THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE BILL

INTRODUCED BY KULA, DeLUCA, GOODMAN, MAHONEY, BRENNAN, V. BROWN, CALTAGIRONE, COHEN, DALEY, DAVIS, FREEMAN, GEORGE, GIBBONS, HALUSKA, JOSEPHS, KOTIK, LONGIETTI, MANN, McGEEHAN, MUNDY, M. O'BRIEN, PASHINSKI, PAYTON, READSHAW, K. SMITH AND WAGNER, MARCH 1, 2011

REFERRED TO COMMITTEE ON INSURANCE, MARCH 1, 2011  

AN ACT

Providing for health care coverage; and imposing penalties.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1.  Short title.

This act shall be known and may be cited as the Health Care

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.

"Department."  The Insurance Department of the Commonwealth.

"Facility."  An institution providing health care services or

a health care setting, including hospitals and other licensed

inpatient centers, ambulatory surgical or treatment centers,

skilled nursing centers, residential treatment centers,

diagnostic, laboratory and imaging centers and rehabilitation

and other therapeutic health settings.

"Grandfathered plan coverage."  Coverage provided by a health

carrier in which an individual was enrolled on March 23, 2010

for as long as it maintains that status in accordance with

Federal regulations.

"Group health insurance coverage."  Health insurance coverage

offered in connection with a group health plan.

"Group health plan."  An employee welfare benefit plan as

defined in section 3(1) of the Employee Retirement Income

Security Act of 1974 (Public Law 93-406, 88 Stat. 829) to the

extent that the plan provides medical care and includes items

and services paid for as medical care to current and former

employees, or their dependents as defined under the terms of the

plan directly or through insurance, reimbursement or otherwise.

"Health benefit plan."

(1)  A policy, contract, certificate or agreement offered

by a health carrier to provide, deliver, arrange for, pay for

or reimburse any of the costs of health care services. The

term includes short-term and catastrophic health insurance

policies and a policy that pays on a cost-incurred basis,

except as otherwise exempted under this definition.

(2)  The term does not include:

(i)  Coverage only for accident, or disability income

insurance, or any combination thereof.

(ii)  Coverage issued as a supplement to liability

insurance.

(iii)  Liability insurance, including general

liability insurance and automobile liability insurance.

(iv)  Workers' compensation or similar insurance.

(v)  Automobile medical payment insurance.

(vi)  Credit-only insurance.

(vii)  Coverage for on-site medical clinics.

(viii)  Other similar insurance coverage, specified

in Federal regulations issued under the Health Insurance

Portability and Accountability Act of 1996 (Public Law

104-191, 110 Stat. 1936) under which benefits for medical

care are secondary or incidental to other insurance

benefits.

(3)  The term does not include the following benefits if

they are provided under a separate policy, certificate or

contract of insurance or are otherwise not an integral part

of the plan:

(i)  Limited scope dental or vision benefits.

(ii)  Benefits for long-term care, nursing home care,

home health care, community-based care, or any

combination thereof.

(iii)  Other similar, limited benefits specified in

Federal regulations issued under the Health Insurance

Portability and Accountability Act of 1996.

(4)  The term does not include the following benefits if

the benefits are provided under a separate policy,

certificate or contract of insurance, there is no

coordination between the provision of the benefits and any

exclusion of benefits under any group health plan maintained

by the same plan sponsor and the benefits are paid with

respect to an event without regard to whether benefits are

provided with respect to the event under any group health

plan maintained by the same plan sponsor:

(i)  Coverage only for a specified disease or

illness.

(ii)  Hospital indemnity or other fixed indemnity

insurance.

(5)  The term does not include the following if offered

as a separate policy, certificate or contract of insurance:

(i)  Medicare supplemental health insurance as

defined under section 1882(g)(1) of the Social Security

Act (49 Stat. 620, 42 U.S.C. § 1882(g)(1)).

(ii)  Coverage supplemental to the coverage provided

under the Civilian Health and Medical Program of the

Uniformed Services (CHAMPUS).

(iii)  Similar supplemental coverage provided to

coverage under a group health plan.

"Health care professional."  A physician, certified nurse

midwife, dentist, podiatrist, nurse, nurse practitioner,

chiropractor or other health care practitioner licensed,

accredited or certified to perform specified health care

services consistent with state law.

"Health care provider" or "provider."  A health care

professional or a facility.

"Health carrier."  A company or health insurance entity

licensed in this Commonwealth to offer or issue any individual

or group health, sickness or accident policy or subscriber

contract or certificate or plan that provides medical or health

care coverage by a health care facility or licensed health care

provider that is governed under this act or any of the

following:

(1)  Article XXIV of the act of May 17, 1921 (P.L.682,

No.284), known as 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)  The act of May 18, 1976 (P.L.123, No.54), known as

the Individual Accident and Sickness Insurance Minimum

Standards Act.

(4)  40 Pa.C.S. Ch. 61 (relating to hospital plan

corporations) or Ch. 63 (relating to professional health

services plan corporations).

"Health maintenance organization."  An organized system which

combines the delivery and financing of health care and which

provides basic health services to voluntarily enrolled

subscribers for a fixed prepaid fee.

"Individual health insurance coverage."  Health insurance

coverage offered to individuals in the individual market, which

includes a health benefit plan provided to individuals through a

trust arrangement, association or other discretionary group that

is not an employer plan, but does not include short-term limited

duration insurance. A health carrier offering health insurance

coverage in connection with a group health plan shall not be

deemed to be a health carrier offering individual health

insurance coverage solely because the carrier offers a

conversion policy.

"Managed care plan."  A health benefit plan that requires a

covered person to use, or creates incentives, including

financial incentives, for a covered person to use health care

providers managed, owned, under contract with or employed by the

health carrier.

"Medical care."  Amounts paid for:

(1)  The diagnosis, care, mitigation, treatment or

prevention of disease, or amounts paid for the purpose of

affecting any structure or function of the body.

(2)  Transportation primarily for and essential to

medical care under paragraph (1).

(3)  Insurance covering medical care under paragraphs (1)

and (2).

"Network."  The group of participating health care

professionals providing services to a managed care plan.

Section 3.  Coverage for preventive items and services.

(a)  Requirement.--A health carrier shall provide coverage

for all of the following items and services and may not impose

any cost-sharing requirements, such as a copayment, coinsurance

or deductible, with respect to the following items and services:

(1)  Except as provided under subsection (b), evidence-

based items or services that have in effect a rating of A or

B in the recommendations of the United States Preventive

Services Task Force as of September 23, 2010, with respect to

the individual involved.

(2)  Immunizations for routine use in children,

adolescents and adults 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. For purposes of this paragraph:

(i)  A recommendation from the Advisory Committee on

Immunization Practices of the Centers for Disease Control

and Prevention is considered in effect after it has been

adopted by the Director of the Centers for Disease

Control and Prevention.

(ii)  A recommendation is considered to be for

routine use if it is listed on the Immunization Schedules

of the Centers for Disease Control and Prevention.

(3)  With respect to infants, children and adolescents,

evidence-informed preventive care and screenings provided for

in comprehensive guidelines supported by the Health Resources

and Services Administration.

(4)  With respect to women and to the extent not

described under paragraph (1), evidence-informed preventive

care and screenings provided for in comprehensive guidelines

supported by the Health Resources and Services

Administration.

(b)  Cessation.--

(1)  (i)  A health carrier shall not be required to

provide coverage for items or services specified in any

recommendation or guideline described under subsection

(a) after the recommendation or guideline is no longer

described under subsection (a).

(ii)  Other provisions of Federal or State law may

apply in connection with a health carrier's ceasing to

provide coverage for the items or services, including

section 2715(d)(4) of the Public Health Services Act,

which requires a health carrier to give 60 days advance

notice to a covered person before any material

modification will become effective.

(2)  For purposes of subsection (a) and for the purpose

of any other provision of law, the United States Preventive

Services Task Force recommendations regarding breast cancer

screening, mammography and prevention issued in November 2009

are not considered to be current.

(c)  Revision.--A health carrier shall, at least annually at

the beginning of each new plan year or policy year, revise the

preventive services covered under its health benefit plans under

this section consistent with the recommendations of the United

States Preventive Services Task Force, the Advisory Committee on

Immunization Practices of the Centers for Disease Control and

Prevention and the guidelines with respect to infants, children,

adolescents and women evidence-based preventive care and

screenings by the Health Resources and Services Administration

in effect at the time of the revision.

Section 4.  Coverage for office visits in conjunction with

preventive items and services.

(a)  Cost-sharing.--Except as provided under subsection (b),

a health carrier may impose cost-sharing requirements with

respect to an office visit if an item or service described under

section 3:

(1)  Is billed separately or is tracked as individual

encounter data separately from the office visit.

(2)  Is not billed separately or is not tracked as

individual encounter data separately from the office visit

and the primary purpose of the office visit is not the

delivery of the item or service.

(b)  Cost.--A health carrier may not impose cost-sharing

requirements with respect to an office visit if an item or

service described under section 3 is not billed separately or is

not tracked as individual encounter data separately from the

office visit and the primary purpose of the office visit is the

delivery of the item or service.

Section 5.  Preventive items and services delivered by out-of-

network providers.

(a)  Benefits not required.--Nothing in this act shall

require a health carrier that has a network of providers to

provide benefits for items and services described under section

3 that are delivered by an out-of-network provider.

(b)  Cost-sharing.--Nothing under section 3 shall preclude a

health carrier that has a network of providers from imposing

cost-sharing requirements for items or services described under

section 3 that are delivered by an out-of-network provider.

Section 6.  Reasonable medical management.

Nothing in this act shall prevent a health carrier from using

reasonable medical management techniques to determine the

frequency, method, treatment or setting for an item or service

described under section 3 to the extent not specified in the

recommendation or guideline.

Section 7.  Additional services.

Nothing in this act shall prohibit a health carrier from

providing coverage for items and services in addition to those

recommended by the United States Preventive Services Task Force

or the Advisory Committee on Immunization Practices of the

Centers for Disease Control and Prevention, or provided by

guidelines supported by the Health Resources and Services

Administration, or from denying coverage for items and services

that are not recommended by that task force or that advisory

committee, or under those guidelines. A health carrier may

impose cost-sharing requirements for a treatment not described

under section 3 even if the treatment results from an item or

service described under section 3.

Section 8.  Enforcement.

(a)  Penalties and remedies.--Upon a determination by hearing

that this act has been violated, the commissioner may pursue one

or more of the following courses of action:

(1)  Issue an order requiring the person in violation to

cease and desist from engaging in the violation.

(2)  Suspend or revoke or refuse to issue or renew the

certificate or license of the person in violation.

(3)  Impose a civil penalty of not more than $5,000 for

each violation.

(4)  Impose any other penalty or remedy deemed

appropriate by the commissioner, including restitution.

(b)  Other remedies.--The enforcement remedies imposed under

this section shall be in addition to any other remedies or

penalties that may be imposed by statute. Violations of this

article are deemed and defined by the commissioner to be an

unfair method of competition and an unfair or deceptive act or

practice under the act of July 22, 1974 (P.L.589, No.205), known

as the Unfair Insurance Practices Act.

Section 9.  Applicability.

(a)  Applicability.--Except as provided under subsection (b),

this act shall apply to a health carrier providing coverage

under an individual or group health benefit plan.

(b)  Exception.--This act shall not apply to grandfathered

plan coverage.

Section 10.  Regulations.

The department shall promulgate regulations necessary to

implement this act.

Section 20.  Effective date.

This act shall take effect in 60 days.