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§ 991.2304-A. Contracts and coverage packages

Purdon's Pennsylvania Statutes and Consolidated StatutesTitle 40 P.S. InsuranceEffective: July 11, 2022

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: July 11, 2022
40 P.S. § 991.2304-A
Formerly cited as PA ST 40 P.S. § 991.2311
§ 991.2304-A. Contracts and coverage packages
Currentness
(a) Paid from fund.--In addition to any other requirements provided by law, the fund shall be operated in accordance with the following:
(1) The fund must be dedicated exclusively for distribution by the department through contracts in order to provide free and subsidized health care services under this article, based on an actuarially sound and adequate review, and to develop and implement outreach activities required under section 2305-A.1
(2) The fund, along with Federal, State and other funds available for the program, must be used for health care coverage for children as specified in this article. The department shall ensure that the program is implemented Statewide.
(3) The department must award contracts paid from the fund in accordance with the following:
(i) All contracts awarded under this subsection must be awarded through a competitive procurement process. The department and the Insurance Department must use their best efforts to ensure that eligible children across this Commonwealth have access to health care services to be provided under this article.
(ii) No more than 10% of the amount of the contract may be used for administrative expenses of the contractor. If a contractor presents documented evidence that administrative expenses for purposes of expanded outreach and systems and operational changes are in excess of 10% of the amount of the contract, the department shall make an additional allotment of funds, not to exceed 2% of the amount of the contract, to the contractor to the extent that the department finds the expenses reasonable and necessary.
(iii) At least 84% of the amount of the contract shall be used to provide health care services for children eligible for care under this article.
(iv) In determining the amount of the contract which may be used for the purposes specified in subparagraphs (ii) and (iii), any Federal and State taxes that would be deducted from premium revenue in determining an issuer's medical loss ratio under 45 CFR 158.221 (relating to formula for calculating an issuer's medical loss ratio), including a managed care organization assessment imposed on a contractor under the act of June 13, 1967 (P.L. 31, No. 21),2 known as the Public Welfare Code, shall be excluded.
(b) Solicitation of contracts.--The department must solicit bids and award contracts through a competitive procurement process in accordance with the following:
(1) To the fullest extent practicable, contracts shall be awarded to insurers that contract with providers to provide primary care services for enrollees on a cost-effective basis. The department shall require contractors to use appropriate cost-management methods so that basic primary coverage services can be provided to the maximum number of eligible children and, if possible, to pursue and utilize available public and private funds.
(2) To the fullest extent practicable, the department must require that a contractor comply with all procedures relating to coordination of health care services as required by the department or the Insurance Department. The following apply:
(i) The department may not develop or utilize bidding or service zones that limit a health service corporation or hospital plan corporation contractor from submitting a bid.
(ii) If a health service corporation or hospital plan corporation is only able to service certain counties in this Commonwealth, the department shall solicit and accept bids from any health service corporation or hospital plan corporation for those counties in which it provides services.
(iii) The department may not exclude or limit a health service corporation or hospital plan corporation from submitting a bid to service a county in this Commonwealth.
(3) Contracts may be for a term of up to three years, with the option to extend for two one-year periods.
(c) Bidding.--Upon receipt of a solicitation from the department, each health service corporation and hospital plan corporation shall directly, or at the corporation's discretion through their affiliated entities doing business in this Commonwealth, submit a bid or proposal to the department to carry out the purposes of this article in the area serviced by the corporation. If a health service corporation or hospital plan corporation directly submits a bid or proposal, the bid or proposal shall be for those counties in which it is permitted to offer its products.
(d) Bidding by other insurers.--All other insurers may submit a bid or proposal to the department to carry out the purposes of this article.
(e) Duties of contractor.--A contractor with whom the department enters into a contract shall do the following:
(1) Ensure to the maximum extent possible that eligible children have access to primary health care physicians and nurse practitioners within the contractor's service area.
(2) Contract with qualified, cost-effective providers, which may include primary health care physicians, nurse practitioners, clinics and HMOs, to provide primary and preventive health care for enrollees on a basis best calculated to manage the costs of the services, including, but not limited to, using managed health care techniques and other appropriate medical cost-management methods.
(3) Ensure that the family of a child who may be eligible for medical assistance receives assistance in applying for medical assistance.
(4) Maintain waiting lists of children financially eligible for coverage who have applied for coverage but who were not enrolled due to lack of funds.
(5) Notify families of children who are paying a premium of any changes in such premium or copayment requirements.
(6) Collect premiums or copayments from the family of a child receiving coverage as may be required.
(7) Cancel coverage for nonpayment of premium, in accordance with all applicable insurance laws.
(8) Strongly encourage all providers who provide primary care to eligible children to participate in medical assistance as qualified EPSDT providers and to continue to provide care to children who become ineligible for coverage under the provisions of this article but who qualify for medical assistance.
(9) Subject to any necessary Federal approval, provide the following minimum coverage package, which may not conflict with Federal law, regulation or guidance, for eligible children:
(i) Preventive care. This subparagraph shall include:
(A) Well-child care visits in accordance with the schedule established by the American Academy of Pediatrics and the services related to the visits, including immunizations, health education, tuberculosis testing and developmental screening in accordance with the routine schedule of well-child care visits.
(B) A comprehensive physical examination, including X-rays if necessary, for any child exhibiting symptoms of possible child abuse.
(ii) Diagnosis and treatment of illness or injury, including all medically necessary services related to the diagnosis and treatment of sickness and injury and other conditions provided on an ambulatory basis, such as laboratory tests, wound dressing and casting to immobilize fractures.
(iii) Injections and medications provided at the time of the office visit or therapy and outpatient surgery performed in the office, a hospital or freestanding ambulatory service center, including anesthesia provided in conjunction with such service or during emergency medical service.
(iv) Emergency accident and emergency medical care.
(v) Prescription drugs.
(vi) Emergency, preventive and routine dental care. This subparagraph does not include orthodontia or cosmetic surgery.
(vii) Emergency, preventive and routine vision care, including the cost of corrective lenses and frames, not to exceed two prescriptions per year.
(viii) Emergency, preventive and routine hearing care.
(ix) Inpatient hospitalization.
(10) The department may implement a premium assistance program permitted under Federal regulations and as permitted through Federal waiver or State plan amendment made pursuant to this article. Notwithstanding any other law to the contrary, if it is more cost effective to purchase health care from a parent's employer-based program and the employer-based program meets the minimum coverage requirements, employer-based coverage may be purchased in place of enrollment in the children's health insurance program established under this article. An insurer must honor a request for enrollment and purchase of employee group health insurance requested on behalf of an individual applying for coverage under this chapter if the individual:
(i) is a resident of this Commonwealth;
(ii) is qualified based on income under section 2302-A;3 and
(iii) meets the citizenship requirements of section 2302-A(c)(1)(iv).
(11) The department shall have the authority to review, audit and approve annual administrative expenses incurred by contractors under this section.
(12) Except for children covered under paragraph (10), each contractor shall provide a coverage identification card to each eligible child covered under contracts executed under this article. The card must not specifically identify the holder as low income.
(f) Waiver of minimum.--The department may grant a waiver of the minimum coverage package of subsection (e)(9) upon demonstration by the applicant that the applicant is providing health care services for eligible children that meet the purposes and intent of this article.
(g) Review.--
(1) The department, in consultation with appropriate Commonwealth agencies, shall review enrollment patterns for both the free coverage program and the subsidized coverage program. The department shall consider the relationship, if any, among enrollment, enrollment fees, income levels and family composition.
(2) Based on the results of this study and the availability of funds, the department may adjust the maximum income ceiling for free coverage and the maximum income ceiling for subsidized coverage by regulation. The maximum income ceiling for free coverage may not be raised above 200% of the Federal poverty level.
(h) Limit.--Notwithstanding subsection (g) and subject to section 2307-A,4 the maximum income ceiling for subsidized coverage under section 2302-A(d)(2), (3) or (4) may not be raised above 300% of the Federal poverty level.

Credits

1921, May 17, P.L. 682, No. 284, art. XXIII-A, § 2304-A, added 2015, Dec. 20, P.L. 461, No. 84, § 3, imd. effective. Amended 2022, July 11, P.L. 1618, No. 94, § 1, imd. effective.
<See 40 P.S. § 991.2309-A for expiration of Article XXIII-A.>

Footnotes

1
40 P.S. § 991.2305-A.
2
62 P.S. § 101 et seq.
3
40 P.S. § 991.2302-A.
4
40 P.S. § 991.2307-A.
40 P.S. § 991.2304-A, PA ST 40 P.S. § 991.2304-A
Current through Act 10 of the 2024 Regular Session. Some statute sections may be more current, see credits for details.
End of Document