1Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
2act relating to insurance; amending, revising, and
3consolidating the law providing for the incorporation of
4insurance companies, and the regulation, supervision, and
5protection of home and foreign insurance companies, Lloyds
6associations, reciprocal and inter-insurance exchanges, and
7fire insurance rating bureaus, and the regulation and
8supervision of insurance carried by such companies,
9associations, and exchanges, including insurance carried by
10the State Workmen's Insurance Fund; providing penalties; and
11repealing existing laws," further providing for the
12definition of "uninsured period" and for children's health
13care.

14The General Assembly of the Commonwealth of Pennsylvania
15hereby enacts as follows:

16Section 1. The definition of "uninsured period" in section
172303 of the act of May 17, 1921 (P.L.682, No.284), known as The
18Insurance Company Law of 1921, amended November 2, 2006
19(P.L.1314, No.136), is amended to read:

20Section 2303. Definitions.--As used in this article, the
21following words and phrases shall have the meanings given to

1them in this section:

2* * *

3["Uninsured period." Except for children two years of age or
4less, a continuous period of time of not less than six (6)
5consecutive months immediately preceding enrollment during which
6a child has been without health care insurance coverage in
7accordance with the requirements of this article.]

8* * *

9Section 2. Section 2311(c), (f.1) and (l) of the act,
10amended November 2, 2006 (P.L.1314, No.136), are amended to
11read:

12Section 2311. Children's Health Care.--* * *

13(c) (1) Any insurer receiving funds from the department to
14provide coverage of health care services shall enroll, to the
15extent that funds are available, any child who meets all of the
16following:

17(i) Is a resident of this Commonwealth.

18(ii) Is not covered by a health insurance plan, a self-
19insurance plan or a self-funded plan or is not eligible for or
20covered by medical assistance, including the Healthy Beginnings
21Program.

22(iii) Is qualified based on income under subsection (d) or
23(e).

24(iv) Meets the citizenship requirements of Title XXI of the
25Social Security Act (49 Stat. 620, 42 U.S.C. § 1397aa et seq.).

26(1.1) Beginning January 1, 2007, and subject to the
27provisions of section 2314, any insurer receiving funds from the
28department to provide coverage of health care services under
29this section shall enroll, to the extent that funds are
30available, any child who meets all of the following:

1(i) Is a resident of this Commonwealth.

2(ii) Is not covered by a health insurance plan, a self-
3insurance plan or a self-funded plan, or is not provided access
4to health care coverage by court order, or is not eligible for
5or covered by a medical assistance program administered by the
6Department of Public Welfare, including the Healthy Beginnings
7Program.

8(iii) Is qualified based on income under subsection (d),
9(e.1), (e.2), (e.3) or (e.4) [and meets the uninsured period
10requirements as provided in subsection (f.1)].

11(iv) Meets the citizenship requirements of Title XXI of the
12Social Security Act.

13(2) Enrollment may not be denied on the basis of a
14preexisting condition, nor may diagnosis or treatment for the
15condition be excluded based on the condition's preexistence.

16* * *

17(f.1) [To be eligible for coverage under subsections (e.1),
18(e.2), (e.3) and (e.4), a child over two (2) years of age must
19have been uninsured for the uninsured period unless:

20(1) the child's parent is eligible to receive benefits
21pursuant to the act of December 5, 1936 (2nd Sp.Sess., 1937
22P.L.2897, No.1), known as the "Unemployment Compensation Law";

23(2) the child's parent was covered by a health insurance
24plan, a self-insurance plan or a self-funded plan but, at the
25time of application for coverage, is no longer employed and is
26ineligible to receive benefits under the "Unemployment
27Compensation Law"; or

28(3) a child is transferring from one government-subsidized
29health care program to another.] (Reserved).

30* * *

1(l) A contractor with whom the department enters into a
2contract shall do the following:

3(1) Ensure to the maximum extent possible that eligible
4children have access to primary health care physicians and nurse
5practitioners within the contractor's service area.

6(2) Contract with qualified, cost-effective providers, which
7may include primary health care physicians, nurse practitioners,
8clinics and health maintenance organizations, to provide primary
9and preventive health care for enrollees on a basis best
10calculated to manage the costs of the services, including, but
11not limited to, using managed health care techniques and other
12appropriate medical cost-management methods.

13(3) Ensure that the family of a child who may be eligible
14for medical assistance receives assistance in applying for
15medical assistance.

16(4) Maintain waiting lists of children financially eligible
17for benefits who have applied for benefits but who were not
18enrolled due to lack of funds.

19(4.1) Notify families of children who are paying a premium
20of any changes in such premium or copayment requirements.

21(4.2) Collect such premiums or copayments from the family of
22any child receiving benefits as may be required.

23(4.3) Cancel policies for nonpayment of premium, in
24accordance with all other applicable insurance laws.

25(5) Strongly encourage all providers who provide primary
26care to eligible children to participate in medical assistance
27as qualified EPSDT providers and to continue to provide care to
28children who become ineligible for coverage under the provisions
29of this article but who qualify for medical assistance.

30(6) Subject to any necessary Federal approval, provide the

1following minimum benefit package for eligible children:

2(i) Preventive care. This subparagraph includes well-child
3care visits in accordance with the schedule established by the
4American Academy of Pediatrics and the services related to those
5visits, including, but not limited to, immunizations, health
6education, tuberculosis testing and developmental screening in
7accordance with routine schedule of well-child visits. Care
8shall also include a comprehensive physical examination,
9including X-rays if necessary, for any child exhibiting symptoms
10of possible child abuse.

11(ii) Diagnosis and treatment of illness or injury, including
12all medically necessary services related to the diagnosis and
13treatment of sickness and injury and other conditions provided
14on an ambulatory basis, such as laboratory tests, wound dressing
15and casting to immobilize fractures.

16(iii) Injections and medications provided at the time of the
17office visit or therapy and outpatient surgery performed in the
18office, a hospital or freestanding ambulatory service center,
19including anesthesia provided in conjunction with such service
20or during emergency medical service.

21(iv) Emergency accident and emergency medical care.

22(v) Prescription drugs.

23(vi) Emergency, preventive and routine dental care. This
24subparagraph does not include orthodontia or cosmetic surgery.

25(vii) Emergency, preventive and routine vision care,
26including the cost of corrective lenses and frames, not to
27exceed two prescriptions per year.

28(viii) Emergency, preventive and routine hearing care.

29(ix) Inpatient hospitalization up to ninety (90) days per
30year for eligible children.

1(6.1) The department shall implement a premium assistance
2program permitted under Federal regulations and as permitted
3through Federal waiver or State plan amendment made pursuant to
4this article. Notwithstanding any other law to the contrary, in
5the event it is more cost effective to purchase health care from
6a parent's employer-based program and the employer-based program
7meets the minimum coverage requirements, employer-based coverage
8may be purchased in place of enrollment in the health insurance
9program established under this subdivision. An insurer shall
10honor a request for enrollment and purchase of employe group
11health insurance requested on behalf of an individual applying
12for coverage under this article if that individual:

13(i) is a resident of this Commonwealth;

14(ii) is qualified based on income under section 2311(d),
15(e.1), (e.2) or (e.3);

16[(iii) meets the uninsured period, except that any delay due
17to an enrollment restriction, which may not exceed ninety (90)
18days, or due to the length of the department's cost
19effectiveness determination shall be counted towards calculating
20the uninsured period;] and

21[(iv)] (iii) meets the citizenship requirements of section
222311(c)(1.1)(iv).

23(6.2) The department shall have the authority to review,
24audit and approve annual administrative expenses incurred by
25contractors pursuant to this section.

26(7) Except for children covered under paragraph (6.1), each
27contractor shall provide an insurance identification card to
28each eligible child covered under contracts executed under this
29article. The card must not specifically identify the holder as
30low income.

1* * *

2Section 3. This act shall take effect immediately.