PRINTER'S NO. 3600
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
2564
Session of
2024
INTRODUCED BY HADDOCK, HILL-EVANS, HARRIS, HANBIDGE, PIELLI,
GIRAL, DONAHUE, FREEMAN, KIM, OTTEN, KHAN, PROBST,
SCHLOSSBERG, DELLOSO, CIRESI, VENKAT, MAYES, CEPEDA-FREYTIZ,
SANCHEZ AND DALEY, SEPTEMBER 11, 2024
REFERRED TO COMMITTEE ON INSURANCE, SEPTEMBER 11, 2024
AN ACT
Providing for health insurance access protections; imposing
duties on the Insurance Department and the Insurance
Commissioner; 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
Insurance Access Protection 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:
"Affordable Care Act." Collectively, the Patient Protection
and Affordable Care Act (Public Law 111-148, 124 Stat. 119) and
the Health Care and Education Reconciliation Act of 2010 (Public
Law 111-152, 124 Stat. 1029).
"Commissioner." The Insurance Commissioner of the
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Commonwealth.
"Department." The Insurance Department of the Commonwealth.
"Enrollee." A policyholder, subscriber, covered person or
other individual who is entitled to receive health care services
under a health insurance policy.
"Grandfathered health plan." Individual or group health
insurance coverage in which an individual was enrolled prior to
the date of enactment of the Affordable Care Act or as otherwise
specified in section 1251 of the Affordable Care Act (42 U.S.C.
§ 18011).
"Group health insurance policy." A policy, subscriber
contract, certificate or plan issued by an insurer that provides
medical or health care coverage on an annual basis to
individuals who obtain health insurance coverage through a
group.
"Health factor." An element related to an individual's
physical or mental makeup, including:
(1) Health status.
(2) Medical condition.
(3) Claims experience.
(4) Receipt of health care.
(5) Medical history.
(6) Genetic information.
(7) Evidence of insurability, including conditions
arising out of acts of domestic violence.
(8) Disability.
"Health insurance policy." As follows:
(1) A policy, subscriber contract, certificate or plan
issued by an insurer that provides medical or health care
coverage.
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(2) The term does not include any of the following:
(i) An accident only policy.
(ii) A credit only policy.
(iii) A long-term care or disability income policy.
(iv) A specified disease policy.
(v) A Medicare supplement policy.
(vi) A fixed indemnity policy.
(vii) A dental only policy.
(viii) A vision only policy.
(ix) A workers' compensation policy.
(x) An automobile medical payment policy.
(xi) A policy under which benefits are provided by
the Federal Government to active or former military
personnel and their dependents.
(xii) A hospital indemnity policy.
(xiii) Any other similar policies providing for
limited benefits.
"Individual health insurance policy." A policy, subscriber
contract, certificate or plan issued by an insurer that provides
medical or health care coverage on an annual basis to an
individual other than in connection with a group.
"Individual market." The market for health insurance
coverage offered to individuals other than in connection with a
group.
"Insurer." An entity that offers, issues or renews an
individual or group health insurance policy that provides
medical or health care coverage by a health care facility or
licensed health care provider and that is governed under any of
the following:
(1) The act of May 17, 1921 (P.L.682, No.284), known as
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The Insurance Company Law of 1921, including section 630 and
Article XXIV of 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) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations).
(4) 40 Pa.C.S. Ch. 63 (relating to professional health
services plan corporations).
"Preexisting condition." A health condition present before
the date of enrollment for coverage, or if coverage is denied,
the date of the denial, whether or not any medical advice,
diagnosis, care or treatment was recommended or received before
that date.
"Small group market." The market for health insurance for
coverage offered through a group health insurance policy for a
group of 2 to 50 individuals, exclusive of their dependents.
"Wellness program." A program offered by an employer that is
designed to promote health or prevent disease.
Section 3. Prohibitions concerning discrimination based on
preexisting conditions or health factors.
(a) Prohibition concerning eligibility for and enrollment in
health insurance.--An insurer offering, issuing or renewing an
individual or group health insurance policy may not impose any
rule for initial or continued eligibility of any individual to
enroll in or renew a health insurance policy based on any
preexisting condition or health factor in relation to an
individual or a dependent of the individual.
(b) Prohibition concerning premium rates.--
(1) An insurer offering, issuing or renewing an
individual or group health insurance policy may not require
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an individual to pay a premium rate that is greater than the
premium rate for a similarly situated individual enrolled in
the policy on the basis of any preexisting condition or
health factor in relation to an individual or a dependent of
the individual.
(2) Nothing in paragraph (1) shall be construed to
prevent an insurer offering a group health insurance policy
from establishing premium discounts or rebates or modifying
otherwise applicable copayments or deductibles in return for
adherence to a wellness program. Pending the promulgation of
regulations by the department, a wellness program shall be
subject to limitations as may be established in Federal law
or regulation.
(c) Prohibition concerning benefit coverage.--An insurer
offering, issuing or renewing an individual or group health
insurance policy may not exclude or deny coverage for any
benefit provided for in a policy based on any preexisting
condition or health factor in relation to an individual or a
dependent of the individual.
Section 4. Limitations on premium rating factors.
(a) Premium rate.--With respect to the premium rate charged
by an insurer for health insurance coverage offered in the
individual or small group market, the premium rate may only vary
for a particular plan or coverage based on the following:
(1) Family size.
(2) Geographic rating area.
(3) Age, except that the rate shall not vary by more
than 3 to 1 for adults except as provided under subsection
(d).
(4) Tobacco use, except that the rate shall not vary by
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more than 1.5 to 1 except as provided under subsection (d).
(b) Geographic rating areas.--The department may specify the
geographic rating areas by publication on the department's
publicly accessible Internet website and shall transmit notice
to the Legislative Reference Bureau for publication in the next
available issue of the Pennsylvania Bulletin. Prior to
publication, the department shall provide a 30-day comment
period and shall consult with insurers offering health insurance
policies in this Commonwealth.
(c) Age bands.--The department may define the permissible
age bands for rating purposes by publication on the department's
publicly accessible Internet website and shall transmit notice
to the Legislative Reference Bureau for publication in the next
available issue of the Pennsylvania Bulletin. Prior to
publication, the department shall provide a 30-day comment
period and shall consult with insurers offering health insurance
policies in this Commonwealth.
(d) Adjustment of age and tobacco rating variations.--The
department may, by regulation, adjust the rating bands for age
and tobacco use.
Section 5. Single risk pools.
(a) Individual market.--Except as permitted in accordance
with an innovation waiver under 40 Pa.C.S. Ch. 95 (relating to
reinsurance program), an insurer shall consider all enrollees in
all health insurance policies offered by the insurer in the
individual market, other than grandfathered health plans, to be
members of a single risk pool.
(b) Small group market.--An insurer shall consider all
enrollees in all health insurance policies offered by the
insurer in the small group market, other than grandfathered
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health plans, to be members of a single risk pool.
Section 6. Regulations.
(a) Authority to promulgate.--The department may promulgate
regulations as may be necessary and appropriate to carry out the
provisions of this act.
(b) Temporary regulations.--
(1) Notwithstanding any other provision of law, in order
to facilitate the prompt implementation of this act, the
department may issue temporary regulations which shall expire
no later than two years following publication of the
temporary regulations in the Pennsylvania Bulletin. The
temporary regulations shall be exempt from the following:
(i) Section 612 of the act of April 9, 1929
(P.L.177, No.175), known as The Administrative Code of
1929.
(ii) Sections 201, 202, 203, 204 and 205 of the act
of July 31, 1968 (P.L.769, No.240), referred to as the
Commonwealth Documents Law.
(iii) Section 204(b) of the act of October 15, 1980
(P.L.950, No.164), known as the Commonwealth Attorneys
Act.
(iv) The act of June 25, 1982 (P.L.633, No.181),
known as the Regulatory Review Act.
(2) The authority of the department to issue temporary
regulations under this subsection shall expire two years from
the effective date of this section. Regulations adopted after
the two-year period shall be promulgated as provided by
statute.
Section 7. Enforcement.
(a) Penalties.--Upon satisfactory evidence of the violation
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of any section of this act by an insurer or any other person,
one or more of the following penalties may be imposed at the
commissioner's discretion:
(1) Suspension or revocation of the license of the
offending insurer or other person.
(2) Refusal, for a period not to exceed one year, to
issue a new license to the offending insurer or other person.
(3) A fine of not more than $5,000 for each violation of
this act.
(4) A fine of not more than $10,000 for each willful
violation of this act.
(b) Limitations.--
(1) Fines imposed against an individual insurer under
this act may not exceed $500,000 in the aggregate during a
single calendar year.
(2) Fines imposed against any other person under this
act may not exceed $100,000 in the aggregate during a single
calendar year.
(c) Additional remedies.--The enforcement remedies imposed
under this section are in addition to any other remedies or
penalties that may be imposed under any other applicable law of
this Commonwealth, including:
(1) The act of July 22, 1974 (P.L.589, No.205), known as
the Unfair Insurance Practices Act. Violations of this act
shall be deemed to be an unfair method of competition and an
unfair or deceptive act or practice under the Unfair
Insurance Practices Act.
(2) The act of December 18, 1996 (P.L.1066, No.159),
known as the Accident and Health Filing Reform Act.
(3) The act of June 25, 1997 (P.L.295, No.29), known as
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the Pennsylvania Health Care Insurance Portability Act.
(d) Administrative procedure.--The administrative provisions
of this section shall be subject to 2 Pa.C.S. Ch. 5 Subch. A
(relating to practice and procedure of Commonwealth agencies).
A party against whom penalties are assessed in an administrative
action may appeal to Commonwealth Court as provided in 2 Pa.C.S.
Ch. 7 Subch. A (relating to judicial review of Commonwealth
agency action).
Section 8. Notice.
The commissioner shall transmit notice to the Legislative
Reference Bureau for publication in the next available issue of
the Pennsylvania Bulletin if any of the following occurs:
(1) The Congress of the United States repeals, in whole
or in part, any of the following:
(i) 42 U.S.C. § 300gg (relating to fair health
insurance premiums).
(ii) 42 U.S.C. § 300gg-3 (relating to prohibition of
preexisting condition exclusions or other discrimination
based on health status).
(iii) 42 U.S.C. § 300gg-4 (relating to prohibiting
discrimination against individual participants and
beneficiaries based on health status).
(iv) 42 U.S.C. § 18032(c) (relating to consumer
choice).
(2) A court of the United States abrogates, vacates or
invalidates any of the following, in whole or in part, or a
regulation implementing any of the following, in whole or in
part:
(i) 42 U.S.C. § 300gg.
(ii) 42 U.S.C. § 300gg-3.
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(iii) 42 U.S.C. § 300gg-4.
(iv) 42 U.S.C. § 18032(c).
(3) The executive branch of the United States refuses to
enforce or repeals a regulation implementing, in whole or in
part, any of the following:
(i) 42 U.S.C. § 300gg.
(ii) 42 U.S.C. § 300gg-3.
(iii) 42 U.S.C. § 300gg-4.
(iv) 42 U.S.C. § 18032(c).
Section 9. Implementation.
The implementation of this act shall be limited to the
provisions necessary to achieve a substitute coverage
requirement for the portion or portions of 42 U.S.C. § 300gg
(relating to fair health insurance premiums), 42 U.S.C. § 300gg-
3 (relating to prohibition of preexisting condition exclusions
or other discrimination based on health status), 42 U.S.C. §
300gg-4 (relating to prohibiting discrimination against
individual participants and beneficiaries based on health
status) or 42 U.S.C. § 18032(c) (relating to consumer choice)
that are impacted by the occurrence of any of the events
described in section 8.
Section 10. Repeals.
All acts and parts of acts are repealed insofar as they are
inconsistent with this act.
Section 11. Effective date.
This act shall take effect as follows:
(1) The following shall take effect immediately:
(i) Section 8.
(ii) Section 9.
(iii) This section.
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(2) The remainder of this act shall take effect upon
publication of the notice in section 8.
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