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| PRIOR PRINTER'S NOS. 514, 1852 | PRINTER'S NO. 1865 |
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| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
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| SENATE BILL |
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| INTRODUCED BY FOLMER, TOMLINSON, BROWNE, ALLOWAY, EARLL, ORIE, SCARNATI, SMUCKER, ERICKSON, PICCOLA, CORMAN, PILEGGI, GREENLEAF, WAUGH, WONDERLING, M. WHITE, BAKER AND D. WHITE, MARCH 2, 2009 |
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| SENATOR CORMAN, APPROPRIATIONS, RE-REPORTED AS AMENDED, APRIL 19, 2010 |
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| AN ACT |
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1 | Establishing the Pennsylvania High-Risk Health Insurance Pool, |
2 | the Pennsylvania High-Risk Health Insurance Pool Fund and the |
3 | State Comprehensive Health Insurance Pool Board; providing |
4 | for the powers and duties of the pool and the board, for |
5 | selection of administering insurer and for payment of plan |
6 | costs; and prescribing plan benefits. |
7 | The General Assembly of the Commonwealth of Pennsylvania |
8 | hereby enacts as follows: |
9 | Section 1. Short title. |
10 | This act shall be known and may be cited as the High-Risk |
11 | Health Insurance Pool Act. |
12 | Section 2. Definitions. |
13 | The following words and phrases when used in this act shall |
14 | have the meanings given to them in this section unless the |
15 | context clearly indicates otherwise: |
16 | "Board." The State Comprehensive Health Insurance Pool |
17 | Board. |
18 | "Commissioner." The Insurance Commissioner of the |
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1 | Commonwealth. |
2 | "Fund." The Pennsylvania High-Risk Health Insurance Pool |
3 | Fund. |
4 | "Health insurance." A hospital or medical expense incurred |
5 | policy, nonprofit health care services plan contract, health |
6 | maintenance organization, subscriber contract or any other |
7 | health care plan or arrangement that pays for or furnishes |
8 | medical or health care services whether by insurance or |
9 | otherwise, when sold to an individual or as a group policy. This |
10 | term does not include short-term, accident, dental-only, fixed |
11 | indemnity, limited benefit or credit insurance, coverage issued |
12 | as a supplement to liability insurance, insurance arising out of |
13 | a workers' compensation or similar law, automobile medical- |
14 | payment insurance or insurance under which benefits are payable |
15 | with or without regard to fault and which is statutorily |
16 | required to be contained in any liability insurance policy or |
17 | equivalent self-insurance. |
18 | "Insured." A person who is a legal resident of this |
19 | Commonwealth and a citizen of the United States who is eligible |
20 | to receive benefits from the pool. The term includes a dependent |
21 | and family member. |
22 | "Insurer." An entity that is authorized in this Commonwealth |
23 | to write health insurance or that provides health insurance in |
24 | this Commonwealth. The term includes an insurance company, |
25 | nonprofit health care services plan, fraternal benefits society, |
26 | health maintenance organization, third-party administrators, |
27 | State or local governmental unit, to the extent permitted by |
28 | Federal law any self-insured arrangement covered by section 3 of |
29 | the Employee Retirement Income Security Act of 1974 (Public Law |
30 | 93-406, 29 U.S.C. § 1002), that provides health care benefits in |
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1 | this Commonwealth, any other entity providing a plan of health |
2 | insurance or health benefits subject to State insurance |
3 | regulation and any reinsurer or stop-loss plan providing |
4 | reinsurance or stop-loss coverage to a health insurer in this |
5 | Commonwealth. |
6 | "Medicare." Coverage under both Parts A and B of Title XVIII |
7 | of the Social Security Act (42 U.S.C. § 1395 et seq.). |
8 | "Physician." An individual licensed to practice medicine |
9 | under the laws of this Commonwealth. |
10 | "Plan." The Comprehensive Health Insurance Plan as adopted |
11 | by the State Comprehensive Health Insurance Board. |
12 | "Pool." The Pennsylvania High-Risk Health Insurance Pool. |
13 | "Preexisting condition." A condition for which medical |
14 | advice, care or treatment was recommended or received during the |
15 | six months prior to effective date of coverage under the pool. |
16 | Except as otherwise provided in this act, preexisting conditions | <-- |
17 | shall not be covered during the 12 months following the person's |
18 | effective date of coverage under the plan. |
19 | "Producer." A person who is licensed to sell health |
20 | insurance in this Commonwealth. |
21 | "Resident." Any of the following: |
22 | (1) An individual who has been legally domiciled in this |
23 | Commonwealth for a minimum of 90 days for persons eligible | <-- |
24 | for enrollment in the pool. |
25 | (2) An individual who is legally domiciled in this |
26 | Commonwealth and is eligible for enrollment in the pool as a |
27 | result of the Health Insurance Portability and Accountability |
28 | Act of 1996 (Public Law 104-191, 110 Stat. 1936). |
29 | (3) An individual who is legally domiciled in the pool | <-- |
30 | this Commonwealth and is eligible for enrollment as a result | <-- |
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1 | of the Trade Adjustment Assistance Reform Act of 2002 (Public |
2 | Law 107-210, 116 Stat. 933). |
3 | "State-mandated health insurance benefit." The right, | <-- |
4 | established by an act of the General Assembly, of an insured |
5 | under a health insurance policy to receive reimbursement from |
6 | the insurer of an expenditure or cost of a medical test, |
7 | procedure or service related to the health of the insured, which |
8 | test, procedure or service is provided by a medical provider. |
9 | Section 3. Pennsylvania High-Risk Health Insurance Pool. |
10 | (a) Establishment.--A nonprofit legal entity to be known as |
11 | the Pennsylvania High-Risk Health Insurance Pool is hereby |
12 | established. |
13 | (b) Availability date for health insurance policies.--Health |
14 | insurance policies available in accordance with this act shall |
15 | be available for sale within one year from the effective date of |
16 | this section. |
17 | (c) Fund.--The Pennsylvania High-Risk Health Insurance Pool |
18 | Fund is established in the State Treasury. |
19 | Section 4. Pool coverage eligibility. |
20 | (a) General rule.--Any individual person who is and |
21 | continues to be a resident of this Commonwealth and a citizen of |
22 | the United States shall be eligible for coverage from the pool |
23 | if evidence is provided of one of the following: |
24 | (1) (i) A notice of rejection or refusal to issue |
25 | substantially similar insurance for health reasons by two |
26 | insurers, provided that at least two insurers offer |
27 | individual health insurance coverage in this |
28 | Commonwealth. |
29 | (ii) If only one insurer offers individual market |
30 | health insurance coverage in this Commonwealth then one |
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1 | rejection shall be sufficient. |
2 | (iii) A rejection or refusal by an insurer offering |
3 | only stop-loss, excess loss or reinsurance coverage with |
4 | respect to the applicant shall not be sufficient except |
5 | under this subsection. |
6 | (2) (i) A refusal by two insurers to issue insurance |
7 | except at a rate exceeding the pool rate, provided that |
8 | at least two insurers offer individual health insurance |
9 | coverage in this Commonwealth. |
10 | (ii) If only one insurer offers individual market |
11 | health insurance coverage in this Commonwealth, then one |
12 | quote that exceeds the pool rate shall be sufficient. |
13 | (3) A diagnosis of the individual with one of the |
14 | medical or health conditions listed by the board in |
15 | accordance with section 6. A person diagnosed with one or |
16 | more of these conditions shall be eligible for a pool |
17 | coverage without applying for health insurance coverage. |
18 | (4) For persons eligible due to eligibility under the |
19 | Health Insurance Portability and Accountability Act of 1996 |
20 | (Public Law 104-191, 110 Stat. 1936), the maintenance of |
21 | health insurance coverage for the previous 18 months with no |
22 | gap in coverage greater than 63 days of which the most recent |
23 | coverage was through an employer-sponsored plan. |
24 | (5) For persons eligible as a result of certification |
25 | for Federal trade adjustment assistance or for pension |
26 | benefit guarantee corporation assistance as provided by the |
27 | Trade Adjustment Assistance Reform Act of 2002 (Public Law |
28 | 107-210. 116 Stat. 933), coverage with no preexisting |
29 | conditions limitation for individuals with three months of |
30 | prior creditable coverage with a break in coverage of no more |
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1 | than 63 days. |
2 | (b) Dependents.--Each dependent of a person who is eligible |
3 | for coverage from the pool shall also be eligible for coverage |
4 | from the pool. In the instance of a child who is the primary |
5 | insured, resident family members shall also be eligible for |
6 | coverage. |
7 | (c) Preexisting waiting periods.--A person may maintain pool |
8 | coverage for the period of time the person is satisfying a |
9 | preexisting waiting period under another health insurance policy |
10 | or insurance arrangement intended to replace the pool policy. |
11 | (d) Conditions for ineligibility.--A person is ineligible |
12 | for coverage from the pool if the person: |
13 | (1) has in effect on the date pool coverage takes effect |
14 | health insurance coverage from an insurer or insurance |
15 | arrangement; |
16 | (2) is eligible for other health care benefits at the |
17 | time application is made to the pool, including COBRA |
18 | continuation except: |
19 | (i) coverage, including COBRA continuation, other |
20 | continuation or conversion coverage, maintained for the |
21 | period of time the person is satisfying any preexisting |
22 | condition waiting period under a pool policy; |
23 | (ii) employer group coverage conditioned by the |
24 | limitations described by subsection (a)(4) and (5); or |
25 | (iii) individual coverage conditioned by the |
26 | limitation described by subsection (a)(1), (2) or (3). |
27 | (3) has terminated coverage in the pool within 12 months |
28 | of the date that application is made to the pool unless the |
29 | person demonstrates a good faith reason for the termination; |
30 | (4) is confined in a county jail or imprisoned in a |
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1 | State correctional institution; |
2 | or |
3 | (5) has not had prior coverage with the pool terminated |
4 | for nonpayment of premiums or fraud. |
5 | (e) Waiver of preexisting condition requirements.--Pool |
6 | preexisting condition requirements shall be waived for the |
7 | following individuals: |
8 | (1) an individual for whom, as of the date on which the |
9 | individual seeks plan coverage, the aggregate of the periods |
10 | of creditable coverage is 18 months or more and whose most |
11 | recent prior creditable coverage was under group health |
12 | insurance coverage offered by a health insurance issuer, a |
13 | group health plan, a governmental plan, or a church plan, or |
14 | health insurance coverage offered in connection with any such |
15 | plans, or any other type of creditable coverage that may be |
16 | required by the Health Insurance Portability and |
17 | Accountability Act of 1996, or the regulations under that |
18 | act; |
19 | (2) an individual who is eligible for Federal trade |
20 | adjustment assistance or for pension benefit guarantee |
21 | corporation assistance, as provided by the Trade Adjustment |
22 | Assistance Reform Act of 2002, provided that as of the date |
23 | on which the individual was certified as eligible for Federal |
24 | trade adjustment assistance, the individual had at least |
25 | three months of prior creditable coverage with no longer than |
26 | a 63-day break in coverage as established by the Trade |
27 | Adjustment Assistance Reform Act of 2002 or the regulations |
28 | under that act. |
29 | (f) Termination of pool coverage.--Pool coverage shall |
30 | terminate: |
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1 | (1) on the date a person is no longer a resident of the | <-- |
2 | person's state this Commonwealth, except for a child who is a | <-- |
3 | student under 23 years of age and who is financially |
4 | dependent on a parent, a child for whom a person may be |
5 | obligated to pay child support or a child of any age who is |
6 | disabled and dependent on a parent; |
7 | (2) on the date a person requests coverage to end; |
8 | (3) on the death of the covered person; |
9 | (4) on the date State law requires cancellation of the |
10 | policy; |
11 | (5) at the option of the pool, 30 days after the pool |
12 | sends to the person an inquiry concerning the person's |
13 | eligibility, including an inquiry concerning the person's |
14 | residence, to which the person does not reply; |
15 | (6) on the 31st day after the day on which a premium |
16 | payment for pool coverage becomes due, if the payment is not |
17 | made before that date; or | <-- |
18 | (7) on the date a person reaches the maximum lifetime | <-- |
19 | limit, as provided in this act; or |
20 | (8) (7) at such time as the person ceases to meet the | <-- |
21 | eligibility requirements of this section. |
22 | (g) Termination due to eligibility.--A person who ceases to |
23 | meet the eligibility requirements of this section may have the |
24 | person's coverage terminated at the end of the policy period. |
25 | Section 5. State Comprehensive Health Insurance Pool Board. |
26 | (a) Establishment.--The State Comprehensive Health Insurance |
27 | Pool Board is established. The board members shall be appointed |
28 | as follows: |
29 | (1) One representative of a domestic insurance company |
30 | appointed by the President pro tempore of the Senate from a |
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1 | list supplied by the Insurance Federation of Pennsylvania, |
2 | Inc., or its successor. |
3 | (2) One representative of a domestic insurance company |
4 | appointed by the Speaker of the House of Representatives from |
5 | a list supplied by the Insurance Federation of Pennsylvania, |
6 | Inc., or its successor. |
7 | (3) One representative of a nonprofit health care |
8 | service plan appointed by the President pro tempore of the |
9 | Senate. |
10 | (4) One representative of a health maintenance |
11 | organization appointed by the Speaker of the House of |
12 | Representatives. |
13 | (5) One member representing the medical provider |
14 | community, such as a physician licensed to practice medicine |
15 | in this Commonwealth or a hospital administrator appointed by |
16 | the Secretary of Health from lists supplied by the |
17 | Pennsylvania Medical Society, or its successor, and the |
18 | Hospital & Healthsystem Association of Pennsylvania, or its |
19 | successor. |
20 | (6) Five members of the general public who are not |
21 | employed by or affiliated with an insurance company or plan, |
22 | group hospital or other health care provider and are not |
23 | reasonably expected to qualify for coverage in the pool, with |
24 | one appointment by each of the following: the Majority Leader |
25 | of the Senate, the Minority Leader of the Senate, the |
26 | Majority Leader of the House of Representatives, the Minority |
27 | Leader of the House of Representatives and the Insurance |
28 | Commissioner. |
29 | No elected official may be a member of the board. |
30 | (b) Special qualification.--In making appointments to the |
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1 | board, efforts shall be made to ensure that at least one person |
2 | serving on the board is at least 60 years of age. |
3 | (c) Terms of board members.--The original members of the |
4 | board shall be appointed for the following terms: |
5 | (1) Three Four members for a term of one year. | <-- |
6 | (2) Two Three members for a term of two year. | <-- |
7 | (3) Two Three members for a term of three years. | <-- |
8 | (4) All terms after the initial term shall be for three |
9 | years. |
10 | (d) Chairman.--The board shall elect one of its members as |
11 | chairman, who may serve in that capacity only for two years. |
12 | (e) Reimbursement of expenses.--Members of the board may be |
13 | reimbursed from moneys of the pool for actual and necessary |
14 | expenses incurred by them in the performance of their official |
15 | duties as members of the board but shall not otherwise be |
16 | compensated for their services. |
17 | (f) Limitation of liability.--Members of the board are not |
18 | liable for an action or omission performed in good faith in the |
19 | performance of powers and duties under this act, and no cause of |
20 | action may arise against a member for the action or omission. |
21 | (g) Plan to be submitted.-- |
22 | (1) The board shall adopt a plan pursuant to this act |
23 | and submit its articles, bylaws and operating rules to the |
24 | commissioner for approval. |
25 | (2) If the board fails to adopt a plan and suitable |
26 | articles, bylaws and operating rules within 180 days after |
27 | appointment of the board, the commissioner shall promulgate |
28 | rules to effectuate the provisions of this act and such rules |
29 | shall remain in effect until superseded by a plan and |
30 | articles, bylaws and operating procedures submitted by the |
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1 | board and approved by the commissioner. |
2 | Section 6. Board duties. |
3 | The board shall: |
4 | (1) Operate, supervise and administer the pool. |
5 | (2) Establish administrative and accounting procedures |
6 | for the operation of the pool. |
7 | (3) Establish procedures under which applicants and |
8 | participants in the plan may have grievances reviewed by an |
9 | impartial body and reported to the board. |
10 | (4) Select an administering insurer in accordance with |
11 | section 8. |
12 | (5) Require that all policy forms issued by the board |
13 | conform to standard forms developed by the board. The forms |
14 | shall be approved by the commissioner. |
15 | (6) Develop a program to publicize the existence of the |
16 | plan, the eligibility requirements of the plan, the |
17 | procedures for enrollment in the plan and shall maintain |
18 | public awareness of the plan. |
19 | (7) Promulgate a list of medical or health conditions |
20 | for which a person shall be eligible for pool coverage |
21 | without applying for health insurance. The list shall be |
22 | effective on the first day of the operation of the pool and |
23 | may be amended from time to time as may be appropriate. |
24 | (8) No later than June 1 of each year, make an annual |
25 | report to the Governor, the General Assembly and the |
26 | commissioner. The report shall summarize the activities of |
27 | the pool in the preceding calendar year, including |
28 | information regarding net written and earned premiums, plan |
29 | enrollment, administration expenses and paid and incurred |
30 | losses. |
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1 | Section 7. Operation of pool. |
2 | (a) General rule.--The pool may exercise any of the |
3 | authority that an insurance company authorized to write health |
4 | insurance in this Commonwealth may exercise under the laws of |
5 | this Commonwealth. |
6 | (b) Specific powers.--As part of its authority, the pool |
7 | may: |
8 | (1) Provide health benefits coverage to persons who are |
9 | eligible for that coverage under this act. |
10 | (2) Enter into contracts that are necessary to carry out |
11 | this act, including, with the approval of the commissioner, |
12 | entering into contracts with similar pools in other states |
13 | for the joint performance of common administrative functions |
14 | or with other organizations for the performance of |
15 | administrative functions. |
16 | (3) Sue or be sued, including taking any legal actions |
17 | necessary or proper to recover or collect assessments due the |
18 | pool. |
19 | (4) Institute any legal action necessary to avoid |
20 | payment of improper claims against the pool or the coverage |
21 | provided by or through the pool, to recover any amounts |
22 | erroneously or improperly paid by the pool, to recover any |
23 | amount paid by the pool as a mistake of fact or law and to |
24 | recover other amounts due the pool. |
25 | (5) Establish appropriate rates, copayments, | <-- |
26 | deductibles, rate schedules, rate adjustments, expense |
27 | allowance, agents' referral fees and claim reserve formulas |
28 | and perform any actuarial function appropriate to the |
29 | operation of the pool. |
30 | (6) Adopt policy forms, endorsements and riders and |
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1 | applications for coverage. |
2 | (7) Issue insurance policies subject to this act and the |
3 | plan of operation. |
4 | (8) Appoint appropriate legal, actuarial and other |
5 | committees that are necessary to provide technical assistance |
6 | in operating the pool and performing any of the functions of |
7 | the pool. |
8 | (9) Employ and set the compensation of any persons |
9 | necessary to assist the pool in carrying out its |
10 | responsibilities and functions. |
11 | (10) Contract for stop-loss insurance for risks incurred |
12 | by the pool. |
13 | (11) Borrow money as necessary to implement the purposes | <-- |
14 | of the pool. |
15 | (12) (11) Issue additional types of health insurance | <-- |
16 | policies to provide optional coverage which comply with |
17 | applicable provisions of Federal and State law, including |
18 | Medicare supplemental health insurance. |
19 | (13) (12) Provide for and employ cost containment | <-- |
20 | measures and requirements, including, but not limited to, |
21 | preadmission screening, second surgical opinion and |
22 | concurrent utilization case management for the purpose of |
23 | making the benefit plans more cost effective. |
24 | (14) (13) Design, utilize, contract or otherwise arrange | <-- |
25 | for delivery of cost-effective health care services, |
26 | including establishing or contracting with preferred provider |
27 | organizations and health maintenance organizations. |
28 | (15) (14) Provide for reinsurance on either a | <-- |
29 | facultative or treaty basis, or both. |
30 | (15) Comply with the provisions of 62 Pa.C.S. Pt. I | <-- |
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1 | (relating to Commonwealth Procurement Code) in the award of |
2 | any contract for goods or services. |
3 | (16) Develop and implement bylaws that prohibit a member |
4 | of the board from voting on the selection of an insurer as |
5 | the plan's administrating insurer or on a contract for goods |
6 | or services, where the board member has a conflict of |
7 | interest resulting from employment or membership on the |
8 | governing board of the insurer or the company that would |
9 | provide the goods or services under the contract. The bylaws |
10 | shall include a procedure for a board member to disclose |
11 | potential voting conflicts to the other board members. |
12 | Section 8. Selection of administering insurer. |
13 | (a) General rule.--The board shall select an insurer, |
14 | through a competitive bidding process, to administer the plan. |
15 | The board shall evaluate the bids submitted under this |
16 | subsection based on criteria established by the board, which |
17 | criteria shall include, but not be limited to, the following: |
18 | (1) The insurer's proven ability to handle large group |
19 | accident and health policies insurance. |
20 | (2) The efficiency of the insurer's claims-paying |
21 | procedures. |
22 | (3) An estimate of total charges for administering the |
23 | plan. |
24 | (b) Term of contract.-- |
25 | (1) The administering insurer must enter into a contract |
26 | with the board. The term of the contract shall be for a |
27 | period of three years. |
28 | (2) At least one year prior to the expiration of each |
29 | three-year period of service by an administering insurer, the |
30 | board shall invite all insurers, including the current |
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1 | administering insurer, to submit bids to serve as the |
2 | administering insurer for the succeeding three-year period. |
3 | (3) The selection of the administering insurer for the |
4 | succeeding three-year period shall be made at least six |
5 | months prior to the end of the current three-year period. |
6 | (c) Duties of administering insurer.--The administering |
7 | insurer shall: |
8 | (1) Perform all eligibility and administrative claims- |
9 | payment functions relating to the plan. |
10 | (2) Pay an agent's referral fee as established by the |
11 | board to each agent who refers an applicant to the plan, if |
12 | the applicant is accepted. The selling or marketing of plans |
13 | shall not be limited to the administering insurer or its |
14 | agents. The referral fees shall be paid by the administering |
15 | insurer from moneys received as premiums for the plan. |
16 | (3) Establish a premium billing procedure for collection |
17 | of premiums from persons insured under the plan. |
18 | (4) Perform all necessary functions to assure timely |
19 | payment of benefits to covered persons under the plan, |
20 | including, but not limited to, the following: |
21 | (i) Making available information relating to the |
22 | proper manner of submitting a claim for benefits under |
23 | the plan and distributing forms upon which submissions |
24 | will be made. |
25 | (ii) Evaluating the eligibility of each claim for |
26 | payment under the plan. |
27 | (iii) Notifying each claimant within 30 days after |
28 | receiving a properly completed and executed proof of |
29 | loss, whether the claim is accepted, rejected or |
30 | compromised. |
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1 | (5) Submit regular reports to the board regarding the |
2 | operation of the plan. The frequency, content and form of the |
3 | reports shall be determined by the board. |
4 | (6) Following the close of each calendar year, determine |
5 | net premiums, reinsurance premiums less administrative |
6 | expenses allowance, the expense of administration pertaining |
7 | to the reinsurance operations of the pool and the incurred |
8 | losses for the year, and report this information to the board |
9 | and the commissioner. |
10 | (7) Pay claims expenses from the premium payments |
11 | received from or on behalf of covered persons under the plan. |
12 | Section 9. Payment of plan costs. |
13 | (a) General rule.--The board shall pay plan costs, excluding | <-- |
14 | any premium, deductible and copayment subsidies, first from |
15 | Federal funds, if any, that are transferred to the fund under | <-- |
16 | subsection (b) and that exceed premium, deductible and copayment | <-- |
17 | subsidy costs in a policy year. The remainder of the plan costs, |
18 | excluding premium, deductible and copayment subsidy costs, shall |
19 | be paid as follows: | <-- |
20 | (1) 66 2/3% from premiums paid by eligible persons. |
21 | (2) 33 1/3% from transfers or appropriations to the |
22 | fund. |
23 | (b) Application for Federal funds.--The board shall make |
24 | application for any Federal grants or other sources under which |
25 | the plan may be eligible to receive moneys. To the extent |
26 | allowable, the board shall use any moneys received from a |
27 | Federal grant or other source to offset plan deficits before |
28 | drawing from any alternative funding sources. |
29 | (c) Surplus funds.-- |
30 | (1) If grants, assessments and other receipts by the |
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1 | pool exceed the actual losses and administrative expenses of |
2 | the plan, the excess shall be held at interest and used by |
3 | the board to offset future losses or to reduce premiums. |
4 | (2) As used in this subsection, the term "future losses" |
5 | include reserves for claims incurred but not reported. |
6 | Section 10. Direct insurance by pool. |
7 | The coverage provided by the plan shall be directly insured |
8 | by the pool and the policies administered through the |
9 | administering insurer. |
10 | Section 11. Plan benefits. |
11 | (a) General rule.--The plan shall offer in an annually |
12 | renewable policy the coverage specified in this section for each |
13 | eligible person. In approving any of the benefit plans to be |
14 | offered by the plan, the board shall establish such benefit |
15 | levels, deductibles, coinsurance factors, exclusions and |
16 | limitations as it may deem appropriate and that it believes to |
17 | be generally reflective of and commensurate with individual |
18 | market health insurance that is provided in the individual |
19 | health insurance market in this Commonwealth. |
20 | (b) High deductible health plan option.--Notwithstanding any |
21 | other provisions of this section, the plan shall provide every |
22 | eligible person the option of selecting a health plan option |
23 | from at least one high deductible health plan that would qualify |
24 | to be used in conjunction with a health savings account under |
25 | section 223 of the Internal Revenue Code of 1986 (Public Law |
26 | 99-514, 26 U.S.C. § 1 et seq.). In conjunction with such a high |
27 | deductible health plan, the plan shall provide for the |
28 | establishment and administration of health savings accounts on |
29 | behalf of eligible persons who chose to be covered by a high |
30 | deductible health plan under this section. |
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1 | (c) Major medical expense coverage.--The plan shall offer |
2 | major medical expense coverage to every eligible person who is |
3 | not eligible for Medicare. Major medical expense coverage |
4 | offered under the plan shall pay an eligible person's covered |
5 | expenses, subject to a lifetime limit of $1,000,000 per covered | <-- |
6 | individual. |
7 | (d) Covered expenses.-- |
8 | (1) The usual customary charges or negotiable |
9 | reimbursement for the following services and articles, when |
10 | prescribed by a physician and medically necessary, shall be |
11 | covered expenses: |
12 | (i) Hospital services. |
13 | (ii) Professional services for the diagnosis or |
14 | treatment of injuries, illness or conditions, other than |
15 | dental, which are rendered by a physician or by others at |
16 | his direction. |
17 | (iii) Drugs requiring a physician's prescription. |
18 | (iv) Services of a licensed skilled nursing facility |
19 | for eligible individuals, ineligible for Medicare, for |
20 | not more than 100 calendar days during a policy year, if |
21 | the services and reimbursements are the type which would |
22 | qualify as reimbursable services under Medicare. |
23 | (v) Services of a home health agency, which services |
24 | are of a type that would qualify reimbursable services |
25 | under Medicare. |
26 | (vi) Use of radium or other radioactive materials. |
27 | (vii) Oxygen. |
28 | (viii) Anesthetics. |
29 | (ix) Prosthesis, other than dental prosthesis. |
30 | (x) Rental or purchase, as appropriate, of durable |
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1 | medical equipment, other than eyeglasses and hearing |
2 | aids. |
3 | (xi) Diagnostic X-rays and laboratory tests. |
4 | (xii) Oral surgery for partially or completely |
5 | erupted, impacted teeth and oral surgery with respect to |
6 | the tissues of the mouth when not performed in connection |
7 | with the extraction or repair of teeth. |
8 | (xiii) Services of a physical therapist. |
9 | (xiv) Transportation provided by a licensed |
10 | ambulance service to the nearest facility qualified to |
11 | treat a condition. |
12 | (xv) Processing of blood, including, but not limited |
13 | to, collecting, testing, fractioning and distributing |
14 | blood. |
15 | (xvi) Services for the treatment of alcohol and drug |
16 | abuse, but the insured shall be required to make a 50% |
17 | copayment, and the payment of the plan shall not exceed |
18 | $4,000. |
19 | (xvii) As an option, made available at an additional |
20 | premium, services provided by a duly licensed |
21 | chiropractor. |
22 | (e) Excluded expenses.--Covered expenses shall not include |
23 | the following: |
24 | (1) A charge for treatment for cosmetic purposes, other |
25 | than for repair or treatment of an injury or congenital |
26 | bodily defect to restore normal bodily functions. |
27 | (2) A charge for care which is primarily for custodial |
28 | or domiciliary purposes which does not qualify as an eligible |
29 | service under Medicaid. |
30 | (3) A charge for confinement in a private room, to the |
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1 | extent that the charge is in excess of the charge by the |
2 | institution for its most common semiprivate room unless a |
3 | private room is prescribed as medically necessary by a |
4 | physician. |
5 | (4) Any part of a charge for services or articles |
6 | rendered or provided by a physician or other health care |
7 | personnel that exceeds the prevailing charge in the locality |
8 | where the service is provided or any charge for services or |
9 | articles not medically necessary. |
10 | (5) A charge for services or articles the provision of |
11 | which is not within the authorized scope of practice of the |
12 | institution or individual providing the services or articles. |
13 | (6) An expense incurred prior to the effective date of |
14 | the coverage under the plan for the person on whose behalf |
15 | the expense was incurred. |
16 | (7) A charge for routine physical examinations. |
17 | (8) A charge for the services of blood donors and any |
18 | fee for the failure to replace the first three pints of blood |
19 | provided to an eligible person annually. |
20 | (9) A charge for personal services or supplies provided |
21 | by a hospital or nursing home or any other nonmedical or |
22 | nonprescribed services or supplies. |
23 | (f) Annual deductible choices.--The board shall provide for |
24 | at least two choices of annual deductibles for major medical |
25 | expenses, plus the benefits payable under any other type of |
26 | insurance coverage or workers' compensation, provided that if |
27 | two individual members of a family satisfy the applicable |
28 | deductible, no other members of the family shall be required to |
29 | meet deductibles for the remainder of that calendar year. |
30 | (g) Schedule of premium rates to be determined.-- |
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1 | (1) The board shall annually determine the schedule of |
2 | premium rates, copayments and deductibles for each benefit | <-- |
3 | plan option offered by the pool. |
4 | (2) Rates and rate schedules may be adjusted for |
5 | appropriate risk factors, including age and variation in |
6 | claim costs, and the board may consider appropriate risk |
7 | factors in accordance with established actuarial and |
8 | underwriting practices. The adjustment in rates and rating | <-- |
9 | schedules attributed to the difference in age between the |
10 | oldest insured person and the youngest insured person shall |
11 | not exceed a 4-to-1 ratio. |
12 | (3) (i) The board shall determine the standard risk |
13 | rate by considering the premium rates charged by other |
14 | insurers offering health insurance coverage to |
15 | individuals. The standard risk rate shall be established |
16 | using reasonable actuarial techniques and shall reflect |
17 | anticipated experience and expenses for such coverage. |
18 | (ii) The initial pool rate may not be less than 150% |
19 | and may not exceed 200% of rates established as |
20 | applicable for individual standard rates. |
21 | (iii) Subsequent rates shall be established to |
22 | provide fully for the expected costs of claims, including |
23 | recovery of prior losses, expenses of operation, |
24 | investment income of claim reserves and any other cost |
25 | factors subject to the limitations described in this |
26 | subsection. |
27 | (iv) In no event shall pool rates exceed 200% of |
28 | rates applicable to individual standard risks. |
29 | (4) All rates and rate schedules shall be submitted to |
30 | the commissioner for approval, and the pool may not use them |
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1 | unless the commissioner approves the rates and rate |
2 | schedules. The commissioner in evaluating the rates and rate |
3 | schedule of the pool shall consider the factors provided by |
4 | this section. |
5 | (h) Last payer of benefits.--The board shall provide that |
6 | the pool shall be the last payer of benefits whenever any other |
7 | benefit or source of third party payment is available. |
8 | Section 12. Effective date. |
9 | This act shall take effect in 60 days. |
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