY 24 Section 321. Pennsylvania Health Care Agency. 25 (a) Establishment of agency.--There is hereby established 26 the Pennsylvania Health Care Agency. The agency shall administer 27 the plan and is the sole agency authorized to accept applicable 28 grants-in-aid from the Federal Government and State government. 29 It shall use such funds in order to secure full compliance with 30 provisions of Federal and State law and to carry out the 20070H1660B2195 - 11 -
1 purposes established under this act. All grants-in-aid accepted 2 by the agency shall be deposited into the Pennsylvania Health 3 Care Trust Fund established under this act, together with other 4 revenues raised within this Commonwealth to fund the plan. 5 (b) Appointment of executive director.--The executive 6 director of the agency shall be appointed by the Governor for a 7 term of three years and is the chief administrator of the plan. 8 (c) Personnel and employees.--The board shall employ and fix 9 the compensation of agency personnel as needed by the agency to 10 properly discharge the agency's duties. The employment of 11 personnel by the board is subject to the civil service laws of 12 this Commonwealth. The board shall employ personnel including, 13 but not limited to, the following leadership positions, all of 14 whom will report to the executive director of the agency: 15 (1) Administrator for planning, research and 16 development. 17 (2) Administrator for finance. 18 (3) Administrator for quality assurance. 19 (4) Administrator for consumer affairs and health 20 education. 21 (5) Administrator of health claims. 22 (6) Administrator for volunteer services. 23 (7) Administrator for provider coordination. 24 (8) Administrator for law. 25 (9) Administrator of transition services until the 26 termination of this position on December 31, 2012. 27 (10) Beneficiary advocate. 28 Section 322. Executive director duties. 29 The executive director shall oversee the operation of the 30 agency and the agency's performance of any duties assigned by 20070H1660B2195 - 12 -
1 the board. 2 Section 323. Administrator for planning, research and 3 development. 4 The executive director of the agency shall determine the 5 duties of the administrator of planning, research and 6 development. Those duties shall include, but not be limited to, 7 the following: 8 (1) Establishing policy on medical issues, population- 9 based public health issues, research priorities, scope of 10 services, the expansion of participants' access to health 11 care services and the evaluation of the performance of the 12 plan. 13 (2) Investigating proposals for innovative approaches 14 for the promotion of health, the prevention of disease and 15 injury, patient education, research and the delivery of 16 health care services. 17 (3) Establishing standards and criteria for evaluating 18 applications from health care facilities for capital 19 improvements. 20 (4) Evaluating environmental risks and coordinating 21 agency policy with other governmental and nongovernmental 22 entities committed to assuring health by reducing 23 environmental hazards. 24 Section 324. Administrator for consumer affairs and health 25 education. 26 The executive director of the agency shall determine the 27 duties of the administrator for consumer affairs and health 28 education. Those duties shall include, but not be limited to, 29 the following: 30 (1) Developing educational and informational guides for 20070H1660B2195 - 13 -
1 consumers that describe consumer rights and responsibilities 2 and that inform consumers of effective ways to exercise 3 consumer rights to obtain health care services. The guides 4 shall be easy to read and understand and available in English 5 and in other languages. The agency shall make the guide 6 available to the public through public outreach and 7 educational programs and through the Internet website of the 8 agency. 9 (2) Establishing a toll-free telephone number to receive 10 questions and complaints regarding the agency and the 11 agency's services. The agency's Internet website shall 12 provide complaint forms and instructions online. 13 (3) Examining suggestions from the public. 14 (4) Making recommendations for improvements to the 15 board. 16 (5) Examining the extent to which individual health care 17 facilities in a region meet the needs of the community in 18 which they are located. 19 (6) Receiving, investigating and responding to all 20 consumer complaints about any aspect of the plan and, where 21 appropriate, referring the results of all investigations of 22 questioned care to the appropriate provider or health care 23 facility licensing board or, in cases of possible violation 24 of law, to a law enforcement agency. 25 (7) Publishing an annual report for the public, the 26 Governor and the General Assembly that contains a Statewide 27 evaluation of the agency. 28 (8) Holding public hearings in each congressional 29 district, at least annually, for public input. 30 Section 325. Administrator for quality assurance. 20070H1660B2195 - 14 -
1 The executive director of the agency shall determine the 2 duties of the administrator of quality assurance. Those duties 3 shall include, but not be limited to, the following: 4 (1) Studying and reporting on the efficacy of health 5 care treatments and medications for particular conditions. 6 (2) Identifying causes of medical errors and devising 7 procedures to reduce their frequency. 8 (3) Establishing an evidence-based formulary. 9 (4) Identifying treatments and medications that are 10 unsafe or have no proven value. 11 (5) Establishing a process for soliciting information on 12 medical standards from providers and consumers for purposes 13 of this section. 14 (6) Independently reviewing all claims submitted to the 15 administrator of health claims to determine if correctable 16 errors have occurred or whether there are patterns of errors 17 or complications which require closer investigation, 18 evaluation and correction, and then to assure all such 19 appropriate measures are recommended in writing to the 20 executive director. 21 Section 326. Administrator for finance. 22 The executive director of the agency shall determine the 23 duties of the administrator of finance. Those duties shall 24 include, but not be limited to, the following: 25 (1) Administering the trust. 26 (2) Making payments to participating providers within 27 five business days of submission and to other providers 28 within 30 days of submission. 29 (3) Developing a system of simplified, secure and 30 centralized electronic claims and payments employing the best 20070H1660B2195 - 15 -
1 technology with assured backup and catastrophe recovery 2 contingencies and facilities. 3 (4) Communicating to the State Treasurer when funds are 4 needed from the trust for the operation of the plan. 5 (5) Developing information systems for utilization 6 review. 7 (6) Investigating and recommending for appropriate civil 8 and/or criminal prosecution possible provider or consumer 9 fraud. 10 Section 327. Administrator for claims. 11 The executive director of the agency shall determine the 12 duties of the administrator of claims. Those duties shall 13 include, but not be limited to, the following: 14 (1) Establishing a system of administrative procedures, 15 health claim hearing officers and appeal panel for the 16 processing of patient claims. 17 (2) Supervising the health claims hearing officers to 18 assure swift and fair processing of claims. 19 (3) Reviewing all appeals from the determinations of the 20 health claims hearing officers, and then advising the 21 executive director who shall then make the final agency 22 determination. 23 (4) Supervising follow-up oversight of awarded claims to 24 determine when or if adjustments to the awarded compensation 25 is appropriate given improvement in the awardee's condition 26 and if so to initiate appropriate review procedures before 27 the health claims hearing officers. 28 Section 328. Administrator for volunteer services. 29 The executive director of the agency shall determine the 30 duties of the administrator for volunteer services. Those duties 20070H1660B2195 - 16 -
1 shall include, but not be limited to, the following: 2 (1) Coordinating with the State Treasurer to establish 3 procedures necessary to implement the volunteer tax rebate 4 provisions of this act. 5 (2) Investigating the status of volunteerism in this 6 Commonwealth in firefighting, search and rescue, emergency 7 response and otherwise as it pertains to the health of 8 Pennsylvanians and the means by which citizens can be 9 encouraged to volunteer. 10 (3) Developing programs to encourage blood and organ 11 donation in this Commonwealth. 12 (4) Making recommendations to the executive director and 13 the board for programs and initiatives that will best support 14 and encourage health-related volunteerism in this 15 Commonwealth. 16 Section 329. Administrator for provider coordination. 17 The executive director of the agency shall determine the 18 duties of the administrator for provider coordination. Those 19 duties shall include, but not be limited to, all of the 20 following: 21 (1) Processing all applications for participating 22 provider status. 23 (2) Assisting participating providers in their efforts 24 to meet the qualification requirements established by the 25 board. 26 (3) Establishing an inquiry office to assist 27 participating providers with regard to proper submission of 28 requests for reimbursements. 29 Section 330. Administrator for law. 30 The executive director of the agency shall determine the 20070H1660B2195 - 17 -
1 duties of the administrator for law. Those duties shall include, 2 but not be limited to, the following: 3 (1) Establishing, supervising and maintaining a team of 4 legal professionals as necessary to support all of the legal 5 representation needs of the agency. 6 (2) Defending the interests of the plan before the 7 health claims hearing officers and before the courts against 8 nonmeritorious claims. 9 (3) Representing the board in disciplinary actions 10 against participating providers. 11 (4) Serving as the principal ethics officer for the 12 agency. 13 Section 331. Administrator for transition services. 14 The executive director of the agency shall determine the 15 duties of the administrator of transition services. Those duties 16 shall include, but not be limited to, the following: 17 (1) Establishing procedures for identifying 18 Pennsylvanians whose livelihood will be detrimentally 19 affected by the passage of this act. 20 (2) Establishing procedures to most efficiently and 21 effectively transition such persons into positions with the 22 agency where appropriate or to other health-related fields 23 where the passage of this act will create an immediate need 24 for qualified employees. 25 (3) Reporting to the administrator of finance with 26 respect to the financial requirements to support the eligible 27 displaced citizens and to assist in the filing for 28 transitional wage replacement benefits approved by the board. 29 (4) Planning for the discontinuance of this division of 30 the board on December 31, 2012. 20070H1660B2195 - 18 -
1 Section 332. Administrator for beneficiary advocate. 2 The executive director of the agency shall determine the 3 duties of the beneficiary advocate. Those duties shall include, 4 but not be limited to, the following: 5 (1) Establishment of a readily accessible beneficiary 6 telephone and Internet website resource in instances where 7 they are having difficulties securing necessary care through 8 the plan. This office shall make immediate inquiries to 9 ascertain the nature of the difficulties and to resolve the 10 beneficiary's problem. 11 (2) Where a beneficiary seeks specialized care from 12 outside this Commonwealth and from other than a participating 13 provider, the beneficiary advocate shall assist in the proper 14 application for an extension of benefits on behalf of the 15 beneficiary. 16 (3) Management of death claim dependent trusts. 17 SUBCHAPTER C 18 (Reserved) 19 SUBCHAPTER D 20 (Reserved) 21 SUBCHAPTER E 22 (Reserved) 23 SUBCHAPTER F 24 IMMUNITY 25 Section 371. Immunity. 26 In the absence of fraud or bad faith, the advisory panel, the 27 board and agency and their respective members and employees 28 shall incur no liability in relation to the performance of their 29 duties and responsibilities under this act. The Commonwealth 30 shall incur no liability in relation to the implementation and 20070H1660B2195 - 19 -
1 operation of the plan. 2 CHAPTER 5 3 PENNSYLVANIA HEALTH CARE PLAN 4 Section 501. General provisions. 5 (a) Establishment of plan.--There is hereby established the 6 Pennsylvania Health Care Plan that shall be administered by the 7 independent Pennsylvania Health Care Agency under the direction 8 of the Pennsylvania Health Care Board. 9 (b) Coverage.--The plan shall provide health care coverage 10 for all citizens of this Commonwealth and for certain eligible 11 visitors. The agency shall work simultaneously to control health 12 care costs, achieve measurable improvement in health care 13 outcomes, promote a culture of health awareness, increase 14 satisfaction with the health care system, adopt an optional no- 15 fault administrative system to fairly compensate those whose 16 conditions are made worse by the treatments they receive or 17 through failures to receive appropriate care, implement policies 18 that strengthen and improve culturally sensitive care, and 19 develop an integrated health care database to support health 20 care planning and quality assurance. 21 (c) Reforms.--The board shall implement the reforms adopted 22 by the General Assembly hereby on January 1, 2008. 23 Section 502. Universal health care access eligibility. 24 (a) Eligibility.--All Pennsylvania citizens, including 25 documented aliens, full-time out-of-State students attending 26 school in this Commonwealth, homeless persons and migrant 27 agricultural workers and their accompanying families are 28 eligible beneficiaries under the plan. The board shall establish 29 standards and a simple procedure to demonstrate proof of 30 eligibility. 20070H1660B2195 - 20 -
1 (b) Enrollment.--Enrollment in the plan shall be automatic 2 and beneficiaries shall be provided with access cards with 3 appropriate proof of identity technology and privacy protection. 4 Individuals covered under a collective bargaining agreement that 5 provides health benefits at least as extensive as the plan, as 6 certified by the executive director, shall not be eligible for 7 plan benefits. 8 (c) Waivers.--If waivers are not obtained from the medical 9 assistance and/or Medicare programs operated under Title XVIII 10 or XIX of the Social Security Act (49 Stat. 620, 42 U.S.C. § 301 11 et seq.), the medical assistance and Medicare nonwaived programs 12 shall act as the primary insurers for those eligible for such 13 coverage, and the plan shall serve as the secondary or 14 supplemental plan of health coverage. Until such time as waivers 15 are obtained, the plan will not pay for services for persons 16 otherwise eligible for the same benefits under Medicare or 17 Medicaid. The plan shall also be secondary to benefits provided 18 to military veterans except where reasonable and timely access, 19 as defined by the board, is denied or unavailable through the 20 United States Veterans' Administration, in which instance the 21 plan will be primary and will seek reasonable reimbursement from 22 the United States Veterans' Administration for the services 23 provided to veterans. 24 (d) Priority of plans.--A plan of employee health coverage 25 provided by an out-of-State employer to a Pennsylvania resident 26 working outside of this Commonwealth shall serve as the 27 employee's primary plan of health coverage, and the plan shall 28 serve as the employee's secondary plan of health coverage. 29 (e) Reimbursement.--The plan shall reimburse participating 30 providers practicing outside of this Commonwealth at plan rates, 20070H1660B2195 - 21 -
1 or reasonable locally prevailing rate, for health care services 2 rendered to a beneficiary while the beneficiary is out of this 3 Commonwealth. Services provided to a beneficiary out of this 4 Commonwealth by other than a participating provider shall be 5 reimbursed to the beneficiary or to the provider at a fair and 6 reasonable rate for that location. 7 (f) Presumption of eligibility.--Any individual who arrives 8 at a health care facility unconscious or otherwise unable due to 9 their mental or physical condition to document eligibility for 10 coverage shall be presumed to be eligible, and emergency care 11 shall be provided without delay occasioned over issues of 12 ability to pay. 13 (g) Rules.--The board shall adopt rules assuring that any 14 participating provider who renders humanitarian emergency or 15 urgent care within this Commonwealth to a not actually eligible 16 recipient shall nevertheless be reimbursed for such care from 17 the plan subject to such rules as will reasonably limit the 18 frequency of such events to protect the fiscal integrity of the 19 plan. It shall be the agency's responsibility to secure 20 reimbursement for the costs paid for such care from any 21 appropriate third party funding source, or from the individual 22 to whom the services were rendered. 23 Section 503. Covered services. 24 (a) Benefits package.--The board shall establish a single 25 health benefits package within the plan that shall include, but 26 not be limited to, all of the following: 27 (1) Inpatient and outpatient care, both primary and 28 secondary. 29 (2) Emergency services. 30 (3) Emergency and other medically necessary transport to 20070H1660B2195 - 22 -
1 covered health services. 2 (4) Rehabilitation services, including speech, 3 occupational and physical therapy. 4 (5) Inpatient and outpatient mental health services and 5 substance abuse treatment. 6 (6) Hospice care. 7 (7) Prescription drugs and prescribed medical nutrition. 8 (8) Vision care, aids and equipment. 9 (9) Hearing care, hearing aids and equipment. 10 (10) Diagnostic medical tests, including laboratory 11 tests and imaging procedures. 12 (11) Medical supplies and prescribed medical equipment. 13 (12) Immunizations, preventive care, health maintenance 14 care and screening. 15 (13) Dental care. 16 (14) Home health care services. 17 (15) Chiropractic and massage therapy. 18 (16) Long-term care for those unable to care for 19 themselves independently and including assisted and skilled 20 care. 21 (b) Exclusions for preexisting conditions.--The plan shall 22 not exclude or limit coverage due to preexisting conditions. 23 (c) Copayments, deductibles, etc.--Beneficiaries of the plan 24 are not subject to copayments, deductibles, point-of-service 25 charges or any other fee or charge for a service within the 26 package and shall not be directly billed nor balance billed by 27 participating providers for covered benefits provided to the 28 beneficiary. Where a beneficiary has directly paid for 29 nonemergency services of a nonparticipating provider, the 30 beneficiary may submit a claim for reimbursement from the plan 20070H1660B2195 - 23 -
1 for the amount the plan would have paid a participating provider 2 for the same service. Where emergency services are rendered by a 3 nonparticipating provider, the beneficiary shall receive 4 reimbursement of the full amount paid to such nonparticipating 5 provider not to exceed 125% of the amount the plan would have 6 paid a participating provider for the same service. 7 (d) Exclusions of coverage.--The board shall remove or 8 exclude procedures and treatments, equipment and prescription 9 drugs from the plan benefit package that the board finds unsafe 10 or that add no therapeutic value. 11 (e) The board shall exclude coverage for any surgical, 12 orthodontic or other procedure or drug that the board determines 13 was or will be provided primarily for cosmetic purposes unless 14 required to correct a congenital defect, to restore or correct 15 disfigurements resulting from injury or disease or that is 16 certified to be medically necessary by a qualified, licensed 17 provider. 18 (f) Choice by beneficiary.--Beneficiaries shall normally be 19 granted free choice of the participating providers, including 20 specialists, without preapprovals or referrals. However, the 21 board shall adopt procedures to restrict such free choice for 22 those individuals who engage in patterns of wasteful or abusive 23 self-referrals to specialists. Specialists who provide primary 24 care to a self-referred beneficiary will be reimbursed at the 25 board-approved primary care rate established for the service in 26 that community. 27 (g) Service.--No participating provider shall be compelled 28 to offer any particular service so long as the refusal is 29 general, consistent and not discriminatory. 30 (h) Discrimination.--The plan and participating providers 20070H1660B2195 - 24 -
1 shall not discriminate on the basis of race, ethnicity, national 2 origin, gender, age, religion, sexual orientation, health 3 status, mental or physical disability, employment status, 4 veteran status or occupation. 5 Section 504. Excess and collective bargaining agreement health 6 insurance coverage. 7 Subject to the regulations of the Insurance Commissioner and 8 all applicable laws, private health insurers shall be authorized 9 to offer coverage supplemental to the package approved and 10 provided automatically under this act. Private insurers shall 11 also be authorized to offer programs to support the health care 12 terms of a collective bargaining agreement provided that such 13 benefits are at least as comprehensive as those provided under 14 the plan. 15 Section 505. Duplicate coverage. 16 The agency is subrogated to and shall be deemed an assignee 17 of all rights of a beneficiary who has received duplicate health 18 care benefits, or who has a right to such benefits, under any 19 other policy or contract of health care or under any government 20 program. 21 Section 506. Subrogation. 22 (a) General rule.--The agency shall have no right of 23 subrogation against a beneficiary's third-party claims for harm 24 or losses not covered under this act. Nor shall any beneficiary 25 under this act have a claim against a third-party tortfeasor for 26 the services provided or available to the beneficiary under this 27 act. In all personal injury actions accruing and prosecuted by a 28 beneficiary on or after January 1, 2008, the presiding judge 29 shall advise any jury that all health care expenses have been or 30 will be paid under the plan, and, therefore, no claim for past 20070H1660B2195 - 25 -
1 or future health care benefits is pending before the court. 2 (b) Exception.--The exception to the general rule of no 3 subrogation shall be that the agency retains its equitable right 4 to subrogation to the recovery, including the recovery for 5 noneconomic damages, of those persons opting out of the no-fault 6 administrative remedies adopted herein and who successfully 7 prosecute to verdict or settlement a claim for health care 8 professional or institutional negligence. The agency's right to 9 subrogation shall be absolute and shall not be subject to 10 reduction for attorney fees or costs of litigation. 11 Section 507. Eligible participating providers and availability 12 of services. 13 (a) General rule.--All licensed health care providers and 14 facilities are eligible to become a participating provider in 15 the plan in which instance they shall enjoy the rights and have 16 the duties as set forth in the plan as stated in this section or 17 as adopted by the board from time to time. Nonparticipating 18 providers shall not enjoy the rights nor bear the duties of 19 participating providers. 20 (b) Required notice.--In advance of initially providing 21 services to a beneficiary, nonparticipating providers shall 22 advise the beneficiary at the time the appointment is made that 23 the person or entity is a nonparticipating provider and that the 24 recipient of the service will be initially personally 25 responsible for the entire cost of the service and ultimately 26 responsible for the cost in excess of the reimbursement approved 27 by the board for participating providers. Failure to make such 28 financial disclosure will be deemed a fraud on the beneficiary 29 and entitle the beneficiary to a refund equal to 200% of the 30 amount paid to the nonparticipating provider in excess of the 20070H1660B2195 - 26 -
1 board-approved reimbursement for the services rendered, plus all 2 reasonable fees for collection. The burden of proof that such 3 disclosure was made shall be on the nonparticipating provider. 4 (c) Plan by board.--The board shall assess the number of 5 primary and specialty providers needed to supply adequate health 6 care services in this Commonwealth generally and in all 7 geographic areas and shall develop a plan to meet that need. The 8 board shall develop financial incentives for participating 9 providers in order to maintain and increase access to health 10 care services in underserved areas of this Commonwealth. 11 (d) Reimbursements.--Reimbursements shall be determined by 12 the board in such a fashion as to assure that a participating 13 provider receives compensation for services that fairly and 14 fully reflect the skill, training, operating overhead included 15 in the costs of providing the service, capital costs of 16 facilities and equipment, cost of consumables and the expense of 17 safely discarding medical waste, plus a reasonable profit 18 sufficient to encourage talented individuals to enter the field 19 and for investors to make capital available for the construction 20 of state-of-the-art health care facilities in this Commonwealth. 21 (e) Adjustments to reimbursements.--Participating providers 22 shall have the right alone or collectively to petition the board 23 for adjustments to reimbursements believed to be too low. Such 24 petitions shall be initially evaluated by the administrator of 25 provider services, with input from the Health Advisory Panel, 26 who shall submit a report to the executive director within 30 27 days. The executive director will then submit a recommendation 28 to the board for action at the next scheduled board meeting. 29 Participating providers who remain dissatisfied after the board 30 has ruled may appeal the board's determination to the Court of 20070H1660B2195 - 27 -
1 Common Pleas of Dauphin County, which shall review the action of 2 the board on an abuse of discretion standard. 3 (f) Evaluation of access to care.--The board annually shall 4 evaluate access to trauma care, diagnostic imaging technology, 5 emergency transport and other vital urgent care requirements and 6 shall establish measures to assure beneficiaries have equitable 7 and ready access to such resources regardless of where in this 8 Commonwealth they may be. 9 (g) Performance reports.--The board, with the assistance of 10 the Health Advisory Panel and the administrator of quality 11 assurance, shall define performance criteria and goals for the 12 plan and shall make a written report to the General Assembly at 13 least annually on the plan's performance. All such reports, 14 including the survey results obtained, shall be made publicly 15 available with the goal of total transparency and open self- 16 analysis as a defining quality of the agency. The board shall 17 establish a system to monitor the quality of health care and 18 patient and provider satisfaction and to adopt a system to 19 devise improvements and efficiencies to the provision of health 20 care services. 21 (h) Data reporting.--All participating providers shall 22 provide data to the agency promptly upon the request of the 23 executive director. 24 (i) Coordination of services.--The board shall coordinate 25 the provision of health care services with any other 26 Commonwealth and local agencies that provide health care 27 services directly to their charges or residents. 28 Section 508. Rational cost containment. 29 (a) Approval of expenditures.--As part of its cost 30 containment mission, the board shall screen and approve or 20070H1660B2195 - 28 -
1 disapprove private or public expenditures for new health care 2 facilities and other capital investments that may lead to 3 redundant and inefficient health care provider capacity. 4 Procedures shall be adopted for this purpose with an emphasis 5 upon efficiency and a fair and open consideration of all 6 applications. 7 (b) Capital investments.--All capital investments valued at 8 one million dollars or greater, including the costs of studies, 9 surveys, design plans and working drawing specifications, and 10 other activities essential to planning and execution of capital 11 investment and all capital investments that change the bed 12 capacity of a health care facility by more than 10% over a 24- 13 month period or that add a new service or license category shall 14 require the approval of the board. When a facility, an 15 individual acting on behalf of a facility or any other purchaser 16 obtains by lease or comparable arrangement any facility or part 17 of a facility, or any equipment for a facility, the market value 18 of which would have been a capital expenditure, the lease or 19 arrangement shall be considered a capital expenditure for 20 purposes of this section. 21 (c) Deemed approval.--Capital investment programs submitted 22 for approval shall be deemed approved unless specifically 23 rejected by the board within 60 days from the date the 24 submissions are received by the executive director. 25 (d) Recommendations.--Recommendations of the Pennsylvania 26 Heath Cost Containment Council, Pittsburgh Regional Health Care 27 Initiative and such other public and private authoritative 28 bodies as shall be identified from time to time by the board 29 shall be received by the executive director and submitted to the 30 board with the executive director's recommendation regarding 20070H1660B2195 - 29 -
1 implementation of the recommended reforms. The board shall 2 receive input from all interested parties and then shall vote 3 upon all such recommendations within 60 days. Where procedural 4 or protocol reforms are adopted, participating providers will be 5 required to implement such designated best practices within the 6 next 60 days. 7 (e) Required investments.--If mandated reforms require the 8 acquisition of additional equipment, participating providers 9 shall make such investments within one year, and, upon 10 application, the board shall provide financing for such mandated 11 equipment on reasonable terms. 12 (f) Sanctions.--Participating providers refusing to adopt 13 recommended reforms shall, after a reasonable opportunity to be 14 heard, be subject to such sanctions as the board shall deem 15 appropriate and necessary up to and including the suspension or 16 permanent decertification of the provider. 17 CHAPTER 7 18 NO-FAULT ADMINISTRATIVE REMEDIES 19 Section 701. Rationalization of remedies for errors and 20 complications. 21 A primary objective of the board shall be to reduce the 22 frequency of medical errors and complications and to establish a 23 no-fault administrative procedure for fair and expeditious 24 compensation to those who suffer injuries or complications 25 relating to their care. 26 Section 702. Voluntary waiver of tort remedies and choice to 27 retain tort remedies. 28 Beneficiaries under the plan shall be conclusively deemed to 29 have voluntarily waived all other common law and statutory tort 30 remedies against any participating provider for alleged 20070H1660B2195 - 30 -
1 professional negligence, error of judgment or failure to secure 2 informed consent. Beneficiaries under the plan not willing to 3 waive such common law and statutory remedies may opt out of the 4 no-fault administrative remedies set forth in this act at any 5 time prior to the events complained of. Nonparticipating 6 providers shall not fall within the protections of the waiver of 7 tort remedies. 8 Section 703. No-fault administrative remedies for those not 9 opting out. 10 (a) Compensation.--In exchange for the waiver of their 11 traditional tort remedies, beneficiaries who suffer a new injury 12 or complication directly related to the care provided by, or 13 medications or treatments prescribed by a participating provider 14 shall be entitled to expedited compensation without proof of 15 professional negligence or error of judgment. Where the 16 application for compensation does not arise from a new injury or 17 complication but rather asserts a failure of a participating 18 provider to properly intervene, and thus mitigate the natural 19 progress of a disease or injury, proof of a departure from the 20 standard of care must be demonstrated by a preponderance of the 21 credible evidence for the claimant to qualify for compensation. 22 Out-of-state patients seeking care in Pennsylvania from a 23 participating provider shall, prior to treatment unless 24 unconscious or other circumstances prevent it, be provided with 25 a form approved by the board on which the patient can opt in or 26 opt out of the no-fault administrative remedies. Where no 27 election is made, the patient shall be conclusively presumed to 28 have chosen to participate in the no-fault administrative 29 remedies should the occasion arise. 30 (b) Other compensation.--In further exchange for the waiver 20070H1660B2195 - 31 -
1 of their traditional tort remedies, beneficiaries not opting out 2 of the no-fault administrative remedies and who assert that they 3 did not give their informed consent to an invasive procedure or 4 treatment, but who have not suffered a new injury or 5 complication thereby, shall be entitled to compensation upon 6 proof of the failure of the participating provider, or the 7 provider's representative, to provide at least the level of 8 information required for the procedure at issue pursuant to 9 guidelines adopted by the board. 10 (c) Award of damages.--Eligible claimants not opting out of 11 the no-fault administrative remedies shall be entitled to awards 12 to be determined by the health claims hearing officers as 13 follows: 14 (1) For past and/or continuing lost earning capacity, up 15 to a maximum of $5,000 per month. 16 (2) For noneconomic harm, defined as past and/or 17 continuing pain, suffering, disfigurement and/or 18 inconvenience, up to a maximum of $5,000 per month. 19 (3) For a failure of informed consent, either alone or 20 in conjunction with an award for past and or continuing lost 21 earning capacity and/or noneconomic harm, a maximum single 22 lump-sum payment of $10,000. 23 (4) For death, and in addition to the lost earning 24 capacity and noneconomic harm endured prior to death, up to a 25 maximum of $10,000 per month for 120 months to be placed in 26 trust for the benefit of the decedent's dependents. The trust 27 shall be managed by the office of the beneficiary advocate 28 under guidelines adopted by the board. 29 (d) Adjustments of limits.--The board shall adjust the 30 limits of compensation annually to account for inflation, and 20070H1660B2195 - 32 -
1 all awards for continuing lost earning capacity and/or 2 noneconomic damages shall be adjusted annually at the same rate 3 of inflation as determined by the board. 4 (e) Payment from trust.--The cost of all such compensation 5 shall be paid from the trust. No participating provider shall be 6 held financially responsible for any portion of the compensation 7 award nor shall participating providers be required to fund the 8 cost of such awards collectively through any assessment or 9 premium. 10 Section 704. Administrative claims procedures. 11 (a) Application for compensation.--The board shall adopt 12 simplified procedures for the submission of applications for no- 13 fault compensation under this act to the administrator of health 14 claims. The procedures shall provide for the expeditious 15 handling and approval of any clearly qualifying claims. Where 16 fact-finding is required in whole or in part, such claims shall 17 be presented expeditiously to a health claims hearing officer 18 for findings. Administrative appeals to the executive director 19 shall be permitted, and, where a claimant has been denied 20 compensation or contests the sufficiency of the award, claimant 21 shall have an appeal to the Court of Common Pleas of Dauphin 22 County which will consider the adequacy of the compensation on a 23 de novo basis with the power to increase or decrease the amount 24 awarded administratively. However, such court shall not have the 25 power to award compensation in excess of the limits established 26 by this act. 27 (b) Attorney fees.--Where on appeal to the Court of Common 28 Pleas of Dauphin County a denied claim is approved or an 29 administrative award is increased by at least 25%, the court 30 shall also award a reasonable attorney fee of no more than 20% 20070H1660B2195 - 33 -
1 and all reasonable litigation expenses including the cost of 2 expert witnesses and exhibits. 3 (c) Adjustment of awards.--The board shall further adopt 4 procedures whereby awards granted under this section for 5 continuing harms shall be subject to increase, not to exceed the 6 limits, or decrease upon a showing of a material change in the 7 claimant's condition. Continuing benefits shall be contingent 8 upon the reasonable cooperation of the claimant with respect to 9 the rehabilitation and mitigation of the claimant's injury. 10 (d) Administrative procedure.--The board shall adopt 11 administrative procedure to review appeals of participating 12 providers with respect to denials or adjustment of reimbursement 13 which appeals must be filed within 90 days of the notice of a 14 denied or adjusted reimbursement. 15 Section 705. Beneficiary right to counsel. 16 (a) Choice of counsel.--Beneficiaries seeking to file a 17 claim for no-fault compensation under this act shall have the 18 right to be represented by legal counsel of their choice. 19 (b) Fee agreement.--Any contingent fee agreement entered 20 into between a beneficiary claimant and their legal counsel 21 shall be limited as follows: 22 (1) Five percent where the claim is administratively 23 approved without a hearing. 24 (2) Ten percent where the claim proceeds to a hearing. 25 (3) Twenty percent where the claim is resolved after 26 appeal. 27 Section 706. Quality assurance follow-up to claims. 28 (a) Investigations.--All claims of error, complication or 29 failure of informed consent shall simultaneously be submitted 30 for analysis and quality assurance investigation through the 20070H1660B2195 - 34 -
1 office of the administrator for quality assurance. The 2 beneficiary submitting the claim shall be advised of the 3 progress of the inquiry and invited to present such information 4 or testimony as they deem necessary to the full and fair 5 consideration of the matters reported. Beneficiaries may attend 6 and/or be represented during this process by counsel of their 7 choosing at their own expense or may request the assistance at 8 no cost of a qualified advocate from the office of the 9 administrator of consumer affairs. 10 (b) Representation of providers.--Participating providers 11 who are the subject of an inquiry initiated by a beneficiary 12 application for compensation may attend and/or be represented by 13 counsel of their choosing at their own expense or may request 14 the assistance at no cost of a qualified advocate from the 15 office of the administrator for provider coordination. 16 (c) Reports.--At the conclusion of the inquiry, the 17 administrator of quality assurance shall submit a report and 18 recommendations to the executive director who shall then take 19 such action as they deem necessary under the circumstances to 20 avoid a recurrence of any avoidable errors. A copy of the 21 recommendations shall be provided to the beneficiary who 22 initiated the claim and also to the participating provider 23 involved in the inquiry. The report will be forwarded to 24 appropriate licensing authorities for further action. 25 Section 707. Surviving tort claims against participating 26 providers. 27 (a) Optional remedies.--Otherwise eligible persons who have 28 opted out of the no-fault administrative remedies of the plan 29 shall retain their right to pursue traditional tort remedies 30 against participating providers through the courts of this 20070H1660B2195 - 35 -
1 Commonwealth and, where jurisdictional requirements are 2 satisfied, through the courts of the United States. 3 (b) Legal counsel.--In all such cases participating 4 providers shall have the right to legal counsel of their choice 5 the reasonable cost of which shall be paid by the plan as will 6 the reasonable cost of experts and other trial expenses. In the 7 event of a final award in favor of the persons filing the claim, 8 the plan shall further provide primary indemnification of up to 9 three million dollars per claim and six million dollars per 10 annual aggregate claims per participating provider. 11 (c) Excess liability coverage.--In the event the private 12 insurance market does not make excess coverage available to 13 participating providers at reasonable cost, the board shall 14 recommend to the General Assembly the establishment of an excess 15 liability insurance pool sponsored by the Commonwealth and 16 financed with premiums to be paid by those participating 17 providers who seek additional protection above and beyond the 18 protection provided in subsection (b). 19 Section 708. Claims against nonparticipating providers. 20 Health care providers opting out of the plan shall be 21 responsible for the cost of their legal defense and shall be 22 further responsible to the patient and/or the plan for any 23 settlement or award, if any. Where the plan has paid for health 24 care-related costs arising from an alleged failure of due care 25 by a nonparticipating provider and where the injured party has 26 otherwise been made whole, the plan shall be subrogated to the 27 claim to the extent of the medical expenses incurred or that 28 have been found will be incurred. 29 Section 709. Parallel no-fault compensation for beneficiaries 30 injured by nonparticipating providers. 20070H1660B2195 - 36 -
1 Beneficiaries who have not opted out of the no-fault 2 administrative remedies pursuant to section 702, and who believe 3 they have been harmed by the negligence of a nonparticipating 4 provider, may elect, alone or in addition to pursuing 5 traditional tort claims against the nonparticipating providers, 6 to submit a claim under section 704, in which instance the plan 7 shall be subrogated to and/or credited with the beneficiary's 8 recovery, net of reasonable attorney fees and expenses, from the 9 nonparticipating provider to the extent of economic, noneconomic 10 and/or failure of informed consent benefits paid to such 11 beneficiaries. 12 CHAPTER 9 13 PENNSYLVANIA HEALTH CARE TRUST FUND 14 Section 901. Pennsylvania Health Care Trust Fund. 15 (a) Establishment.--The Pennsylvania Health Care Trust Fund 16 is hereby established within the State Treasury. All moneys 17 collected and received by the plan shall be transmitted to the 18 State Treasurer for deposit into the fund, to be used 19 exclusively to finance the plan. 20 (b) State Treasurer.--The State Treasurer may invest the 21 principal and interest earned by the fund in any manner 22 authorized under law for the investment of Commonwealth moneys. 23 Any revenue or interest earned from the investments shall be 24 credited to the fund. 25 (c) Administrator of finance.--The administrator of finance 26 of the agency shall notify the board when the monthly 27 expenditures or anticipated future expenditures of the plan 28 appear to be in excess of the anticipated future revenues for 29 the same period. The board shall implement appropriate measures 30 upon such notification. Such measures shall include the 20070H1660B2195 - 37 -
1 adjustment of the Wellness Tax as necessary to ensure the 2 solvency of the trust. 3 Section 902. Rolling budget process. 4 (a) Estimated annual budget.--The board shall prepare and 5 recommend to the General Assembly an estimated annual budget for 6 health care, which budget specifies an estimated requirement for 7 health care provided under this act. The budget shall include 8 all of the following components: 9 (1) A system budget covering all expenditures for the 10 agency. 11 (2) A capital investment budget. 12 (3) A purchasing budget. 13 (4) A research and innovation budget. 14 (b) Budget projections.--In preparing the budget, the board 15 shall consider anticipated increased expenditures and savings, 16 including, but not limited to, projected increases in 17 expenditures due to improved access for underserved populations 18 and improved reimbursement for primary care, projected 19 administrative savings under the single-payer mechanism, 20 projected savings in prescription drug expenditures under 21 competitive bidding and a single buyer, and projected savings 22 due to provision of primary care rather than emergency room 23 treatment. 24 (c) Rolling budget.--The board shall operate on a rolling 25 budget whereby it will anticipate its funding needs 90 days in 26 advance and shall seek adjustments from the General Assembly to 27 The Employer Health Services Levy and/or The Individual Wellness 28 Tax to assure solvency of the plan and to avoid unnecessary cash 29 surpluses in the trust. 30 Section 903. Limitation on administrative expense. 20070H1660B2195 - 38 -
1 The system budget referred to in this chapter shall comprise 2 the cost of the agency, services and benefits provided, 3 administration, data gathering, planning and other activities 4 and revenues deposited with the system account of the trust. The 5 board shall limit administrative costs to 5% of the agency 6 budget and shall annually evaluate methods to reduce 7 administrative costs and publicly report the results of that 8 evaluation. 9 Section 904. Funding sources. 10 Funding of the plan shall be obtained from the following 11 dedicated sources: 12 (1) Funds obtained from existing or future Federal 13 health care programs. 14 (2) Funds from dedicated sources specified by the 15 General Assembly. 16 (3) Receipts from the tax of 10% of gross payroll, 17 including self-employment profits. One percent of the tax 18 shall become effective the date that shall be the first day 19 of a calendar month no less than 32 days after the effective 20 date of this act, and the tax shall become fully effective 21 November 1, 2007. Employers who are part of a collective 22 bargaining agreement whereby the health care benefits are no 23 less generous than those provided under the plan shall be 24 excused from paying 90% of the tax. 25 (4) Receipts from the Individual Wellness Tax of 3% of 26 personal earned, passive, pension and investment income. One- 27 half of one percent of the Individual Wellness Tax shall 28 become effective the date that shall be the first day of a 29 calendar month no less than 32 days after the effective date 30 of this act, and the IWT tax shall become fully effective 20070H1660B2195 - 39 -
1 November 1, 2007. Employees who are part of a collective 2 bargaining agreement whereby the health care benefits are no 3 less generous than those provided under the plan shall be 4 excused from paying 90% of the Individual Wellness Tax. 5 (5) In the event the General Assembly has not responded 6 to a request by the board for an increase in funding in 7 anticipation of projected expenses, the board is hereby 8 authorized to order a temporary increase, for no more than 90 9 days, in the Employer Health Services Tax and/or the 10 Individual Wellness Tax of no more than 250 basis points each 11 to respond to a threatened insolvency of the plan. 12 CHAPTER 11 13 TRANSITIONAL SUPPORT AND TRAINING FOR DISPLACED WORKERS 14 Section 1101. Transitional support and training for displaced 15 workers. 16 (a) Determination of administrator.--The administrator of 17 transition services shall determine which citizens of this 18 Commonwealth employed by a health care insurer, health insuring 19 corporation or other health care-related business have lost 20 their employment as a result of the implementation and operation 21 of the plan. The administrator also shall determine the amount 22 of monthly wages that the individual has lost due to the plan's 23 implementation. The department shall attempt to position these 24 displaced workers in comparable positions of employment or 25 assist in the retraining and placement of such displaced 26 employees elsewhere. 27 (b) Information.--The administrator of transition services 28 shall forward the information on the amount of monthly wages 29 lost by Commonwealth residents due to the implementation of the 30 plan to the board. The board shall determine the amount of 20070H1660B2195 - 40 -
1 compensation required to assure income maintenance and training 2 that each displaced worker shall receive on a case-by-case basis 3 and shall submit a claim to the trust for payment. A displaced 4 worker, however, shall not receive compensation or training 5 assistance from the trust in excess of $5,000 per month for two 6 years. Compensation paid to the displaced worker under this 7 section shall serve as a supplement to any compensation the 8 worker receives from any other source including unemployment 9 insurance. 10 (c) Coordination of services.--The administrator of 11 transition services shall fully coordinate activity with public 12 and private services also available or actually participating in 13 the assistance to the affected individuals. 14 (d) Appeals.--Persons dissatisfied with the level of 15 assistance they are receiving may appeal to the office of the 16 executive director whose determination shall be final and not 17 subject to appeal. 18 CHAPTER 13 19 VOLUNTEER EMERGENCY RESPONDER NETWORK 20 Section 1301. Preservation of volunteer emergency responder 21 network. 22 Because this Commonwealth is dependent upon the volunteered 23 services of firefighters, emergency medical technicians and 24 search and rescue workers, the board is further charged with 25 administering a Commonwealth income tax credit program for such 26 volunteers. 27 Section 1302. Eligibility certification. 28 Annually, in January, administrators of volunteer 29 firefighting and rescue departments, emergency medical 30 technicians and paramedics stations and similar volunteer 20070H1660B2195 - 41 -
1 emergency entities shall certify the identity of Commonwealth 2 residents providing active services during the prior calendar 3 year. 4 Section 1303. Eligibility criteria. 5 Active status shall require a minimum of 200 hours of service 6 during the preceding year and response to no less than 50% of 7 the emergency calls during at least three of the four calendar 8 quarters. 9 Section 1304. Amount of tax credit. 10 Each volunteer certified as active shall be granted a credit 11 equal to $1,000 toward their State income tax obligation under 12 Article III of the act of March 4, 1971 (P.L.6, No.2), known as 13 the Tax Reform Code of 1971. Any eligible volunteer who does not 14 incur $1,000 in annual State income tax liability shall 15 nevertheless be eligible for a refund equal to the amount the 16 credit exceeds that volunteer's tax obligation. 17 Section 1305. Reimbursement of Department of Revenue. 18 The State Treasury shall be reimbursed the value of such 19 volunteer credits from the fund. 20 CHAPTER 15 21 MISCELLANEOUS PROVISIONS 22 Section 1501. Effective date. 23 This act shall take effect immediately. F20L35JAM/20070H1660B2195 - 42 -