Bill Text: PA HB480 | 2011-2012 | Regular Session | Introduced

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Bill Title: Providing for health care provider choice; and imposing penalties.

Spectrum: Partisan Bill (Democrat 20-0)

Status: (Introduced - Dead) 2011-02-16 - Referred to INSURANCE [HB480 Detail]

Download: Pennsylvania-2011-HB480-Introduced.html

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PRINTER'S NO. 718
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No. 480 Session of2011
INTRODUCED BY MATZIE, BARBIN, V. BROWN, D. COSTA, CALTAGIRONE, DeLUCA, GEORGE, HALUSKA, HORNAMAN, KORTZ, KOTIK, KULA, LONGIETTI, MANN, MUNDY, M. O'BRIEN, PASHINSKI, STURLA AND DAVIS, FEBRUARY 16, 2011
REFERRED TO COMMITTEE ON INSURANCE, FEBRUARY 16, 2011
AN ACT
Providing for health care provider choice; and imposing
penalties.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Short title.
This act shall be know and may be cited as the Health Care
Professional Choice Act.
Section 2. Definitions.
The following words and phrases when used in this act shall
have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Commissioner." The Insurance Commissioner of the
Commonwealth.
"Covered person." A policyholder, subscriber, enrollee or
other individual participating in a health benefit plan.
"Department." The Insurance Department of the Commonwealth.
"Grandfathered plan coverage." Coverage provided by a health
carrier in which an individual was enrolled on March 23, 2010
for as long as it maintains that status in accordance with
Federal regulations.
"Group health insurance coverage." Health insurance coverage
offered in connection with a group health plan.
"Group health plan." An employee welfare benefit plan as
defined in section 3(1) of the Employee Retirement Income
Security Act of 1974 (Public Law 93-406, 88 Stat. 829) to the
extent that the plan provides medical care and includes items
and services paid for as medical care to current and former
employees, or their dependents as defined under the terms of the
plan directly or through insurance, reimbursement or otherwise.
"Health benefit plan."
(1) A policy, contract, certificate or agreement offered
by a health carrier to provide, deliver, arrange for, pay for
or reimburse any of the costs of health care services. The
term includes short-term and catastrophic health insurance
policies and a policy that pays on a cost-incurred basis,
except as otherwise exempted under this definition.
(2) The term does not include:
(i) Coverage only for accident, or disability income
insurance, or any combination thereof.
(ii) Coverage issued as a supplement to liability
insurance.
(iii) Liability insurance, including general
liability insurance and automobile liability insurance.
(iv) Workers' compensation or similar insurance.
(v) Automobile medical payment insurance.
(vi) Credit-only insurance.
(vii) Coverage for on-site medical clinics.
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(viii) Other similar insurance coverage, specified
in Federal regulations issued under the Health Insurance
Portability and Accountability Act of 1996 (Public Law
104-191, 110 Stat. 1936) under which benefits for medical
care are secondary or incidental to other insurance
benefits.
(3) The term does not include the following benefits if
they are provided under a separate policy, certificate or
contract of insurance or are otherwise not an integral part
of the plan:
(i) Limited scope dental or vision benefits.
(ii) Benefits for long-term care, nursing home care,
home health care, community-based care, or any
combination thereof.
(iii) Other similar, limited benefits specified in
Federal regulations issued under the Health Insurance
Portability and Accountability Act of 1996.
(4) The term does not include the following benefits if
the benefits are provided under a separate policy,
certificate or contract of insurance, there is no
coordination between the provision of the benefits and any
exclusion of benefits under any group health plan maintained
by the same plan sponsor and the benefits are paid with
respect to an event without regard to whether benefits are
provided with respect to the event under any group health
plan maintained by the same plan sponsor:
(i) Coverage only for a specified disease or
illness.
(ii) Hospital indemnity or other fixed indemnity
insurance.
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(5) The term does not include the following if offered
as a separate policy, certificate or contract of insurance:
(i) Medicare supplemental health insurance as
defined under section 1882(g)(1) of the Social Security
Act (49 Stat. 620, 42 U.S.C. § 1882(g)(1)).
(ii) Coverage supplemental to the coverage provided
under the Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS).
(iii) Similar supplemental coverage provided to
coverage under a group health plan.
"Health care professional." A physician, certified nurse
midwife, dentist, podiatrist, nurse, nurse practitioner,
chiropractor or other health care practitioner licensed,
accredited or certified to perform specified health care
services consistent with state law.
"Health carrier." A company or health insurance entity
licensed in this Commonwealth to offer or issue any individual
or group health, sickness or accident policy or subscriber
contract or certificate or plan that provides medical or health
care coverage by a health care facility or licensed health care
provider that is governed under this act or any of the
following:
(1) Article XXIV of the act of May 17, 1921 (P.L.682,
No.284), known as The Insurance Company Law of 1921.
(2) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
(3) The act of May 18, 1976 (P.L.123, No.54), known as
the Individual Accident and Sickness Insurance Minimum
Standards Act.
(4) 40 Pa.C.S. Ch. 61 (relating to hospital plan
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corporations) or Ch. 63 (relating to professional health
services plan corporations).
"Health maintenance organization." An organized system which
combines the delivery and financing of health care and which
provides basic health services to voluntarily enrolled
subscribers for a fixed prepaid fee.
"Individual health insurance coverage." Health insurance
coverage offered to individuals in the individual market, which
includes a health benefit plan provided to individuals through a
trust arrangement, association or other discretionary group that
is not an employer plan, but does not include short-term limited
duration insurance. A health carrier offering health insurance
coverage in connection with a group health plan shall not be
deemed to be a health carrier offering individual health
insurance coverage solely because the carrier offers a
conversion policy.
"Managed care plan." A health benefit plan that requires a
covered person to use, or creates incentives, including
financial incentives, for a covered person to use health care
providers managed, owned, under contract with or employed by the
health carrier.
"Medical care." Amounts paid for:
(1) The diagnosis, care, mitigation, treatment or
prevention of disease, or amounts paid for the purpose of
affecting any structure or function of the body.
(2) Transportation primarily for and essential to
medical care under paragraph (1).
(3) Insurance covering medical care under paragraphs (1)
and (2).
"Network." The group of participating health care
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professionals providing services to a managed care plan.
"Participant." As defined in section 3(7) of the Employee
Retirement Income Security Act of 1974 (Public Law 93-406, 88
Stat. 829).
"Participating health care professional." A health care
professional who, under a contract with the health carrier or
with its contractor or subcontractor, has agreed to provide
health care services to covered persons with an expectation of
receiving payment, other than coinsurance, copayments or
deductibles, directly or indirectly from the health carrier.
"Primary care health care professional." A health care
professional designated by a covered person to supervise,
coordinate or provide initial care or continuing care to the
covered person, who may be required by the health carrier to
initiate a referral for specialty care and maintain supervision
of health care services rendered to the covered person.
"Subscriber." In the case of an individual health insurance
contract, the person in whose name the contract is issued.
Section 3. Choice of health care professional.
(a) Designation.--
(1) If a health carrier offering group or individual
health insurance coverage requires or provides for the
designation by a covered person of a participating primary
health care professional, the health carrier shall permit
each covered person to:
(i) Designate any participating primary care health
care professional who is available to accept the covered
person.
(ii) For a child, designate any participating
physician who specializes in pediatrics as the child's
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primary care health care professional and is available to
accept the child.
(2) The provisions of paragraph (1)(ii) shall not be
construed to waive any exclusions of coverage under the terms
and conditions of the health benefit plan with respect to
coverage of pediatric care.
(b) Obstetrical or gynecological care.--
(1) If a health carrier provides coverage for
obstetrical or gynecological care and requires the
designation by a covered person of a participating primary
care health care professional, the health carrier:
(i) Shall not require any person's, including a
primary care health care professional's, prior
authorization or referral in the case of a female covered
person who seeks coverage for obstetrical or
gynecological care provided by a participating health
care professional who specializes in obstetrics or
gynecology.
(ii) Shall treat the provision of obstetrical and
gynecological care, and the ordering of related
obstetrical and gynecological items and services, under
subparagraph (i).
(2) (i) The health carrier may require the health care
professional to agree to otherwise adhere to the health
carrier's policies and procedures, including procedures
for obtaining prior authorization and provider services
in accordance with a treatment plan, if any, approved by
the health carrier.
(ii) For purposes of paragraph (1)(i), a health care
professional who specializes in obstetrics or gynecology
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means any individual, including an individual other than
a physician, who is authorized under State law to provide
obstetrical or gynecological care.
(3) The provisions of paragraph (1)(i) shall not be
construed to:
(i) Waive any exclusions of coverage under the terms
and conditions of the health benefit plan with respect to
coverage of obstetrical or gynecological care.
(ii) Preclude the health carrier involved from
requiring that the participating health care professional
providing obstetrical or gynecological care notify the
primary care health care professional or the health
carrier of treatment decisions.
Section 4. Notice.
(a) Requirement.--A health carrier shall provide notice to
covered persons of the terms and conditions of the plan related
to the designation of a participating health care professional
provided under section 3 and of a covered person's rights with
respect to those provisions.
(b) Form.--
(1) In the case of group health insurance coverage, the
notice shall be developed by the department using the notice
developed by the National Association of Insurance
Commissioners described under the appendix A of the National
Association of Insurance Commissioners model law entitled
"Choice of Health Care Professionals Notice" and shall be
included whenever the health carrier provides a participant
with a summary plan description or other similar description
of benefits under the health benefit plan.
(2) In the case of individual health insurance coverage,
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the notice described shall be developed by the department
using the notice developed by the National Association of
Insurance Commissioners described in the appendix of the
model law entitled "Choice of Health Professionals Notice"
and shall be included whenever the health carrier provides a
primary subscriber with a policy, certificate or contract of
health insurance.
Section 5. Enforcement.
(a) Penalties and remedies.--Upon a determination by hearing
that this act has been violated, the commissioner may pursue one
or more of the following courses of action:
(1) Issue an order requiring the person in violation to
cease and desist from engaging in the violation.
(2) Suspend or revoke or refuse to issue or renew the
certificate or license of the person in violation.
(3) Impose a civil penalty of not more than $5,000 for
each violation.
(4) Impose any other penalty or remedy deemed
appropriate by the commissioner, including restitution.
(b) Other remedies.--The enforcement remedies imposed under
this section shall be in addition to any other remedies or
penalties that may be imposed by statute. Violations of this
article are deemed and defined by the commissioner to be an
unfair method of competition and an unfair or deceptive act or
practice under the act of July 22, 1974 (P.L.589, No.205), known
as the Unfair Insurance Practices Act.
Section 6. Applicability.
(a) Applicability.--Except as provided under subsection (b),
this act shall apply to a health carrier providing coverage
under an individual or group health benefit plan.
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(b) Exception.--This act shall not apply to grandfathered
plan coverage.
Section 7. Regulations.
The department shall promulgate regulations necessary to
implement this act.
Section 20. Effective date.
This act shall take effect in 60 days.
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