THE GENERAL ASSEMBLY OF PENNSYLVANIA

SENATE BILL

INTRODUCED BY FOLMER AND PICCOLA, MARCH 2, 2009

REFERRED TO BANKING AND INSURANCE, MARCH 2, 2009  

AN ACT

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

act relating to insurance; amending, revising, and

consolidating the law providing for the incorporation of

insurance companies, and the regulation, supervision, and

protection of home and foreign insurance companies, Lloyds

associations, reciprocal and inter-insurance exchanges, and

fire insurance rating bureaus, and the regulation and

supervision of insurance carried by such companies,

associations, and exchanges, including insurance carried by

the State Workmen's Insurance Fund; providing penalties; and

repealing existing laws," in provisions relating to

children's health care, further providing for the children's

health care program and for State plan.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1.  Section 2311(c)(1.1), (e.1), (e.2), (e.3), (e.4),

(f.1), (f.2), (l)(6.1) and (o) of the act of May 17, 1921 (P.L.

682, No.284), known as The Insurance Company Law of 1921,

amended November 2, 2006 (P.L.1314, No.136), are amended and the

section is amended by adding a subsection to read:

Section 2311.  Children's Health Care.--* * *

(c)  * * *

(1.1)  Beginning January 1, 2007, and subject to the

provisions of section 2314, any insurer receiving funds from the

department to provide coverage of health care services under

this section shall enroll, to the extent that funds are

available, any child who meets all of the following:

(i)  Is a resident of this Commonwealth.

(ii)  Is not covered by a health insurance plan, a self-

insurance plan or a self-funded plan, or is not provided access

to health care coverage by court order, or is not eligible for

or covered by a medical assistance program administered by the

Department of Public Welfare, including the Healthy Beginnings

Program.

(iii)  Is qualified based on income under subsection (d)[,

(e.1), (e.2), (e.3) or (e.4) and meets the uninsured period

requirements as provided in subsection (f.1)].

(iv)  Meets the citizenship requirements of Title XXI of the

Social Security Act.

* * *

[(e.1)  The provision of health care insurance for an

eligible child whose family income is greater than two hundred

per centum (200%) of the Federal poverty level but no greater

than two hundred fifty per centum (250%) of the Federal poverty

level may be subsidized by the fund at a rate not to exceed

seventy-five per centum (75%) of the per member per month

premium cost.

(e.2)  The provision of health care insurance for an eligible

child whose family income is greater than two hundred fifty per

centum (250%) of the Federal poverty level but no greater than

two hundred seventy-five per centum (275%) of the Federal

poverty level may be subsidized by the fund at a rate not to

exceed sixty-five per centum (65%) of the per member per month

premium cost.

(e.3)  The provision of health care insurance for an eligible

child whose family income is greater than two hundred seventy-

five per centum (275%) of the Federal poverty level but no

greater than three hundred per centum (300%) of the Federal

poverty level may be subsidized by the fund at a rate not to

exceed sixty per centum (60%) of the per member per month

premium cost.

(e.4)  The following apply:

(1)  For an eligible child whose family income is greater

than the maximum level established under subsection (o), the

family may purchase the minimum benefit package set forth in

subsection (l)(6) for that child at the per month per member

premium cost, which cost shall be derived separately from the

other eligibility categories in the program, as long as the

family demonstrates on an annual basis and in a manner

determined by the department either one of the following:

(i)  The family is unable to afford individual or group

coverage because that coverage would exceed ten per centum (10%)

of the family income or because the total cost of coverage for

the child is one hundred fifty per centum (150%) of the greater

of:

(A)  the premium cost established under this subsection for

that service area; or

(B)  the premium cost established under the program for that

service area.

(ii)  The family has been refused coverage by an insurer due

to the child or a member of that child's immediate family having

a preexisting condition and coverage is not available to the

child.

(2)  For purposes of this subsection, "coverage" shall not

include coverage offered through accident only, fixed indemnity,

limited benefit, credit, dental, vision, specified disease,

Medicare supplement, Civilian Health and Medical Program of the

Uniformed Services (CHAMPUS) supplement, long-term care or

disability income, workers' compensation or automobile medical

payment insurance.]

(f)  The family of an eligible child whose family income

makes the child eligible for free care but who cannot receive

care due to lack of funds in the fund may purchase coverage for

the child at cost.

[(f.1)  To be eligible for coverage under subsections (e.1),

(e.2), (e.3) and (e.4), a child over two (2) years of age must

have been uninsured for the uninsured period unless:

(1)  the child's parent is eligible to receive benefits

pursuant to the act of December 5, 1936 (2nd Sp.Sess., 1937 P.L.

2897, No.1), known as the "Unemployment Compensation Law";

(2)  the child's parent was covered by a health insurance

plan, a self-insurance plan or a self-funded plan but, at the

time of application for coverage, is no longer employed and is

ineligible to receive benefits under the "Unemployment

Compensation Law"; or

(3)  a child is transferring from one government-subsidized

health care program to another.

(f.2)  For enrollees under subsections (e.1), (e.2), (e.3)

and (e.4), the following apply:

(1)  The department shall have the authority to impose

copayments for the following services, except as otherwise

prohibited by law:

(i)  Outpatient visits.

(ii)  Emergency room visits.

(iii)  Prescription medications.

(iv)  Any other service defined by the department.

(2)  The department shall have the authority to establish and

adjust the levels of these copayments in order to impose

reasonable cost sharing and to encourage appropriate utilization

of these services. In no event shall the premiums and copayments

for enrollees under subsections (e.1), (e.2) and (e.3) amount to

more than the per centum of total household income which is in

accord with the requirements of the Centers for Medicare and

Medicaid Services.]

* * *

(l)  A contractor with whom the department enters into a

contract shall do the following:

* * *

(6.1)  The department shall implement a premium assistance

program permitted under Federal regulations and as permitted

through Federal waiver or State plan amendment made pursuant to

this article. Notwithstanding any other law to the contrary, in

the event it is more cost effective to purchase health care from

a parent's employer-based program and the employer-based program

meets the minimum coverage requirements, employer-based coverage

may be purchased in place of enrollment in the health insurance

program established under this subdivision. An insurer shall

honor a request for enrollment and purchase of employe group

health insurance requested on behalf of an individual applying

for coverage under this article if that individual:

(i)  is a resident of this Commonwealth;

(ii)  is qualified based on income under section 2311(d)[,

(e.1), (e.2) or (e.3)] or (e);

(iii)  meets the uninsured period, except that any delay due

to an enrollment restriction, which may not exceed ninety (90)

days, or due to the length of the department's cost

effectiveness determination shall be counted towards calculating

the uninsured period; and

(iv)  meets the citizenship requirements of section 2311(c)

(1.1)(iv).

* * *

[(o)  Notwithstanding subsection (n), beginning January 1,

2007, and thereafter, and subject to the provisions of section

2314, the maximum income ceiling for subsidized insurance shall

not be raised above three hundred per centum (300%) of the

Federal poverty level.]

Section 2.  Section 2314 of the act, added November 2, 2006

(P.L.1314, No.136), is amended to read:

Section 2314.  State Plan.--The department, in cooperation

with the Department of Public Welfare, shall amend the State

plan as deemed necessary to carry out the provisions of this

article. [The repeal of section 2311(e) and (f) and the

expansion of financial eligibility under section 2311(e.1), (e.

2) and (e.3) shall be contingent upon Federal approval.]

Section 3.  This act shall take effect in 60 days.