PRINTER'S NO. 112
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No.
51
Session of
2021
INTRODUCED BY HUGHES, KEARNEY, BLAKE, BOSCOLA, BREWSTER,
CAPPELLETTI, COLLETT, COMITTA, COSTA, FONTANA, HAYWOOD, KANE,
MUTH, SABATINA, SANTARSIERO, SAVAL, SCHWANK, STREET,
TARTAGLIONE, A. WILLIAMS AND L. WILLIAMS, JANUARY 28, 2021
REFERRED TO BANKING AND INSURANCE, JANUARY 28, 2021
AN ACT
Providing for individual and group health care insurance
coverage protections and for core health benefits; imposing
penalties; and providing for applicability and for
regulations.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Short title.
This act shall be known and may be cited as the Health
Insurance Core Benefits Coverage Act.
Section 2. Definitions.
The following words and phrases when used in this act 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.
"Group health insurance policy." A policy, subscriber
contract, certificate or plan issued by an insurer that provides
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medical or health care coverage on an annual basis to
individuals who obtain health insurance coverage through a
group.
"Health insurance policy." A policy, subscriber contract,
certificate or plan issued by an insurer that provides medical
or health care coverage. The term does not include any of the
following:
(1) An accident only policy.
(2) A credit only policy.
(3) A long-term care or disability income policy.
(4) A specified disease policy.
(5) A Medicare supplement policy.
(6) A fixed indemnity policy.
(7) A dental only policy.
(8) A vision only policy.
(9) A workers' compensation policy.
(10) An automobile medical payment policy.
(11) A policy under which benefits are provided by the
Federal Government to active or former military personnel and
their dependents.
(12) Any other similar policies providing for limited
benefits.
"Individual health insurance policy." A policy, subscriber
contract, certificate or plan issued by an insurer that provides
medical or health care coverage on an annual basis to an
individual other than in connection with a group.
"Insurer." An entity that offers, issues or renews an
individual or group health insurance policy, contract or plan
that provides medical or health care coverage by a health care
facility or licensed health care provider and that is governed
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under any of the following:
(1) The act of May 17, 1921 (P.L.682, No.284), known as
The Insurance Company Law of 1921, including section 630 and
Article XXIV thereof.
(2) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
(3) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations).
(4) 40 Pa.C.S. Ch. 63 (relating to professional health
services plan corporations).
Section 3. Core health benefits.
(a) Benefits.--Except as otherwise provided in this section,
an insurer offering, issuing or renewing an individual health
insurance policy or group health insurance policy shall include
health benefits in at least the following general categories and
the items and services covered within the categories:
(1) Ambulatory patient services.
(2) Emergency services.
(3) Hospitalization.
(4) Maternity and newborn care.
(5) Mental health and substance use disorder services,
including 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 oral and vision care.
(b) Comprehensiveness.--
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(1) An individual health insurance policy or group
health insurance policy shall cover health benefits at least
as comprehensive as the health benefits required to be
covered in an individual health insurance policy or a small
group policy first offered or issued in this Commonwealth in
2018.
(2) A large group health insurance policy also shall
cover health benefits required to be covered in a large group
policy first offered or issued in this Commonwealth in 2018.
(c) Modifications.--The department may add a health benefit
or exempt a health benefit required to be covered under this
section through a regulation promulgated under section 4. In
determining whether to add a health benefit or exempt a health
benefit required to be covered under this section, the
department shall consider all of the following:
(1) The balance of the health benefits in the categories
specified under subsection (a) and whether the health
benefits are not unduly weighted toward any category.
(2) The health care needs of the diverse segments of the
population, including women, children, individuals with
disabilities and other diverse groups.
(3) The potential for discrimination against individuals
because of their age or expected length of life, present or
predicted disability, degree of medical dependency, quality
of life or other health conditions.
(4) The accessibility of the health benefits, including
the cost of the health benefits.
(5) Changes in medical evidence or scientific
advancement.
(d) Management techniques.--Nothing in this section shall be
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construed to prevent an insurer from appropriately utilizing
reasonable medical management techniques.
Section 4. Regulations.
(a) Authority to promulgate.--The department may promulgate
regulations as may be necessary and appropriate to carry out the
provisions of this act.
(b) Temporary regulations.--
(1) Notwithstanding any other provision of law, in order
to facilitate the prompt implementation of this act, the
department may issue temporary regulations which shall expire
no later than two years following publication of the
temporary regulations in the Pennsylvania Bulletin. The
temporary regulations shall be exempt from the following:
(i) Sections 201, 202, 203, 204 and 205 of the act
of July 31, 1968 (P.L.769, No.240), referred to as the
Commonwealth Documents Law.
(ii) Section 204(b) of the act of October 15, 1980
(P.L.950, No.164), known as the Commonwealth Attorneys
Act.
(iii) The act of June 25, 1982 (P.L.633, No.181),
known as the Regulatory Review Act.
(iv) Section 612 of the act of April 9, 1929
(P.L.177, No.175), known as The Administrative Code of
1929.
(2) The authority of the department to issue temporary
regulations under this subsection shall expire two years from
the effective date of this section. Regulations adopted after
the two-year period shall be promulgated as provided by
statute.
Section 5. Enforcement.
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(a) General rule.--Upon satisfactory evidence of the
violation of any section of this act by an insurer or any other
person, one or more of the following penalties may be imposed at
the commissioner's discretion:
(1) Suspension or revocation of the license of the
offending insurer or other person.
(2) Refusal, for a period not to exceed one year, to
issue a new license to the offending insurer or other person.
(3) A fine of not more than $5,000 for each violation of
this act.
(4) A fine of not more than $10,000 for each willful
violation of this act.
(b) Limitations.--
(1) Fines imposed against an individual insurer under
this act may not exceed $500,000 in the aggregate during a
single calendar year.
(2) Fines imposed against any other person under this
act may not exceed $100,000 in the aggregate during a single
calendar year.
(c) Additional remedies.--The enforcement remedies imposed
under this section are in addition to any other remedies or
penalties that may be imposed under any other applicable law of
this Commonwealth, including:
(1) The act of July 22, 1974 (P.L.589, No.205), known as
the Unfair Insurance Practices Act. Violations of this act
shall be deemed to be an unfair method of competition and an
unfair or deceptive act or practice under the Unfair
Insurance Practices Act.
(2) The act of December 18, 1996 (P.L.1066, No.159),
known as the Accident and Health Filing Reform Act.
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(3) The act of June 25, 1997 (P.L.295, No.29), known as
the Pennsylvania Health Care Insurance Portability Act.
(d) Administrative procedure.--The administrative provisions
of this section shall be subject to 2 Pa.C.S. Ch. 5 Subch. A
(relating to practice and procedure of Commonwealth agencies).
A party against whom penalties are assessed in an administrative
action may appeal to Commonwealth Court as provided in 2 Pa.C.S.
Ch. 7 Subch. A (relating to judicial review of Commonwealth
agency action).
Section 6. Applicability.
This act shall apply as follows:
(1) For health insurance policies for which either rates
or forms are required to be filed with the department, this
act shall apply to any policy for which a form or rate is
first filed on or after the effective date of this act.
(2) For health insurance policies for which neither
rates nor forms are required to be filed with the department,
this act shall apply to any policy issued or renewed on or
after 180 days after the effective date of this act.
Section 7. Repeals.
All acts and parts of acts are repealed insofar as they are
inconsistent with this act.
Section 8. Effective date.
This act shall take effect immediately.
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