PRINTER'S NO. 728
No. 676 Session of 2001
INTRODUCED BY SCHWARTZ, STOUT, BODACK, MUSTO, TARTAGLIONE,
KITCHEN, MELLOW, BOSCOLA, WAGNER, LOGAN, COSTA AND KASUNIC,
MARCH 20, 2001
REFERRED TO BANKING AND INSURANCE, MARCH 20, 2001
AN ACT
1 Requiring health insurers, health service corporations and
2 health maintenance organizations to provide individual child
3 health benefits coverage on a continuous open enrollment
4 basis.
5 The General Assembly of the Commonwealth of Pennsylvania
6 hereby enacts as follows:
7 Section 1. Short title.
8 This act shall be known and may be cited as the Individual
9 Child Health Benefits Act.
10 Section 2. Definitions.
11 The following words and phrases when used in this act shall
12 have the meanings given to them in this section unless the
13 context clearly indicates otherwise:
14 "Carrier." An insurance company, health service corporation
15 or health maintenance organization authorized to issue health
16 benefits plans in this Commonwealth. For purposes of this act,
17 carriers that are affiliated companies shall be treated as one
18 carrier.
1 "Commissioner." The Insurance Commissioner of the
2 Commonwealth.
3 "Department." The Insurance Department of the Commonwealth.
4 "Eligible person." A person who is a resident of this
5 Commonwealth who is 18 years of age or younger and who is not
6 eligible to be insured under Medicare or Medicaid.
7 "Financially impaired." A carrier which, after the effective
8 date of this act, is not insolvent but is deemed by the
9 Insurance Commissioner to be potentially unable to fulfill its
10 contractual obligations or a carrier which is placed under an
11 order of rehabilitation or conservation by a court of competent
12 jurisdiction.
13 "Health benefits plan." A hospital and medical expense
14 insurance policy, health service corporation contract or health
15 maintenance organization subscriber contract delivered or issued
16 for delivery in this Commonwealth. The term does not include the
17 following plans, policies or contracts: accident only, credit,
18 disability, long-term care, Medicare supplement coverage,
19 CHAMPUS supplement coverage, coverage for Medicare services
20 pursuant to a contract with the Federal Government, coverage for
21 Medicaid services pursuant to a contract with the Commonwealth,
22 coverage arising out of a workers' compensation or similar law,
23 automobile medical payment insurance or hospital confinement
24 indemnity coverage.
25 "Preexisting condition." A condition that, during a
26 specified period of not more than six months immediately
27 preceding the effective date of coverage, had manifested itself
28 in such a manner as would cause an ordinarily prudent person to
29 seek medical advice, diagnosis, care or treatment, or for which
30 medical advice, diagnosis, care or treatment was recommended or
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1 received as to that condition or as to a pregnancy existing on
2 the effective date of coverage.
3 Section 3. Child health benefits plan required.
4 No later than 180 days after the effective date of this act,
5 a carrier shall, as a condition of issuing health benefits plans
6 in this Commonwealth, offer an individual child health benefits
7 plan. The plan shall be offered on a continuous open enrollment
8 basis, except that a carrier shall not be required to offer
9 coverage if the commissioner finds that the acceptance of
10 applications for coverage would place the carrier in a
11 financially impaired condition. Additionally, a carrier must:
12 (1) Contract with providers in such a way as to ensure
13 that enrollees have access to the services covered by the
14 minimum benefits plan required to be offered under this act.
15 (2) Ensure that the family of a child who may be
16 eligible for medical assistance receives information about
17 and assistance in applying for medical assistance, including,
18 at a minimum, written notice of the telephone number and
19 address of the county assistance office where the family can
20 apply for medical assistance.
21 (3) Ensure that the family of a child who may be
22 eligible for other publicly or privately subsidized health
23 insurance programs, receives information about and assistance
24 in applying for such programs, including, at a minimum,
25 written notice of the telephone number and address of the
26 location where the family can apply for publicly or privately
27 subsidized health insurance.
28 (4) Comply with the reporting requirements of this act
29 and any other applicable requirement in law or regulation.
30 Section 4. Benefits of plan.
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1 (a) General rule.--An individual child health benefits plan
2 shall provide, at a minimum, the minimum benefits package for
3 children as established in section 2311(l)(6) of the act of May
4 17, 1921 (P.L.682, No.284), known as The Insurance Company Law
5 of 1921.
6 (b) Deductibles and copayments prohibited.--A carrier may
7 not impose a deductible or copayment requirement for individual
8 child health benefits plans offered under this act, except as
9 provided under Article XXIII of the Insurance Company Law of
10 1921.
11 (c) Preexisting conditions.--An individual child health
12 benefits plan offered under this act may not contain a
13 limitation on coverage for preexisting conditions.
14 Section 5. Guarantee of coverage and renewal of policy.
15 A child health benefits plan issued under this act is subject
16 to the following provisions:
17 (1) The health benefits plan shall guarantee coverage
18 for an eligible person at a premium consistent with the
19 provisions of section 6.
20 (2) A health benefits plan shall be renewable with
21 respect to an eligible person at the option of the policy or
22 contract holder, except under the following circumstances:
23 (i) Nonpayment of the required premiums by the
24 policy or contract holder.
25 (ii) Fraud or misrepresentation by the policy or
26 contract holder, including constructive fraud, with
27 respect to coverage of eligible persons.
28 (iii) Termination of eligibility of the policy or
29 contract holder.
30 Section 6. Policy premiums.
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1 An individual child health benefits plan offered pursuant to
2 this act shall be offered at a premium not to exceed the premium
3 of a carrier under contract with the Commonwealth to provide
4 children's health insurance under Article XXIII of the act of
5 May 17, 1921 (P.L.682, No.284), known as The Insurance Company
6 Law of 1921.
7 Section 7. Duties of department.
8 The department shall:
9 (1) Promulgate regulations necessary to implement this
10 act, including punitive actions to be taken against carriers
11 that fail to comply with this act.
12 (2) Review and approve child health benefits plans and
13 premiums.
14 (3) Monitor, review and evaluate the adequacy,
15 accessibility and availability of the services covered by
16 individual child health benefits plans required to be offered
17 under this act.
18 (4) In conjunction with the Department of Public
19 Welfare, ensure that the family of a child who is determined
20 not to be eligible for medical assistance, or who is
21 determined not to be eligible for other publicly or privately
22 subsidized health insurance programs, receives information
23 about and assistance in applying for an individual child
24 health benefits plan under this act, including, at a minimum,
25 written notice of the telephone number and address of the
26 location where the family can apply for the health insurance.
27 (5) Report annually to the Governor, the General
28 Assembly and the public on the total number of children's
29 health insurance inquiries received, the number of children
30 enrolled in individual child health benefits plans, the
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1 number of children referred to medical assistance or other
2 publicly or privately subsidized health insurance programs
3 and the number of inquiries which resulted in neither the
4 enrollment of a child nor a referral to other publicly or
5 privately subsidized health insurance programs. The report
6 shall include the department's evaluation of the adequacy,
7 accessibility and availability of the services covered by
8 individual child health benefits plans required to be offered
9 under this act.
10 Section 8. Effective date.
11 This act shall take effect in 60 days.
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