Pennsylvania Statutes Title 35 P.S. Health and Safety § 5701.1303. Adult basic coverage insurance program
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(a) Program establishment.--There is established in the department an adult basic coverage insurance program. Fund appropriations to the department for the program shall be used for contracts to provide basic health care insurance for eligible adults and outreach activities. The department shall, to the greatest extent practicable, ensure that all eligible adults in this Commonwealth have access to the program established in this section.
(b) Eligible adult responsibilities.--An eligible adult seeking to purchase adult basic coverage insurance shall:
(1) Submit an application to the department.
(2) Pay to the department or its contractor an amount of $30 per month of coverage. Beginning January 1, 2003, the monthly payment amount shall be adjusted based on the annual change in the Consumer Price Index for the 12 preceding months for which data is available. Notification of any change in the monthly payment amount shall be provided to eligible adults participating in the program.
(3) Be responsible for any required copayments for health care services rendered under the benefit package in subsection (f)(2).
(4) Notify the department or its contractor of any change in the eligible adult's income.
(c) Purchase of insurance.--An eligible adult's payment to the department or its contractor under subsection (b)(2) shall be used to purchase the benefit package and shall be received in a timely manner. The appropriations for the program shall be used by the department to pay the difference between the premium cost of the benefit package and the eligible adult's payment. Subsidization of the benefit package is contingent upon the amount of the appropriations to the program and limited to eligible adults in compliance with subsection (b). Nothing under this section shall constitute an entitlement derived from the Commonwealth or a claim on any funds of the Commonwealth.
(d) Potential waiting list.--The department shall maintain a waiting list of eligible adults who have applied for adult basic coverage insurance but who are not enrolled due to insufficient appropriations. An eligible adult on the waiting list may purchase the benefit package at the monthly per member premium cost negotiated by the department.
(e) Department responsibilities.--The department shall:
(1) Administer the adult basic coverage insurance program on a Statewide basis.
(2) Enter into contracts for health care insurance in accordance with 62 Pa.C.S. (relating to procurement). The department may award contracts on a multiple award basis.
(3) Conduct monitoring, oversight and audits of executed contracts for enforcement purposes.
(4) Ensure that the eligibility of enrolled individuals receiving subsidization of the benefit package is redetermined on an annual basis.
(5) In consultation with appropriate Commonwealth agencies, monitor, review and evaluate the insurer's benefit package for the adequacy, accessibility and availability of the services required under subsection (f).
(6) In consultation with appropriate Commonwealth agencies, establish and coordinate the development, implementation and supervision of an outreach plan.
(7) Prepare and submit, by November 30, 2002, and annually thereafter a report to the chair and minority chair of the Banking and Insurance Committee of the Senate and to the chair and minority chair of the Insurance Committee of the House of Representatives regarding the number of eligible adults purchasing the adult basic coverage insurance, with a geographic distribution; the insurers participating in the program; the scope of the services being provided, the level of outreach; the cost of the insurance; and the amount an eligible adult contributes toward the insurance, including any copayments and adjustments due to the Consumer Price Index adjustment factor under subsection (b)(2). The annual report shall be made available for public inspection and posted on the department's publicly accessible World Wide Web site.
(f) Request for proposals.--In accordance with subsection (e)(2), the department shall issue a request for proposals for the adult basic coverage insurance. The request shall require:
(1) An offeror to assure that if selected as a contractor it will do all of the following:
(i) Ensure that eligible adults have access to primary health care physicians and nurse practitioners.
(ii) Contract with qualified, cost-effective providers, which may include primary health care physicians, nurse practitioners, clinics and health maintenance organizations, to provide health care for eligible adults in a manner that best manages the costs of the services and utilizes other appropriate medical cost-management methods.
(iii) Ensure that the individual applying for coverage is an eligible adult. If a review of the individual's application for coverage indicates that the individual is not eligible for adult basic coverage insurance but may be eligible for medical assistance, the application for benefits and all accompanying documentation shall be promptly transmitted to the appropriate county assistance office for a determination of eligibility for medical assistance or other Federal, State and local resources available to the individual.
(iv) Not prohibit enrollment based upon a preexisting condition nor exclude a diagnosis or treatment for the condition based on the condition's preexistence.
(v) Provide the benefit package to eligible adults consistent with the scope and duration requirements of the request for proposals.
(vi) Provide an insurance identification card to each eligible adult covered under a contract executed under this section. The card shall not identify the eligible adult as low income.
(vii) Require each primary care physician providing primary care services under this section to make necessary arrangements for admission to hospitals and for necessary specialty care.
(viii) Not pay any claim on behalf of an eligible adult unless all other Federal, State and local resources are first utilized.
(2) A benefit package with scope and duration determined by the department that includes:
(i) Preventive care.
(ii) Physician services.
(iii) Diagnosis and treatment of illness or injury, including all medically necessary covered services related to the diagnosis and treatment of sickness and injury and other conditions provided on an ambulatory basis, such as laboratory tests, x-rays, wound dressing and casting to immobilize fractures.
(iv) Inpatient hospitalization.
(v) Outpatient hospital services.
(vi) Emergency accident and emergency medical care.
(g) Proposals.--Upon publication of a request for proposals, an entity and its subsidiaries that operate subject to the provisions of 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63 1 (relating to professional health services plan corporations), or both, shall submit a proposal to the department to carry out the purposes of this section. Upon publication of a request for proposals, an insurer doing business in this Commonwealth may submit a proposal to the department to carry out the purposes of this section.
(h) Reviewing, scoring and selection of proposals.--The department shall review and score the proposals on the basis of all of the requirements for the adult basic coverage insurance program. The department may include such other criteria in the request for proposals and in the scoring and selection of the proposals that the department, in the exercise of its administrative duties under this section, deems necessary; however, the department shall:
(1) Select, to the greatest extent practicable, offerors that contract with providers to provide health care services on a cost-effective basis. The department shall select offerors that use appropriate cost-management methods that enable the program to provide coverage to the maximum number of eligible adults and that, whenever possible, pursue and utilize available public and private funds.
(2) Select, to the greatest extent practicable, only offerors that comply with all procedures relating to coordination of benefits as required by the department and the Department of Public Welfare.
(3) Select offerors that limit administrative expenses to no more than 10% of the amount of any contract. If after the first two full years of operation any contractor presents documented evidence that administrative expenses are in excess of 10% of the amount of the contract, the department may make an additional payment, not to exceed 1% of the amount of the contract, for future administrative expenses to the contractor to the extent that the department finds the expenses reasonable and necessary.
(i) Negotiations.--The department shall not negotiate a contract for a period in excess of three years.
(j) Limitation.--In no case shall the total aggregate amount of annual contracts entered into pursuant to this section exceed the amount of the aggregate annual appropriations to the department for the adult basic coverage insurance program.
Cite this article: FindLaw.com - Pennsylvania Statutes Title 35 P.S. Health and Safety § 5701.1303. Adult basic coverage insurance program - last updated January 01, 2022 | https://codes.findlaw.com/pa/title-35-ps-health-and-safety/pa-st-sect-35-5701-1303.html
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