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§ 991.2302-A. Children's health care

Purdon's Pennsylvania Statutes and Consolidated StatutesTitle 40 P.S. InsuranceEffective: December 20, 2015

Purdon's Pennsylvania Statutes and Consolidated Statutes
Title 40 P.S. Insurance (Refs & Annos)
Chapter 2. Insurance Companies (Refs & Annos)
Article XXIII-a. Comprehensive Health Care for Uninsured Children (Refs & Annos)
Effective: December 20, 2015
40 P.S. § 991.2302-A
Formerly cited as PA ST 40 P.S. § 991.2311
§ 991.2302-A. Children's health care
Currentness
(a) Federal funds.--Notwithstanding any other provision of law, the department shall ensure the receipt of Federal financial participation under Title XXI1 for services provided under this chapter.
(b) General care.--To ensure that inpatient hospital care is provided to eligible children, each primary care provider furnishing primary care services shall make necessary arrangements for admission to the hospital and for necessary specialty care.
(c) Enrollment.--Subject to the provisions of section 2304-A,2 an insurer receiving funds from the department to provide coverage of health care services under this section shall enroll, to the extent that funds are available, any child who meets all of the following:
(1) Is a resident of this Commonwealth.
(2) Is not:
(i) Covered by a health insurance plan.
(ii) Covered by a self-insurance plan.
(iii) Covered by a self-funded plan.
(iv) Provided access to health care coverage by court order.
(v) Eligible for or covered by a medical assistance program administered by the department, including the Healthy Beginnings Program.
(3) Is qualified based on income under subsections (d) and (e).
(4) Meets the citizenship requirements of Title XXI.
(d) Income levels.--The provision of health care insurance for eligible children shall be in accordance with the following:
(1) Free to a child whose family income is no greater than 200% of the Federal poverty level.
(2) May be subsidized by the fund at a rate not to exceed 75% of the per member per month premium cost for a child whose family income is greater than 200% of the Federal poverty level but not greater than 250% of the Federal poverty level.
(3) May be subsidized by the fund at a rate not to exceed 65% of the per member per month premium cost for a child whose family income is greater than 250% of the Federal poverty level but not greater than 275% of the Federal poverty level.
(4) May be subsidized by the fund at a rate not to exceed 60% of the per member per month premium for a child whose family income is greater than 275% of the Federal poverty level but not greater than 300% of the Federal poverty level.
(5) Notwithstanding paragraphs (1), (2), (3) and (4), for purposes of determining cost-sharing obligations of a family with income levels specified under paragraphs (2), (3) and (4), the per member per month premium shall exclude the cost related to an assessment imposed on a contractor relating to managed care organization assessments under the act of June 13, 1967 (P.L. 31, No. 21),3 known as the Public Welfare Code.
(e) Income exceeding limits.--The following apply:
(1) For an eligible child whose family income is greater than the maximum level established under section 2304-A(h), the family may purchase the minimum coverage package under 2304-A(e)(9) for that child at the per member per month premium cost. The cost shall be derived separately from the other eligibility categories in the program. The family may purchase the minimum coverage package if the family demonstrates on an annual basis and in a manner determined by the department that the family is unable to afford individual or group coverage because of one of the following reasons:
(i) The coverage would exceed 10% of the family income.
(ii) The total cost of coverage for the child is 150% of the greater of:
(A) the premium cost established under this subsection for that service area; or
(B) the premium cost established under the program for that service area.
(2) For purposes of this subsection, the per member per month premium cost shall exclude the cost related to the managed care organization assessment imposed on a contractor under the Public Welfare Code.
(3) For purposes of this subsection, the term “coverage” may not include coverage offered through accident only, fixed indemnity, limited benefit, credit, dental, vision, specified disease, Medicare supplement, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement, long-term care or disability income, workers' compensation or automobile medical payment insurance.
(f) Powers and duties.--
(1) For enrollees under subsection (d)(2), (3) or (4) or (e), the following apply:
(i) The department may impose copayments for the following services, except as otherwise prohibited by law:
(A) Outpatient visits.
(B) Emergency room visits.
(C) Prescription medications.
(D) Any other service defined by the department.
(ii) The department may establish and adjust the levels of these copayments in order to impose reasonable cost sharing and to encourage appropriate utilization of these services. The premiums and copayments for enrollees under subsection (d)(2), (3) or (4) may not amount to more than the percent of total household income which is in accordance with the requirements of the Centers for Medicare and Medicaid Services.
(2) The department shall:
(i) Administer the children's health insurance program in accordance with this chapter.
(ii) Review all bids and approve and execute all contracts for the purpose of expanding access to health care services for eligible children as provided for in this article.
(iii) Conduct monitoring and oversight of contracts.
(iv) Issue an annual report to the Governor, the General Assembly and the public for each calendar year no later than March 1 of each year providing for the following:
(A) The primary health services funded for the year.
(B) The outreach and enrollment efforts and the number of children by county and by percent of the Federal poverty level who are receiving health care services.
(C) The projected number of eligible children by county and by percent of the Federal poverty level.
(D) The number of eligible children on waiting lists for enrollment in the children's health insurance program established under this article by county and by percent of the Federal poverty level.
(E) The details of the department's efforts on the implementation of express lane eligibility.
(v) In consultation with appropriate Commonwealth agencies, coordinate the development and supervision of the outreach plan required under section 2305-A.4
(vi) In consultation with appropriate Commonwealth agencies, monitor, review and evaluate the adequacy, accessibility and availability of services delivered to children who are enrolled in the children's health insurance program established under this article.
(vii) Enter into arrangements, including memoranda of understanding, with the Insurance Department and other appropriate Federal or State agencies, as may be necessary to carry out the department's duties under this article.
(3) The department may promulgate regulations necessary for the implementation and administration of this article.

Credits

1921, May 17, P.L. 682, No. 284, art. XXIII-A, § 2302-A, added 2015, Dec. 20, P.L. 461, No. 84, § 3, imd. effective.
<See 40 P.S. § 991.2309-A for expiration of Article XXIII-A.>

Footnotes

1
42 U.S.C.A. § 1397aa et seq.
2
40 P.S. § 991.2304-A.
3
62 P.S. § 101 et seq.
4
40 P.S. § 991.2305-A.
40 P.S. § 991.2302-A, PA ST 40 P.S. § 991.2302-A
Current through Act 10 of the 2024 Regular Session. Some statute sections may be more current, see credits for details.
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