Pennsylvania Consolidated & Unconsolidated Statutes
Chapter 33 - Health Care Cost Containment
Section 3307 - Mandated health benefits

In relation to current law or proposed legislation, the council shall, upon the request of the appropriate committee chairperson in the Senate and in the House of Representatives or upon the request of the Secretary of Health or the Secretary of Human Services, provide information on the proposed mandated health benefit pursuant to the following:
(1) The General Assembly declares that proposals for mandated health benefits or mandated health insurance coverage should be accompanied by adequate, independently certified documentation defining the social and financial impact and medical efficacy of the proposal. To that end, the council, upon receipt of such requests, is authorized to conduct a preliminary review of the material submitted by both proponents and opponents concerning the proposed mandated benefit. If, after this preliminary review, the council is satisfied that both proponents and opponents have submitted sufficient documentation necessary for a review under paragraphs (3) and (4), the council is directed to contract with individuals, pursuant to the selection procedures for vendors set forth in section 3314 (relating to contracts with vendors), who will constitute a Mandated Benefits Review Panel to review mandated benefits proposals and provide independently certified documentation, as provided for in this section.
(2) The panel shall consist of the following senior researchers, each of whom shall be a recognized expert:
(i) one in health research;
(ii) one in biostatistics;
(iii) one in economic research;
(iv) one, a physician, in the appropriate specialty with current knowledge of the subject being proposed as a mandated benefit; and
(v) one with experience in insurance or actuarial research.
(3) The Mandated Benefits Review Panel shall have the following duties and responsibilities:
(i) To review documentation submitted by a person proposing or opposing mandated benefits within 90 days of submission of the documentation to the panel.
(ii) To report to the council, pursuant to the council's review under subparagraph (i), the following:
(A) Whether or not the documentation is complete as defined in paragraph (4).
(B) Whether or not the research cited in the documentation meets professional standards.
(C) Whether or not all relevant research respecting the proposed mandated benefit has been cited in the documentation.
(D) Whether or not the conclusions and interpretations in the documentation are consistent with the data submitted.
(4) A person proposing or opposing legislation mandating benefits coverage should, to provide the Mandated Benefits Review Panel with sufficient information to carry out the Mandated Benefits Review Panel's duties and responsibilities under paragraph (3), submit documentation to the council, pursuant to the procedure established under paragraph (5), which demonstrates the following:
(i) The extent to which the proposed benefit and the services the proposed benefit would provide are needed by, available to and utilized by the population of this Commonwealth.
(ii) The extent to which insurance coverage for the proposed benefit already exists or, if no coverage exists, the extent to which the lack of coverage results in inadequate health care or financial hardship for the population of this Commonwealth.
(iii) The demand for the proposed benefit from the public and the source and extent of opposition to mandating the benefit.
(iv) All relevant findings bearing on the social impact of the lack of the proposed benefit.
(v) If the proposed benefit mandates coverage of a particular therapy, the results of at least one professionally accepted, controlled trial comparing the medical consequences of the proposed therapy, alternative therapies and no therapy.
(vi) If the proposed benefit mandates coverage of an additional class of practitioners, the results of at least one professionally accepted, controlled trial comparing the medical results achieved by the additional class of practitioners and those practitioners already covered by benefits.
(vii) The results of any other relevant research.
(viii) Evidence of the financial impact of the proposed legislation, including at least the following:
(A) The extent to which the proposed benefit would increase or decrease cost for treatment or service.
(B) The extent to which similar mandated benefits in other states have affected charges, costs and payments for services.
(C) The extent to which the proposed benefit would increase the appropriate use of the treatment or service.
(D) The impact of the proposed benefit on administrative expenses of health care insurers.
(E) The impact of the proposed benefits on benefits costs of purchasers.
(F) The impact of the proposed benefits on the total cost of health care within this Commonwealth.
(5) The procedure for review of documentation shall be as follows:
(i) A person wishing to submit information on proposed legislation mandating insurance benefits for review by the panel must submit the documentation specified under paragraph (4) to the council.
(ii) The council shall, within 30 days of receipt of the documentation:
(A) Publish in the Pennsylvania Bulletin notice of receipt of the documentation, a description of the proposed legislation, provision for a period of 60 days for public comment and the time and place at which a person may examine the documentation.
(B) Submit copies of the documentation to the Secretary of Health, the Secretary of Human Services and the Insurance Commissioner, who shall review and submit comments to the council on the proposed legislation within 30 days.
(C) Submit copies of the documentation to the panel, which shall review the documentation and issue their findings, subject to paragraph (3), within 90 days.
(iii) Upon receipt of the comments of the Secretary of Health, the Secretary of Human Services and the Insurance Commissioner and of the findings of the panel, under subparagraph (ii), but no later than 120 days following the publication required in subparagraph (ii), the council shall submit the comments and findings, together with the council's recommendations respecting the proposed legislation, to the Governor, the President pro tempore of the Senate, the Speaker of the House of Representatives, the Secretary of Health, the Secretary of Human Services, the Insurance Commissioner and the person who submitted the information under subparagraph (i).