The Pennsylvania HEALTH LAW PROJECT
The PA Senate Public Health & Welfare Committee will be holding
a series of hearings in 4 locations around the State on health
care provided by managed care entities (HMOs & PPOs). A list
of the dates and locations of the hearings follows. The hearings
are nominally about Senate Bill 100, a summary of which also follows.
However, the fundamental purpose of the hearings is for the Senators
involved to decide whether the problems that have been reported
regarding managed are just isolated incidents or systemic problems
requiring legislative intervention.
Their decision will be based, in part, on the kind and amount
of testimony they receive. Therefor, persons with experiences
involving managed care who are able to get to one of the hearings,
are urged to contact the Executive Director of the Senate Public
Health & Welfare Committee to see about testifying. The Director's
name is Scott Johnson and his phone number is (717) 787-8524.
People who cannot get to one of the hearings can submit written
testimony to us at the address above and we will make sure it
is distributed to the Committee Members.
These hearings are being held on managed care health plans provided through employers as well as managed care through Medical Assistance (Access). For additional information, contact David Gates at the phone numbers above.
FROM: Senator Harold F. Mowery, Jr., Chairman ~
Senate Public Health and Welfare Committee \
SUBJECT: Public Hearings on Senate Bill 100
The Senate Public Health and Welfare Committee will be holding
statewide public hearings on Senate Bill I 100, which addresses
a variety of public concerns regarding the quality of health care
provided by managed care systems. The following hearings have
Thursday, April 3rd
State Capitol Building Room 8EB East Wing 10 A.M. to 3:00
Thursday. May 1st
Erie City Council Chamber
Erie City Hall
626 State Street
Erie, PA 16501
9:00 AM to 1:00 PM
Friday, May 2nd
Greentree Municipal Building
10 West Manilla Drive
Greentree, PA 15220
9:00 AM to 1:00 PM to 1:OO PM
Wednesday, May 21st
Bethlehem Town Hall 10 East Church Street Bethlehem, PA 18018
1:00 P.M. to 5:00 P. M.
Thursday, May 22nd
Radisson Hotel Philadelphia Northeast
2400 Old Lincoln Highway
Trevose, PA 19053
9:00 AM to 1:00 PM
In an effort to gather informed comment on this proposed legislation,
you are invited to recommend an individual who would be available
to testify at the above referenced hearings. Please notify Scott
Johnson (717787-8524) of your recommendations at least one
week before the hearing date. Also, please contact Mr. Johnson
if you plan to attend, or if you have any questions regarding
Quality Health Care Protection Act Bill
Senator Tim Murphy
The `'Quality Health Care Protection Act', would ensure that Commonwealth
patients are guaranteed quality health care. To this end. patients/enrollees
within any managed care entity (MCE)) would be guaranteed several
consumer protections. including the following:
Notification to enrollee All prospective
or current enrollees would be notified in writing of medical coverage
and any changes. All materials must be produced in clear, understandable
language and provide a complete description of the plan. This
description will include, but not be limited to' 11 ) coverage
limits; (2) rules regarding utilization review; (3) financial
responsibilities of the enrollee: (4) explanations of the grievance
process, (5) limited utilization incentive plans; and (6) limitation
on choices of health care providers.
Access to Services Health care coverage
offered by a MCE must be accessible to all enrollees. In addition,
treatment could not be refused for any secondary disorder/diagnosis
diagnosis related to a diagnosis for a noncovered condition
if the secondary disorder/diagnosis is otherwise covered.
Utilization Review Program The medical
director responsible for all decisions under a utilization review
program must be a licensed physician. The program must be developed
in consultation with providers and enrollees and distributed among
each group. The utilization review board would be required to
respond to authorization requests within 2 business days for a
nonemergency and 24 hours for an emergency. A program could
not deny services unless the procedure reviewed by a health care
professional who is authorized to perform the service that is
subject of the adverse action. A program must have a procedure
that would allow enrollees to appeal a decision withholding treatment.
A program would not be able to retroactively deny coverage for
services when prior approval has been obtained, unless the approval
was based upon fraudulent information.
Incentives To Withhold Treatment Any
incentives financial or otherwise. encouraging a provider to prescribe
less than "medically necessary and appropriate care"
to patients would be expressly prohibited.
Confidentiality All patient information
would remain completely confidential with accessibility only available
to those persons with a professional interest in the patient.
Emergency Services In the event of a
health care emergency, an enrollee's examination and treatment
in the emergency room would be covered. The attending provider
may initiate necessary intervention to stabilize the condition
of the patient without seeking or receiving previous authorization
by the MCE. An "emergency" is considered the sudden
onset of a medical condition that the absence of immediate medical
attention could reasonably be expected by a "prudent and
reasonable lay person.'' who possesses an average knowledge of
health and medicine to seek medical attention.
Continuity of Care If an enrollee's
medical provider is terminated, he/she will be able to continue
to receive services from that provider until either the end of
the enrollee's period of enrollment or for up to one year of treatment.
whichever is later in the case of ( I ) postoperative followup
care; (2) ontological treatment; (3) psychiatric treatment; and
(4) obstetrical care throughout the duration of the pregnancy
and childbirth. During the period, services will be covered under
the same terms when the provider participated in the plan.
Point of Service Plan Option Enrollees will
have an opportunity, during the enrollment period and during a
onemonth period in each year following. to enroll in a POS
option and be provided with a detailed explanation of the financial
costs to be incurred. An enrollee involved in the POS option may
received a covered service from nonparticipating provider,
but he/she may be required to pay a higher annual premium which
reflects the actuarial value of this expanded coverage or an annual
deductive plus a coinsurance
share which shall not exceed 20 percent of the costs of the services
provided or both.
Medical Gag Clause Prohibition Providers
may not be penalized for discussing medically necessary or appropriate
care with or on behalf of patients. Any provisions prohibiting
a provider from completely disclosing benefit coverage offered
by the MCE will be considered void. In addition. providers could
not be terminated from or denied access to the provider network
for advocating medically appropriate health care.
To ensure the foregoing protections. the Act would require all managed care entities (MCEs) to undergo certification in order to qualify as a health care insurance provider in Pennsylvania. HMOs which currently hold a certificate of authority under the "Health Maintenance Organization Act" would be exempt from obtaining a managed care plan certificate. but will be required to satisfy all other requirements of the Act. The Secretary of Health will issue a "managed care plan certificate" to all qualifying MCEs. The certificate will be valid for 3 years with renewal subject to the approval of the Secretary.