2023 Pennsylvania Consolidated & Unconsolidated Statutes › Title 35 - HEALTH AND SAFETY › Chapter 33 - Health Care Cost Containment › Section 3302 - Definitions

§ 3302. Definitions.
The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise:
"Ambulatory service facility."
A facility licensed in this Commonwealth which is not part of a hospital and which provides medical, diagnostic or surgical treatment to patients not requiring hospitalization, including ambulatory surgical facilities, ambulatory imaging or diagnostic centers, birthing centers, freestanding emergency rooms and any other facilities providing ambulatory care which charge a separate facility charge. The term does not include the offices of private physicians or dentists, whether for individual or group practices.
"Charge"
or
"rate."
The amount billed by a provider for specific goods or services provided to a patient, prior to any adjustment for contractual allowances.
"Council."
The Health Care Cost Containment Council.
"Covered services."
Any health care services or procedures connected with episodes of illness or injury that require either inpatient hospital care or major ambulatory service, including any initial and follow-up outpatient services associated with the episode of illness or injury before, during or after inpatient hospital care or major ambulatory service. The term does not include routine outpatient services connected with episodes of illness that do not require hospitalization or major ambulatory service.
"Data."
Data collected by the council under section 3305 (relating to data submission and collection). The term includes raw data.
"Data source."
The term includes a provider.
"Health care facility."
A general or special hospital, including:
(1) Psychiatric hospitals.
(2) Kidney disease treatment centers, including freestanding hemodialysis units.
(3) Ambulatory service facilities.
(4) Hospices, including hospices operated by an agency of State or local government.
"Health care insurer."
As follows:
(1) A person, corporation or other entity that offers administrative, indemnity or payment services for health care in exchange for a premium or service charge under a program of health care benefits, including, but not limited to:
(i) An insurance company, association or exchange issuing health insurance policies in this Commonwealth governed by the act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921.
(ii) A hospital plan corporation as defined in 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations).
(iii) A professional health service corporation as defined in 40 Pa.C.S. Ch. 63 (relating to professional health services plan corporations).
(iv) A health maintenance organization governed by the act of December 29, 1972 (P.L.1701, No.364), known as the Health Maintenance Organization Act.
(v) A third-party administrator governed by Article X of the act of May 17, 1921 (P.L.789, No.285), known as The Insurance Department Act of 1921.
(2) The term does not include:
(i) Employers, labor unions or health and welfare funds jointly or separately administered by employers or labor unions that purchase or self-fund a program of health care benefits for their employees or members and their dependents.
(ii) The following types of insurance or any combination thereof:
(A) Accident only.
(B) Fixed indemnity.
(C) Hospital indemnity.
(D) Limited benefit.
(E) Credit.
(F) Dental.
(G) Vision.
(H) Specified disease.
(I) Medicare supplement.
(J) Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement.
(K) Long-term care or disability income.
(L) Workers' compensation.
(M) Automobile medical payment insurance.
"Health maintenance organization."
An organized system which combines the delivery and financing of health care and which provides basic health services to voluntarily enrolled subscribers for a fixed prepaid fee, as defined in the Health Maintenance Organization Act.
"Hospital."
An institution licensed in this Commonwealth which is:
(1) A general, mental, chronic disease or other type of hospital.
(2) A kidney disease treatment center, including kidney disease treatment centers operated by an agency of State or local government.
"Major ambulatory service."
Surgical or medical procedures, including diagnostic and therapeutic radiological procedures, commonly performed in hospitals or ambulatory service facilities, which are not of a type commonly performed, or which cannot be safely performed, in physicians' offices and which require special facilities such as operating rooms or suites or special equipment such as fluoroscopic equipment or computed tomographic scanners, or a postprocedure recovery room or short-term convalescent room.
"Medical procedure incidence variations."
The variation in the incidence in the population of specific medical, surgical and radiological procedures in any given year, expressed as a deviation from the norm, as these terms are defined in the classical statistical definition of "variation," "incidence," "deviation" and "norm."
"Payment."
The payments that providers actually accept for their services, exclusive of charity care, rather than the charges they bill.
"Payor."
Any person or entity, including, but not limited to, health care insurers and purchasers, that make direct payments to providers for covered services.
"Physician."
An individual licensed under the laws of this Commonwealth to practice medicine and surgery within the scope of the act of October 5, 1978 (P.L.1109, No.261), known as the Osteopathic Medical Practice Act, or the act of December 20, 1985 (P.L.457, No.112), known as the Medical Practice Act of 1985.
"Preferred provider organization."
Any arrangement between a health care insurer and providers of health care services which specifies rates of payment to such providers which differ from their usual and customary charges to the general public and which encourages enrollees to receive health services from such providers.
"Provider."
A hospital, a health care facility, an ambulatory service facility or a physician.
"Provider quality."
The extent to which a provider renders care that, within the capabilities of modern medicine, obtains for patients medically acceptable health outcomes and prognoses, adjusted for patient severity, and treats patients compassionately and responsively.
"Provider service effectiveness."
The effectiveness of services rendered by a provider, determined by measurement of the medical outcome of patients grouped by severity receiving those services.
"Purchaser."
Corporations, labor organizations or other entities that purchase benefits which provide covered services for their employees or members, either through a health care insurer or by means of a self-funded program of benefits, and a certified bargaining representative that represents a group or groups of employees for whom employers purchase a program of benefits which provide covered services, but excluding any entity defined in this section as a "health care insurer."
"Severity."
In any patient, the measureable degree of the potential for failure of one or more vital organs.
Cross References.
Section 3302 is referred to in section 3305 of this title.