H0746B2004A01820     DMS:EAZ  06/16/09     #90        A01820

AMENDMENTS TO HOUSE BILL NO. 746

Sponsor: REPRESENTATIVE KILLION

Printer's No. 2004

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Amend Bill, page 1, lines 15 through 31; page 2, line 1, by

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striking out "Amending the act of May 17," in line 15, all of

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lines 16 through 31, page 1 and all of line 1, page 2 and

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inserting

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Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An

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act relating to insurance; amending, revising, and consolidating

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the law providing for the incorporation of insurance companies,

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and the regulation, supervision, and protection of home and

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foreign insurance companies, Lloyds associations, reciprocal and

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inter-insurance exchanges, and fire insurance rating bureaus,

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and the regulation and supervision of insurance carried by such

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companies, associations, and exchanges, including insurance

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carried by the State Workmen's Insurance Fund; providing

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penalties; and repealing existing laws," requiring the Insurance

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Department to develop standard health benefit plans that certain

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insurers shall offer to individuals and small employers; and

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requiring the Insurance Department to facilitate the

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availability of standard health benefit plan information by

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electronic and other means.

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Amend Bill, page 23, lines 24 through 30; pages 24 through

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42, lines 1 through 30; page 43, lines 1 through 11, by striking

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out all of said lines on said pages and inserting

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Section 1.  The act of May 17, 1921 (P.L.682, No.284), known

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as The Insurance Company Law of 1921, is amended by adding an

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article to read:

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ARTICLE XLII

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LIFELINE HEALTH INSURANCE

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Section 4201.  Definitions.

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The following words and phrases when used in this article

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shall have the meanings given to them in this section unless the

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context clearly indicates otherwise:

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"Commissioner."  The Insurance Commissioner of the

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Commonwealth.

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"Department."  The Insurance Department of the Commonwealth.

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"Dependent child."  A natural or adopted child of a qualified

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individual. The term includes a stepchild who resides in a

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qualified individual's household if the qualified individual has

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assumed the financial responsibility for the child and another

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parent is not legally responsible for the support and medical

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expenses of the child.

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"Eligible dependent."  A spouse of a qualified individual and

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any dependent children who are under 19 years of age.

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"Health benefit plan."  An individual or group health

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insurance policy, subscriber contract, certificate or plan that

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provides health or sickness and accident coverage which is

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offered by an insurer. The term does not include any of the

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following:

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(1)  An accident only policy.

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(2)  A limited benefit policy.

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(3)  A credit only policy.

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(4)  A long-term or disability income policy.

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(5)  A long-term care policy.

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(6)  A specified disease policy.

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(7)  A Medicare supplement policy.

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(8)  A Civilian Health and Medical Program of the

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Uniformed Services (CHAMPUS) supplement policy.

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(9)  A fixed indemnity policy.

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(10)  A dental only policy.

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(11)  A vision only policy.

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(12)  A workers' compensation policy.

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(13)  An automobile medical payment policy under 75

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Pa.C.S. (relating to vehicles).

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"High deductible health plan."  A health insurance policy

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that would qualify as a high deductible health plan under

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section 223(c)(2) of the Internal Revenue Code of 1986 (Public

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Law 99-514, 26 U.S.C. § 223(c)(2)).

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"Insurer."  A company or health insurance entity licensed in

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this Commonwealth to issue any individual or group health

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insurance, sickness or accident policy, subscriber contract,

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certificate or plan that provides medical or health care

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coverage by a health care facility or licensed health care

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provider that is offered or governed under any of the following:

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(1)  This act.

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(2)  The act of December 29, 1972 (P.L.1701, No.364),

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known as the Health Maintenance Organization Act.

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(3)  The act of May 18, 1976 (P.L.123, No.54), known as

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the Individual Accident and Sickness Insurance Minimum

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Standards Act.

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(4)  40 Pa.C.S. Ch. 61 (relating to hospital plan

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corporations) or 63 (relating to professional health services

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plan corporations).

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"Licensee."  An individual who is licensed by the Department

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of State to provide professional health care services in this

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Commonwealth.

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"LifeLine health plan."  A health benefit plan that offers

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the following, subject to the provisions of section 4202:

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(1)  Twenty-one days of inpatient hospital surgical and

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medical coverage per policy year.

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(2)  Coverage for four office visits for primary health

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care services for covered services rendered by a licensee,

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subject to a copayment for each visit of $10 for treatment of

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injury or illness.

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(3)  Coverage for surgery and anesthesia.

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(4)  Coverage for emergency accident and medical

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treatment.

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(5)  Coverage for diagnostic services up to $1,000 per

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policy year.

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(6)  Coverage for chemotherapy and radiation treatment.

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(7)  Coverage for maternity care.

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(8)  Coverage for newborn care for up to 31 days

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following birth.

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"Participating insurer."  An insurer that offers health

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benefit plans to groups or individuals and which has health

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benefit plans in force covering in the aggregate at least

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100,000 qualified individuals in this Commonwealth.

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"Small employer.  In connection with a group health plan with

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respect to a calendar year and a plan year, an employer who

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employs an average of at least two but not more than 50 eligible

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employees on business days during the preceding calendar year

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and who employs at least two eligible employees on the first day

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of the plan year. In the case of an employer which was not in

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existence throughout the preceding calendar year, the

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determination whether an employer is a small employer shall be

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based on the average number of eligible employees that it is

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reasonably expected that the employer will employ on business

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days in the current calendar year.

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"Standard health benefit plan."  The LifeLine health plan and

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any high deductible health plan offered by participating

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insurers to individuals and employers.

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Section 4202.  Offering of standard health benefit plans.

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(a)  Offering of plans.--All participating insurers shall

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offer the standard benefit plans specified under this article to

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individuals and to employers for the benefit of individuals

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employed by them.

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(b)  Inclusion in coverage.--If coverage is provided to

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eligible dependents under a LifeLine health plan, the coverage

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shall include dependent children of the insured from the moment

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of birth and for adopted dependent children with prior coverage

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from the date of the interlocutory decree of adoption. The

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participating insurer may require that the insured give notice

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to it of any newborn child within 90 days following the birth of

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the child and of any adopted child within 60 days of the date

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the insured has filed a petition to adopt.

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(c)  Exclusion.--Participating insurers may exclude coverage

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under a LifeLine health plan for an individual who has not been

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covered by a health benefit plan for more than 30 days for up to

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one year for medical conditions for which medical advice or

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treatment was received by the individual during the 12 months

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prior to the effective date of the individual's LifeLine health

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plan policy.

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(d)  Applicability.--No law, regulation or administrative

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directive requiring the coverage of a health care benefit or

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service or requiring the reimbursement, utilization or inclusion

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of a specific category of licensee shall apply to LifeLine

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health plans delivered or issued for delivery in this

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Commonwealth under the authority granted under this article,

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including the provision of the benefits or requirements mandated

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under Article VI-A or by regulations promulgated under this

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article.

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Section 4203.  Facilitation by the department of access to

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standard health benefit plans and related

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information.

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(a)  Duty of department.--The department shall take all

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actions necessary to effectuate the provisions of this article

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such that participating insurers are able to make standard

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benefit plans available not later than 180 days following the

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effective date of this section.

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(b)  Demonstration of coverage.--

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(1)  Each insurer shall, not more than 90 days after the

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effective date of this section, demonstrate to the

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commissioner all of the following:

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(i)  If it has health benefit plans in force covering

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a sufficient number of individuals to qualify as a

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participating insurer.

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(ii)  If qualified as a participating insurer, that

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it has the capacity to issue standard health benefit

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plans and provide information sufficient to permit the

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department to discharge the responsibilities assigned to

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it under subsection (d).

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(iii)  If qualified as a participating insurer, that

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it has undertaken a process to make standard benefit

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plans available not later than 180 days following the

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effective date of this section.

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(2)  The commissioner shall notify an insurer of its

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qualification as a participating insurer under this

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subsection.

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(c)  Demonstration of capacity.--

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(1)  An insurer shall, within 30 days of first providing

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coverage under health benefit plans to a sufficient number of

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individuals to qualify as a participating insurer under this

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article, demonstrate to the commissioner all of the

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following:

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(i)  That it has the capacity to issue standard

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health benefit plans and provide information sufficient

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to permit the department to discharge the

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responsibilities assigned to it under subsection (d).

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(ii)  That it has undertaken a process to make

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standard benefit plans available not later than 180 days

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following provision of the information to the

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commissioner.

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(2)  The commissioner shall notify an insurer of its

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qualification as a participating insurer under this

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subsection.

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(d)  Facilitation.--The department shall facilitate the

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availability of information relating to standard health benefit

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plans by electronic and other means, inclusive of pricing and

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benefit information and all other relevant information, so that

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prospective purchasers of the plans have the ability to compare

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benefits, terms, conditions and pricing among all participating

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insurers.

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(e)  Provision of information.--Participating insurers shall

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provide the department, at its request, with information

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sufficient to enable it to discharge its responsibilities under

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subsection (d).

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Section 4204.  Small employer premium rates at renewal.

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The percentage increase in the premium rate an insurer shall

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charge to a small employer for a new rating period may not

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exceed the sum of the following:

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(1)  The percentage change in the premium rate measured

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from the first day of the prior rating period to the first

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day of the rating period.

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(2)  An adjustment, not to exced 25% annually and

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adjusted pro rata for rating periods of less than one year,

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due to the claim experience, health status or duration of

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coverage of the employees or dependents of the small employer

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as determined from the insurer's rate manual for the class of

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business.

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(3)  Any adjustment due to change in coverage or change

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in the case characteristics of the small employer as

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determined from the insurer's rate manual for the class of

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business.

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Section 4205.  Records and reporting.

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A participating insurer shall provide an annual report to the

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department in a form prescribed by the department enumerating

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all of the following:

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(1)  The number of individuals covered under standard

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health benefit plans, including coverage provided both

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directly to individuals and through employers.

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(2)  The number of persons receiving coverage both under

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LifeLine health benefit plans and through high deductible

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health plans.

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Section 4206.  Petition for exception.

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(a)  Petition.--

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(1)  An insurer may, after the third anniversary of its

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qualification as a participating insurer, petition the

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commissioner to be relieved of the obligation to offer

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LifeLine health plans under this article.

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(2)  The commissioner may grant the petition upon a

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finding that the petitioner has used its commercially

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reasonable best efforts to market and issue the coverage and

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that continuation of the efforts would not provide LifeLine

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health plan coverage to a sufficient number of individuals to

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justify continued efforts to market and issue the coverage.

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(b)  Arrangements.--The commissioner shall, as a condition

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for approving a petition described under subsection (a), require

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that arrangements be made for the orderly disposition of

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outstanding coverage.

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Section 2.  This act shall take effect in 60 days.