PRINTER'S NO. 3648
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
2434
Session of
2020
INTRODUCED BY THOMAS, CIRESI, HILL-EVANS, READSHAW, SCHWEYER AND
TOMLINSON, APRIL 28, 2020
REFERRED TO COMMITTEE ON INSURANCE, APRIL 28, 2020
AN ACT
Amending Title 40 (Insurance) of the Pennsylvania Consolidated
Statutes, providing for on-exchange insurers.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Title 40 of the Pennsylvania Consolidated
Statutes is amended by adding a chapter to read:
CHAPTER 96
ON-EXCHANGE INSURERS
Sec.
9601. Definitions.
9602. Essential health benefits.
9603. Preexisting conditions.
9604. Limits on coverage.
9605. Dependent coverage.
9606. Premiums.
9607. Comparative purchasing options.
§ 9601. Definitions.
The following words and phrases when used in this chapter
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shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Preexisting condition exclusion." As defined in section
2704 of the Public Health Service Act (58 Stat. 682, 42 U.S.C. §
300gg-3).
§ 9602. Essential health benefits.
An insurer that offers a health insurance policy through the
exchange must include coverage for the following health care
services and benefits in the following categories:
(1) Ambulatory patient services.
(2) Emergency services.
(3) Hospitalization.
(4) Maternity and newborn health care.
(5) Mental health and substance use disorder services,
including, but not limited to, behavioral health treatment.
(6) Prescription drugs.
(7) Rehabilitative and habilitative services and
devices.
(8) Laboratory services.
(9) Preventive and wellness services and chronic disease
management.
(10) Pediatric services, including, but not limited to,
oral and vision care.
§ 9603. Preexisting conditions.
An insurer that offers a health insurance policy through the
exchange may not impose a preexisting condition exclusion.
§ 9604. Limits on coverage.
An insurer that offers a health insurance policy through the
exchange may not establish any the following:
(1) A lifetime limit on the dollar value of benefits for
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any enrollee.
(2) Annual limits on the dollar value of benefits for
any participant or beneficiary.
§ 9605. Dependent coverage.
An insurer that offers a health insurance policy through the
exchange that provides dependent coverage of children shall
continue to make the coverage available for an adult child until
the child turns 26 years of age. Nothing in this section shall
require an insurer to make coverage available for a child of a
child receiving dependent coverage.
§ 9606. Premiums.
(a) Premium revenue.--The ratio of the amount of premium
revenue expended by the insurer on reimbursement for clinical
services provided to enrollees under a health care plan and for
activities that improve health care quality to the total amount
of premium revenue for the plan year may not be less than 80%.
(b) Duties of department.--The department shall:
(1) Establish a process for the annual review of
unreasonable increases in premiums for health insurance
coverage. The process shall require an insurer to submit to
the department a justification for an unreasonable premium
increase prior to the implementation of the increase. The
insurer shall prominently post the premium increase
information on the insurer's publicly accessible Internet
website.
(2) Ensure the public disclosure of information on
premium increases and justifications for all insurers.
(3) Consider whether particular insurers should be
excluded from participation in the exchange based on a
pattern or practice of excessive or unjustified premium
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increases.
(4) Monitor premium increases of health insurance
coverage offered through the exchange and outside of an
exchange.
(5) Require insurers seeking certification as qualified
health plans to submit a justification for any premium
increase prior to implementation of the increase. An insurer
shall prominently post premium increase information on the
insurer's publicly accessible Internet website. The
department shall take this information into consideration
when determining whether to make these health plans available
through the exchange.
§ 9607. Comparative purchasing options.
The exchange authority shall establish a standardized format
to be used for the presentation of information for use by
consumers to identify affordable health insurance coverage
options in this Commonwealth. The format shall, at a minimum,
require the inclusion of information on the percentage of total
premium revenue expended on nonclinical costs, eligibility,
availability, premium rates and cost sharing with respect to
health insurance coverage options and be consistent with the
standards adopted for the uniform explanation of coverage as
provided for in section 2715 of the Public Health Service Act
(58 Stat. 682, 42 U.S.C. § 300gg-15).
Section 2. This act shall take effect in 60 days.
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