reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 242 - MEDICAL PROFESSIONAL LIABILITY CATASTROPHE LOSS FUND › Section 242.19 - Investment transactions

Current through Register Vol. 54, No. 28, July 13, 2024
For the purposes of investing funds generated by the
				  operations of the Fund, and only for investment purposes, the Director will
				  cause all investments now owned in the name of the Fund and hereafter purchased
				  by the Fund under section 1 of the act of April 25, 1929 (P. L. 723, No. 315)
				  (72
				  P. S. §
										3603) to be held in the
				  shortened name of "Medcat & Co." Such name will constitute the sole name
				  under which the Director may invest funds. The Director will give notice to all
				  parties with whom he deals in pursuit of his investment responsibilities, by
				  citation of this section, of the existence of the Fund as the real party in
				  interest in Medcat & Co. transactions.
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 242 - MEDICAL PROFESSIONAL LIABILITY CATASTROPHE LOSS FUND › Section 242.20 - Formal and informal complaints; procedure

Current through Register Vol. 54, No. 28, July 13, 2024
Under 1 Pa. Code §
									31.1 (relating to scope of part),
				  1 Pa. Code Part II (relating to general rules of administrative practice and
				  procedure) is applicable to the activities of and proceedings before the fund.
				  These provisions will govern the procedure to be followed in handling formal
				  and informal complaints addressed to the Fund.
The provisions of this §
											242.20 issued under sections 206
					 and 506 of The Administrative Code of 1929 (71 P. S. §§
												66 and
					 186); section 701(e)(4) of
					 the Health Care Services Malpractice Act (40 P. S. §
												1301.701(e)(4)); and
					 2
					 Pa.C.S. §
												102(a).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 243 - MEDICAL MALPRACTICE AND HEALTH-RELATED SELF-INSURANCE PLANS › Section 243.1 - Purpose

Current through Register Vol. 54, No. 28, July 13, 2024
The purposes of this chapter are to provide a procedure for
				  the approval of self-insurance plans, provide for the orderly transition
				  between commercial insurance and self-insurance that provides continuous and
				  adequate protection, encourage effective risk management in order to enhance
				  patient care, and provide for adequate funding by a health care provider,
				  thereby enhancing prompt payment of claims of those persons that may avail
				  themselves of the services provided by the health care
				  provider.
The provisions of this §
											243.1 amended under The Insurance
					 Department Act of 1921 (40 P.S. §§
												1-321); The Insurance Company Law of 1921
					 (40
					 P.S. §§
												341-991); and sections 206,
					 506, 1501 and 1502 of The Administrative Code of 1929 (71 P.S.
					 §§
												66,
					 186,
					 411 and
					 412); and the Health Care
					 Services Malpractice Act (40 P.S. §§
												1301.101-1301.1006).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 243 - MEDICAL MALPRACTICE AND HEALTH-RELATED SELF-INSURANCE PLANS › Section 243.4 - Reporting requirements for self-insurance plans

Current through Register Vol. 54, No. 28, July 13, 2024
A health care provider with an approved self-insurance plan
				  shall report to the Commissioner not later than 6 months following the end of
				  the hospital's fiscal year the experience of the prior fiscal year. The reports
				  shall include the following:
(1) A
				certificate of acceptable audit of the self-insurance trust fund by a certified
				public accountant (CPA) and a copy of the CPA report.
(2) A balance sheet, an income and expense
				exhibit and other financial exhibits which the Commissioner may
				require.
(3) A comprehensive report
				of the risk management program of the self-insurance plan. A provider may
				substitute the proof of current 3-year accreditation by the Joint Commission on
				Accreditation of Hospitals and the current Department of Health audit showing a
				satisfactory status in place of the comprehensive report.
(4) Other information as the Commissioner may
				reasonably request.
The provisions of this §
											243.4 amended under The Insurance
					 Department Act of 1921 (40 P. S. §§
												1-321); The Insurance Company Law of 1921
					 (40
					 P. S. §§
												341-991); and sections
					 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
					 §§
												66,
					 186,
					 411 and
					 412); and the Health Care
					 Services Malpractice Act (40 P. S. §§
												1301.101-1301.1006).
This section cited in 31 Pa. Code §
											243.3 (relating to standards for
					 self-insurance plans).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 243 - MEDICAL MALPRACTICE AND HEALTH-RELATED SELF-INSURANCE PLANS › Section 243.5 - Approval of risk management plan by Commissioner

Current through Register Vol. 54, No. 28, July 13, 2024
An insurance company, entity, association or other unit
				  desiring to gain approval of a plan of risk management to which health care
				  providers may subscribe in fulfillment of the requirements under this chapter
				  shall submit the plan to the Commissioner for approval. Before the Commissioner
				  will grant approval, a plan shall have the following:
(1) A complete risk management manual
				containing a detailed description of the operation of the plan.
(2) An established broad-based risk
				management committee. The committee shall at least include the risk manager,
				the chief executive officer or a designee from administration, the president of
				the medical staff or a designee who is a member of the medical staff, the
				director of nursing or a designee who is a registered nurse and a member of the
				medical records department.
(3) A
				subscription to a hospital utilization project or its equivalent.
(4) A risk management monitoring system to
				include self audits done on a scheduled basis.
(5) An operational set of medical staff
				bylaws approved by the Joint Commission on Accreditation of Hospitals or the
				Department of Health.
The provisions of this §
											243.5 amended under The Insurance
					 Department Act of 1921 (40 P. S. §§
												1-321); The Insurance Company Law of 1921
					 (40
					 P. S. §§
												341-991); and sections
					 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
					 §§
												66,
					 186,
					 411 and
					 412); and the Health Care
					 Services Malpractice Act (40 P. S. §§
												1301.101-1301.1006).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 243 - MEDICAL MALPRACTICE AND HEALTH-RELATED SELF-INSURANCE PLANS › Section 243.6 - Standards for institutional plan of risk management for hospitals and nursing homes

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A hospital
				plan of risk management shall provide for certification by the management to be
				made to the Commissioner of satisfactory compliance with the following:
(1) The Medical Practice Act of 1985
				(63
				P. S. §§
											422.1-422.45), the
				Osteopathic Medical Practice Act (63 P. S. §§
											271.1-271.18) or the Podiatry Practice Act
				(63
				P. S. §§
											42.1-42.21c).
(2) The provisions for professional standards
				review in section 1160 of the Social Security Act (42 U.S.C.A. §
											1320c-9).
(3) A 3-year accreditation by the Joint
				Commission on Accreditation of Hospitals.
(4) The continuing education requirements of
				the Pennsylvania Medical Society, the Pennsylvania Osteopathic Medical
				Association, the Pennsylvania Podiatry Association or their
				equivalent.
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 243 - MEDICAL MALPRACTICE AND HEALTH-RELATED SELF-INSURANCE PLANS › Section 243.7 - Standards for noninstitutional plan of risk management

Current through Register Vol. 54, No. 28, July 13, 2024
For noninstitutional plans of risk management, §
									243.6 (relating to standards for
				  institutional plan of risk management for hospitals and nursing homes) applies,
				  except for subsection (a)(3).
The provisions of this §
											243.7 amended under The Insurance
					 Department Act of 1921 (40 P. S. §§
												1-321); The Insurance Company Law of 1921
					 (40
					 P. S. §§
												341-991); and sections
					 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
					 §§
												66,
					 186,
					 411 and
					 412); and the Health Care
					 Services Malpractice Act (40 P. S. §§
												1301.101-1301.1006).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 243 - MEDICAL MALPRACTICE AND HEALTH-RELATED SELF-INSURANCE PLANS › Section 243.9 - Government plan for self-insurance

Current through Register Vol. 54, No. 28, July 13, 2024
A government plan of self-insurance shall meet the financial
				  standards of this chapter for a health care provider. However, the Commissioner
				  may waive the provisions of §
									243.3 (relating to standards for
				  self-insurance plans) upon satisfactory evidence that the elements of a sound
				  self-insurance plan are operational, including but not limited to the elements
				  of financial viability, claims handling capability and plan of risk
				  management.
The provisions of this §
											243.9 issued under The Insurance
					 Company Law of 1921 (40 P. S. §§
												341-991); and sections 206, 506, 1501 and
					 1502 of The Administrative Code of 1929 (71 P. S.
					 §§
												66,
					 186,
					 411 and
					 412); and the Health Care
					 Services Malpractice Act (40 P. S. §§
												1301.101-1301.1006).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 243 - MEDICAL MALPRACTICE AND HEALTH-RELATED SELF-INSURANCE PLANS › Section 243.10 - Fees and examination

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				health care provider submitting an application for approval of a self-insurance
				plan shall reimburse the Department for actual costs incurred in the
				examination or approval, or both, of the plan.
(b) The health care provider is responsible
				for reimbursing the Department for actual costs incurred in subsequent
				reexamination of the self-insurance plan. The examination may be required as
				deemed appropriate by the Commissioner.
The provisions of this §
											243.10 amended under The Insurance
					 Department Act of 1921 (40 P. S. §§
												1-321); The Insurance Company Law of 1921
					 (40
					 P. S. §§
												341-991); and sections
					 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
					 §§
												66,
					 186,
					 411 and
					 412); and the Health Care
					 Services Malpractice Act (40 P. S. §§
												1301.101-1301.1006).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 243 - MEDICAL MALPRACTICE AND HEALTH-RELATED SELF-INSURANCE PLANS › Section 243.11 - Compliance by existing self-insured hospitals

Current through Register Vol. 54, No. 28, July 13, 2024
A health care provider currently operating under an approved
				  self-insurance plan shall comply with the capitalization requirements of §
									243.3 (relating to standards for
				  self-insurance plans) by November 18, 1987. Compliance shall be attained by
				  meeting the capitalization levels set for the corresponding years the current
				  self-insurance plans have been in existence. For example, a self-insurance plan
				  approved by the Commissioner in 1986 shall have at least $200,000 in its trust
				  fund by November 18, 1987, or a plan approved in 1985 shall have at least
				  $325,000 by November 18, 1987.
The provisions of this §
											243.11 amended under The Insurance
					 Department Act of 1921 (40 P. S. §§
												1-321); The Insurance Company Law of 1921
					 (40
					 P. S. §§
												341-991); and sections
					 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
					 §§
												66,
					 186,
					 411 and
					 412); and the Health Care
					 Services Malpractice Act (40 P. S. §§
												1301.101-1301.1006).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 244 - PROFESSIONAL LIABILITY INSURERS › Section 244.1 - Required provision for professional liability policies

Current through Register Vol. 54, No. 28, July 13, 2024
A professional liability insurance policy issued or renewed
				  on or after January 1, 1978, to a health care provider, as defined in the
				  Health Care Services Malpractice Act (40 P. S. §§
										1301.101-1301.1006), in fulfillment of the
				  statutory insurance requirements under the act, shall include a provision
				  requiring insureds thereunder to subscribe to and actively participate in a
				  risk management plan sponsored by or acceptable to the insurance company and
				  the Insurance Commissioner.
The provisions of this §
											244.1 amended under The Insurance
					 Department Act of 1921 (40 P. S. §§
												1-321); The Insurance Company Law of 1921
					 (40
					 P. S. §§
												341-991); and sections
					 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
					 §§
												66,
					 186,
					 411 and
					 412); and the Health Care
					 Services Malpractice Act (40 P. S. §§
												1301.101-1301.1006).
This section cited in 31 Pa. Code §
											244.2 (relating to submission to
					 Insurance Commissioner).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 244 - PROFESSIONAL LIABILITY INSURERS › Section 244.2 - Submission to Insurance Commissioner

Current through Register Vol. 54, No. 28, July 13, 2024
The plan of risk management shall be submitted to the
				  Insurance Commissioner with the submission of the revised policy or amendatory
				  rider implementing the requirements of §
									244.1 (relating to required
				  provision for professional liability policies).
The provisions of this §
											244.2 amended under The Insurance
					 Department Act of 1921 (40 P. S. §§
												1-321); The Insurance Company Law of 1921
					 (40
					 P. S. §§
												341-991); and sections
					 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
					 §§
												66,
					 186,
					 411 and
					 412); and the Health Care
					 Services Malpractice Act (40 P. S. §§
												1301.101-1301.1006).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 244 - PROFESSIONAL LIABILITY INSURERS › Section 244.3 - Standards for institutional plan of risk management for hospitals and nursing homes

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A hospital
				plan of risk management shall provide for certification by the individual or
				entities so empowered in the plan of risk management to be made to the
				Insurance Commissioner of satisfactory compliance with the following:
(1) The Medical Practice Act of 1985
				(63
				P. S. §§
											422.1-422.45); the
				Osteopathic Medical Practice Act (63 P. S. §§
											271.1-271.18) or the Podiatry Practice Act
				(63
				P. S. §§
											42.1-42.21c).
(2) The provisions for professional standards
				review in section 1160 of the Social Security Act (42 U.S.C.A. §
											1320c-9).
(3) A 3-year accreditation by the Joint
				Commission on Accreditation of Hospitals.
(4) The continuing education requirements of
				the Pennsylvania Medical Society, the Pennsylvania Osteopathic Medical
				Association, the Pennsylvania Podiatry Association or their
				equivalent.
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 244 - PROFESSIONAL LIABILITY INSURERS › Section 244.4 - Standards for noninstitutional plan of risk management

Current through Register Vol. 54, No. 28, July 13, 2024
For noninstitutional plans of risk management, §
									244.3 (relating to standards for
				  institutional plan of risk management for hospitals and nursing homes) applies,
				  except for subsection (a)(3).
The provisions of this §
											244.4 issued under The Insurance
					 Department Act of 1921 (40 P. S. §§
												1-321); The Insurance Company Law of 1921
					 (40
					 P. S. §§
												341-991); and sections
					 206, 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
					 §§
												66,
					 186,
					 411 and
					 412); and the Health Care
					 Services Malpractice Act (40 P. S. §§
												1301.101-1301.1006).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 245 - EMERGENCY SURCHARGE › Section 245.1 - Purpose

Current through Register Vol. 54, No. 28, July 13, 2024
The purpose of this chapter is to establish uniform
				  procedures to be followed by basic coverage insurance carriers and health care
				  providers in the billing, collection and remittance of emergency surcharge
				  monies if an emergency surcharge is levied by the Commissioner under the
				  authority granted in section 701(e) of the act (40 P.S. §
										1301.701(e)).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 245 - EMERGENCY SURCHARGE › Section 245.2 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
				  have the following meanings, unless the context clearly indicates
				  otherwise:
Act
-The Health Care Services Malpractice
				  Act (40 P.S. §§
										1301.101-1301.1006).
Carrier's annual premium
-For each inforce
				  policy as of August 31 of the emergency surcharge year, the 12 month premium
				  calculated by using the rating factors for the risk as of August 31 of the
				  emergency surcharge year and applying the rates in effect as of the
				  policyholder's most recent previous annual anniversary date. If the policy has
				  a 6 month policy period, the rate is twice such rate; if the policy has a 3
				  month policy period, the rate is four times such rate. For policies of other
				  terms, the rate shall be calculated on a similar basis.
Commissioner
-The Insurance Commissioner of
				  the Commonwealth.
Department
-The Insurance Department of the
				  Commonwealth.
Emergency surcharge year
-The calendar year
				  during which the Commissioner has determined an emergency surcharge to be
				  necessary.
Fund
-The Medical Professional Liability
				  Catastrophe Loss Fund.
Inforce policy
-A policy which provides
				  basic coverage insurance to a policyholder for an incident on August 31 of the
				  emergency surcharge year. If the policy provides occurrence type coverages, the
				  policy is considered inforce if the policy includes coverage for incidents
				  occurring on August 31 of the emergency surcharge year. If the policy provides
				  claims made type coverage, the policy is considered inforce if the policy
				  includes coverage for incidents reported on August 31 of the emergency
				  surcharge year. For the purpose of determining inforce policies or
				  exposures:
(i) Expired claims made
				policies which have been endorsed with a reporting endorsement-tail
				coverage-may not constitute an inforce policy as of August 31 of the emergency
				surcharge year.
(ii) In the case of
				inforce occurence policies which have been endorsed to provide prior acts
				coverage, the prior acts portion may not constitute a part of an inforce policy
				as of August 31 of the emergency surcharge year.
Inforce self-insurance plan
-An approved
				  self-insurance plan in accordance with section 701 of the act (40 P.S. §
										1301.701) providing protection for an
				  incident occurring on August 31 of the emergency surcharge year.
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 245 - EMERGENCY SURCHARGE › Section 245.3 - Applicability

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Within 15 days
				of the date of the Commissioner's written request, the following information
				shall be reported to the Commissioner in writing:
(1) Insurance carriers writing medical
				malpractice coverage on a Pennsylvania health care provider, as defined by the
				act, shall record the policy underwriting information in sufficient detail to
				identify the individual policyholder, the inforce policy as of August 31 of
				each year and the corresponding carrier's annual premium for each
				policyholder.
(2) Each self-insured
				health care provider shall make available to the Fund sufficient details for
				the Fund to identify the Pennsylvania health care providers covered by an
				inforce self-insurance plan as of August 31 of each year.
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 245 - EMERGENCY SURCHARGE › Section 245.4 - Notice and amounts of surcharge

Current through Register Vol. 54, No. 28, July 13, 2024
If the Commissioner determines a surcharge is necessary, he
				  will publish notice of the rate of the emergency surcharge in the
Pennsylvania Bulletin
as soon as a decision to levy a
				  surcharge is made. If notice is not published on or before September 30 of the
				  emergency surcharge year, insurers and the Fund will be notified directly in
				  writing by the Department. Failure of the Department to publish a notice in the
Pennsylvania Bulletin
on or before September 30 of any year
				  may not relieve the insurer of the duty to collect and remit the surcharge
				  under this chapter.
This section cited in 31 Pa. Code §
											245.5 (relating to billing of
					 emergency surcharge).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 245 - EMERGENCY SURCHARGE › Section 245.5 - Billing of emergency surcharge

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				Each basic coverage insurance carrier shall bill its insured health care
				providers the appropriate emergency surcharge amounts within 15 days after
				notification as provided in §
									245.4 (relating to notice and
				amounts of surcharge).
(b) The Fund
				will bill self-insured health care providers the appropriate emergency
				surcharge amounts within 15 days after notification as provided in §
				245.4.
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 245 - EMERGENCY SURCHARGE › Section 245.6 - Remittance of emergency surcharge amounts

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Health care providers shall remit
				emergency surcharge payments to their insurance carrier or, in the case of
				self-insureds, directly to the Fund within 30 days of being notified of the
				amount due and payable.
(b) By
				December 1, the carrier shall remit to the Fund emergency surcharge amounts
				received to date. By December 15, the carrier shall remit to the Fund emergency
				surcharge amounts received from December 1 to December 15. Thereafter, the
				carrier shall remit to the Fund emergency surcharge amounts received on or
				after December 15 in accordance with the monthly reporting relationship
				established with the Fund under §
									242.6 (relating to reporting forms
				and procedures).
This section cited in 31 Pa. Code §
											245.7 (relating to reporting
					 forms); and 31 Pa. Code §
											245.8 (relating to
					 compliance).
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 245 - EMERGENCY SURCHARGE › Section 245.7 - Reporting forms

Current through Register Vol. 54, No. 28, July 13, 2024
The appropriate reporting form as required by §
									242.6 (relating to reporting forms
				  and procedures) shall be identified as emergency surcharge and submitted to the
				  Fund with the emergency surcharge amounts. If preparation of the appropriate
				  reporting form would delay remittance of the emergency surcharge amounts beyond
				  the remittance schedule as set forth in §
									245.6(b)
				  (relating to remittance of emergency surcharge amounts), the emergency
				  surcharge amounts shall be remitted immediately and the appropriate form shall
				  be submitted as soon thereafter as possible.
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 245 - EMERGENCY SURCHARGE › Section 245.8 - Compliance

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The basic
				coverage insurance carrier shall promptly notify the Fund in accordance with
				§
									245.6 (relating to remittance of
				emergency surcharge amounts) of the identity of those health care providers who
				have failed to pay the emergency surcharge.
(b) If a health care provider fails to comply
				with section 701(e) of the act (40 P.S. §
										1301.701(e)) or this
				chapter, the Director of the Fund will notify the applicable licensure board
				for possible disciplinary action against the health care provider's license
				under section 701(f) of the act (40 P.S. §
										1301.701(f)).
(c) A health care provider failing to pay the
				emergency surcharge within the time limits set forth in §
									245.6 (relating to remittance of
				emergency surcharge amounts) may not be covered by the Fund in the event of
				loss.
(d) Failure of any party to
				act within the time required by this chapter may not relieve another party from
				the obligation to act under this chapter.
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 247 - COVERAGE AND CLAIMS ISSUES-STATEMENT OF POLICY › Section 247.1 - Excess coverage-implementation of new limits

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The act of November 26, 1996 (P. L. 776,
				No. 135) (Act 135) amended the Health Care Services Malpractice Act (act)
				(40
				P. S. §§
										1301.101-1301.1004). Act
				135 redistributes coverage responsibilities between the primary carriers and
				the Medical Professional Liability Catastrophe Loss Fund (Fund). This
				redistribution continues the maximum statutory limit of $1.2 million per claim
				for each health care provider. This is an indication that the General Assembly
				did not intend to reduce the available insurance coverage to pay settlements or
				awards in excess medical malpractice cases.
(b) The structure of Act 135 is such that an
				issue arises as to the timing of a particular claim and the policy year in
				which a loss (that is, claim) arises. By way of example, an annual primary
				policy issued November 1, 1996, which runs until October 31, 1997, shall by law
				carry a $200,000 primary limit. If a claim occurs pre-December 31, 1996, the
				Fund's limit of liability, per the statute, will be $1 million. However, if the
				claim arises on or after January 1, 1997, through October 31, 1997, the plain
				language of the statute would mandate the Fund's liability is only $900,000.
				Neither the amendments themselves nor the Legislative history suggest that this
				was a result intended by the General Assembly. Therefore, in instances where
				the coverage level of the primary policy and the Fund limits do not reach the
				$1.2 million total, the Fund will provide its coverage as required by law,
				recognizing the amount of primary coverage available from the insurance policy,
				issued in compliance with Act 135, against which the claim is made.
Pennsylvania Code › Title 31 - INSURANCE › Part IX - Medical Catastrophe Loss Fund › Chapter 247 - COVERAGE AND CLAIMS ISSUES-STATEMENT OF POLICY › Section 247.2 - Section 605 amendment implementation

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The act of November 26, 1996 (P. L. 776,
				No. 135) (Act 135) added language to section 605 of the Health Care Services
				Malpractice Act (act) (40 P. S. §
										1301.605). Specifically, Act 135 added a
				notification provision, under which the primary carrier must notify the Medical
				Professional Liability Catastrophe Loss Fund (Fund) within 180 days of the date
				on which the notice of claim was received by the health care provider or his
				insurer. Secondly, Act 135 added language with regard to the issue of
				"continuing course of treatment." This latter provision relates to multiple
				treatments or consultations which take place less than 4 years before the date
				on which a claim was made against a health care provider (40 P. S. §
										1301.605). Both amendments to Section 605
				were made effective immediately by Act 135, and by implication, will return to
				primary carriers additional cases for coverage and defense, and will place the
				Fund in the role of excess carrier for the claim.
(b) The notification requirements of Act 135
				are procedural in nature, and require as a condition precedent to Section 605
				status that timely notice of the claim must be provided to the Fund. Therefore,
				it is incumbent upon insureds, self-insureds and primary carriers to timely
				notify the Fund of a claim. Because of its procedural nature, the amendment
				will be implemented commensurate with the effective date of Act 135, that is
				November 27, 1996, and will apply to all claims reported on or after that
				date.
(c) The Fund will implement
				the continuing course of treatment amendments effective November 27, 2000,
				which is 4 years after the effective date of the Section 605 amendments. This
				determination is intended to provide primary carriers with the ability to build
				into their rate filings the costs associated with additional risks and
				liabilities that will accrue once the new amendments have been fully
				implemented.
(d) As to the
				continuing course of treatment provision, the Fund believes that the General
				Assembly intended that the continuing course of care relate to the
				manifestation of the claimed injury, and should not apply to unrelated
				treatments or consultations. By way of example, when a patient has been treated
				by a physician for routine cancer screening and examinations more than 4 years
				prior to a claim being made for delay in diagnosis of cancer, and sees the same
				physician within the 4-year period only for treatment of a hangnail, Section
				605 coverage would apply to the claim of delay in diagnosis of cancer. In
				contrast, a claim alleging professional liability revolving around the hangnail
				would be considered an excess claim.
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter A - GENERAL INFORMATION › Section 301.1 - Applicability

Current through Register Vol. 54, No. 28, July 13, 2024
This chapter applies to persons who propose to establish,
					 maintain and operate an HMO within this Commonwealth, with the exception of HMO
					 programs exempted under sections 16 and 17(b) of the act (40 P. S. §§
											1566 and
					 1567(b)).
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter B - DEVELOPMENT OF A HEALTH MAINTENANCE ORGANIZATION › Section 301.21 - Preapplication development activities

Current through Register Vol. 54, No. 28, July 13, 2024
Corporations in the process of developing an HMO are urged,
					 but not required, to periodically inform the Department of their developmental
					 activities and to make use of Department technical advice and
					 assistance.
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter C - APPLICATION FOR CERTIFICATION OF AUTHORITY › Section 301.41 - Prohibition against uncertified HMOs

Current through Register Vol. 54, No. 28, July 13, 2024
No corporation may solicit enrollment of members, enroll
					 members or deliver prepaid basic health care services by, through, or in an HMO
					 until it has received a certificate of authority to operate and maintain the
					 HMO from the Secretary and the Commissioner.
This section is cited in 31 Pa. Code §
												301.301 (relating to definitions);
						and 31 Pa. Code §
												301.303 (relating to certificate
						of authority).
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter C - APPLICATION FOR CERTIFICATION OF AUTHORITY › Section 301.43 - Review by the Department

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Before
				  the Department issues a certificate of authority, a thorough review will be
				  made to determine whether the proposed HMO, the plan under which it proposes to
				  operate and the services which it proposes to provide are consistent with the
				  act and this chapter.
(b) Within 10
				  business days of receiving an application for a certificate of authority, the
				  Department will determine whether the application contains the items listed in
				  §
										301.42 (relating to content of
				  application for certificate of authority). If the Department determines that
				  the application is not complete, it will send a written request to the
				  applicant corporation stating specifically what additional information is
				  needed.
(c) The application for a
				  certificate of authority will not be considered complete until the additional
				  information is received by the Department.
(d) Upon receipt of a completed application
				  for a certificate of authority, the Department will publish a notification of
				  receipt of the filing in the
Pennsylvania Bulletin
in order to
				  provide an opportunity for public comment.
(e) Within 90 days of receipt of a completed
				  application for a certificate of authority, the Secretary and Commissioner will
				  jointly do either of the following:
(1)
				  Approve the application and issue a certificate of authority.
(2) Disapprove the application specifying in
				  writing the reasons for the disapproval. Disapproval of an application may be
				  appealed under 2 Pa.C.S. (relating to administrative agency law and
				  procedure).
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter D - OPERATIONAL STANDARDS FOR A HEALTH MAINTENANCE ORGANIZATION › Section 301.61 - Operational standards

Current through Register Vol. 54, No. 28, July 13, 2024
A corporation receiving a certificate of authority to
					 establish and operate an HMO under the act shall provide quality health care
					 services in a cost-effective manner and in a manner which does not impair the
					 corporation's ability to deliver, arrange for the delivery of or pay for health
					 services for its members.
The provisions of this §
												301.61 amended under sections 206,
						506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
						§§
													66,
						186,
						411 and
						412); and the Health
						Maintenance Organization Act (40 P. S. §§
													1551-1567).
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter D - OPERATIONAL STANDARDS FOR A HEALTH MAINTENANCE ORGANIZATION › Section 301.62 - Subscriber contracts and evidences of coverage

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
General filing
				  procedure.
(1)
Number of
				  copies
. The HMO shall file group and nongroup contract forms and
				  evidences of coverage, in duplicate. One copy will be retained by the
				  Department, and the other copy will be returned to the HMO with the action
				  taken by the Department noted thereon.
(2)
Time of filing
. Contract
				  forms and evidences of coverage shall be filed with the Commissioner and deemed
				  approved unless explicitly rejected within 60 days of the filing. Disapproval
				  of a filing by the Commissioner may be appealed under 2 Pa.C.S. (relating to
				  administrative law and procedure).
(3)
Form number
. A form
				  shall be identified with a distinguishing form number on the cover of the
				  form.
(4)
Hypothetical
				  data
. Blank spaces in the proposed contract form and evidence of
				  coverage shall be completed with hypothetical data demonstrating the purpose
				  and use of the forms.
(5)
Final print required
. Contract forms and evidences of coverage
				  shall be submitted in final print, in the form intended for actual issue, for
				  formal filing. Initial submissions of contract forms and evidences of coverage
				  may be in other than final print when the HMO desires a preliminary review of
				  forms before preparing final printed documents.
(6)
Letter of submission
.
				  The letter of submission shall be in duplicate and shall contain:
(i) The form number of each form
				  submitted.
(ii) An explanation of
				  the coverage provided.
(iii) An
				  explanation of the specific purpose and use of the form.
(iv) Identification of the previously
				  approved form which is to be replaced by the newly submitted form.
(v) Identification of forms no longer being
				  used by the HMO.
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter D - OPERATIONAL STANDARDS FOR A HEALTH MAINTENANCE ORGANIZATION › Section 301.64 - Solicitors and agents

Current through Register Vol. 54, No. 28, July 13, 2024
Solicitors and agents for an HMO shall be licensed as, and
					 subject to the statutes pertaining to, insurance agents.
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter D - OPERATIONAL STANDARDS FOR A HEALTH MAINTENANCE ORGANIZATION › Section 301.65 - Transfer of funds

Current through Register Vol. 54, No. 28, July 13, 2024
(a) No funds,
				  except for the purchase of goods and contracted services, may be transferred
				  out of this Commonwealth by an HMO without the prior approval and written
				  consent of the Department.
(b) A
				  licensed HMO may continue to transfer funds in accordance with a procedure or
				  system which was in operation on February 21, 1987, if it submits for the
				  Department's review a complete and accurate description of the transfer
				  procedure by April 22, 1987. If the Department disapproves of the transfer
				  procedure and system, the HMO will be notified in writing, specifying the
				  reason for the disapproval. The HMO will be permitted a reasonable period of
				  time, to be identified in the notice of disapproval but not less than 45 days,
				  in which to discontinue the transfers and return funds to this
				  Commonwealth.
This section cited in 31 Pa. Code §
												303.1 (relating to review of
						requests of health maintenance organizations to transfer funds out of this
						Commonwealth-statement of policy).
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter E - CONTINUING SUPERVISION OF OPERATIONAL HEALTH MAINTENANCE ORGANIZATIONS › Section 301.81 - Financial reports

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An HMO shall
				  submit to the Department before March 1 of each year an annual financial report
				  for the preceding calendar year in a form prescribed by the
				  Commissioner.
(b) During the
				  initial 5 years of operation, an HMO shall submit to the Department quarterly
				  financial reports in a form prescribed by the Commissioner. The reports shall
				  be submitted within 45 days following the end of a calendar quarter.
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter E - CONTINUING SUPERVISION OF OPERATIONAL HEALTH MAINTENANCE ORGANIZATIONS › Section 301.82 - Departmental investigation

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department may investigate further information contained in or forming the
				  basis of reports submitted according to this chapter.
(b) Investigation may include onsite
				  inspection of the HMO's facilities and records of the HMO.
(c) The Commissioner or an agent shall have
				  free access to the books, records, papers and documents that relate to the
				  business of the HMO.
(d) The
				  Department may charge the HMO for the services of its examiners in the manner
				  it charges insurance companies as prescribed in section 216 of The Insurance
				  Department Act of one thousand nine hundred and twenty-one (40 P. S. §
											54) and under the funding requirements set
				  forth by the National Association of Insurance Commissioners (NAIC).
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter E - CONTINUING SUPERVISION OF OPERATIONAL HEALTH MAINTENANCE ORGANIZATIONS › Section 301.83 - Federally qualified HMOs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In
				  applying this chapter to Federally-qualified HMOs, the Department may take into
				  account the extent of compliance with Federal standards.
(b) If there is a conflict or potential
				  conflict between this chapter and Federal regulations applicable to
				  Federally-qualified HMOs, the Department will coordinate directly with the
				  appropriate Federal authority to attempt to remove or resolve the
				  conflict.
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter E - CONTINUING SUPERVISION OF OPERATIONAL HEALTH MAINTENANCE ORGANIZATIONS › Section 301.84 - Exceptions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department
				  may, for good cause and only if financial viability of the HMO or the welfare
				  of a citizen would not be impaired, grant exceptions to this chapter when the
				  policy objectives and intentions of this chapter are otherwise substantially
				  met.
(b) A request for exceptions
				  to this chapter shall be made in writing to the Department. A request, whether
				  approved or not, will be retained on file by the Department. An approved
				  request shall be retained on file by the corporation during the period the
				  exception remains in effect.
(c) An
				  exception granted under this chapter may be revoked by the Department for good
				  cause whenever the policy objectives and reasons for granting the exception
				  will no longer be furthered.
(d)
				  The Department will give written notice by certified mail, return receipt
				  requested, revoking an exception and will state the reason for its action and a
				  specific date upon which the exception will be terminated.
(e) The Department will provide for a
				  reasonable time between the date of written notice of revocation and the date
				  of termination of an exception for the HMO from compliance with this
				  chapter.
(f) Failure of the HMO to
				  comply by the specified date may result in action to revoke the previously
				  approved certificate of authority.
(g) The Department's denial or revocation of
				  an exception is a final agency action and is appealable under
				  2
				  Pa.C.S. §§
											701-704 (relating to
				  judicial review of Commonwealth agency action).
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter F - PENALTY PROVISIONS › Section 301.101 - Violations

Current through Register Vol. 54, No. 28, July 13, 2024
A violation of this chapter is punishable under section 15
					 of the act (40 P. S. §
											1565) and
					 other applicable statutes of the Commonwealth.
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter G - PROTECTION AGAINST INSOLVENCY › Section 301.121 - Protections against insolvency

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  A new certificate of authority filing shall include procedures to be
				  implemented to meet the requirements for protection against
				  insolvency.
(b) Requirements for
				  protection against insolvency include:
(1) For
				  new plans filing for a certificate of authority, a minimum initial net worth of
				  $1.5 million.
(2) For every
				  operational HMO, minimum net worth equal to the greater of $1 million or 3
				  months uncovered health care expenditures for Pennsylvania enrollees as
				  reported on the most recent financial statement filed with the Commissioner. A
				  dedicated funding commitment, such as an irrevocable letter of credit or other
				  instrument from a parent company, may be considered in assessing net worth, if
				  approved by the Commissioner. This commitment would not be considered a
				  substitute for a capital infusion needed to obtain a positive net
				  worth.
Pennsylvania Code › Title 31 - INSURANCE › Part X - Health Maintenance Organization › Chapter 301 - HEALTH MAINTENANCE ORGANIZATION › Subchapter G - PROTECTION AGAINST INSOLVENCY › Section 301.122 - Hold harmless

Current through Register Vol. 54, No. 28, July 13, 2024
A contract between an HMO and a participating provider of
					 health care services shall include a provision to the following effect:
(Provider) hereby agrees that in no event, including, but
					 not limited to non-payment by the HMO, HMO insolvency or breach of this
					 agreement, shall (Provider) bill, charge, collect a deposit from, seek
					 compensation, remuneration or reimbursement from, or have any recourse against
					 subscriber/enrollee or persons other than HMO acting on their behalf for
					 services listed in this Agreement. This provision shall not prohibit collection
					 of supplemental charges or copayments on the HMO's or provider's behalf made in
					 accordance with the terms of the applicable agreement between the HMO and
					 subscriber/enrollee. "(Provider) further agrees that (1) the hold harmless
					 provisions herein shall survive the termination of the (applicable Provider
					 contract) regardless of the cause giving rise to termination and shall be
					 construed to be for the benefit of the HMO subscriber/enrollee and that (2)
					 this hold harmless provision supersedes any oral or written contrary agreement
					 now existing or hereafter entered into between (Provider) and
					 subscriber/enrollee or persons acting on their behalf. "Any modification,
					 addition, or deletion to the provisions of this section shall become effective
					 on a date no earlier than fifteen (15) days after the Secretary of Health has
					 received written notice of such proposed changes."
This section is cited in 31 Pa. Code §
												301.314 (relating to Department
						review).