S1137B1621A06114 MSP:JB 03/11/08 #90 A06114
AMENDMENTS TO SENATE BILL NO. 1137
Sponsor: REPRESENTATIVE KILLION
Printer's No. 1621
1 Amend Title, page 1, line 21, by inserting after
2 "expiration;"
3 providing for LifeLine health insurance;
4 Amend Bill, page 20, by inserting between lines 26 and 27
5 Section 5.1. The act is amended by adding a chapter to read:
6 CHAPTER 43
7 LIFELINE HEALTH INSURANCE
8 Section 4301. Scope of chapter.
9 This chapter relates to LifeLine health insurance.
10 Section 4302. Statement of purpose.
11 The General Assembly recognizes the need for individuals and
12 employers in this Commonwealth to have the opportunity to
13 acquire affordable health benefit plans that provide appropriate
14 and affordable coverage. The General Assembly seeks to increase
15 the availability of coverage by specifying health benefit plans
16 which certain insurers shall offer and also to require the
17 Insurance Department to take steps to facilitate the
18 availability of information relating to the plans and their
19 terms, conditions and premiums through electronic and other
20 media.
21 Section 4303. Definitions.
22 The following words and phrases when used in this chapter
23 shall have the meanings given to them in this section unless the
24 context clearly indicates otherwise:
25 "Commissioner." The Insurance Commissioner of the
26 Commonwealth.
27 "Department." The Insurance Department of the Commonwealth.
28 "Dependent child." A natural or adopted child of a qualified
29 individual. The term includes a stepchild who resides in a
30 qualified individual's household if the qualified individual has
31 assumed the financial responsibility for the child and another
32 parent is not legally responsible for the support and medical
33 expenses of the child.
34 "Eligible dependent." A spouse of a qualified individual and
35 a dependent child who is under 19 years of age.
36 "Health benefit plan." An individual or group health
37 insurance policy, subscriber contract, certificate or plan which
38 provides health or sickness and accident coverage which is
39 offered by an insurer. The term does not include any of the
40 following:
1 (1) An accident only policy.
2 (2) A limited benefit policy.
3 (3) A credit only policy.
4 (4) A long-term or disability income policy.
5 (5) A specified disease policy.
6 (6) A Medicare supplement policy.
7 (7) A Civilian Health and Medical Program of the
8 Uniformed Services (CHAMPUS) supplement policy.
9 (8) A fixed indemnity policy.
10 (9) A dental only policy.
11 (10) A vision only policy.
12 (11) A workers' compensation policy.
13 (12) An automobile medical payment policy under 75
14 Pa.C.S. (relating to vehicles).
15 "High deductible health plan." A health insurance policy
16 that would qualify as a high deductible health plan under
17 section 223(c)(2) of the Internal Revenue Code of 1986 (Public
18 Law 99-514, 26 U.S.C. § 223(c)(2)).
19 "Insurer." A company or health insurance entity licensed in
20 this Commonwealth to issue any individual or group health,
21 sickness or accident policy or subscriber contract or
22 certificate or plan that provides medical or health care
23 coverage by a health care facility or licensed health care
24 provider that is offered or governed under any of the following:
25 (1) The act of May 17, 1921 (P.L.682, No.284), known as
26 The Insurance Company Law of 1921.
27 (2) The act of December 29, 1972 (P.L.1701, No.364),
28 known as the Health Maintenance Organization Act.
29 (3) The act of May 18, 1976 (P.L.123, No.54), known as
30 the Individual Accident and Sickness Insurance Minimum
31 Standards Act.
32 (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan
33 corporations) or 63 (relating to professional health services
34 plan corporations).
35 "Licensee." An individual who is licensed by the Department
36 of State to provide professional health care services in this
37 Commonwealth.
38 "LifeLine health plan." A health benefit plan that offers
39 the following, subject to the provisions of section 4304:
40 (1) Twenty-one days of inpatient hospital surgical and
41 medical coverage per policy year.
42 (2) Coverage for four office visits for primary health
43 care services for covered services rendered by a licensee,
44 subject to a copayment for each visit of $10 for treatment of
45 injury or illness.
46 (3) Coverage for surgery and anesthesia.
47 (4) Coverage for emergency accident and medical
48 treatment.
49 (5) Coverage for diagnostic services up to $1,000 per
50 policy year.
51 (6) Coverage for chemotherapy and radiation treatment.
52 (7) Coverage for maternity care.
53 (8) Coverage for newborn care for up to 31 days
54 following birth.
55 "Participating insurer." An insurer that offers health
56 benefit plans to groups or individuals and which has health
57 benefit plans in force covering in the aggregate at least
58 100,000 qualified individuals in this Commonwealth.
59 "Standard health benefit plan." The LifeLine health plan and
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1 any high deductible health plan offered by participating
2 insurers to individuals and employers.
3 Section 4304. Offering of standard health benefit plans.
4 (a) Offering of plans.--All participating insurers shall
5 offer the standard benefit plans specified under this chapter to
6 individuals and to employers for the benefit of individuals
7 employed by them.
8 (b) Inclusion in coverage.--If coverage is provided to
9 eligible dependents under a LifeLine health plan, the coverage
10 shall include dependent children of the insured from the moment
11 of birth and for adopted dependent children with prior coverage
12 from the date of the interlocutory decree of adoption. The
13 participating insurer may require that the insured give notice
14 to it of any newborn child within 90 days following the birth of
15 the newborn child and of any adopted child within 60 days of the
16 date the insured has filed a petition to adopt.
17 (c) Exclusion.--Participating insurers may exclude coverage
18 under a LifeLine health plan for an individual who has not been
19 covered by a health benefit plan for more than 30 days for up to
20 one year for medical conditions for which medical advice or
21 treatment was received by the individual during the 12 months
22 prior to the effective date of the individual's LifeLine health
23 plan policy.
24 (d) Applicability.--No law, regulation or administrative
25 directive requiring the coverage of a health care benefit or
26 service or requiring the reimbursement, utilization or inclusion
27 of a specific category of licensee shall apply to LifeLine
28 health plans delivered or issued for delivery in this
29 Commonwealth under the authority granted under this chapter,
30 including the provision of the benefits or requirements mandated
31 by Article VI-A of the act of May 17, 1921 (P.L.682, No.284),
32 known as The Insurance Company Law of 1921, or by regulations
33 promulgated under this chapter.
34 Section 4305. Facilitation by the department of access to
35 standard health benefit plans and related
36 information.
37 (a) Duty of department.--The department shall take all
38 actions necessary to effectuate the provisions of this chapter
39 such that participating insurers are able to make standard
40 benefit plans available not later than 180 days following the
41 effective date of this section.
42 (b) Demonstration of coverage.--
43 (1) Each insurer shall, not more than 90 days after the
44 effective date of this section, demonstrate to the
45 commissioner all of the following:
46 (i) If it has health benefit plans in force covering
47 a sufficient number of individuals to qualify as a
48 participating insurer.
49 (ii) If qualified as a participating insurer, that
50 it has the capacity to issue standard health benefit
51 plans and provide information sufficient to permit the
52 department to discharge the responsibilities assigned to
53 it under subsection (d).
54 (iii) If qualified as a participating insurer, that
55 it has undertaken a process to make standard benefit
56 plans available not later than 180 days following the
57 effective date of this section.
58 (2) The commissioner shall notify an insurer of its
59 qualification as a participating insurer under this
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1 subsection.
2 (c) Demonstration of capacity.--
3 (1) An insurer shall, within 30 days of first providing
4 coverage under health benefit plans to a sufficient number of
5 individuals to qualify as a participating insurer under this
6 chapter, demonstrate to the commissioner all of the
7 following:
8 (i) That it has the capacity to issue standard
9 health benefit plans and provide information sufficient
10 to permit the department to discharge the
11 responsibilities assigned to it under subsection (d).
12 (ii) That it has undertaken a process to make
13 standard benefit plans available not later than 180 days
14 following provision of the information to the
15 commissioner.
16 (2) The commissioner shall notify an insurer of its
17 qualification as a participating insurer under this
18 subsection.
19 (d) Facilitation.--The department shall facilitate the
20 availability of information relating to standard health benefit
21 plans by electronic and other media, inclusive of pricing and
22 benefit information and all other relevant information, such
23 that prospective purchasers of the plans have the ability to
24 compare benefits, terms, conditions and pricing among all
25 participating insurers.
26 (e) Provision of information.--Participating insurers shall
27 provide the department, at its request, with information
28 sufficient to enable it to discharge its responsibilities under
29 subsection (d).
30 Section 4306. Records and reporting.
31 A participating insurer shall provide an annual report to the
32 department in a form prescribed by the department enumerating
33 all of the following:
34 (1) The number of individuals covered under standard
35 health benefit plans, coverage provided both directly to
36 individuals and through employers.
37 (2) The number of persons receiving coverage both under
38 LifeLine health benefit plans and through high deductible
39 health plans.
40 Section 4307. Petition for exception.
41 (a) Petition.--An insurer may, after the third anniversary
42 of its qualification as a participating insurer, petition the
43 commissioner to be relieved of the obligation to offer LifeLine
44 health plans under this chapter. The commissioner may grant the
45 petition upon a finding that the petitioner has used its
46 commercially reasonable best efforts to market and issue the
47 coverage and that continuation of the efforts would not provide
48 LifeLine health plan coverage to a sufficient number of
49 individuals to justify continued efforts to market and issue the
50 coverage.
51 (b) Arrangements.--The commissioner shall, as a condition
52 for approving a petition described under subsection (a), require
53 that arrangements be made for the orderly disposition of
54 outstanding coverage.
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