S1137B1621A06114       MSP:JB  03/11/08    #90             A06114
                       AMENDMENTS TO SENATE BILL NO. 1137
                                    Sponsor:  REPRESENTATIVE KILLION
                                           Printer's No. 1621

     1       Amend Title, page 1, line 21, by inserting after
     2    "expiration;"
     3               providing for LifeLine health insurance;
     4       Amend Bill, page 20, by inserting between lines 26 and 27
     5       Section 5.1.  The act is amended by adding a chapter to read:
     6                               CHAPTER 43
     7                       LIFELINE HEALTH INSURANCE
     8    Section 4301.  Scope of chapter.
     9       This chapter relates to LifeLine health insurance.
    10    Section 4302.  Statement of purpose.
    11       The General Assembly recognizes the need for individuals and
    12    employers in this Commonwealth to have the opportunity to
    13    acquire affordable health benefit plans that provide appropriate
    14    and affordable coverage. The General Assembly seeks to increase
    15    the availability of coverage by specifying health benefit plans
    16    which certain insurers shall offer and also to require the
    17    Insurance Department to take steps to facilitate the
    18    availability of information relating to the plans and their
    19    terms, conditions and premiums through electronic and other
    20    media.
    21    Section 4303.  Definitions.
    22       The following words and phrases when used in this chapter
    23    shall have the meanings given to them in this section unless the
    24    context clearly indicates otherwise:
    25       "Commissioner."  The Insurance Commissioner of the
    26    Commonwealth.
    27       "Department."  The Insurance Department of the Commonwealth.
    28       "Dependent child."  A natural or adopted child of a qualified
    29    individual. The term includes a stepchild who resides in a
    30    qualified individual's household if the qualified individual has
    31    assumed the financial responsibility for the child and another
    32    parent is not legally responsible for the support and medical
    33    expenses of the child.
    34       "Eligible dependent."  A spouse of a qualified individual and
    35    a dependent child who is under 19 years of age.
    36       "Health benefit plan."  An individual or group health
    37    insurance policy, subscriber contract, certificate or plan which
    38    provides health or sickness and accident coverage which is
    39    offered by an insurer. The term does not include any of the
    40    following:

     1           (1)  An accident only policy.
     2           (2)  A limited benefit policy.
     3           (3)  A credit only policy.
     4           (4)  A long-term or disability income policy.
     5           (5)  A specified disease policy.
     6           (6)  A Medicare supplement policy.
     7           (7)  A Civilian Health and Medical Program of the
     8       Uniformed Services (CHAMPUS) supplement policy.
     9           (8)  A fixed indemnity policy.
    10           (9)  A dental only policy.
    11           (10)  A vision only policy.
    12           (11)  A workers' compensation policy.
    13           (12)  An automobile medical payment policy under 75
    14       Pa.C.S. (relating to vehicles).
    15       "High deductible health plan."  A health insurance policy
    16    that would qualify as a high deductible health plan under
    17    section 223(c)(2) of the Internal Revenue Code of 1986 (Public
    18    Law 99-514, 26 U.S.C. § 223(c)(2)).
    19       "Insurer."  A company or health insurance entity licensed in
    20    this Commonwealth to issue any individual or group health,
    21    sickness or accident policy or subscriber contract or
    22    certificate or plan that provides medical or health care
    23    coverage by a health care facility or licensed health care
    24    provider that is offered or governed under any of the following:
    25           (1)  The act of May 17, 1921 (P.L.682, No.284), known as
    26       The Insurance Company Law of 1921.
    27           (2)  The act of December 29, 1972 (P.L.1701, No.364),
    28       known as the Health Maintenance Organization Act.
    29           (3)  The act of May 18, 1976 (P.L.123, No.54), known as
    30       the Individual Accident and Sickness Insurance Minimum
    31       Standards Act.
    32           (4)  40 Pa.C.S. Ch. 61 (relating to hospital plan
    33       corporations) or 63 (relating to professional health services
    34       plan corporations).
    35       "Licensee."  An individual who is licensed by the Department
    36    of State to provide professional health care services in this
    37    Commonwealth.
    38       "LifeLine health plan."  A health benefit plan that offers
    39    the following, subject to the provisions of section 4304:
    40           (1)  Twenty-one days of inpatient hospital surgical and
    41       medical coverage per policy year.
    42           (2)  Coverage for four office visits for primary health
    43       care services for covered services rendered by a licensee,
    44       subject to a copayment for each visit of $10 for treatment of
    45       injury or illness.
    46           (3)  Coverage for surgery and anesthesia.
    47           (4)  Coverage for emergency accident and medical
    48       treatment.
    49           (5)  Coverage for diagnostic services up to $1,000 per
    50       policy year.
    51           (6)  Coverage for chemotherapy and radiation treatment.
    52           (7)  Coverage for maternity care.
    53           (8)  Coverage for newborn care for up to 31 days
    54       following birth.
    55       "Participating insurer."  An insurer that offers health
    56    benefit plans to groups or individuals and which has health
    57    benefit plans in force covering in the aggregate at least
    58    100,000 qualified individuals in this Commonwealth.
    59       "Standard health benefit plan."  The LifeLine health plan and

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     1    any high deductible health plan offered by participating
     2    insurers to individuals and employers.
     3    Section 4304.  Offering of standard health benefit plans.
     4       (a)  Offering of plans.--All participating insurers shall
     5    offer the standard benefit plans specified under this chapter to
     6    individuals and to employers for the benefit of individuals
     7    employed by them.
     8       (b)  Inclusion in coverage.--If coverage is provided to
     9    eligible dependents under a LifeLine health plan, the coverage
    10    shall include dependent children of the insured from the moment
    11    of birth and for adopted dependent children with prior coverage
    12    from the date of the interlocutory decree of adoption. The
    13    participating insurer may require that the insured give notice
    14    to it of any newborn child within 90 days following the birth of
    15    the newborn child and of any adopted child within 60 days of the
    16    date the insured has filed a petition to adopt.
    17       (c)  Exclusion.--Participating insurers may exclude coverage
    18    under a LifeLine health plan for an individual who has not been
    19    covered by a health benefit plan for more than 30 days for up to
    20    one year for medical conditions for which medical advice or
    21    treatment was received by the individual during the 12 months
    22    prior to the effective date of the individual's LifeLine health
    23    plan policy.
    24       (d)  Applicability.--No law, regulation or administrative
    25    directive requiring the coverage of a health care benefit or
    26    service or requiring the reimbursement, utilization or inclusion
    27    of a specific category of licensee shall apply to LifeLine
    28    health plans delivered or issued for delivery in this
    29    Commonwealth under the authority granted under this chapter,
    30    including the provision of the benefits or requirements mandated
    31    by Article VI-A of the act of May 17, 1921 (P.L.682, No.284),
    32    known as The Insurance Company Law of 1921, or by regulations
    33    promulgated under this chapter.
    34    Section 4305.  Facilitation by the department of access to
    35                   standard health benefit plans and related
    36                   information.
    37       (a)  Duty of department.--The department shall take all
    38    actions necessary to effectuate the provisions of this chapter
    39    such that participating insurers are able to make standard
    40    benefit plans available not later than 180 days following the
    41    effective date of this section.
    42       (b)  Demonstration of coverage.--
    43           (1)  Each insurer shall, not more than 90 days after the
    44       effective date of this section, demonstrate to the
    45       commissioner all of the following:
    46               (i)  If it has health benefit plans in force covering
    47           a sufficient number of individuals to qualify as a
    48           participating insurer.
    49               (ii)  If qualified as a participating insurer, that
    50           it has the capacity to issue standard health benefit
    51           plans and provide information sufficient to permit the
    52           department to discharge the responsibilities assigned to
    53           it under subsection (d).
    54               (iii)  If qualified as a participating insurer, that
    55           it has undertaken a process to make standard benefit
    56           plans available not later than 180 days following the
    57           effective date of this section.
    58           (2)  The commissioner shall notify an insurer of its
    59       qualification as a participating insurer under this

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     1       subsection.
     2       (c)  Demonstration of capacity.--
     3           (1)  An insurer shall, within 30 days of first providing
     4       coverage under health benefit plans to a sufficient number of
     5       individuals to qualify as a participating insurer under this
     6       chapter, demonstrate to the commissioner all of the
     7       following:
     8               (i)  That it has the capacity to issue standard
     9           health benefit plans and provide information sufficient
    10           to permit the department to discharge the
    11           responsibilities assigned to it under subsection (d).
    12               (ii)  That it has undertaken a process to make
    13           standard benefit plans available not later than 180 days
    14           following provision of the information to the
    15           commissioner.
    16           (2)  The commissioner shall notify an insurer of its
    17       qualification as a participating insurer under this
    18       subsection.
    19       (d)  Facilitation.--The department shall facilitate the
    20    availability of information relating to standard health benefit
    21    plans by electronic and other media, inclusive of pricing and
    22    benefit information and all other relevant information, such
    23    that prospective purchasers of the plans have the ability to
    24    compare benefits, terms, conditions and pricing among all
    25    participating insurers.
    26       (e)  Provision of information.--Participating insurers shall
    27    provide the department, at its request, with information
    28    sufficient to enable it to discharge its responsibilities under
    29    subsection (d).
    30    Section 4306.  Records and reporting.
    31       A participating insurer shall provide an annual report to the
    32    department in a form prescribed by the department enumerating
    33    all of the following:
    34           (1)  The number of individuals covered under standard
    35       health benefit plans, coverage provided both directly to
    36       individuals and through employers.
    37           (2)  The number of persons receiving coverage both under
    38       LifeLine health benefit plans and through high deductible
    39       health plans.
    40    Section 4307.  Petition for exception.
    41       (a)  Petition.--An insurer may, after the third anniversary
    42    of its qualification as a participating insurer, petition the
    43    commissioner to be relieved of the obligation to offer LifeLine
    44    health plans under this chapter. The commissioner may grant the
    45    petition upon a finding that the petitioner has used its
    46    commercially reasonable best efforts to market and issue the
    47    coverage and that continuation of the efforts would not provide
    48    LifeLine health plan coverage to a sufficient number of
    49    individuals to justify continued efforts to market and issue the
    50    coverage.
    51       (b)  Arrangements.--The commissioner shall, as a condition
    52    for approving a petition described under subsection (a), require
    53    that arrangements be made for the orderly disposition of
    54    outstanding coverage.

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