H0947B0955A01442 SFR:AAS 06/04/21 #90 A01442
AMENDMENTS TO HOUSE BILL NO. 947
Sponsor: REPRESENTATIVE ZIMMERMAN
Printer's No. 955
Amend Bill, page 1, lines 1 through 12, by striking out all
of said lines and inserting
Amending Title 40 (Insurance) of the Pennsylvania Consolidated
Statutes, in regulation of insurers and related persons
generally, providing for group market provisions.
Amend Bill, page 1, lines 15 through 22; page 2, lines 1
through 30; page 3, lines 1 through 24; by striking out all of
said lines on said pages and inserting
Section 1. Title 40 of the Pennsylvania Consolidated
Statutes is amended by adding a chapter to read:
CHAPTER 41
GROUP MARKET PROVISIONS
Subchapter
A. Preliminary Provisions
B. Procedures
C. Miscellaneous Provisions
SUBCHAPTER A
PRELIMINARY PROVISIONS
Sec.
4101. Definitions.
§ 4101. Definitions.
The following words and phrases when used in this chapter
shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Commissioner." The Insurance Commissioner of the
Commonwealth.
"Department." The Insurance Department of the Commonwealth.
"Insurer." An entity licensed by the department with
accident and health authority to issue a policy, subscriber
contract, certificate or plan that provides medical or health
care coverage, including emergency services, and is offered or
governed under any of the following:
(1) The act of May 17, 1921 (P.L.682, No.284), known as
The Insurance Company Law of 1921, including section 630 and
Article XXIV thereof.
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(2) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
(3) Chapter 61 (relating to hospital plan corporations)
or 63 (relating to professional health services plan
corporations).
SUBCHAPTER B
PROCEDURES
Sec.
4111. Furnishing claims experience data to policyholders.
§ 4111. Furnishing claims experience data to policyholders.
(a) General rule.--Subject to the other provisions of this
chapter, each insurer shall furnish claims experience data to
group policyholders within 30 days of a group policyholder's
request unless the information has been furnished to the group
policyholder within the preceding six months.
(b) Applicable group size.--Claims experience data shall be
furnished for each group of 51 or more covered employes, members
or enrollees, not including dependents.
(c) Claims experience data defined.--For purposes of this
chapter, claims experience data includes, for at least the last
two policy years, if applicable, separated by policy year, the
aggregated dollar value of each of the following:
(1) Earned premiums.
(2) Total incurred claims, including paid, reserved and
incurred but not reserved claims, inclusive of high amount
claims, pooled claims, capitated expenses and noncapitated
expenses.
(3) Any amounts incurred in excess of the individual
pooling or stop-loss point applicable to the group.
(4) Any amounts under a provider reimbursement
methodology other than fee for service that were allocated to
the group or otherwise accounted for in rating the group's
policy.
(d) Fee permitted.--An insurer may charge a fee for
providing the claims experience data to a group policyholder.
The fee shall be:
(1) Reasonable.
(2) Not unfairly discriminatory.
(3) In accord with a schedule or methodology filed with
the department at least 30 days prior to use, which schedule
shall become effective unless disapproved by the department
prior to use.
(e) Privacy protection.--In providing claims experience data
to a group policyholder under this chapter, an insurer shall
adhere to all Federal and State laws regarding disclosure of
protected health or personal information.
SUBCHAPTER C
MISCELLANEOUS PROVISIONS
Sec.
4121. Regulations.
4122. Enforcement and penalties.
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§ 4121. Regulations.
The department may promulgate regulations as necessary and
appropriate to implement this chapter.
§ 4122. Enforcement and penalties.
(a) General rule.--Subject to the other provisions of this
section, upon satisfactory evidence of the violation of any
section of this chapter by an insurer or any other person, one
or more of the following penalties may be imposed at the
commissioner's discretion:
(1) Suspension or revocation of the license of the
offending insurer or other person.
(2) Refusal, for a period not to exceed one year, to
issue a new license to the offending insurer or other person.
(3) A fine of not more than $5,000 for each violation of
this chapter.
(4) A fine of not more than $10,000 for each willful
violation of this chapter.
(b) Limitations.--
(1) Fines imposed under this section against an insurer
may not exceed $500,000 in the aggregate during a single
calendar year.
(2) Fines imposed under this section against any other
person may not exceed $100,000 in the aggregate during a
single calendar year.
(c) Additional remedies.--The enforcement remedies imposed
under this section are in addition to other remedies or
penalties that may be imposed under other applicable law of this
Commonwealth, including:
(1) The act of December 18, 1996 (P.L.1066, No.159),
known as the Accident and Health Filing Reform Act.
(2) The act of July 22, 1974 (P.L.589, No.205), known as
the Unfair Insurance Practices Act. Violations of this
chapter shall be deemed to be unfair methods of competition
and unfair or deceptive acts or practices under the Unfair
Insurance Practices Act.
(3) The act of June 25, 1997 (P.L.295, No.29), known as
the Pennsylvania Health Care Insurance Portability Act.
(d) Administrative procedure.--
(1) The administrative provisions of this section shall
be subject to 2 Pa.C.S. Ch. 5 Subch. A (relating to practice
and procedure of Commonwealth agencies).
(2) A party against whom penalties are assessed in an
administrative action may appeal to Commonwealth Court as
provided in 2 Pa.C.S. Ch. 7 Subch. A (relating to judicial
review of Commonwealth agency action).
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