PRINTER'S NO. 2452
No. 1966 Session of 1999
INTRODUCED BY STEELMAN, VEON, BELARDI, TRELLO, COLAFELLA,
BELFANTI, LUCYK, PISTELLA, DeLUCA, MANN, FAIRCHILD, BEBKO-
JONES, SOLOBAY, FREEMAN, THOMAS, FRANKEL, MUNDY, JOSEPHS,
SHANER, HORSEY, MELIO, WASHINGTON, YOUNGBLOOD, HARHAI,
YUDICHAK AND CURRY, OCTOBER 18, 1999
REFERRED TO COMMITTEE ON INSURANCE, OCTOBER 18, 1999
AN ACT
1 Providing for health insurance policy disclosures.
2 The General Assembly of the Commonwealth of Pennsylvania
3 hereby enacts as follows:
4 Section 1. Short title.
5 This act shall be known and may be cited as the Health
6 Insurance Policy Disclosure Act.
7 Section 2. Definitions.
8 The following words and phrases when used in this act shall
9 have the meanings given to them in this section unless the
10 context clearly indicates otherwise:
11 "Health insurance policy." An individual or group health
12 insurance policy, contract or plan which provides medical or
13 health care coverage by a health care facility or licensed
14 health care provider on an expense-incurred service or prepaid
15 basis and which is offered by or is governed under any of the
16 following:
1 (1) Act of May 17, 1921 (P.L.682, No.284), known as The
2 Insurance Company Law of 1921.
3 (2) Subarticle (f) of Article IV of the act of June 13,
4 1967 (P.L.31, No.21), known as the Public Welfare Code.
5 (3) Act of December 29, 1972 (P.L.1701, No.364), known
6 as the Health Maintenance Organization Act.
7 (4) Act of May 18, 1976 (P.L.123, No.54), known as the
8 Individual Accident and Sickness Insurance Minimum Standards
9 Act.
10 (5) Act of December 14, 1992 (P.L.835, No.134), known as
11 the Fraternal Benefit Societies Code.
12 (6) A nonprofit corporation subject to 40 Pa.C.S. Chs.
13 61 (relating to hospital plan corporations) and 63 (relating
14 to professional health services plan corporations).
15 "Provider." A person providing medical, nursing or other
16 health care services of any kind or a hospital, nursing home,
17 hospice, drug and alcohol services provider, clinic, blood bank,
18 plasmapheresis or other blood product center, organ or tissue
19 bank, sperm bank, clinical laboratory or a health care
20 institution required to be licensed in this Commonwealth.
21 Section 3. Health insurance policy disclosures.
22 (a) General rule.--Each health insurance policy offered to
23 the public within this Commonwealth shall provide disclosure
24 forms as required by this section. The disclosure form shall be
25 in a form prescribed by the Insurance Commissioner.
26 (b) Content of disclosure form.--Each disclosure form shall
27 contain at least all of the following information:
28 (1) A separate roster of the health insurer's primary
29 care physicians who are licensed under the act of December
30 20, 1985 (P.L.457, No.112), known as the Medical Practice Act
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1 of 1985, or the act of October 5, 1978 (P.L.1109, No.261),
2 known as the Osteopathic Medical Practice Act, including the
3 degree, practice specialty, office location and hours,
4 initial year of licensure and year licensed to practice in
5 Pennsylvania for each physician.
6 (2) In concise and specific terms:
7 (i) The full premium cost of the health insurance
8 policy.
9 (ii) Any copayment, coinsurance or deductible
10 requirements that an insured or the insured's family may
11 incur in obtaining coverage under the health insurance
12 policy and any reservation by the health insurance policy
13 to change premiums.
14 (iii) The health care benefits to which an insured
15 would be entitled, including any limitations on coverage.
16 (iv) Any limitations on participation in
17 experimental treatment, clinical trials, the use of
18 alternative medical providers or the use of nonformulary
19 medications.
20 (3) An identification of where and in what manner an
21 insured may obtain services, including the procedures for
22 selecting or changing primary care physicians and the
23 locations of hospitals and outpatient treatment centers that
24 are under contract with the health insurer.
25 (4) Any limitations of the services, kinds of service,
26 benefits and exclusions that apply to the health insurance
27 policy. A description of the limitations shall include:
28 (i) Procedures for emergency room, nighttime or
29 weekend visits and referrals to specialist physicians.
30 (ii) Whether services received outside the health
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1 insurance policy are covered and in what manner they are
2 covered.
3 (iii) Procedures an insured must follow, if any, to
4 obtain prior authorization for services.
5 (iv) A statement regarding whether or not providers
6 must comply with any specified numbers, targeted averages
7 or maximum durations of patient visits. If any of these
8 are required of providers, the disclosure shall state the
9 specific requirements.
10 (v) The procedure to be followed by an insured for
11 consulting a physician other than the primary care
12 physician and whether the insured's primary care
13 physician, the health insurer's medical director or a
14 committee must first authorize the referral.
15 (vi) Whether a point of service option is available
16 and, if so, how it is structured.
17 (5) Grievance procedures for claim or treatment denials,
18 dissatisfaction with care and access to care issues.
19 (6) A response as to whether an insurer's physician is
20 restricted to prescribing drugs from the health insurer's
21 list or formulary and the extent to which an insured will be
22 reimbursed for costs of a drug that is not on the health
23 insurer's list or formulary.
24 (7) A response to whether provider compensation programs
25 include any incentives or penalties that are intended to
26 encourage providers to withhold services or minimize or avoid
27 referrals to specialists. If these types of incentives or
28 penalties are included, the health insurer shall provide a
29 concise description of them. The health insurer may also
30 include, in a separate section, a concise explanation or
19990H1966B2452 - 4 -
1 justification for the use of these incentives or penalties.
2 (8) A statement that the disclosure form is a summary
3 only and that evidence of coverage is determined by the
4 governing contractual provisions of the health insurance
5 policy.
6 (c) Approval prerequisite.--No health insurer may
7 disseminate a completed disclosure form until that form has been
8 approved by the Insurance Commissioner. For purposes of this
9 section, no health insurer shall be required to submit to the
10 Insurance Commissioner its separate roster of plan physicians or
11 any roster updates.
12 (d) Information to employers.--Upon request, a health
13 insurer shall provide the information required under subsection
14 (b) to:
15 (1) Any employer who is considering participating in a
16 health insurance policy that is offered by the health
17 insurer.
18 (2) Any employer that is considering renewal of a health
19 insurance policy that is provided by the health insurer.
20 Section 4. Duty of employers.
21 (a) Disclosure to employees.--An employer shall provide to
22 its eligible employees the disclosures required under section
23 3(b) no later than the initiation of any open enrollment period
24 or at least ten days before any employee enrollment deadline
25 that is not associated with an open enrollment period.
26 (b) Contract without disclosure prohibited.--No employer may
27 execute a contract with a health insurer until the employer
28 receives the information required under section 3(b).
29 Section 5. Effective date.
30 This act shall take effect in 90 days.
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