Regular Session 2009-2010 House Bill 746 P.N. 2004 Amendment 2009 1820

H0746B2004A01820 DMS:EAZ 06/16/09 #90 A01820

AMENDMENTS TO HOUSE BILL NO. 746

Printer's No. 2004

Amend Bill, page 1, lines 15 through 31; page 2, line 1, by

striking out "Amending the act of May 17," in line 15, all of

lines 16 through 31, page 1 and all of line 1, page 2 and

inserting

Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An

act relating to insurance; amending, revising, and consolidating

the law providing for the incorporation of insurance companies,

and the regulation, supervision, and protection of home and

foreign insurance companies, Lloyds associations, reciprocal and

inter-insurance exchanges, and fire insurance rating bureaus,

and the regulation and supervision of insurance carried by such

companies, associations, and exchanges, including insurance

carried by the State Workmen's Insurance Fund; providing

penalties; and repealing existing laws," requiring the Insurance

Department to develop standard health benefit plans that certain

insurers shall offer to individuals and small employers; and

requiring the Insurance Department to facilitate the

availability of standard health benefit plan information by

electronic and other means.

Amend Bill, page 23, lines 24 through 30; pages 24 through

42, lines 1 through 30; page 43, lines 1 through 11, by striking

out all of said lines on said pages and inserting

Section 1. The act of May 17, 1921 (P.L.682, No.284), known

as The Insurance Company Law of 1921, is amended by adding an

article to read:

ARTICLE XLII

LIFELINE HEALTH INSURANCE

Section 4201. Definitions.

The following words and phrases when used in this article

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.

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"Dependent child." A natural or adopted child of a qualified

individual. The term includes a stepchild who resides in a

qualified individual's household if the qualified individual has

assumed the financial responsibility for the child and another

parent is not legally responsible for the support and medical

expenses of the child.

"Eligible dependent." A spouse of a qualified individual and

any dependent children who are under 19 years of age.

"Health benefit plan." An individual or group health

insurance policy, subscriber contract, certificate or plan that

provides health or sickness and accident coverage which is

offered by an insurer. The term does not include any of the

following:

(1) An accident only policy.

(2) A limited benefit policy.

(3) A credit only policy.

(4) A long-term or disability income policy.

(5) A long-term care policy.

(6) A specified disease policy.

(7) A Medicare supplement policy.

(8) A Civilian Health and Medical Program of the

Uniformed Services (CHAMPUS) supplement policy.

(9) A fixed indemnity policy.

(10) A dental only policy.

(11) A vision only policy.

(12) A workers' compensation policy.

(13) An automobile medical payment policy under 75

Pa.C.S. (relating to vehicles).

"High deductible health plan." A health insurance policy

that would qualify as a high deductible health plan under

section 223(c)(2) of the Internal Revenue Code of 1986 (Public

Law 99-514, 26 U.S.C. § 223(c)(2)).

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

this Commonwealth to issue any individual or group health

insurance, sickness or accident policy, subscriber contract,

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 any of the following:

(1) This act.

(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 63 (relating to professional health services

plan corporations).

"Licensee." An individual who is licensed by the Department

of State to provide professional health care services in this

Commonwealth.

"LifeLine health plan." A health benefit plan that offers

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the following, subject to the provisions of section 4202:

(1) Twenty-one days of inpatient hospital surgical and

medical coverage per policy year.

(2) Coverage for four office visits for primary health

care services for covered services rendered by a licensee,

subject to a copayment for each visit of $10 for treatment of

injury or illness.

(3) Coverage for surgery and anesthesia.

(4) Coverage for emergency accident and medical

treatment.

(5) Coverage for diagnostic services up to $1,000 per

policy year.

(6) Coverage for chemotherapy and radiation treatment.

(7) Coverage for maternity care.

(8) Coverage for newborn care for up to 31 days

following birth.

"Participating insurer." An insurer that offers health

benefit plans to groups or individuals and which has health

benefit plans in force covering in the aggregate at least

100,000 qualified individuals in this Commonwealth.

"Small employer. In connection with a group health plan with

respect to a calendar year and a plan year, an employer who

employs an average of at least two but not more than 50 eligible

employees on business days during the preceding calendar year

and who employs at least two eligible employees on the first day

of the plan year. In the case of an employer which was not in

existence throughout the preceding calendar year, the

determination whether an employer is a small employer shall be

based on the average number of eligible employees that it is

reasonably expected that the employer will employ on business

days in the current calendar year.

"Standard health benefit plan." The LifeLine health plan and

any high deductible health plan offered by participating

insurers to individuals and employers.

Section 4202. Offering of standard health benefit plans.

(a) Offering of plans.--All participating insurers shall

offer the standard benefit plans specified under this article to

individuals and to employers for the benefit of individuals

employed by them.

(b) Inclusion in coverage.--If coverage is provided to

eligible dependents under a LifeLine health plan, the coverage

shall include dependent children of the insured from the moment

of birth and for adopted dependent children with prior coverage

from the date of the interlocutory decree of adoption. The

participating insurer may require that the insured give notice

to it of any newborn child within 90 days following the birth of

the child and of any adopted child within 60 days of the date

the insured has filed a petition to adopt.

under a LifeLine health plan for an individual who has not been

covered by a health benefit plan for more than 30 days for up to

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one year for medical conditions for which medical advice or

treatment was received by the individual during the 12 months

prior to the effective date of the individual's LifeLine health

plan policy.

(d) Applicability.--No law, regulation or administrative

directive requiring the coverage of a health care benefit or

service or requiring the reimbursement, utilization or inclusion

of a specific category of licensee shall apply to LifeLine

health plans delivered or issued for delivery in this

Commonwealth under the authority granted under this article,

including the provision of the benefits or requirements mandated

under Article VI-A or by regulations promulgated under this

article.

Section 4203. Facilitation by the department of access to

standard health benefit plans and related

information.

(a) Duty of department.--The department shall take all

actions necessary to effectuate the provisions of this article

such that participating insurers are able to make standard

benefit plans available not later than 180 days following the

effective date of this section.

(b) Demonstration of coverage.--

(1) Each insurer shall, not more than 90 days after the

effective date of this section, demonstrate to the

commissioner all of the following:

(i) If it has health benefit plans in force covering

a sufficient number of individuals to qualify as a

participating insurer.

(ii) If qualified as a participating insurer, that

it has the capacity to issue standard health benefit

plans and provide information sufficient to permit the

department to discharge the responsibilities assigned to

it under subsection (d).

(iii) If qualified as a participating insurer, that

it has undertaken a process to make standard benefit

plans available not later than 180 days following the

effective date of this section.

(2) The commissioner shall notify an insurer of its

qualification as a participating insurer under this

subsection.

(1) An insurer shall, within 30 days of first providing

coverage under health benefit plans to a sufficient number of

individuals to qualify as a participating insurer under this

article, demonstrate to the commissioner all of the

following:

(i) That it has the capacity to issue standard

health benefit plans and provide information sufficient

to permit the department to discharge the

responsibilities assigned to it under subsection (d).

(ii) That it has undertaken a process to make

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standard benefit plans available not later than 180 days

following provision of the information to the

commissioner.

(2) The commissioner shall notify an insurer of its

qualification as a participating insurer under this

subsection.

(d) Facilitation.--The department shall facilitate the

availability of information relating to standard health benefit

plans by electronic and other means, inclusive of pricing and

benefit information and all other relevant information, so that

prospective purchasers of the plans have the ability to compare

benefits, terms, conditions and pricing among all participating

insurers.

(e) Provision of information.--Participating insurers shall

provide the department, at its request, with information

sufficient to enable it to discharge its responsibilities under

subsection (d).

Section 4204. Small employer premium rates at renewal.

The percentage increase in the premium rate an insurer shall

charge to a small employer for a new rating period may not

exceed the sum of the following:

(1) The percentage change in the premium rate measured

from the first day of the prior rating period to the first

day of the rating period.

(2) An adjustment, not to exced 25% annually and

adjusted pro rata for rating periods of less than one year,

due to the claim experience, health status or duration of

coverage of the employees or dependents of the small employer

as determined from the insurer's rate manual for the class of

business.

(3) Any adjustment due to change in coverage or change

in the case characteristics of the small employer as

determined from the insurer's rate manual for the class of

business.

Section 4205. Records and reporting.

A participating insurer shall provide an annual report to the

department in a form prescribed by the department enumerating

all of the following:

(1) The number of individuals covered under standard

health benefit plans, including coverage provided both

directly to individuals and through employers.

(2) The number of persons receiving coverage both under

LifeLine health benefit plans and through high deductible

health plans.

Section 4206. Petition for exception.

(a) Petition.--

(1) An insurer may, after the third anniversary of its

qualification as a participating insurer, petition the

commissioner to be relieved of the obligation to offer

LifeLine health plans under this article.

(2) The commissioner may grant the petition upon a

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finding that the petitioner has used its commercially

reasonable best efforts to market and issue the coverage and

that continuation of the efforts would not provide LifeLine

health plan coverage to a sufficient number of individuals to

justify continued efforts to market and issue the coverage.

(b) Arrangements.--The commissioner shall, as a condition

for approving a petition described under subsection (a), require

that arrangements be made for the orderly disposition of

outstanding coverage.

Section 2. This act shall take effect in 60 days.

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