HOUSE AMENDED
PRIOR PRINTER'S NO. 2050 PRINTER'S NO. 2219
No. 1335 Session of 2006
INTRODUCED BY ARMSTRONG AND STACK, SEPTEMBER 20, 2006
AS AMENDED ON THIRD CONSIDERATION, HOUSE OF REPRESENTATIVES,
OCTOBER 24, 2006
AN ACT
1 Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
2 act relating to insurance; amending, revising, and
3 consolidating the law providing for the incorporation of
4 insurance companies, and the regulation, supervision, and
5 protection of home and foreign insurance companies, Lloyds
6 associations, reciprocal and inter-insurance exchanges, and
7 fire insurance rating bureaus, and the regulation and
8 supervision of insurance carried by such companies,
9 associations, and exchanges, including insurance carried by
10 the State Workmen's Insurance Fund; providing penalties; and
11 repealing existing laws," FURTHER PROVIDING, IN CASUALTY <--
12 INSURANCE, FOR POLICY CONDITIONS AND FOR GROUP ACCIDENT AND
13 SICKNESS INSURANCE; PROVIDING, IN CASUALTY INSURANCE, FOR
14 AUTISM SPECTRUM DISORDERS COVERAGE AND FOR TICK-BORNE
15 ILLNESSES; PROVIDING FOR RETROACTIVE DENIAL OF
16 REIMBURSEMENTS; AND further providing, in health care
17 insurance, for individual accessibility, for conversion
18 policies and for sunset.
19 The General Assembly of the Commonwealth of Pennsylvania
20 hereby enacts as follows:
21 Section 1. Section 1009-A of the act of May 17, 1921 <--
22 (P.L.682, No.284), known as The Insurance Company Law of 1921,
23 is amended by adding a subsection to read:
24 SECTION 1. SECTION 617 OF THE ACT OF MAY 17, 1921 (P.L.682, <--
1 NO.284), KNOWN AS THE INSURANCE COMPANY LAW OF 1921, REPEALED
2 AND ADDED MAY 25, 1951 (P.L.417, NO.99), AMENDED JANUARY 18,
3 1968 (1967 P.L.969, NO.433) AND JULY 31, 1968 (P.L.1031,
4 NO.311), IS AMENDED TO READ:
5 SECTION 617. CONDITIONS SUBJECT TO WHICH POLICIES ARE TO BE
6 ISSUED.--(A) NO SUCH POLICY SHALL BE DELIVERED OR ISSUED FOR
7 DELIVERY TO ANY PERSON IN THIS COMMONWEALTH UNLESS:
8 (1) THE ENTIRE MONEY AND OTHER CONSIDERATIONS THEREFOR ARE
9 EXPRESSED THEREIN; AND
10 (2) THE TIME AT WHICH THE INSURANCE TAKES EFFECT AND
11 TERMINATES IS EXPRESSED THEREIN; AND
12 (3) IT PURPORTS TO INSURE ONLY ONE PERSON, EXCEPT THAT A
13 POLICY MAY INSURE, ORIGINALLY OR BY SUBSEQUENT AMENDMENT, UPON
14 THE APPLICATION OF AN ADULT HEAD OF A FAMILY WHO SHALL BE DEEMED
15 THE POLICYHOLDER, ANY TWO OR MORE ELIGIBLE MEMBERS OF THAT
16 FAMILY, INCLUDING HUSBAND, WIFE, DEPENDENT CHILDREN OR ANY
17 CHILDREN UNDER A SPECIFIED AGE WHICH SHALL NOT EXCEED [NINETEEN]
18 TWENTY-THREE YEARS AND ANY OTHER PERSON DEPENDENT UPON THE
19 POLICYHOLDER; AND
20 (4) THE STYLE, ARRANGEMENT AND OVER-ALL APPEARANCE OF THE
21 POLICY GIVE NO UNDUE PROMINENCE TO ANY PORTION OF THE TEXT, AND
22 UNLESS EVERY PRINTED PORTION OF THE TEXT OF THE POLICY AND OF
23 ANY ENDORSEMENTS OR ATTACHED PAPERS IS PLAINLY PRINTED IN LIGHT-
24 FACED TYPE OF A STYLE IN GENERAL USE, THE SIZE OF WHICH SHALL BE
25 UNIFORM AND NOT LESS THAN TEN-POINT WITH A LOWER-CASE UNSPACED
26 ALPHABET LENGTH NOT LESS THAN ONE HUNDRED AND TWENTY-POINT (THE
27 "TEXT" SHALL INCLUDE ALL PRINTED MATTER EXCEPT THE NAME AND
28 ADDRESS OF THE INSURER, NAME OR TITLE OF THE POLICY, THE BRIEF
29 DESCRIPTION, IF ANY, AND CAPTIONS AND SUBCAPTIONS); AND
30 (5) THE EXCEPTIONS AND REDUCTIONS OF INDEMNITY ARE SET FORTH
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1 IN THE POLICY AND, EXCEPT THOSE WHICH ARE SET FORTH IN SECTION
2 SIX HUNDRED EIGHTEEN OF THIS ACT, ARE PRINTED, AT THE INSURER'S
3 OPTION, EITHER INCLUDED WITH THE BENEFIT PROVISION TO WHICH THEY
4 APPLY, OR UNDER AN APPROPRIATE CAPTION SUCH AS "EXCEPTIONS," OR
5 "EXCEPTIONS AND REDUCTIONS": PROVIDED, THAT IF AN EXCEPTION OR
6 REDUCTION SPECIFICALLY APPLIES ONLY TO A PARTICULAR BENEFIT OF
7 THE POLICY, A STATEMENT OF SUCH EXCEPTION OR REDUCTION SHALL BE
8 INCLUDED WITH THE BENEFIT PROVISION TO WHICH IT APPLIES; AND
9 (6) EACH SUCH FORM, INCLUDING RIDERS AND ENDORSEMENTS, SHALL
10 BE IDENTIFIED BY A FORM NUMBER IN THE LOWER LEFT-HAND CORNER OF
11 THE FIRST PAGE THEREOF; AND
12 (7) IT CONTAINS NO PROVISION PURPORTING TO MAKE ANY PORTION
13 OF THE CHARTER, RULES, CONSTITUTION, OR BY-LAWS OF THE INSURER A
14 PART OF THE POLICY UNLESS SUCH PORTION IS SET FORTH IN FULL IN
15 THE POLICY, EXCEPT IN THE CASE OF THE INCORPORATION OF, OR
16 REFERENCE TO, A STATEMENT OF RATES OR CLASSIFICATION OF RISKS,
17 OR SHORT-RATE TABLE FILED WITH THE COMMISSIONER; AND
18 (8) IF SUCH POLICY IS ENTITLED OR REFERRED TO AS "NON-
19 CANCELLABLE," SUCH "NON-CANCELLABLE" POLICY IS AUTOMATICALLY
20 RENEWABLE UNTIL AGE SIXTY UPON PAYMENT OF THE REQUIRED PREMIUMS
21 BY THE INSURED; AND
22 (9) A POLICY DELIVERED OR ISSUED FOR DELIVERY AFTER JANUARY
23 1, 1968, UNDER WHICH COVERAGE OF A DEPENDENT OF A POLICYHOLDER
24 TERMINATES AT A SPECIFIED AGE SHALL, WITH RESPECT TO AN
25 UNMARRIED CHILD COVERED BY THE POLICY PRIOR TO THE ATTAINMENT OF
26 THE AGE OF [NINETEEN] TWENTY-THREE WHO IS INCAPABLE OF SELF-
27 SUSTAINING EMPLOYMENT BY REASON OF MENTAL RETARDATION [OR],
28 PHYSICAL HANDICAP OR RECEIVING TREATMENT FOR DRUG OR ALCOHOL
29 ADDICTION, AND WHO BECAME SO INCAPABLE PRIOR TO ATTAINMENT OF
30 AGE [NINETEEN] TWENTY-THREE AND WHO IS CHIEFLY DEPENDENT UPON
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1 SUCH POLICYHOLDER FOR SUPPORT AND MAINTENANCE, NOT SO TERMINATE
2 WHILE THE POLICY REMAINS IN FORCE AND THE DEPENDENT REMAINS IN
3 SUCH CONDITION, IF THE POLICYHOLDER HAS WITHIN THIRTY-ONE DAYS
4 OF SUCH DEPENDENT'S ATTAINMENT OF THE LIMITING AGE SUBMITTED
5 PROOF OF SUCH DEPENDENT'S INCAPACITY AS DESCRIBED HEREIN. THE
6 FOREGOING PROVISIONS OF THIS PARAGRAPH SHALL NOT REQUIRE AN
7 INSURER TO INSURE A DEPENDENT WHO IS A MENTALLY RETARDED [OR],
8 PHYSICALLY HANDICAPPED CHILD OR RECEIVING TREATMENT FOR DRUG OR
9 ALCOHOL ADDICTION WHERE THE POLICY IS UNDERWRITTEN ON EVIDENCE
10 OF INSURABILITY BASED ON HEALTH FACTORS SET FORTH IN THE
11 APPLICATION OR WHERE SUCH DEPENDENT DOES NOT SATISFY THE
12 CONDITIONS OF THE POLICY AS TO ANY REQUIREMENT FOR EVIDENCE OF
13 INSURABILITY OR OTHER PROVISIONS OF THE POLICY, SATISFACTION OF
14 WHICH IS REQUIRED FOR COVERAGE THEREUNDER TO TAKE EFFECT. IN ANY
15 SUCH CASE THE TERMS OF THE POLICY SHALL APPLY WITH REGARD TO THE
16 COVERAGE OR EXCLUSION FROM COVERAGE OF SUCH DEPENDENT.
17 (10) EXCEPT FOR A SINGLE PREMIUM NONRENEWABLE POLICY, IT
18 SHALL HAVE PROMINENTLY PRINTED THEREON A NOTICE STATING IN
19 SUBSTANCE THAT THE POLICYHOLDER SHALL BE PERMITTED TO RETURN THE
20 POLICY WITHIN TEN DAYS OF ITS DELIVERY AND TO HAVE THE PREMIUM
21 PAID REFUNDED IF AFTER EXAMINATION OF THE POLICY, THE
22 POLICYHOLDER IS NOT SATISFIED WITH IT FOR ANY REASON. IF A
23 POLICYHOLDER PURSUANT TO SUCH NOTICE, RETURNS THE POLICY TO THE
24 INSURER AT ITS HOME OR BRANCH OFFICE OR TO THE AGENT THROUGH
25 WHOM IT WAS PURCHASED, IT SHALL BE VOID FROM THE BEGINNING AND
26 THE PARTIES SHALL BE IN THE SAME POSITION AS IF NO POLICY HAD
27 BEEN ISSUED.
28 (B) IF ANY POLICY IS ISSUED BY AN INSURER DOMICILED IN THIS
29 COMMONWEALTH FOR DELIVERY TO A PERSON RESIDING IN ANOTHER STATE,
30 AND IF THE OFFICIAL HAVING RESPONSIBILITY FOR THE ADMINISTRATION
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1 OF THE INSURANCE LAWS OF SUCH OTHER STATE SHALL HAVE ADVISED THE
2 COMMISSIONER THAT ANY SUCH POLICY IS NOT SUBJECT TO APPROVAL OR
3 DISAPPROVAL BY SUCH OFFICIAL, THE COMMISSIONER MAY BY RULING
4 REQUIRE THAT SUCH POLICY MEET THE STANDARDS SET FORTH IN
5 SUBSECTION (A) OF THIS SECTION AND IN SECTION SIX HUNDRED
6 EIGHTEEN.
7 SECTION 2. SECTION 621.2(A) OF THE ACT, AMENDED FEBRUARY 17,
8 1994 (P.L.92, NO.9), IS AMENDED TO READ:
9 SECTION 621.2. GROUP ACCIDENT AND SICKNESS INSURANCE.--(A)
10 GROUP ACCIDENT AND SICKNESS INSURANCE IS HEREBY DECLARED TO BE
11 THAT FORM OF ACCIDENT AND SICKNESS INSURANCE COVERING GROUPS OF
12 PERSONS DEFINED IN THIS SECTION WITH OR WITHOUT ONE OR MORE
13 MEMBERS OF THEIR FAMILIES OR ONE OR MORE OF THEIR DEPENDENTS, OR
14 COVERING ONE OR MORE MEMBERS OF THE FAMILIES OR ONE OR MORE
15 DEPENDENTS OF SUCH GROUPS OR PERSONS AND ISSUED UPON THE
16 FOLLOWING BASIS:
17 (1) UNDER A POLICY ISSUED TO AN EMPLOYER OR TRUSTEES OF A
18 FUND ESTABLISHED BY AN EMPLOYER, WHO SHALL BE DEEMED THE
19 POLICYHOLDER INSURING AT LEAST TEN EMPLOYES OF SUCH EMPLOYER FOR
20 THE BENEFIT OF PERSONS OTHER THAN THE EMPLOYER. THE TERM
21 "EMPLOYES," AS USED HEREIN, SHALL BE DEEMED TO INCLUDE THE
22 OFFICERS, MANAGERS AND EMPLOYES OF THE EMPLOYER, THE INDIVIDUAL
23 PROPRIETOR OR PARTNER, IF THE EMPLOYER IS AN INDIVIDUAL
24 PROPRIETOR OR PARTNERSHIP, THE OFFICERS, MANAGERS AND EMPLOYES
25 OF SUBSIDIARY OR AFFILIATED CORPORATIONS, THE INDIVIDUAL
26 PROPRIETORS, PARTNERS AND EMPLOYES OF INDIVIDUALS AND FIRMS, IF
27 THE BUSINESS OF THE EMPLOYER AND SUCH INDIVIDUAL OR FIRM IS
28 UNDER COMMON CONTROL THROUGH STOCK OWNERSHIP, CONTRACT OR
29 OTHERWISE. THE TERM "EMPLOYES," AS USED HEREIN, MAY INCLUDE
30 RETIRED EMPLOYES. A POLICY ISSUED TO INSURE EMPLOYES OF A PUBLIC
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1 BODY MAY PROVIDE THAT THE TERM "EMPLOYES" SHALL INCLUDE ELECTED
2 OR APPOINTED OFFICIALS.
3 (2) UNDER A POLICY ISSUED TO AN ASSOCIATION, INCLUDING A
4 LABOR UNION, WHICH SHALL HAVE A CONSTITUTION AND BY-LAWS AND
5 WHICH HAS BEEN ORGANIZED BY OTHER THAN AN INSURER AND IS
6 MAINTAINED IN GOOD FAITH FOR PURPOSES OTHER THAN THAT OF
7 OBTAINING INSURANCE INSURING AT LEAST TWENTY-FIVE MEMBERS,
8 EMPLOYES OR EMPLOYES OF MEMBERS OF THE ASSOCIATION FOR THE
9 BENEFIT OF PERSONS OTHER THAN THE ASSOCIATION OR ITS OFFICERS OR
10 TRUSTEES, WHICH HAS BEEN IN ACTIVE EXISTENCE FOR AT LEAST TWO
11 YEARS, OPERATES FROM OFFICES OTHER THAN THE INSURER'S AND IS
12 CONTROLLED BY PRINCIPALS OTHER THAN THE INSURER'S. THE TERM
13 "EMPLOYES," AS USED HEREIN, MAY INCLUDE RETIRED EMPLOYES.
14 (3) UNDER A POLICY ISSUED TO THE TRUSTEES OF A FUND
15 ESTABLISHED BY AN INSURER FOR TWO OR MORE EMPLOYERS OR BY TWO OR
16 MORE EMPLOYERS OR BY AN INSURER FOR ONE OR MORE LABOR UNIONS OR
17 BY ONE OR MORE LABOR UNIONS OR BY AN INSURER FOR ONE OR MORE
18 EMPLOYERS AND ONE OR MORE LABOR UNIONS OR BY ONE OR MORE
19 EMPLOYERS AND ONE OR MORE LABOR UNIONS OR BY AN INSURER FOR ONE
20 OR MORE ASSOCIATIONS MEETING THE QUALIFICATIONS AS DEFINED IN
21 CLAUSE (2) OR BY ONE OR MORE ASSOCIATIONS MEETING THE
22 QUALIFICATIONS AS DEFINED IN CLAUSE (2), WHICH TRUSTEES SHALL BE
23 DEEMED THE POLICYHOLDER TO INSURE EMPLOYES OF THE EMPLOYERS OR
24 MEMBERS OF THE UNIONS OR MEMBERS, EMPLOYES THEREOF AND EMPLOYES
25 OF THE ASSOCIATIONS FOR THE BENEFIT OF PERSONS OTHER THAN THE
26 EMPLOYERS OR THE UNIONS OR THE ASSOCIATIONS. THE TERM
27 "EMPLOYES," AS USED HEREIN, MAY INCLUDE THE OFFICERS, MANAGERS
28 AND EMPLOYES OF THE EMPLOYER AND THE INDIVIDUAL PROPRIETOR OR
29 PARTNERS, IF THE EMPLOYER IS AN INDIVIDUAL PROPRIETOR OR
30 PARTNERSHIP. THE TERM "EMPLOYES," AS USED HEREIN, MAY INCLUDE
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1 RETIRED EMPLOYES. THE POLICY MAY PROVIDE THAT THE TERM
2 "EMPLOYES" SHALL INCLUDE THE TRUSTEES OR THEIR EMPLOYES, OR
3 BOTH, IF THEIR DUTIES ARE PRINCIPALLY CONNECTED WITH SUCH
4 TRUSTEESHIP.
5 (4) UNDER A POLICY ISSUED TO ANY PERSON OR ORGANIZATION TO
6 WHICH A POLICY OF GROUP LIFE INSURANCE MAY BE ISSUED OR
7 DELIVERED IN THIS COMMONWEALTH TO INSURE ANY CLASS OR CLASSES OF
8 INDIVIDUALS THAT COULD BE INSURED UNDER SUCH GROUP LIFE POLICY.
9 (5) UNDER A POLICY ISSUED TO COVER ANY OTHER SUBSTANTIALLY
10 SIMILAR GROUP, WHICH IN THE DISCRETION OF THE INSURANCE
11 COMMISSIONER MAY BE SUBJECT TO THE ISSUANCE OF A GROUP ACCIDENT
12 AND SICKNESS POLICY OR CONTRACT.
13 (5.1) UNDER A POLICY ISSUED TO A GROUP, OTHER THAN ONE
14 DESCRIBED IN CLAUSES (1) THROUGH (5) AND UNDER WHICH THE
15 INSURANCE COMMISSIONER FINDS THAT THE ISSUANCE IS NOT CONTRARY
16 TO THE BEST INTEREST OF THE PUBLIC, THE ISSUANCE WOULD RESULT IN
17 ECONOMIES OF ACQUISITION OR ADMINISTRATION, AND THE BENEFITS ARE
18 REASONABLE IN RELATION TO THE PREMIUMS CHARGED.
19 (6) A POLICY DELIVERED OR ISSUED FOR DELIVERY ON OR AFTER
20 JANUARY 1, 1968 UNDER WHICH COVERAGE OF A DEPENDENT OF AN
21 EMPLOYE OR OTHER MEMBER OF THE INSURED GROUP TERMINATES AT A
22 SPECIFIED AGE SHALL, WITH RESPECT TO AN UNMARRIED CHILD COVERED
23 BY THE POLICY PRIOR TO THE ATTAINMENT OF THE AGE OF [NINETEEN]
24 TWENTY-THREE WHO IS INCAPABLE OF SELF-SUSTAINING EMPLOYMENT BY
25 REASON OF MENTAL RETARDATION [OR], PHYSICAL HANDICAP OR
26 RECEIVING TREATMENT FOR DRUG OR ALCOHOL ADDICTION AND WHO BECAME
27 SO INCAPABLE PRIOR TO ATTAINMENT OF AGE NINETEEN AND WHO IS
28 CHIEFLY DEPENDENT UPON SUCH EMPLOYE OR MEMBER FOR SUPPORT AND
29 MAINTENANCE, NOT SO TERMINATE WHILE THE INSURANCE OF THE EMPLOYE
30 OR MEMBER REMAINS IN FORCE AND THE DEPENDENT REMAINS IN SUCH
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1 CONDITION, IF THE INSURED EMPLOYE OR MEMBER HAS WITHIN THIRTY-
2 ONE DAYS OF SUCH DEPENDENT'S ATTAINMENT OF THE TERMINATION AGE
3 SUBMITTED PROOF OF SUCH DEPENDENT'S INCAPACITY AS DESCRIBED
4 HEREIN. THE FOREGOING PROVISIONS OF THIS PARAGRAPH SHALL NOT
5 REQUIRE AN INSURER TO INSURE A DEPENDENT WHO IS A MENTALLY
6 RETARDED OR PHYSICALLY HANDICAPPED CHILD OF AN EMPLOYE OR OTHER
7 MEMBER OF THE INSURED GROUP WHERE SUCH DEPENDENT DOES NOT
8 SATISFY THE CONDITIONS OF THE GROUP POLICY AS TO ANY
9 REQUIREMENTS FOR EVIDENCE OF INSURABILITY OR OTHER PROVISIONS AS
10 MAY BE STATED IN THE GROUP POLICY REQUIRED FOR COVERAGE
11 THEREUNDER TO TAKE EFFECT. IN ANY SUCH CASE THE TERMS OF THE
12 POLICY SHALL APPLY WITH REGARD TO THE COVERAGE OR EXCLUSION FROM
13 COVERAGE OF SUCH DEPENDENT.
14 * * *
15 SECTION 3. THE ACT IS AMENDED BY ADDING SECTIONS TO READ:
16 SECTION 635.2. AUTISM SPECTRUM DISORDERS COVERAGE.--(A) A
17 HEALTH INSURANCE POLICY DELIVERED, ISSUED, EXECUTED OR RENEWED
18 BY AN INSURER IN THIS COMMONWEALTH ON OR AFTER THE EFFECTIVE
19 DATE OF THIS SECTION SHALL PROVIDE COVERAGE FOR AUTISM SPECTRUM
20 DISORDERS FOR AN INDIVIDUAL LESS THAN 24 YEARS OF AGE AND
21 INCLUDE COVERAGE FOR THE FOLLOWING CARE AND SERVICES:
22 (1) HABILITATION CARE.
23 (2) PSYCHIATRIC CARE.
24 (3) PSYCHOLOGICAL CARE.
25 (4) REHABILITATION CARE.
26 (5) RESPITE CARE.
27 (6) THERAPEUTIC CARE.
28 (B) COVERAGE PROVIDED UNDER THIS SECTION SHALL BE SUBJECT TO
29 A MAXIMUM OF TWO THOUSAND DOLLARS ($2,000) BENEFIT PER MONTH FOR
30 THE COVERED INDIVIDUAL, ADJUSTED ANNUALLY BY THE AVERAGE
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1 PERCENTAGE INCREASE OR DECREASE OF PRIVATE MEDICAL INSURANCE
2 PREMIUMS EACH YEAR. THIS LIMIT SHALL NOT APPLY TO THE COVERAGE
3 OF OTHER HEALTH CONDITIONS OF THE INDIVIDUAL NOT RELATED TO THE
4 TREATMENT OF AUTISM SPECTRUM DISORDERS.
5 (C) COVERAGE UNDER THIS SECTION SHALL BE SUBJECT TO
6 COPAYMENT, DEDUCTIBLE AND COINSURANCE PROVISIONS OF A HEALTH
7 INSURANCE POLICY TO THE EXTENT THAT OTHER MEDICAL SERVICES
8 COVERED BY THE POLICY ARE SUBJECT TO THOSE PROVISIONS.
9 (D) THIS SECTION SHALL NOT APPLY TO THE FOLLOWING TYPES OF
10 POLICIES:
11 (1) ACCIDENT ONLY.
12 (2) LIMITED BENEFIT.
13 (3) CREDIT.
14 (4) DENTAL.
15 (5) VISION.
16 (6) SPECIFIED DISEASE.
17 (7) MEDICARE SUPPLEMENT.
18 (8) CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED
19 SERVICES (CHAMPUS) SUPPLEMENT.
20 (9) LONG-TERM CARE OR DISABILITY INCOME.
21 (10) WORKERS' COMPENSATION.
22 (11) AUTOMOBILE MEDICAL PAYMENT.
23 (E) AS USED IN THIS SECTION, THE FOLLOWING WORDS AND PHRASES
24 SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SUBSECTION UNLESS
25 THE CONTEXT CLEARLY INDICATES OTHERWISE:
26 (1) "AUTISM SPECTRUM DISORDERS" MEANS ANY OF THE PERVASIVE
27 DEVELOPMENTAL DISORDERS AS DEFINED BY THE MOST RECENT EDITION OF
28 THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM),
29 INCLUDING AUTISTIC DISORDER, RETT'S DISORDER, CHILDHOOD
30 DISINTEGRATIVE DISORDER, ASPERGER'S DISORDER AND PERVASIVE
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1 DEVELOPMENT DISORDER NOT OTHERWISE SPECIFIED.
2 (2) "HABILITATION CARE" MEANS CARE DESIGNED TO ASSIST
3 INDIVIDUALS IN ACQUIRING, RETAINING AND IMPROVING THE SELF-HELP,
4 SOCIALIZATION AND ADAPTIVE SKILLS NECESSARY TO RESIDE
5 SUCCESSFULLY IN HOME OR COMMUNITY-BASED SETTINGS. HABILITATION
6 CARE MAY BE PROVIDED FOR UP TO 24 HOURS A DAY BASED ON THE NEEDS
7 OF THE INDIVIDUAL RECEIVING THE CARE AND INCLUDES, BUT IS NOT
8 LIMITED TO, HEALTH, SOCIAL OR HOME OR COMMUNITY-BASED SERVICES
9 OR OTHER SERVICES NEEDED TO INSURE THE OPTIMAL FUNCTIONING OF AN
10 INDIVIDUAL IN THE INDIVIDUAL'S HOME OR COMMUNITY-BASED SETTING.
11 (3) "HEALTH INSURANCE POLICY" MEANS ANY GROUP HEALTH,
12 SICKNESS OR ACCIDENT POLICY OR SUBSCRIBER CONTRACT OR
13 CERTIFICATE ISSUED BY AN INSURANCE ENTITY SUBJECT TO ONE OF THE
14 FOLLOWING:
15 (I) THIS ACT.
16 (II) THE ACT OF DECEMBER 29, 1972 (P.L.1701, NO.364), KNOWN
17 AS THE "HEALTH MAINTENANCE ORGANIZATION ACT."
18 (III) THE ACT OF MAY 18, 1976 (P.L.123, NO.54), KNOWN AS THE
19 "INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS
20 ACT."
21 (IV) 40 PA.C.S. CH. 61 (RELATING TO HOSPITAL PLAN
22 CORPORATIONS) OR 63 (RELATING TO PROFESSIONAL HEALTH SERVICES
23 PLAN CORPORATIONS).
24 (4) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES
25 PROVIDED BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH HE OR
26 SHE PRACTICES.
27 (5) "PSYCHOLOGICAL CARE" MEANS DIRECT OR CONSULTATIVE
28 SERVICES PROVIDED BY A LICENSED PSYCHOLOGIST IN THE STATE IN
29 WHICH HE OR SHE PRACTICES.
30 (6) "REHABILITATION CARE" MEANS PROFESSIONAL, COUNSELING AND
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1 GUIDANCE SERVICES AND TREATMENT PROGRAMS THAT ARE NECESSARY TO
2 DEVELOP, MAINTAIN AND RESTORE, TO THE MAXIMUM EXTENT
3 PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
4 (7) "RESPITE CARE" MEANS CARE FURNISHED IN RELIEF OF THE
5 PRIMARY CARE-GIVER ON AN INTERMITTENT BASIS FOR A LIMITED PERIOD
6 TO AN INDIVIDUAL WHO RESIDES PRIMARILY IN A PRIVATE RESIDENCE
7 WHEN SUCH CARE WILL HELP THE INDIVIDUAL TO CONTINUE RESIDING IN
8 THE PRIVATE RESIDENCE. THIS TERM SHALL INCLUDE NURSING CARE OR
9 PRIVATE NURSING CARE PROVIDED ON A RESPITE BASIS.
10 (8) "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED
11 OR CERTIFIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS,
12 PHYSICAL THERAPISTS OR BEHAVIORAL HEALTH SPECIALISTS.
13 SECTION 635.3. TICK-BORNE ILLNESSES.--(A) EXCEPT AS
14 PROVIDED IN SUBSECTION (B), EVERY HEALTH CARE POLICY WHICH, ON
15 OR AFTER THE EFFECTIVE DATE OF THIS SECTION, IS DELIVERED,
16 ISSUED FOR DELIVERY, RENEWED, EXTENDED OR MODIFIED IN THIS
17 COMMONWEALTH BY A HEALTH INSURER MUST COVER PRESCRIBED TREATMENT
18 FOR LYME DISEASE OR RELATED TICK-BORNE ILLNESS IF THE DIAGNOSIS
19 AND TREATMENT PLAN ARE DOCUMENTED IN THE PATIENT'S MEDICAL
20 RECORD, INCLUDING LONG-TERM THERAPIES AND TREATMENT AS
21 PRESCRIBED BY THE PATIENT'S ATTENDING PHYSICIAN.
22 (B) SUBSECTION (A) SHALL NOT APPLY TO ANY OF THE FOLLOWING
23 TYPES OF INSURANCE:
24 (1) HOSPITAL INDEMNITY.
25 (2) ACCIDENT.
26 (3) SPECIFIED DISEASE.
27 (4) DISABILITY INCOME.
28 (5) DENTAL.
29 (6) VISION.
30 (7) CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED
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1 SERVICES (CHAMPUS) SUPPLEMENT.
2 (8) MEDICARE SUPPLEMENT.
3 (9) LONG-TERM CARE.
4 (10) OTHER LIMITED INSURANCE BENEFIT PLANS.
5 SECTION 4. THE ACT IS AMENDED BY ADDING AN ARTICLE TO READ:
6 ARTICLE VI-B
7 RETROACTIVE DENIAL OF REIMBURSEMENTS
8 SECTION 601-B. SCOPE OF ARTICLE.
9 THIS ARTICLE SHALL NOT APPLY TO REIMBURSEMENTS MADE AS PART
10 OF AN ANNUAL CONTRACTED RECONCILIATION OF A RISK-SHARING
11 ARRANGEMENT UNDER AN ADMINISTRATIVE SERVICE PROVIDER CONTRACT.
12 SECTION 602-B. DEFINITIONS.
13 THE FOLLOWING WORDS AND PHRASES WHEN USED IN THIS ARTICLE
14 SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SECTION UNLESS THE
15 CONTEXT CLEARLY INDICATES OTHERWISE:
16 "CODE." ANY OF THE FOLLOWING CODES:
17 (1) THE APPLICABLE CURRENT PROCEDURAL TERMINOLOGY (CPT)
18 CODE, AS ADOPTED BY THE AMERICAN MEDICAL ASSOCIATION.
19 (2) IF FOR DENTAL SERVICE, THE APPLICABLE CODE ADOPTED
20 BY THE AMERICAN DENTAL ASSOCIATION.
21 (3) ANOTHER APPLICABLE CODE UNDER AN APPROPRIATE UNIFORM
22 CODING SCHEME USED BY AN INSURER IN ACCORDANCE WITH THIS
23 ARTICLE.
24 "CODING GUIDELINES." THOSE STANDARDS OR PROCEDURES USED OR
25 APPLIED BY A PAYOR TO DETERMINE THE MOST ACCURATE AND
26 APPROPRIATE CODE OR CODES FOR PAYMENT BY THE PAYOR FOR A SERVICE
27 OR SERVICES.
28 "FRAUD." THE INTENTIONAL MISREPRESENTATION OR CONCEALMENT OF
29 INFORMATION IN ORDER TO DECEIVE OR MISLEAD.
30 "HEALTH CARE PROVIDER." A PERSON, CORPORATION, FACILITY,
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1 INSTITUTION OR OTHER ENTITY LICENSED, CERTIFIED OR APPROVED BY
2 THE COMMONWEALTH TO PROVIDE HEALTH CARE OR PROFESSIONAL MEDICAL
3 SERVICES. THE TERM INCLUDES, BUT IS NOT LIMITED TO, A PHYSICIAN,
4 DENTIST, ORTHODONTIST, CHIROPRACTOR, OPTOMETRIST, PROFESSIONAL
5 NURSE, CERTIFIED NURSE-MIDWIFE, PODIATRIST, HOSPITAL, NURSING
6 HOME, AMBULATORY SURGICAL CENTER OR BIRTH CENTER.
7 "INSURER." AN ENTITY SUBJECT TO ANY OF THE FOLLOWING:
8 (1) 40 PA.C.S. CH. 61 (RELATING TO HOSPITAL PLAN
9 CORPORATIONS) OR 63 (RELATING TO PROFESSIONAL HEALTH SERVICES
10 PLAN CORPORATIONS).
11 (2) THIS ACT.
12 (3) THE ACT OF DECEMBER 29, 1972 (P.L.1701, NO.364),
13 KNOWN AS THE HEALTH MAINTENANCE ORGANIZATION ACT.
14 "MEDICAL ASSISTANCE PROGRAM." THE PROGRAM ESTABLISHED UNDER
15 THE ACT OF JUNE 13, 1967 (P.L.31, NO.21), KNOWN AS THE PUBLIC
16 WELFARE CODE.
17 "MEDICARE." THE FEDERAL PROGRAM ESTABLISHED UNDER TITLE
18 XVIII OF THE SOCIAL SECURITY ACT (49 STAT. 620, 42 U.S.C. § 1395
19 ET SEQ.).
20 "REIMBURSEMENT." PAYMENTS MADE TO A HEALTH CARE PROVIDER BY
21 AN INSURER ON EITHER A FEE-FOR-SERVICE, CAPITATED OR PREMIUM
22 BASIS.
23 SECTION 603-B. RETROACTIVE DENIAL OF REIMBURSEMENT.
24 (A) GENERAL RULE.--IF AN INSURER RETROACTIVELY DENIES
25 REIMBURSEMENT TO A HEALTH CARE PROVIDER, THE INSURER MAY ONLY:
26 (1) RETROACTIVELY DENY REIMBURSEMENT FOR SERVICES
27 SUBJECT TO COORDINATION OF BENEFITS WITH ANOTHER INSURER, THE
28 MEDICAL ASSISTANCE PROGRAM OR THE MEDICARE PROGRAM DURING THE
29 12-MONTH PERIOD AFTER THE DATE THAT THE INSURER PAID THE
30 HEALTH CARE PROVIDER; AND
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1 (2) EXCEPT AS PROVIDED IN PARAGRAPH (1), RETROACTIVELY
2 DENY REIMBURSEMENT DURING A 18-MONTH PERIOD AFTER THE DATE
3 THAT THE INSURER PAID THE HEALTH CARE PROVIDER.
4 (B) WRITTEN NOTICE.--AN INSURER THAT RETROACTIVELY DENIES
5 REIMBURSEMENT TO A HEALTH CARE PROVIDER UNDER SUBSECTION (A)
6 SHALL PROVIDE THE HEALTH CARE PROVIDER WITH A WRITTEN STATEMENT
7 SPECIFYING THE BASIS FOR THE RETROACTIVE DENIAL. IF THE
8 RETROACTIVE DENIAL OF REIMBURSEMENT RESULTS FROM COORDINATION OF
9 BENEFITS, THE WRITTEN STATEMENT SHALL PROVIDE THE NAME AND
10 ADDRESS OF THE ENTITY ACKNOWLEDGING RESPONSIBILITY FOR PAYMENT
11 OF THE DENIED CLAIM.
12 SECTION 604-B. EFFECT OF NONCOMPLIANCE.
13 EXCEPT AS PROVIDED IN SECTION 605-B, AN INSURER THAT DOES NOT
14 COMPLY WITH THE PROVISIONS OF SECTION 603-B MAY NOT
15 RETROACTIVELY DENY REIMBURSEMENT OR ATTEMPT IN ANY MANNER TO
16 RETROACTIVELY COLLECT REIMBURSEMENT ALREADY PAID TO A HEALTH
17 CARE PROVIDER.
18 SECTION 605-B. FRAUDULENT OR IMPROPERLY CODED INFORMATION.
19 (A) REASONS FOR DENIAL.--THE PROVISIONS OF SECTION 603-B DO
20 NOT APPLY IF AN INSURER RETROACTIVELY DENIES REIMBURSEMENT TO A
21 HEALTH CARE PROVIDER BECAUSE:
22 (1) THE INFORMATION SUBMITTED TO THE INSURER WAS
23 FRAUDULENT;
24 (2) THE INFORMATION SUBMITTED TO THE INSURER WAS
25 IMPROPERLY CODED AND THE INSURER HAS PROVIDED TO THE HEALTH
26 CARE PROVIDER SUFFICIENT INFORMATION REGARDING THE CODING
27 GUIDELINES USED BY THE INSURER AT LEAST 30 DAYS PRIOR TO THE
28 DATE THE SERVICES SUBJECT TO THE RETROACTIVE DENIAL WERE
29 RENDERED; OR
30 (3) THE CLAIM SUBMITTED TO THE INSURER WAS A DUPLICATE
20060S1335B2219 - 14 -
1 CLAIM.
2 (B) IMPROPER CODING.--INFORMATION SUBMITTED TO THE INSURER
3 MAY BE CONSIDERED TO BE IMPROPERLY CODED UNDER SUBSECTION (A)(2)
4 IF THE INFORMATION SUBMITTED TO THE INSURER BY THE HEALTH CARE
5 PROVIDER:
6 (1) USES CODES THAT DO NOT CONFORM WITH THE CODING
7 GUIDELINES USED BY THE CARRIER APPLICABLE AS OF THE DATE THE
8 SERVICE OR SERVICES WERE RENDERED; OR
9 (2) DOES NOT OTHERWISE CONFORM WITH THE CONTRACTUAL
10 OBLIGATIONS OF THE HEALTH CARE PROVIDER TO THE INSURER
11 APPLICABLE AS OF THE DATE THE SERVICE OR SERVICES WERE
12 RENDERED.
13 SECTION 606-B. COORDINATION OF BENEFITS.
14 IF AN INSURER RETROACTIVELY DENIES REIMBURSEMENT FOR SERVICES
15 AS A RESULT OF COORDINATION OF BENEFITS UNDER PROVISIONS OF
16 SECTION 605-B(A), THE HEALTH CARE PROVIDER SHALL HAVE SIX MONTHS
17 FROM THE DATE OF THE DENIAL, UNLESS AN INSURER PERMITS A LONGER
18 TIME PERIOD, TO SUBMIT A CLAIM FOR REIMBURSEMENT FOR THE SERVICE
19 TO THE INSURER, THE MEDICAL ASSISTANCE PROGRAM OR MEDICARE
20 PROGRAM RESPONSIBLE FOR PAYMENT.
21 SECTION 5. SECTION 1009-A OF THE ACT IS AMENDED BY ADDING A
22 SUBSECTION TO READ:
23 Section 1009-A. Conversion Policies.--* * *
24 (c) The premium rate for an individual who purchases a
25 conversion policy that is also offered by an insurer on a
26 guaranteed issue basis in the individual health insurance market
27 in this Commonwealth shall be the same as the premium rate
28 charged for that policy in the individual market. This premium
29 rate shall be subject to review by the department as set forth
30 in applicable statutes and regulations. Any insurer utilizing
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1 this option shall notify the department.
2 Section 2 6. Section 1012-A of the act, amended December 23, <--
3 2003 (P.L.358, No.50), is amended to read:
4 [Section 1012-A. Expiration.--This article shall expire on
5 December 31, 2006.]
6 Section 3 7. This act shall take effect immediately. <--
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