THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE BILL

INTRODUCED BY PASHINSKI, BISHOP, BRIGGS, CALTAGIRONE, CARROLL, D. COSTA, DALEY, DeLUCA, DeWEESE, DONATUCCI, FABRIZIO, GEORGE, GERGELY, HARKINS, HORNAMAN, JOSEPHS, KORTZ, KOTIK, KULA, MAHONEY, MIRABITO, MURPHY, M. O'BRIEN, SANTONI, STABACK, TAYLOR, WATERS AND YOUNGBLOOD, JUNE 8, 2011

REFERRED TO COMMITTEE ON INSURANCE, JUNE 8, 2011  

AN ACT

Providing for Health Care Insurance Certificate Program;

imposing duties on the Insurance Department; establishing the

Health Care Insurance Certificate Program Fund; providing for

administration of fund; and making a related repeal.

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

Insurance Certificate Program 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:

"Department."  The Insurance Department of the Commonwealth.

"Eligible adult."  A low-income adult who meets all of the

following:

(1)  Legally resides within the United States.

(2)  Has been domiciled in this Commonwealth for at least

90 days prior to enrollment.

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

insurance plan or a self-funded plan.

(4)  Has not been covered by a health insurance plan, a

self-insurance plan or a self-funded plan during the three

months immediately preceding the determination of eligibility

except when one of the following apply:

(i)  The low-income adult is eligible to receive

benefits under the act of December 5, 1936 (2nd Sp.Sess.,

1937 P.L.2897, No.1), known as the Unemployment

Compensation Law.

(ii)  The low-income adult was covered under one of

the above plans but at the time of application for

coverage is no longer employed and is ineligible to

receive benefits pursuant to the Unemployment

Compensation Law.

(iii)  The low-income adult is the spouse of a person

who meets either of the exceptions set forth in

subparagraph (i) or (ii) and both the eligible adult and

the spouse are low income and applying for coverage.

(5)  Is ineligible for medical assistance or Medicare.

"Fund."  The Health Care Insurance Certificate Program Fund

established in section 4.

"Insurer."  A company or health insurance entity licensed in

this Commonwealth to issue an 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 offered or governed under 40 Pa.C.S. Ch. 61

(relating to hospital plan corporations) or 63 (relating to

professional health services plan corporations).

"Program."  The Health Care Insurance Certificate Program

established in section 3.

Section 3.  Health Care Insurance Certificate Program.

(a)  Program establishment.--There is established in the

department the Health Care Insurance Certificate Program for the

purpose of assisting eligible adults in locating and paying for

health insurance. Fund appropriations to the department for the

program shall be used for contracts to provide insurance

certificates for eligible adults and outreach activities. The

department shall, to the greatest extent practicable, ensure

that all eligible adults in this Commonwealth have access to the

program established in this section.

(b)  Eligible adult responsibilities.--An eligible adult

seeking to participate in the program shall:

(1)  Submit an application to the department.

(2)  Pay the appropriate premium charged by an insurer

for the benefits package.

(3)  Be responsible for any required copayments for

health care services rendered under the benefit package in

subsection (g)(2).

(4)  Notify the department and the insurer of a change in

the eligible adult's income.

(c)  Financial assistance generally.--The department shall

carry out the program to provide eligible adults with financial

assistance in the purchase of their benefit packages. The

department shall issue to eligible adults a certificate not to

exceed $500 that shall be used for the purchase of the eligible

adult's health insurance. 

(d)  Purchase of insurance.--An eligible adult's certificate

shall be used to purchase the benefit package and shall be

received in a timely manner. The appropriations for the program

shall be used by the department to pay the difference between

the premium cost of the benefit package and the eligible adult's

payment. Subsidization of the benefit package is contingent upon

the amount of the appropriations to the program and limited to

eligible adults in compliance with subsection (b). Nothing under

this section shall constitute an entitlement derived from the

Commonwealth or a claim on any funds of the Commonwealth.

(e)  Potential waiting list.--The department shall maintain a

waiting list of eligible adults who have applied for the program

but who are not eligible due to insufficient revenues. An

eligible adult on the waiting list may purchase the benefit

package at the premium rates approved by the department.

(f)  Department responsibilities.--The department shall:

(1)  Administer the program on a Statewide basis.

(2)  Develop and make available to the public an

application form that eligible adults can use to apply for

participation in the program.

(3)  Conduct monitoring, oversight and audits of the

program for enforcement purposes.

(4)  Ensure that the eligibility of enrolled individuals

receiving subsidization of the benefit package is

redetermined on an annual basis.

(5)  In consultation with appropriate Commonwealth

agencies, monitor, review and evaluate the insurer's benefit

package for the adequacy, accessibility and availability of

the services required under subsection (g).

(6)  In consultation with appropriate Commonwealth

agencies, establish and coordinate the development,

implementation and supervision of an outreach plan.

(7)  Prepare and submit, by November 30, 2013, and

annually thereafter a report to the chair and minority chair

of the Banking and Insurance Committee of the Senate and to

the chair and minority chair of the Insurance Committee of

the House of Representatives regarding:

(i)  The number of eligible adults participating in

the program, with a geographic distribution. 

(ii)  The insurers participating in the program. 

(iii)  The scope of the services being provided and

the level of outreach. 

(iv)  The cost of the insurance. 

(v)  The amount an eligible adult contributes toward

the insurance, including any copayments and adjustments

due to the Consumer Price Index adjustment factor under

subsection (b)(2). 

The annual report shall be made available for public

inspection and posted on the department's publicly accessible

Internet website.

(g)  Benefit package.--Insurers shall make available for

purchase a benefit package with scope and duration determined by

the department that, at a minimum, includes coverage for:    

(1)  Chemotherapy.

(2)  Initial accident or medical emergency care.

(3)  Inpatient hospital room and board and ancillary

services 21 days per calendar year. 

(4)  Maternity and newborn care.

(5)  Oral surgery.

(6)  Outpatient diagnostic services in a hospital

setting.

(7)  Radiation therapy.

(8)  Surgical services.

(9)  Adult and pediatric examinations.

(10)  Adult and pediatric immunizations.

(11)  Gynecological examination and Pap test once per

calendar year.

(12)  Screening mammogram.

(13)  Anesthesia services.

(14)  Assistant surgery.

(15)  Concurrent care.

(16)  Consultation services with a maximum of one per

specialty.

(17)  A copayment of $50 for emergency services. The

copayment is waived if the patient is admitted.

(18)  Inpatient medical care covered for 21 days per

calendar year.

(19)  Outpatient diagnostic services.

(20)  A copayment of $15 for a primary care physician

office visit; and a copayment of $25 for a specialist visit.

The visits specified in this paragraph are limited to four

combined visits per calendar year.

(21)  Routine newborn care.

(22)  Second surgical opinion.

(23)  Surgery.

(24)  Therapy services.

(25)  Transplant services.

(26)  Other benefits as the department shall require.

(h)  Health insurance premium reduction.--An insurer shall,

upon presentation of a department-issued certificate by an

eligible adult, reduce the amount of the health insurance

premium to be paid by the eligible adult by $500.

Section 4.  Health Care Insurance Certificate Program Fund.

(a)  Establishment.--The Health Care Insurance Certificate

Program Fund is established as a separate fund in the Treasury

Department. The fund shall be administered by the department for

the purpose of maximizing the purchase of health insurance by

eligible adults.

(b)  Administration.--The fund shall be administered by the

department without liability on the part of the Commonwealth

beyond the amount of the fund.

(c)  State Treasurer as custodian of the fund.--The State

Treasurer shall be the custodian of the fund, and disbursements

from the fund shall be paid at the request of the department.

For making payments without audit, the State Treasurer shall not

be under any liability whatsoever. The State Treasurer may

deposit any portion of the fund not needed for immediate use as

other State funds are lawfully deposited. The interest shall be

placed to the credit of the fund.

(d)  Fund deposits.--The revenues associated with the repeal

of section 227 of the act of March 4, 1971 (P.L.6, No.2), known

as the Tax Reform Code of 1971, shall be deposited in the fund.

Section 5.  Administration of fund.

The Governor may transfer to the fund from such funds as may

be appropriate, money necessary to implement this act as quickly

as possible until sufficient revenues are realized by the Health

Care Insurance Certificate Program Fund. A transfer made under

this section shall be repaid with interest under section 2 of

the act of August 22, 1961 (P.L.1049, No.479), entitled "An act

authorizing the State Treasurer under certain conditions to     

transfer sums of money between the General Fund and certain

funds and subsequent transfers of equal sums between such funds,

and making appropriations necessary to effect such transfers."

Section 6.  Regulations.

The department is empowered to promulgate any and all

regulations necessary to implement this act.

Section 19.  Repeals.

Repeals are as follows:

(1)  The General Assembly declares that the repeal under

paragraph (2) is necessary to effectuate this act.

(2)  Section 227 of the act of March 4, 1971 (P.L.6,

No.2), known as the Tax Reform Code of 1971.

Section 20.  Effective date.

This act shall take effect in 60 days.