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 been scheduled:

Thursday, April 3rd

State Capitol Building Room 8E­B East Wing 10 A.M. to 3:00 P.M.

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

Forrest Ballroom

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 these hearings.

Senate Bill_100

Quality Health Care Protection Act Bill Summary

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.