H1050B1064A00674 SFR:EJH 05/23/23 #90 A00674
AMENDMENTS TO HOUSE BILL NO. 1050
Sponsor: REPRESENTATIVE BOYLE
Printer's No. 1064
Amend Bill, page 1, lines 7 through 18; pages 2 through 7,
lines 1 through 30; page 8, line 1; by striking out all of said
lines on said pages and inserting
Section 1. Short title.
This act shall be known and may be cited as the Health
Insurance Preventive Services Coverage Act.
Section 2. Definitions.
The following words and phrases when used in this act shall
have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Commissioner." The Insurance Commissioner of the
Commonwealth.
"Cost sharing." The share of health care costs covered by an
insurance policy that an enrollee pays out-of-pocket. The term
includes deductibles, coinsurance, copayments and similar
charges. The term does not include premium, a balance billed
amount from an out-of-network provider or the cost of a
noncovered service.
"Department." The Insurance Department of the Commonwealth.
"Enrollee." A policyholder, subscriber, covered person or
other individual who is entitled to receive health care services
under a health insurance policy.
"Grandfathered health care plan." Individual or group health
insurance coverage in which an individual was enrolled prior to
the date of enactment of the Patient Protection and Affordable
Care Act (Public Law 111-148, 124 Stat. 119), or as otherwise
specified in 42 U.S.C. § 18011 (relating to preservation of
right to maintain existing coverage).
"Health insurance policy." A policy, subscriber contract,
certificate or plan issued by an insurer that provides medical
or health care coverage. The term does not include any of the
following:
(1) An accident only policy.
(2) A credit only policy.
(3) A long-term care or disability income policy.
(4) A specified disease policy.
(5) A Medicare supplement policy.
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(6) A fixed indemnity policy.
(7) A dental only policy.
(8) A vision only policy.
(9) A workers' compensation policy.
(10) An automobile medical payment policy.
(11) A policy under which benefits are provided by the
Federal Government to active or former military personnel and
their dependents.
(12) A hospital indemnity policy.
(13) Any other similar policy providing for limited
benefits.
"Insurer." An entity that offers, issues or renews a health
insurance policy that provides medical or health care coverage
by a health care facility or licensed health care provider and
that is 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 of The Insurance Company Law of 1921.
(2) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
(3) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations).
(4) 40 Pa.C.S. Ch. 63 (relating to professional health
services plan corporations).
"Out-of-network provider." A provider who does not contract
with an insurer to provide health care services to an enrollee
under a health insurance policy.
Section 3. Preventive services coverage.
(a) Requirements.--
(1) An insurer offering, issuing or renewing a health
insurance policy other than a grandfathered health care plan
shall, at a minimum, provide coverage and may not impose any
cost-sharing requirements for preventive services identified
in paragraph (2), subject to modification of the preventive
services required to be covered with no cost-sharing
requirement in accordance with subsection (b).
(2) Preventive services required to be covered under
this subsection include all of the following:
(i) Evidence-based items or services that have in
effect a rating of "A" or "B" in the current
recommendations of the United States Preventive Services
Task Force as of the date of publication of the notice
under section 8.
(ii) Immunizations that have in effect a
recommendation from the Advisory Committee on
Immunization Practices of the Centers for Disease Control
and Prevention with respect to the individual involved as
of the date of publication of the notice under section 8.
(iii) With respect to infants, children and
adolescents, evidence-informed preventive care and
screenings provided for in the comprehensive guidelines
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supported by the United States Health Resources and
Services Administration as of the date of publication of
the notice under section 8.
(iv) With respect to women, additional preventive
care and screenings not described in subparagraph (i) as
provided for in comprehensive guidelines supported by the
United States Health Resources and Services
Administration for purposes of this paragraph as of the
date of publication of the notice under section 8.
(b) Modification of preventive services.--
(1) The department may add or exempt one or more
preventive services from the preventive services required to
be covered without cost-sharing under this section by
transmitting notice of an addition or exemption to the
Legislative Reference Bureau for publication in the next
available issue of the Pennsylvania Bulletin and shall:
(i) Post notice on the publicly accessible Internet
website of the department.
(ii) Electronically send notice to the chairperson
and minority chairperson of the Banking and Insurance
Committee of the Senate and the chairperson and minority
chairperson of the Insurance Committee of the House of
Representatives.
(2) The department may not add a service unless the
service is:
(i) An evidence-based item or service that has in
effect a rating of "A" or "B" by the United States
Preventive Services Task Force.
(ii) A recommended immunization by the Advisory
Committee on Immunization Practices of the Centers for
Disease Control and Prevention.
(iii) Preventive care or screenings for women,
infants, children or adolescents provided for in the
comprehensive guidelines supported by the United States
Health Resources and Services Administration.
(3) The department may exempt a service if the service
is no longer:
(i) An evidence-based item or service that has in
effect a rating of "A" or "B" by the United States
Preventive Services Task Force.
(ii) A recommended immunization by the Advisory
Committee on Immunization Practices of the Centers for
Disease Control and Prevention.
(iii) Preventive care or screenings for women,
infants, children or adolescents provided for in the
comprehensive guidelines supported by the United States
Health Resources and Services Administration.
(4) Prior to adding or exempting a service as provided
in paragraph (1), the department shall:
(i) Make available for a 15-day public review and
comment period the proposed addition or exemption by
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posting an announcement on the publicly accessible
Internet website of the department.
(ii) Consider all of the following:
(A) Each public comment received under
subparagraph (i).
(B) The potential escalation of the cost of
health care services.
(C) Changes in medical evidence or scientific
advancement.
(D) The potential for discrimination against
individuals by reason of health status or health
status-related factors, race, religion, nationality
or ethnic group, age, sex, occupation, place of
residence or marital status.
(5) An addition or exemption under paragraph (1) shall
apply as follows:
(i) For a health insurance policy for which either
rates or forms are required to be filed with the
department, to a policy for which a form or rate is first
filed on or after the notice.
(ii) For a health insurance policy for which neither
rates nor forms are required to be filed with the
department, to a policy issued or renewed 180 days after
the publication of the notice.
(iii) For an exemption of a service on the grounds
of a potential danger to patients, at a time established
by the commissioner sooner than the time provided in
subparagraphs (i) and (ii).
(c) Construction regarding preventive services coverage.--
Nothing in this section shall be construed to:
(1) Prohibit an insurer from providing coverage for
preventive services in addition to those designated under
this act.
(2) Prohibit an insurer from denying coverage for
preventive services not designated under this act.
(3) Prevent an insurer from utilizing value-based
insurance designs.
(4) Diminish any other law that limits cost sharing for
a health care service.
Section 4. Construction.
(a) Actions of insurer.--Subject to subsection (b), nothing
in this act shall:
(1) Require an insurer that has a network of providers
to provide benefits for items or services described in
section 3 that are delivered by an out-of-network provider.
(2) Preclude an insurer that has a network of providers
from imposing cost-sharing requirements for items or services
described in section 3 that are delivered by an out-of-
network provider.
(b) Coverage and cost-sharing.--If an insurer does not have
in its network a provider who can provide an item or service
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described in section 3, the insurer shall cover the item or
service when performed by an out-of-network provider and may not
impose cost-sharing with respect to the item or service.
(c) Reasonable medical management techniques.--Nothing in
this act shall prevent an insurer from using reasonable medical
management techniques to determine the frequency, method,
treatment or setting for an item or service described in section
3 to the extent not specified in the relevant recommendation or
guideline. To the extent not specified in a recommendation or
guideline, an insurer may rely on the relevant clinical evidence
base and established reasonable medical management techniques to
determine the frequency, method, treatment or setting for
coverage of a recommended preventive health service.
Section 5. Regulations.
The department may promulgate regulations as may be necessary
and appropriate to carry out the provisions of this act.
Section 6. Enforcement.
(a) Penalties.--Upon satisfactory evidence of the violation
of any section of this act 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 act.
(4) A fine of not more than $10,000 for each willful
violation of this act.
(b) Limitations.--
(1) Fines imposed against an individual insurer under
this act may not exceed $500,000 in the aggregate during a
single calendar year.
(2) Fines imposed against any other person under this
act may not exceed $100,000 in the aggregate during a single
calendar year.
(c) Additional remedies.--The enforcement remedies imposed
under this subsection are in addition to any other remedies or
penalties that may be imposed under any other applicable law of
this Commonwealth, including:
(1) The act of July 22, 1974 (P.L.589, No.205), known as
the Unfair Insurance Practices Act. Violations of this act
shall be deemed to be an unfair method of competition and an
unfair or deceptive act or practice under the Unfair
Insurance Practices Act.
(2) The act of December 18, 1996 (P.L.1066, No.159),
known as the Accident and Health Filing Reform 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.--The administrative provisions
of this section shall be subject to 2 Pa.C.S. Ch. 5 Subch. A
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(relating to practice and procedure of Commonwealth agencies). 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).
Section 7. Repeals.
All acts and parts of acts are repealed insofar as they are
inconsistent with this act.
Section 8. Notice.
The commissioner shall transmit notice to the Legislative
Reference Bureau for publication in the next available issue of
the Pennsylvania Bulletin if any of the following occur:
(1) The Congress of the United States repeals, in whole
or in part, 42 U.S.C. § 300gg-13 (relating to coverage of
preventive health services).
(2) A court of the United States with competent
jurisdiction abrogates, vacates or invalidates, in whole or
in part, 42 U.S.C. § 300gg-13.
(3) The executive branch of the United States refuses to
enforce, or repeals a regulation implementing, in whole or in
part, 42 U.S.C. § 300gg-13.
Section 9. Implementation.
The implementation of this act shall be limited to the
provisions necessary to achieve a substitute coverage
requirement for the portion or portions of 42 U.S.C. § 300gg-13
(relating to coverage of preventive health services) that are
impacted by the occurrence of any of the events described in
section 8.
Section 10. Effective date.
This act shall take effect as follows:
(1) The following shall take effect immediately:
(i) Section 8.
(ii) Section 9.
(iii) This section.
(2) The remainder of this act shall take effect upon
publication of the notice in section 8.
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See A00674 in
the context
of HB1050