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| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
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| HOUSE BILL |
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| INTRODUCED BY KILLION, BARRAR, BOYD, CUTLER, ELLIS, GEIST, GROVE, HUTCHINSON, KIRKLAND, MILLARD, MILLER, MUSTIO, PICKETT, REICHLEY, ROSS, STERN, VULAKOVICH, WATSON, BEAR, FLECK, MARSHALL, MAJOR AND MILNE, JANUARY 30, 2009 |
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| REFERRED TO COMMITTEE ON INSURANCE, JANUARY 30, 2009 |
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| AN ACT |
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1 | Requiring the Insurance Department to develop standard health |
2 | benefit plans that certain insurers shall offer to |
3 | individuals and small employers; and requiring the Insurance |
4 | Department to facilitate the availability of standard health |
5 | benefit plan information by electronic and other means. |
6 | The General Assembly of the Commonwealth of Pennsylvania |
7 | hereby enacts as follows: |
8 | Section 1. Short title. |
9 | This act shall be known and may be cited as the LifeLine |
10 | Health Insurance Act. |
11 | Section 2. Statement of purpose. |
12 | The General Assembly finds and declares as follows: |
13 | (1) There is a need for individuals and employers in |
14 | this Commonwealth to have the opportunity to acquire health |
15 | benefit plans that provide appropriate and affordable |
16 | coverage. |
17 | (2) The Commonwealth should increase the availability of |
18 | coverage by specifying health benefit plans which certain |
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1 | insurers shall offer and requiring the Insurance Department |
2 | to take steps to facilitate the availability of information |
3 | relating to the plans and their terms, conditions and |
4 | premiums through electronic and other means. |
5 | Section 3. Definitions. |
6 | The following words and phrases when used in this act shall |
7 | have the meanings given to them in this section unless the |
8 | context clearly indicates otherwise: |
9 | "Commissioner." The Insurance Commissioner of the |
10 | Commonwealth. |
11 | "Department." The Insurance Department of the Commonwealth. |
12 | "Dependent child." A natural or adopted child of a qualified |
13 | individual. The term includes a stepchild who resides in a |
14 | qualified individual's household if the qualified individual has |
15 | assumed the financial responsibility for the child and another |
16 | parent is not legally responsible for the support and medical |
17 | expenses of the child. |
18 | "Eligible dependent." A spouse of a qualified individual and |
19 | any dependent children who are under 19 years of age. |
20 | "Health benefit plan." An individual or group health |
21 | insurance policy, subscriber contract, certificate or plan that |
22 | provides health or sickness and accident coverage which is |
23 | offered by an insurer. The term does not include any of the |
24 | following: |
25 | (1) An accident only policy. |
26 | (2) A limited benefit policy. |
27 | (3) A credit only policy. |
28 | (4) A long-term or disability income policy. |
29 | (5) A specified disease policy. |
30 | (6) A Medicare supplement policy. |
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1 | (7) A Civilian Health and Medical Program of the |
2 | Uniformed Services (CHAMPUS) supplement policy. |
3 | (8) A fixed indemnity policy. |
4 | (9) A dental only policy. |
5 | (10) A vision only policy. |
6 | (11) A workers' compensation policy. |
7 | (12) An automobile medical payment policy under 75 |
8 | Pa.C.S. (relating to vehicles). |
9 | "High deductible health plan." A health insurance policy |
10 | that would qualify as a high deductible health plan under |
11 | section 223(c)(2) of the Internal Revenue Code of 1986 (Public |
12 | Law 99-514, 26 U.S.C. § 223(c)(2)). |
13 | "Insurer." A company or health insurance entity licensed in |
14 | this Commonwealth to issue any individual or group health |
15 | insurance, sickness or accident policy, subscriber contract, |
16 | certificate or plan that provides medical or health care |
17 | coverage by a health care facility or licensed health care |
18 | provider that is offered or governed under any of the following: |
19 | (1) This act. |
20 | (2) The act of December 29, 1972 (P.L.1701, No.364), |
21 | known as the Health Maintenance Organization Act. |
22 | (3) The act of May 18, 1976 (P.L.123, No.54), known as |
23 | the Individual Accident and Sickness Insurance Minimum |
24 | Standards Act. |
25 | (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan |
26 | corporations) or 63 (relating to professional health services |
27 | plan corporations). |
28 | "Licensee." An individual who is licensed by the Department |
29 | of State to provide professional health care services in this |
30 | Commonwealth. |
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1 | "LifeLine health plan." A health benefit plan that offers |
2 | the following, subject to the provisions of section 4: |
3 | (1) Twenty-one days of inpatient hospital surgical and |
4 | medical coverage per policy year. |
5 | (2) Coverage for four office visits for primary health |
6 | care services for covered services rendered by a licensee, |
7 | subject to a copayment for each visit of $10 for treatment of |
8 | injury or illness. |
9 | (3) Coverage for surgery and anesthesia. |
10 | (4) Coverage for emergency accident and medical |
11 | treatment. |
12 | (5) Coverage for diagnostic services up to $1,000 for |
13 | each policy year. |
14 | (6) Coverage for chemotherapy and radiation treatment. |
15 | (7) Coverage for maternity care. |
16 | (8) Coverage for newborn care for up to 31 days |
17 | following birth. |
18 | "Participating insurer." An insurer that offers health |
19 | benefit plans to groups or individuals and which has health |
20 | benefit plans in force covering in the aggregate at least |
21 | 100,000 qualified individuals in this Commonwealth. |
22 | "Standard health benefit plan." The LifeLine health plan and |
23 | any high deductible health plan offered by participating |
24 | insurers to individuals and employers. |
25 | Section 4. Offering of standard health benefit plans. |
26 | (a) Offering of plans.--All participating insurers shall |
27 | offer the standard benefit plans specified under this act to |
28 | individuals and to employers for the benefit of individuals |
29 | employed by them. |
30 | (b) Inclusion in coverage.-- |
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1 | (1) If coverage is provided to eligible dependents under |
2 | a LifeLine health plan, the coverage shall include dependent |
3 | children of the insured from the moment of birth and for |
4 | adopted dependent children with prior coverage from the date |
5 | of the interlocutory decree of adoption. |
6 | (2) The participating insurer may require that the |
7 | insured give notice to it of any newborn child within 90 days |
8 | following the birth of the child and of any adopted child |
9 | within 60 days of the date the insured has filed a petition |
10 | to adopt. |
11 | (c) Exclusion.--Participating insurers may exclude coverage |
12 | under a LifeLine health plan for an individual who has not been |
13 | covered by a health benefit plan for more than 30 days for up to |
14 | one year for medical conditions for which medical advice or |
15 | treatment was received by the individual during the 12 months |
16 | prior to the effective date of the individual's LifeLine health |
17 | plan policy. |
18 | (d) Applicability.--No law, regulation or administrative |
19 | directive requiring the coverage of a health care benefit or |
20 | service or requiring the reimbursement, utilization or inclusion |
21 | of a specific category of licensee shall apply to LifeLine |
22 | health plans delivered or issued for delivery in this |
23 | Commonwealth under the authority granted under this act, |
24 | including the provision of the benefits or requirements mandated |
25 | under Article VI-A of the act of May 17, 1921 (P.L.682, No.284), |
26 | known as The Insurance Company Law of 1921, or by regulations |
27 | promulgated under this act. |
28 | Section 5. Facilitation by the department of access to standard |
29 | health benefit plans and related information. |
30 | (a) Duty of department.--The department shall take all |
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1 | actions necessary to effectuate the provisions of this act so |
2 | that participating insurers are able to make standard benefit |
3 | plans available not later than 180 days following the effective |
4 | date of this section. |
5 | (b) Demonstration of coverage.-- |
6 | (1) Each insurer shall, not more than 90 days after the |
7 | effective date of this section, demonstrate to the |
8 | commissioner all of the following: |
9 | (i) If it has health benefit plans in force covering |
10 | a sufficient number of individuals to qualify as a |
11 | participating insurer. |
12 | (ii) If qualified as a participating insurer, that |
13 | it has the capacity to issue standard health benefit |
14 | plans and provide information sufficient to permit the |
15 | department to discharge the responsibilities assigned to |
16 | it under subsection (d). |
17 | (iii) If qualified as a participating insurer, that |
18 | it has undertaken a process to make standard benefit |
19 | plans available not later than 180 days following the |
20 | effective date of this section. |
21 | (2) The commissioner shall notify an insurer of its |
22 | qualification as a participating insurer under this |
23 | subsection. |
24 | (c) Demonstration of capacity.-- |
25 | (1) An insurer shall, within 30 days of first providing |
26 | coverage under health benefit plans to a sufficient number of |
27 | individuals to qualify as a participating insurer under this |
28 | act, demonstrate to the commissioner that: |
29 | (i) It has the capacity to issue standard health |
30 | benefit plans and provide information sufficient to |
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1 | permit the department to discharge the responsibilities |
2 | assigned to it under subsection (d). |
3 | (ii) It has undertaken a process to make standard |
4 | benefit plans available not later than 180 days following |
5 | provision of the information to the commissioner. |
6 | (2) The commissioner shall notify an insurer of its |
7 | qualification as a participating insurer under this |
8 | subsection. |
9 | (d) Facilitation.--The department shall facilitate the |
10 | availability of information relating to standard health benefit |
11 | plans by electronic and other means, inclusive of pricing and |
12 | benefit information and all other relevant information, so that |
13 | prospective purchasers of the plans have the ability to compare |
14 | benefits, terms, conditions and pricing among all participating |
15 | insurers. |
16 | (e) Provision of information.--Participating insurers shall |
17 | provide the department, at its request, with information |
18 | sufficient to enable it to discharge its responsibilities under |
19 | subsection (d). |
20 | Section 6. Records and reporting. |
21 | A participating insurer shall provide an annual report to the |
22 | department in a form prescribed by the department enumerating: |
23 | (1) The number of individuals covered under standard |
24 | health benefit plans, including coverage provided both |
25 | directly to individuals and through employers. |
26 | (2) The number of persons receiving coverage both under |
27 | LifeLine health benefit plans and through high deductible |
28 | health plans. |
29 | Section 7. Petition for exception. |
30 | (a) General rule.--An insurer may, after the third |
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1 | anniversary of its qualification as a participating insurer, |
2 | petition the commissioner to be relieved of the obligation to |
3 | offer LifeLine health plans under this act. |
4 | (b) Findings by commissioner.--The commissioner may grant |
5 | the petition if the commissioner finds that: |
6 | (1) The petitioner has used its commercially reasonable |
7 | best efforts to market and issue the coverage. |
8 | (2) Continuation of the efforts would not provide |
9 | LifeLine health plan coverage to a sufficient number of |
10 | individuals to justify continued efforts to market and issue |
11 | the coverage. |
12 | (c) Arrangements.--The commissioner shall, as a condition |
13 | for approving a petition described under subsection (a), require |
14 | that arrangements be made for the orderly disposition of |
15 | outstanding coverage. |
16 | Section 8. Effective date. |
17 | This act shall take effect in 60 days. |
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