[full text available at http://www.legis.state.pa.us/WU01/LI/BI/BT/1997/0/SB0100P2003.HTM] PA Act 68, AKA SB 100 of 1997 THE GENERAL ASSEMBLY OF PENNSYLVANIA SENATE BILL No. 100 Session of 1997 INTRODUCED BY MURPHY, WILLIAMS, JUBELIRER, LOEPER, BRIGHTBILL, RHOADES, HECKLER, HELFRICK, STAPLETON, KUKOVICH, GERLACH, TOMLINSON, KITCHEN, STOUT, ULIANA, HART, AFFLERBACH, EARLL, SALVATORE, SCHWARTZ, BODACK, WHITE, O'PAKE, COSTA, THOMPSON, WOZNIAK, CORMAN, BELAN, SLOCUM, WAGNER, LaVALLE, KASUNIC AND CONTI, FEBRUARY 25, 1997 AS AMENDED ON THIRD CONSIDERATION, HOUSE OF REPRESENTATIVES, MAY 6, 1998 AN ACT Providing for access by enrollees of managed care health benefits plans to health care services AND FOR DUTIES OF THE BUREAU OF DRUG AND ALCOHOL PROGRAMS; specifying certain standards relating to financial incentive programs of managed care plans; prohibiting managed care plans from restricting providers from disclosing appropriate health care information to enrollees; specifying certain standards of managed care plans relating to emergency services, termination of contracts and confidentiality; PROVIDING FOR GRIEVANCE PROCEDURES, FOR APPEALS OF DENIAL OF SERVICES, FOR CONSCIENCE PROTECTION AND FOR HEARING AID COVERAGE; requiring certain disclosures to enrollees of managed care plans AND FOR PRIOR APPROVAL OF DEPARTMENT FOR CERTAIN CONTRACTUAL LANGUAGE; and PROVIDING FOR COST CONTAINMENT AND LOSS RATIOS, FOR REIMBURSEMENT FOR DIABETIC SUPPLIES, FOR MEDICAID PHARMACY SERVICES, FOR WORKERS' COMPENSATION SERVICES AND FOR CONSUMER INFORMATION; EXTENDING THE POWERS AND DUTIES OF THE OFFICE OF CONSUMER ADVOCATE; MAKING AN APPROPRIATION; imposing penalties; AND MAKING REPEALS. TABLE OF CONTENTS Section 1. Short title. Section 2. Declaration of policy. Section 3. Definitions. Section 4. Access to services. SECTION 5. DUTIES OF BUREAU OF DRUG AND ALCOHOL PROGRAMS. SECTION 6. PROMPT PAYMENT OF CLEAN CLAIMS. SECTION 7. FINANCIAL INCENTIVES. SECTION 8. MEDICAL GAG CLAUSE PROHIBITION. SECTION 9. EMERGENCY SERVICES. SECTION 10. CONTINUITY OF CARE. SECTION 11. CONFIDENTIALITY. SECTION 12. GRIEVANCE PROCEDURES. SECTION 13. APPEAL OF DENIAL OF SERVICES. SECTION 14. CONSCIENCE PROTECTION. SECTION 15. MENTAL HEALTH NONDISCRIMINATION. SECTION 16. HEARING AID COVERAGE. SECTION 17. PRIOR APPROVAL. SECTION 18. DISCLOSURE. SECTION 19. MEDICAID PHARMACY SERVICES. SECTION 20. REIMBURSEMENT FOR DIABETIC SUPPLIES. SECTION 21. COST CONTAINMENT; LOSS RATIOS. SECTION 22. MANAGED CARE PLAN LIABILITY. SECTION 23. CERTAIN ARRANGEMENTS PROHIBITED. SECTION 24. OFFICE OF CONSUMER ADVOCATE. SECTION 25. CONSUMER INFORMATION. SECTION 26. COMPLIANCE WITH ACT. SECTION 27. PENALTIES. SECTION 28. CONSTRUCTION WITH FEDERAL LAW. SECTION 29. APPLICABLE STATE LAW. SECTION 30. RULES AND REGULATIONS. SECTION 31. WORKERS' COMPENSATION SERVICES, POLICIES OR PRODUCTS. SECTION 32. EFFECTIVE DATE. The General Assembly of the Commonwealth of Pennsylvania hereby enacts as follows: Section 1. Short title. This act shall be known and may be cited as the Quality Health Care Protection Act. Section 2. Declaration of policy. The General Assembly finds and declares as follows: (1) It is a fundamental concern that the people of this Commonwealth have access to quality and affordable health care. (2) It is essential that health care decisions are based solely on the health care needs of the individual. [snip] "EMERGENCY MEDICAL CONDITION." Health care services, INCLUDING MEDICAL AND TRANSPORTATION SERVICES PROVIDED BY A LICENSED AMBULANCE SERVICE, provided after the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (1) placing the health of the individual, or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. "EMERGENCY SERVICES." ALL HEALTH CARE SERVICES, BOTH INPATIENT AND OUTPATIENT, THAT ARE: (1) FURNISHED BY A PROVIDER THAT IS QUALIFIED TO FURNISH SUCH SERVICES UNDER THIS ACT; AND (2) NEEDED TO EVALUATE OR STABILIZE AN EMERGENCY MEDICAL CONDITION. [snip] Section 4. Access to services. A managed care plan shall: (1) Assure both availability and accessibility of adequate personnel and facilities in a timely manner AND WITHIN A REASONABLE DISTANCE enhancing availability, accessibility and continuity of services. (2) Ensure that emergency services are a covered benefit 24 hours a day, seven days a week and provide reasonable payment or reimbursement for emergency services. [snip] Section 9. Emergency services. A MANAGED CARE PLAN SHALL PROVIDE THAT IN THE EVENT AN ENROLLEE SEEKS EMERGENCY SERVICES, THE EMERGENCY PROVIDER SHALL INITIATE NECESSARY INTERVENTION TO EVALUATE OR STABILIZE THE CONDITION OF THE ENROLLEE WITHOUT SEEKING OR RECEIVING AUTHORIZATION FROM THE MANAGED CARE PLAN. THE MANAGED CARE PLAN SHALL PAY FOR ALL REASONABLY NECESSARY COSTS ASSOCIATED WITH THE EMERGENCY SERVICES PROVIDED DURING THE PERIOD OF THE EMERGENCY. AN ENROLLEE MAY BE TRANSFERRED IF, IN THE OPINION OF THE EMERGENCY HEALTH CARE PROVIDER, WITHIN REASONABLE MEDICAL PROBABILITY NO MATERIAL DETERIORATION IS LIKELY TO RESULT FROM OR OCCUR DURING THE TRANSFER OF THE ENROLLEE FROM THE FACILITY. [snip] Section 32. Effective date. THIS ACT SHALL TAKE EFFECT AS FOLLOWS: (1) SECTIONS 5 AND 17 SHALL TAKE EFFECT IN 60 DAYS. (2) SECTION 19 SHALL TAKE EFFECT IN 120 DAYS. (3) THIS SECTION SHALL TAKE EFFECT IMMEDIATELY. (4) THE REMAINDER OF THIS ACT SHALL TAKE EFFECT JANUARY 1, 1999.