CORRECTIVE REPRINT SENATE AMENDED PRIOR PRINTER'S NOS. 1448, 2237, 2326, PRINTER'S NO. 4115 4085, 4107, 4110
No. 1150 Session of 2007
INTRODUCED BY D. O'BRIEN, DeWEESE, PALLONE, PHILLIPS, RAPP, SCAVELLO, STURLA, BAKER, BASTIAN, BOYD, BROOKS, CALTAGIRONE, CARROLL, CLYMER, COHEN, CONKLIN, DALEY, DALLY, DeLUCA, DePASQUALE, DONATUCCI, EVERETT, FREEMAN, GEIST, GEORGE, GIBBONS, GINGRICH, GOODMAN, GRUCELA, HALUSKA, HARKINS, HENNESSEY, HERSHEY, JAMES, JOSEPHS, KAUFFMAN, W. KELLER, KENNEY, KIRKLAND, KOTIK, KULA, LEACH, LENTZ, MAHONEY, MANDERINO, MANN, MARKOSEK, MARSHALL, McILHATTAN, MOYER, MURT, MUSTIO, McGEEHAN, MYERS, NAILOR, M. O'BRIEN, PASHINSKI, PAYNE, PETRONE, PRESTON, READSHAW, REICHLEY, ROSS, SCHRODER, SEIP, SHAPIRO, SHIMKUS, M. SMITH, SOLOBAY, SONNEY, STABACK, STEIL, SURRA, TANGRETTI, TRUE, VEREB, WATSON, J. WHITE, WOJNAROSKI, YUDICHAK, MACKERETH, MANTZ, BARRAR, HORNAMAN, CAUSER, WALKO, HELM, MELIO, DENLINGER, BRENNAN, RAMALEY, DiGIROLAMO, GERGELY, M. KELLER, FRANKEL, FABRIZIO, YOUNGBLOOD, REED, ROAE, CURRY, K SMITH, GALLOWAY, SIPTROTH, RUBLEY, SAMUELSON AND BOBACK, APRIL 30, 2007
AS AMENDED ON SECOND CONSIDERATION, IN SENATE, JUNE 28, 2008
AN ACT 1 Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An <-- 2 act relating to insurance; amending, revising, and 3 consolidating the law providing for the incorporation of 4 insurance companies, and the regulation, supervision, and 5 protection of home and foreign insurance companies, Lloyds 6 associations, reciprocal and inter-insurance exchanges, and 7 fire insurance rating bureaus, and the regulation and 8 supervision of insurance carried by such companies, 9 associations, and exchanges, including insurance carried by 10 the State Workmen's Insurance Fund; providing penalties; and 11 repealing existing laws," providing, in health and accident 12 insurance, for autism spectrum disorders coverage and for 13 treatment of autism spectrum disorders; and further providing 14 for quality health care procedures. 15 AMENDING THE ACT OF MAY 17, 1921 (P.L.682, NO.284), ENTITLED "AN <-- 16 ACT RELATING TO INSURANCE; AMENDING, REVISING, AND
1 CONSOLIDATING THE LAW PROVIDING FOR THE INCORPORATION OF 2 INSURANCE COMPANIES, AND THE REGULATION, SUPERVISION, AND 3 PROTECTION OF HOME AND FOREIGN INSURANCE COMPANIES, LLOYDS 4 ASSOCIATIONS, RECIPROCAL AND INTER-INSURANCE EXCHANGES, AND 5 FIRE INSURANCE RATING BUREAUS, AND THE REGULATION AND 6 SUPERVISION OF INSURANCE CARRIED BY SUCH COMPANIES, 7 ASSOCIATIONS, AND EXCHANGES, INCLUDING INSURANCE CARRIED BY 8 THE STATE WORKMEN'S INSURANCE FUND; PROVIDING PENALTIES; AND 9 REPEALING EXISTING LAWS," IN PRELIMINARY PROVISIONS, FURTHER 10 PROVIDING FOR EFFECT OF ACT ON EXISTING LAWS; IN LIFE 11 INSURANCE, FURTHER PROVIDING FOR ADDITIONAL INVESTMENT 12 AUTHORITY FOR SUBSIDIARIES; IN CASUALTY INSURANCE, PROVIDING 13 FOR AUTISM SPECTRUM DISORDERS COVERAGE AND FOR COLORECTAL 14 CANCER SCREENINGS COVERAGE; IN INSURANCE HOLDING COMPANIES, 15 FURTHER PROVIDING FOR DEFINITIONS, FOR ACQUISITION OF CONTROL 16 OF OR MERGER WITH DOMESTIC INSURER, FOR ACQUISITIONS 17 INVOLVING INSURERS NOT OTHERWISE COVERED AND FOR STANDARDS 18 AND MANAGEMENT OF AN INSURER WITHIN A HOLDING COMPANY SYSTEM; 19 PROVIDING FOR COMMITTEE REVIEW; ESTABLISHING THE INSURANCE 20 RESTRUCTURING RESTRICTED RECEIPT ACCOUNT; PROVIDING FOR 21 COMMUNITY HEALTH REINVESTMENT; AND MAKING A RELATED REPEAL. 22 The General Assembly of the Commonwealth of Pennsylvania 23 hereby enacts as follows: 24 Section 1. The act of May 17, 1921 (P.L.682, No.284), known <-- 25 as The Insurance Company Law of 1921, is amended by adding 26 sections to read: 27 Section 635.2. Autism Spectrum Disorders Coverage.--(a) A 28 health insurance policy or government program shall provide to 29 covered individuals or recipients under twenty-one years of age 30 coverage for the diagnosis of autism spectrum disorders and for 31 the treatment of autism spectrum disorders. To the extent that 32 the diagnosis and treatment of autism spectrum disorders are not 33 already covered by the health insurance policy or government 34 program, coverage under this section shall be included in health 35 insurance policies and contracts under a government program 36 which are delivered, executed, issued, amended, adjusted or 37 renewed on or after one hundred eighty days from the effective 38 date of this section, except that the applicability of this 39 section to government programs shall be contingent upon Federal 40 approval if necessary. 20070H1150B4115 - 2 -
1 (b) Except for the Commonwealth's medical assistance program 2 established under the act of June 13, 1967 (P.L.31, No.21), 3 known as the "Public Welfare Code," and except for the 4 Children's Health Care Program established under this act, 5 coverage provided under this section shall be subject to a 6 maximum benefit of thirty-six thousand dollars ($36,000) per 7 year but shall not be subject to any limits on the number of 8 visits to an autism service provider. After December 30, 2009, 9 the Insurance Commissioner shall, on an annual basis, adjust the 10 maximum benefit for inflation using the Medical care component 11 of the United States Department of Labor Consumer Price Index 12 For All Urban Consumers (CPI-U). The commissioner shall submit 13 the adjusted maximum benefit to the Legislative Reference Bureau 14 for publication annually in the Pennsylvania Bulletin no later 15 than April 1 of each calendar year, and the published adjusted 16 maximum benefit shall be applicable in the following calendar 17 year to health insurance policies and government programs 18 subject to this act. Payments made by an insurer on behalf of a 19 covered individual for any care, treatment, intervention, 20 service or item, the provision of which was for the treatment of 21 a health condition unrelated to the covered individual's autism 22 spectrum disorder, shall not be applied toward any maximum 23 benefit established under this subsection. 24 (c) Coverage under this section shall be subject to 25 copayment, deductible and coinsurance provisions of a health 26 insurance policy or government program to the extent that other 27 medical services covered by the policy or government program are 28 subject to these provisions. 29 (d) This section shall not be construed as limiting benefits 30 which are otherwise available to an individual under a health 20070H1150B4115 - 3 -
1 insurance policy. 2 (e) This section shall not apply to the following types of 3 policies: 4 (1) Accident only. 5 (2) Limited benefit. 6 (3) Credit. 7 (4) Dental. 8 (5) Vision. 9 (6) Specified disease. 10 (7) Medicare supplement. 11 (8) CHAMPUS (Civilian Health and Medical Program of the 12 Uniformed Services) supplement. 13 (9) Long-term care or disability income. 14 (10) Workers' compensation. 15 (11) Automobile medical payment. 16 (12) Hospital indemnity. 17 (f) As used in this section: 18 (1) "Applied behavioral analysis" means the design, 19 implementation and evaluation of environmental modifications, 20 using behavioral stimuli and consequences, to produce socially 21 significant improvement in human behavior, including the use of 22 direct observation, measurement and functional analysis of the 23 relations between environment and behavior. 24 (2) "Autism service provider" means any person, entity or 25 group that provides treatment of autism spectrum disorders. 26 (3) "Autism spectrum disorders" means any of the pervasive 27 developmental disorders as defined by the most recent edition of 28 the Diagnostic and Statistical Manual of Mental Disorders (DSM), 29 including autistic disorder, Asperger's disorder and pervasive 30 developmental disorder not otherwise specified. 20070H1150B4115 - 4 -
1 (4) "Diagnosis of autism spectrum disorders" means medically 2 necessary assessments, evaluations or tests in order to diagnose 3 whether an individual has an autism spectrum disorder. 4 (5) "Evidenced-based research" means research that applies 5 rigorous, systematic and objective procedures to obtain valid 6 knowledge relevant to autism spectrum disorders. 7 (6) "Government program" means any of the following: 8 (i) The Commonwealth's medical assistance program 9 established under the act of June 13, 1967 (P.L.31, No.21), 10 known as the "Public Welfare Code." 11 (ii) The adult basic coverage insurance program established 12 under Chapter 13 of the act of June 26, 2001 (P.L.755, No.77), 13 known as the "Tobacco Settlement Act." 14 (iii) The Children's Health Care Program established under 15 this act. 16 (7) "Health insurance policy" means any group health, 17 sickness or accident policy or subscriber contract or 18 certificate issued by an insurance entity subject to one of the 19 following: 20 (i) This act. 21 (ii) The act of December 29, 1972 (P.L.1701, No.364), known 22 as the "Health Maintenance Organization Act." 23 (iii) The act of May 18, 1976 (P.L.123, No.54), known as the 24 "Individual Accident and Sickness Insurance Minimum Standards 25 Act." 26 (iv) 40 Pa.C.S. Ch. 61 (relating to hospital plan 27 corporations) or 63 (relating to professional health services 28 plan corporations). 29 (8) "Medically necessary" means any care, treatment, 30 intervention, service or item which is prescribed, provided or 20070H1150B4115 - 5 -
1 ordered by a licensed physician, licensed psychologist or 2 certified registered nurse practitioner in accordance with 3 accepted standards of practice and which will, or is reasonably 4 expected to, do any of the following: 5 (i) Prevent the onset of an illness, condition, injury or 6 disability. 7 (ii) Reduce or ameliorate the physical, mental or 8 developmental effects of an illness, condition, injury or 9 disability. 10 (iii) Assist to achieve or maintain maximum functional 11 capacity in performing daily activities, taking into account 12 both the functional capacity of the recipient and those 13 functional capacities that are appropriate of recipients of the 14 same age. 15 (9) "Pharmacy care" means medications prescribed by a 16 licensed physician or certified registered nurse practitioner 17 and any health-related services deemed medically necessary to 18 determine the need or effectiveness of the medications. 19 (10) "Psychiatric care" means direct or consultative 20 services provided by a psychiatrist licensed in the state in 21 which the psychiatrist practices. 22 (11) "Psychological care" means direct or consultative 23 services provided by a psychologist licensed in the state in 24 which the psychologist practices. 25 (12) "Rehabilitative care" means professional, counseling 26 and guidance services and treatment programs, including applied 27 behavioral analysis, which are necessary to develop, maintain 28 and restore, to the maximum extent practicable, the functioning 29 of an individual. 30 (13) "Therapeutic care" means services provided by licensed 20070H1150B4115 - 6 -
1 or certified speech therapists, occupational therapists or 2 physical therapists. 3 (14) "Treatment for autism spectrum disorders" shall include 4 the following care prescribed, provided or ordered for an 5 individual diagnosed with an autism spectrum disorder by a 6 licensed physician, licensed psychologist or certified 7 registered nurse practitioner if the care is determined to be 8 medically necessary: 9 (i) Psychiatric care. 10 (ii) Psychological care. 11 (iii) Rehabilitative care. 12 (iv) Therapeutic care. 13 (v) Pharmacy care. 14 (vi) Any care, treatment, intervention, service or item for 15 individuals with an autism spectrum disorder which is determined 16 by the Department of Public Welfare, based upon its review of 17 best practices or evidenced-based research, to be medically 18 necessary and which is published in the Pennsylvania Bulletin. 19 Any such care, treatment, intervention, service or item which 20 was not previously covered shall be included in any health 21 insurance policy or contract under a government program 22 delivered, issued, executed or renewed on or after 120 days 23 following the date of its publication in the Pennsylvania 24 Bulletin. 25 (g) The Department of Public Welfare shall promulgate 26 regulations establishing standards for qualified autism service 27 providers. For purposes of implementing this section, and 28 notwithstanding any other provision of law, the Secretary of 29 Public Welfare shall promulgate regulations pursuant to section 30 204(1)(iv) of the act of July 31, 1968 (P.L.769, No.240), 20070H1150B4115 - 7 -
1 referred to as the Commonwealth Documents Law, which shall, for 2 120 days from the effective date of this act, be exempt from all 3 of the following acts: 4 (1) Section 205 of the Commonwealth Documents Law. 5 (2) Section 204(b) of the act of October 15, 1980 (P.L.950, 6 No.164), known as the "Commonwealth Attorneys Act." 7 (3) The act of June 25, 1982 (P.L.633, No.181), known as the 8 "Regulatory Review Act." 9 Once the regulations are promulgated, payment for the treatment 10 of autism spectrum disorders covered under this section shall 11 only be made to autism service providers who meet the standards. 12 Section 2116.1. Treatment of Autism Spectrum Disorders.--(a) 13 Except for inpatient services, if an enrollee has obtained 14 authorization through utilization review from a managed care 15 plan, government program or a licensed insurer to receive any 16 care, treatment, intervention, service or item for an autism 17 spectrum disorder, the authorization shall be valid for twelve 18 months, unless the enrollee's primary care provider determines 19 that an earlier re-evaluation is necessary in order to 20 adequately address the clinical needs of the enrollee. 21 (a.1) In applying subsection (a), if within the twelve-month 22 period following the effective date of this section a health 23 insurance policy is delivered, issued, executed or renewed and 24 at the time of such delivery, issuance, execution or renewal an 25 enrollee is receiving any inpatient or outpatient care, 26 treatment, intervention, service or item for an autism spectrum 27 disorder pursuant to an authorization obtained from a government 28 program, and the care, treatment, intervention, service or item 29 is covered under the health insurance policy being delivered, 30 issued, executed or renewed, the authorization from the 20070H1150B4115 - 8 -
1 government program shall remain valid for the remainder of the 2 existing authorization period as to any managed care plan or 3 private insurer and such authorization shall be honored by any 4 managed care plan or private insurer providing coverage to the 5 enrollee. 6 (b) If a health care provider provides care, treatments, 7 interventions, services or items to an enrollee, the coverage of 8 which is required under section 635.2 and the provider is 9 enrolled in the Commonwealth's medical assistance program but is 10 not a network provider with the enrollee's private insurance 11 plan, the provider shall be reimbursed under the terms and 12 conditions applicable to the plan's participating providers. 13 This requirement shall not be subject to any time limitation or 14 transition period, but shall otherwise be in accord with all 15 terms applicable to nonparticipating providers under the managed 16 care continuity of care provisions then in effect. 17 Section 2. Section 2121 of the act, added June 17, 1998 18 (P.L.464, No.68), is amended to read: 19 Section 2121. Procedures.--(a) A managed care plan shall 20 establish a credentialing process to enroll qualified health 21 care providers and create an adequate provider network. The 22 process shall be approved by the department and shall include 23 written criteria and procedures for initial enrollment, renewal, 24 restrictions and termination of credentials for health care 25 providers. 26 (b) [The] Except as provided under subsection (b.1), the 27 department shall establish credentialing standards for managed 28 care plans. The department may adopt nationally recognized 29 accrediting standards to establish the credentialing standards 30 for managed care plans. 20070H1150B4115 - 9 -
1 (b.1) Pursuant to section 635.2(g), the Department of Public 2 Welfare shall establish standards to be utilized by managed care 3 plans for the credentialing of health care providers providing 4 care, treatments, interventions, services or items to enrollees 5 for an autism spectrum disorder as defined under section 635.2. 6 In addition, the department may require that a managed care plan 7 grant credentials to any health care provider whom the 8 Department of Public Welfare determines meets or exceeds the 9 Department of Public Welfare's credentialing standards. 10 (c) A managed care plan shall submit a report to the 11 department regarding its credentialing process at least every 12 two (2) years or as may otherwise be required by the department. 13 (d) A managed care plan shall disclose relevant 14 credentialing criteria and procedures to health care providers 15 that apply to participate or that are participating in the 16 plan's provider network. A managed care plan shall also disclose 17 relevant credentialing criteria and procedures pursuant to a 18 court order or rule. Any individual providing information during 19 the credentialing process of a managed care plan shall have the 20 protections set forth in the act of July 20, 1974 (P.L.564, 21 No.193), known as the "Peer Review Protection Act." 22 (e) No managed care plan shall exclude or terminate a health 23 care provider from participation in the plan due to any of the 24 following: 25 (1) The health care provider engaged in any of the 26 activities set forth in section 2113(c). 27 (2) The health care provider has a practice that includes a 28 substantial number of patients with expensive medical 29 conditions. 30 (3) The health care provider objects to the provision of or 20070H1150B4115 - 10 -
1 refuses to provide a health care service on moral or religious 2 grounds. 3 (f) If a managed care plan denies enrollment or renewal of 4 credentials to a health care provider, the managed care plan 5 shall provide the health care provider with written notice of 6 the decision. The notice shall include a clear rationale for the 7 decision. 8 Section 3. This act shall take effect as follows: 9 (1) The following provisions shall take effect in 90 10 days: 11 (i) The addition of section 635.2(f) and (g) of the 12 act. 13 (ii) The amendment of section 2121 of the act. 14 (iii) This section. 15 (2) The remainder of this act shall take effect in 210 16 days. 17 SECTION 1. SECTION 108 OF THE ACT OF MAY 17, 1921 (P.L.682, <-- 18 NO.284), KNOWN AS THE INSURANCE COMPANY LAW OF 1921, IS AMENDED 19 TO READ: 20 SECTION 108. EFFECT OF ACT ON EXISTING LAWS.--THE PROVISIONS 21 OF THIS ACT, SO FAR AS THEY ARE THE SAME AS THOSE OF EXISTING 22 LAWS, SHALL BE CONSTRUED AS A CONTINUATION OF SUCH LAWS AND NOT 23 AS NEW ENACTMENTS. THE REPEAL BY THIS ACT OF ANY PROVISION OF 24 LAW SHALL NOT REVIVE ANY LAW HERETOFORE REPEALED OR SUPERSEDED, 25 NOR SHALL SUCH REPEAL AFFECT ANY ACT DONE, LIABILITY INCURRED, 26 OR ANY RIGHT ACCRUED OR VESTED, OR ANY SUIT OR PROSECUTION 27 PENDING OR TO BE INSTITUTED TO ENFORCE ANY RIGHT OR PENALTY OR 28 PUNISH ANY OFFENSE UNDER THE AUTHORITY OF THE REPEALED LAWS. THE 29 PROVISIONS OF THIS ACT SHALL NOT LIMIT THE JURISDICTION AND 30 AUTHORITY OF THE OFFICE OF ATTORNEY GENERAL, INCLUDING, BUT NOT 20070H1150B4115 - 11 -
1 LIMITED TO, THE JURISDICTION AND AUTHORITY GRANTED PURSUANT TO 2 THE ACT OF OCTOBER 15, 1980 (P.L.950, NO.164), KNOWN AS THE 3 "COMMONWEALTH ATTORNEYS ACT." 4 SECTION 2. SECTION 405.2(C) OF THE ACT, AMENDED DECEMBER 21, 5 1995 (P.L.714, NO.79), IS AMENDED TO READ: 6 SECTION 405.2. ADDITIONAL INVESTMENT AUTHORITY FOR 7 SUBSIDIARIES.--* * * 8 (C) (1) [AT] EXCEPT AS SET FORTH IN PARAGRAPH (1.1), AT NO <-- 9 TIME SHALL A DOMESTIC LIFE INSURANCE COMPANY MAKE AN INVESTMENT 10 IN ANY SUBSIDIARY WHICH WILL BRING THE AGGREGATE VALUE OF ITS 11 INVESTMENTS, AS DETERMINED FOR ANNUAL STATEMENT PURPOSES BUT NOT 12 IN EXCESS OF COST, IN ALL SUBSIDIARIES UNDER THIS SUBSECTION TO 13 AN AMOUNT IN EXCESS OF [TEN] FIFTEEN PER CENTUM [(10%)] (15%) <-- 14 TEN PER CENTUM (10%) OF ITS TOTAL ADMITTED ASSETS AS OF THE <-- 15 IMMEDIATELY PRECEDING THIRTY-FIRST DAY OF DECEMBER. IN 16 DETERMINING THE AMOUNT OF INVESTMENTS OF ANY DOMESTIC LIFE 17 INSURANCE COMPANY IN SUBSIDIARIES FOR PURPOSES OF THIS 18 SUBSECTION, THERE SHALL BE INCLUDED INVESTMENTS MADE DIRECTLY BY 19 SUCH INSURANCE COMPANY AND, IF SUCH INVESTMENT IS MADE BY 20 ANOTHER SUBSIDIARY, THEN TO THE EXTENT THAT FUNDS FOR SUCH 21 INVESTMENTS ARE PROVIDED BY THE INSURANCE COMPANY FOR SUCH 22 PURPOSE. 23 (1.1) A DOMESTIC LIFE INSURANCE COMPANY MAY INCREASE THE 24 AGGREGATE VALUE OF ITS INVESTMENTS, AS DETERMINED FOR ANNUAL 25 STATEMENT PURPOSES, BUT NOT IN EXCESS OF COST, IN ALL 26 SUBSIDIARIES UNDER THIS SUBSECTION TO AN AMOUNT IN EXCESS OF TEN <-- 27 PER CENTUM (10%) BUT AT NO TIME IN EXCESS OF FIFTEEN PER CENTUM 28 (15%) OF ITS TOTAL ADMITTED ASSETS AS OF THE IMMEDIATELY 29 PRECEDING THIRTY-FIRST DAY OF DECEMBER IF THE INCREASE HAS BEEN 30 APPROVED IN WRITING BY THE INSURANCE DEPARTMENT PRIOR TO MAKING 20070H1150B4115 - 12 -
1 THE INVESTMENT. IF THE INSURANCE DEPARTMENT DOES NOT APPROVE OR <-- 2 DISAPPROVE THE INCREASED INVESTMENT WITHIN THIRTY (30) DAYS OF 3 RECEIPT OF A REQUEST FOR APPROVAL, THE INCREASED INVESTMENT 4 SHALL BE DEEMED APPROVED. IN DETERMINING THE AMOUNT OF 5 INVESTMENTS OF ANY DOMESTIC LIFE INSURANCE COMPANY IN 6 SUBSIDIARIES FOR PURPOSES OF THIS SUBSECTION, THERE SHALL BE 7 INCLUDED INVESTMENTS MADE DIRECTLY BY SUCH INSURANCE COMPANY 8 AND, IF SUCH INVESTMENT IS MADE BY ANOTHER SUBSIDIARY, THEN TO 9 THE EXTENT THAT FUNDS FOR SUCH INVESTMENTS ARE PROVIDED BY THE 10 INSURANCE COMPANY FOR SUCH PURPOSE. 11 (2) THE LIMITATIONS SET FORTH IN CLAUSE (1) OF THIS 12 SUBSECTION SHALL NOT APPLY TO INVESTMENTS IN ANY SUBSIDIARY 13 WHICH IS: 14 (I) AN INSURANCE COMPANY OR A HEALTH MAINTENANCE 15 ORGANIZATION HOLDING A CERTIFICATE OF AUTHORITY UNDER THE ACT OF 16 DECEMBER 29, 1972 (P.L.1701, NO.364), KNOWN AS THE "HEALTH 17 MAINTENANCE ORGANIZATION ACT." 18 (II) A HOLDING COMPANY TO THE EXTENT ITS BUSINESS CONSISTS 19 OF THE HOLDING OF THE STOCK OF, OR OTHERWISE CONTROLLING, ITS 20 OWN SUBSIDIARIES. 21 (III) A CORPORATION WHOSE BUSINESS PRIMARILY CONSISTS OF 22 DIRECT OR INDIRECT OWNERSHIP, OPERATION OR MANAGEMENT OF ASSETS 23 AUTHORIZED AS INVESTMENTS PURSUANT TO SECTIONS 404.1 AND 406. 24 (IV) A COMPANY ENGAGED IN ANY COMBINATION OF THE ACTIVITIES 25 DESCRIBED IN SUBCLAUSES (I), (II) AND (III) OF THIS CLAUSE. 26 INVESTMENTS MADE PURSUANT TO SUBCLAUSE (I) SHALL NOT BE 27 RESTRICTED IN AMOUNT PROVIDED THAT AFTER SUCH INVESTMENT, AS 28 CALCULATED FOR NAIC ANNUAL STATEMENT PURPOSES, THE INSURER'S 29 SURPLUS WILL BE REASONABLE IN RELATION TO THE INSURER'S 30 OUTSTANDING LIABILITIES AND ADEQUATE TO ITS FINANCIAL NEEDS. 20070H1150B4115 - 13 -
1 INVESTMENTS MADE PURSUANT TO SUBCLAUSE (II), OR TO THE EXTENT 2 APPLICABLE IN THIS SUBCLAUSE, SHALL IN ADDITION NOT BE SUBJECT 3 TO ANY LIMITATIONS ON THE AMOUNT OF A DOMESTIC LIFE INSURANCE 4 COMPANY'S ASSETS PROVIDED FOR UNDER ANY OTHER PROVISION OF THIS 5 ACT AND WHICH MIGHT OTHERWISE BE APPLICABLE: PROVIDED, HOWEVER, 6 THAT SUCH LIFE INSURANCE COMPANY'S INVESTMENTS, TO THE EXTENT 7 THAT SUCH LIFE INSURANCE COMPANY PROVIDED THE FUNDS THEREFOR, IN 8 EACH OF THE SUBSIDIARIES OF SUCH HOLDING COMPANY SHALL BE 9 SUBJECT TO THE LIMITATIONS, IF ANY, APPLICABLE TO SUCH 10 INVESTMENT AS IF THE HOLDING COMPANY'S INTEREST IN EACH SUCH 11 SUBSIDIARY WERE INSTEAD OWNED DIRECTLY BY THE LIFE INSURANCE 12 COMPANY. INVESTMENTS MADE PURSUANT TO SUBCLAUSE (III), OR, TO 13 THE EXTENT APPLICABLE, THIS CLAUSE, SHALL BE COUNTED IN 14 DETERMINING THE LIMITATIONS CONTAINED IN APPLICABLE SUBSECTIONS 15 OF SECTIONS 404.2 AND 406: PROVIDED, HOWEVER, THAT THE VALUE AS 16 CALCULATED FOR ANNUAL STATEMENT PURPOSES, BUT NOT IN EXCESS OF 17 THE COST THEREOF, OF SUCH INVESTMENT SHALL INCLUDE ONLY FUNDS 18 PROVIDED BY THE INSURANCE COMPANY THEREFOR. INVESTMENTS MADE IN 19 OTHER SUBSIDIARIES OF SUCH LIFE INSURANCE COMPANY BY ANY 20 SUBSIDIARY DESCRIBED IN SUBCLAUSES (I), (II), (III) AND THIS 21 SUBCLAUSE OR BY A PERSON WHOSE BUSINESS PRIMARILY CONSISTS OF 22 DIRECT OR INDIRECT OWNERSHIP, OPERATION OR MANAGEMENT OF REAL 23 PROPERTY AND INTEREST THEREIN UNDER SECTION 406 SHALL BE DEEMED 24 INVESTMENTS MADE BY THE INSURANCE COMPANY ONLY TO THE EXTENT THE 25 FUNDS FOR SUCH INVESTMENT WERE PROVIDED BY SUCH INSURANCE 26 COMPANY. 27 * * * 28 SECTION 3. THE ACT IS AMENDED BY ADDING SECTIONS TO READ: 29 SECTION 635.2. AUTISM SPECTRUM DISORDERS COVERAGE.--(A) A 30 HEALTH INSURANCE POLICY OR GOVERNMENT PROGRAM COVERED UNDER THIS 20070H1150B4115 - 14 -
1 SECTION SHALL PROVIDE TO COVERED INDIVIDUALS OR RECIPIENTS UNDER 2 TWENTY-ONE (21) YEARS OF AGE COVERAGE FOR THE DIAGNOSTIC 3 ASSESSMENT OF AUTISM SPECTRUM DISORDERS AND FOR THE TREATMENT OF 4 AUTISM SPECTRUM DISORDERS. 5 (B) COVERAGE PROVIDED UNDER THIS SECTION BY AN INSURER SHALL 6 BE SUBJECT TO A MAXIMUM BENEFIT OF THIRTY-SIX THOUSAND DOLLARS 7 ($36,000) PER YEAR BUT SHALL NOT BE SUBJECT TO ANY LIMITS ON THE 8 NUMBER OF VISITS TO AN AUTISM SERVICE PROVIDER FOR TREATMENT OF 9 AUTISM SPECTRUM DISORDERS. AFTER DECEMBER 30, 2011, THE 10 INSURANCE COMMISSIONER SHALL, ON OR BEFORE APRIL 1 OF EACH 11 CALENDAR YEAR, PUBLISH IN THE PENNSYLVANIA BULLETIN AN 12 ADJUSTMENT TO THE MAXIMUM BENEFIT EQUAL TO THE CHANGE IN THE 13 UNITED STATES DEPARTMENT OF LABOR CONSUMER PRICE INDEX FOR ALL 14 URBAN CONSUMERS (CPI-U) IN THE PRECEDING YEAR, AND THE PUBLISHED 15 ADJUSTED MAXIMUM BENEFIT SHALL BE APPLICABLE TO THE FOLLOWING 16 CALENDAR YEARS TO HEALTH INSURANCE POLICIES ISSUED OR RENEWED IN 17 THOSE CALENDAR YEARS. PAYMENTS MADE BY AN INSURER ON BEHALF OF A 18 COVERED INDIVIDUAL FOR TREATMENT OF A HEALTH CONDITION UNRELATED 19 TO OR DISTINGUISHABLE FROM THE INDIVIDUAL'S AUTISM SPECTRUM 20 DISORDER SHALL NOT BE APPLIED TOWARD ANY MAXIMUM BENEFIT 21 ESTABLISHED UNDER THIS SUBSECTION. 22 (C) COVERAGE UNDER THIS SECTION SHALL BE SUBJECT TO 23 COPAYMENT, DEDUCTIBLE AND COINSURANCE PROVISIONS, AND ANY OTHER 24 GENERAL EXCLUSIONS OR LIMITATIONS, OF A HEALTH INSURANCE POLICY 25 OR GOVERNMENT PROGRAM TO THE SAME EXTENT AS OTHER MEDICAL 26 SERVICES COVERED BY THE POLICY OR PROGRAM ARE SUBJECT TO THESE 27 PROVISIONS. 28 (D) THIS SECTION SHALL NOT BE CONSTRUED AS LIMITING BENEFITS 29 WHICH ARE OTHERWISE AVAILABLE TO AN INDIVIDUAL UNDER A HEALTH 30 INSURANCE POLICY OR GOVERNMENT PROGRAM. 20070H1150B4115 - 15 -
1 (D.1) THIS SECTION SHALL NOT BE CONSTRUED AS REQUIRING 2 COVERAGE BY INSURERS OF ANY SERVICE BASED SOLELY ON ITS 3 INCLUSION IN AN INDIVIDUALIZED EDUCATION PROGRAM. CONSISTENT 4 WITH FEDERAL OR STATE LAW AND UPON CONSENT OF THE PARENT OR 5 GUARDIAN OF THE COVERED INDIVIDUAL, THE TREATMENT OF AUTISM 6 SPECTRUM DISORDERS MAY BE COORDINATED WITH ANY SERVICE INCLUDED 7 IN AN INDIVIDUALIZED EDUCATION PROGRAM. COVERAGE FOR THE 8 TREATMENT OF AUTISM SPECTRUM DISORDERS SHALL NOT BE CONTINGENT 9 UPON A COORDINATION OF SERVICES WITH AN INDIVIDUALIZED EDUCATION 10 PROGRAM. 11 (E) (1) THIS SECTION SHALL APPLY TO ANY HEALTH INSURANCE 12 POLICY OFFERED, ISSUED OR RENEWED ON OR AFTER JULY 1, 2009, IN 13 THIS COMMONWEALTH TO GROUPS OF FIFTY-ONE (51) OR MORE EMPLOYEES: 14 PROVIDED, THAT THIS SECTION SHALL NOT INCLUDE THE FOLLOWING 15 POLICIES: 16 (I) ACCIDENT ONLY. 17 (II) FIXED INDEMNITY. 18 (III) LIMITED BENEFIT. 19 (IV) CREDIT. 20 (V) DENTAL. 21 (VI) VISION. 22 (VII) SPECIFIED DISEASE. 23 (VIII) MEDICARE SUPPLEMENT. 24 (IX) CHAMPUS (CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE 25 UNIFORMED SERVICES) SUPPLEMENT. 26 (X) LONG-TERM CARE OR DISABILITY INCOME. 27 (XI) WORKERS' COMPENSATION. 28 (XII) AUTOMOBILE MEDICAL PAYMENT. 29 (2) THIS SECTION SHALL APPLY TO ANY CONTRACT EXECUTED ON OR 30 AFTER JULY 1, 2009, BY THE ADULT BASIC COVERAGE INSURANCE 20070H1150B4115 - 16 -
1 PROGRAM ESTABLISHED UNDER CHAPTER 13 OF THE ACT OF JUNE 26, 2001 2 (P.L.755, NO.77), KNOWN AS THE "TOBACCO SETTLEMENT ACT," OR BY 3 THE CHILDREN'S HEALTH CARE PROGRAM ESTABLISHED UNDER THIS ACT, 4 OR BY ANY SUCCESSOR PROGRAM OF EITHER OF THEM. 5 (3) ON JANUARY 1, 2011, INSURERS SHALL MAKE A REPORT TO THE 6 INSURANCE DEPARTMENT, IN A FORM AND MANNER AS DETERMINED BY THE 7 DEPARTMENT, TO EVALUATE THE IMPLEMENTATION OF THIS SECTION. 8 (F) AS USED IN THIS SECTION: 9 (1) "APPLIED BEHAVIORAL ANALYSIS" MEANS THE DESIGN, 10 IMPLEMENTATION AND EVALUATION OF ENVIRONMENTAL MODIFICATION, 11 USING BEHAVIORAL STIMULI AND CONSEQUENCES, TO PRODUCE SOCIALLY 12 SIGNIFICANT IMPROVEMENT IN HUMAN BEHAVIOR OR TO PREVENT LOSS OF <-- 13 ATTAINED SKILL OR FUNCTION, INCLUDING THE USE OF DIRECT 14 OBSERVATION, MEASUREMENT AND FUNCTIONAL ANALYSIS OF THE 15 RELATIONS BETWEEN ENVIRONMENT AND BEHAVIOR. 16 (2) "AUTISM SERVICE PROVIDER" MEANS ANY OF THE FOLLOWING: 17 (I) A PERSON, ENTITY OR GROUP PROVIDING TREATMENT OF AUTISM 18 SPECTRUM DISORDERS PURSUANT TO A TREATMENT PLAN THAT IS LICENSED 19 OR CERTIFIED IN THIS COMMONWEALTH. 20 (II) ANY PERSON, ENTITY OR GROUP PROVIDING TREATMENT OF 21 AUTISM SPECTRUM DISORDERS PURSUANT TO A TREATMENT PLAN THAT IS 22 ENROLLED IN THE COMMONWEALTH'S MEDICAL ASSISTANCE PROGRAM ON OR 23 BEFORE THE EFFECTIVE DATE OF THIS SECTION. 24 (3) "AUTISM SPECTRUM DISORDERS" MEANS ANY OF THE PERVASIVE 25 DEVELOPMENTAL DISORDERS DEFINED BY THE MOST RECENT EDITION OF 26 THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM), 27 OR ITS SUCCESSOR, INCLUDING AUTISTIC DISORDER, ASPERGER'S 28 DISORDER AND PERVASIVE DEVELOPMENTAL DISORDER NOT OTHERWISE 29 SPECIFIED. 30 (4) "BEHAVIOR SPECIALIST" MEANS AN INDIVIDUAL WHO DESIGNS, 20070H1150B4115 - 17 -
1 IMPLEMENTS OR EVALUATES A BEHAVIOR MODIFICATION INTERVENTION 2 COMPONENT OF A TREATMENT PLAN, INCLUDING THOSE BASED ON APPLIED 3 BEHAVIORAL ANALYSIS, TO PRODUCE SOCIALLY SIGNIFICANT 4 IMPROVEMENTS IN HUMAN BEHAVIOR OR TO PREVENT LOSS OF ATTAINED <-- 5 SKILL OR FUNCTION THROUGH SKILL ACQUISITION AND THE REDUCTION OF 6 PROBLEMATIC BEHAVIOR. 7 (5) "DIAGNOSTIC ASSESSMENT OF AUTISM SPECTRUM DISORDERS" 8 MEANS MEDICALLY NECESSARY ASSESSMENTS, EVALUATIONS OR TESTS 9 PERFORMED BY A LICENSED PHYSICIAN, LICENSED PHYSICIAN ASSISTANT, 10 LICENSED PSYCHOLOGIST OR CERTIFIED REGISTERED NURSE PRACTITIONER 11 TO DIAGNOSE WHETHER AN INDIVIDUAL HAS AN AUTISM SPECTRUM 12 DISORDER. 13 (6) "GOVERNMENT PROGRAM" MEANS ANY OF THE FOLLOWING: 14 (I) THE COMMONWEALTH'S MEDICAL ASSISTANCE PROGRAM 15 ESTABLISHED UNDER THE ACT OF JUNE 13, 1967 (P.L.31, NO.21), 16 KNOWN AS THE "PUBLIC WELFARE CODE." 17 (II) THE ADULT BASIC COVERAGE INSURANCE PROGRAM ESTABLISHED 18 UNDER CHAPTER 13 OF THE ACT OF JUNE 26, 2001 (P.L.755, NO.77), 19 KNOWN AS THE "TOBACCO SETTLEMENT ACT." 20 (III) THE CHILDREN'S HEALTH CARE PROGRAM ESTABLISHED UNDER 21 THIS ACT. 22 (7) "HEALTH INSURANCE POLICY" MEANS ANY GROUP HEALTH, 23 SICKNESS OR ACCIDENT POLICY, OR SUBSCRIBER CONTRACT OR 24 CERTIFICATE OFFERED, ISSUED OR RENEWED BY AN ENTITY SUBJECT TO 25 ONE OF THE FOLLOWING: 26 (I) THIS ACT. 27 (II) THE ACT OF DECEMBER 29, 1972 (P.L.1701, NO.364), KNOWN 28 AS THE "HEALTH MAINTENANCE ORGANIZATION ACT." 29 (III) 40 PA.C.S. CH. 61 (RELATING TO HOSPITAL PLAN 30 CORPORATIONS) OR 63 (RELATING TO PROFESSIONAL HEALTH SERVICE 20070H1150B4115 - 18 -
1 PLAN CORPORATIONS). 2 (8) "INSURER" MEANS ANY ENTITY OFFERING A HEALTH INSURANCE 3 POLICY AS DEFINED IN THIS SECTION. 4 (9) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A 5 LICENSED PHYSICIAN, LICENSED PHYSICIAN ASSISTANT OR CERTIFIED 6 REGISTERED NURSE PRACTITIONER AND ANY ASSESSMENT, EVALUATION OR 7 TEST PRESCRIBED OR ORDERED BY A LICENSED PHYSICIAN, LICENSED 8 PHYSICIAN ASSISTANT OR CERTIFIED REGISTERED NURSE PRACTITIONER 9 TO DETERMINE THE NEED OR EFFECTIVENESS OF SUCH MEDICATIONS. 10 (10) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE 11 SERVICES PROVIDED BY A PHYSICIAN WHO SPECIALIZES IN PSYCHIATRY. 12 (11) "PSYCHOLOGICAL CARE" MEANS DIRECT OR CONSULTATIVE 13 SERVICES PROVIDED BY A PSYCHOLOGIST. 14 (12) "REHABILITATIVE CARE" MEANS PROFESSIONAL SERVICES AND 15 TREATMENT PROGRAMS, INCLUDING APPLIED BEHAVIORAL ANALYSIS, 16 PROVIDED BY AN AUTISM SERVICE PROVIDER. 17 (13) "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY SPEECH 18 LANGUAGE PATHOLOGISTS, OCCUPATIONAL THERAPISTS OR PHYSICAL 19 THERAPISTS. 20 (14) "TREATMENT OF AUTISM SPECTRUM DISORDER" SHALL BE 21 IDENTIFIED IN A TREATMENT PLAN AND SHALL INCLUDE ANY OF THE 22 FOLLOWING MEDICALLY NECESSARY PHARMACY CARE, PSYCHIATRIC CARE, 23 PSYCHOLOGICAL CARE, REHABILITATIVE CARE AND THERAPEUTIC CARE 24 THAT IS: 25 (I) PRESCRIBED, ORDERED OR PROVIDED BY A LICENSED PHYSICIAN, 26 LICENSED PHYSICIAN ASSISTANT, LICENSED PSYCHOLOGIST, LICENSED 27 CLINICAL SOCIAL WORKER OR CERTIFIED REGISTERED NURSE 28 PRACTITIONER. 29 (II) PROVIDED BY AN AUTISM SERVICE PROVIDER. 30 (III) PROVIDED BY A PERSON, ENTITY OR GROUP THAT WORKS UNDER 20070H1150B4115 - 19 -
1 THE DIRECTION OF AN AUTISM SERVICE PROVIDER. 2 (15) "TREATMENT PLAN" MEANS A PLAN FOR THE TREATMENT OF 3 AUTISM SPECTRUM DISORDERS DEVELOPED BY A LICENSED PHYSICIAN OR 4 LICENSED PSYCHOLOGIST PURSUANT TO A COMPREHENSIVE EVALUATION OR 5 REEVALUATION PERFORMED IN A MANNER CONSISTENT WITH THE MOST 6 RECENT CLINICAL REPORT OR RECOMMENDATIONS OF THE AMERICAN 7 ACADEMY OF PEDIATRICS. 8 (G) (1) THE STATE BOARD OF MEDICINE, IN CONSULTATION WITH 9 THE DEPARTMENT OF PUBLIC WELFARE, SHALL PROMULGATE REGULATIONS 10 PROVIDING FOR THE LICENSURE OR CERTIFICATION OF BEHAVIOR 11 SPECIALISTS. BEHAVIOR SPECIALISTS LICENSED OR CERTIFIED BY THE 12 STATE BOARD OF MEDICINE SHALL BE SUBJECT TO ALL DISCIPLINARY 13 PROVISIONS APPLICABLE TO MEDICAL DOCTORS AS SET FORTH IN THE ACT 14 OF DECEMBER 20, 1985 (P.L.457, NO.112), KNOWN AS THE "MEDICAL 15 PRACTICE ACT OF 1985." THE STATE BOARD OF MEDICINE MAY CHARGE 16 REASONABLE FEES AS SET BY BOARD REGULATION FOR LICENSURE OR 17 CERTIFICATES OR APPLICATIONS PERMITTED BY THE "MEDICAL PRACTICE 18 ACT OF 1985." 19 (2) AN APPLICANT APPLYING FOR A LICENSE OR CERTIFICATE AS A 20 BEHAVIOR SPECIALIST SHALL SUBMIT A WRITTEN APPLICATION ON FORMS 21 PROVIDED BY THE STATE BOARD OF MEDICINE EVIDENCING AND INSURING 22 TO THE SATISFACTION OF THE BOARD THAT THE APPLICANT: 23 (I) IS OF GOOD MORAL CHARACTER. 24 (II) HAS RECEIVED A MASTER'S OR HIGHER DEGREE FROM A BOARD- 25 APPROVED, ACCREDITED COLLEGE OR UNIVERSITY, INCLUDING A MAJOR 26 COURSE OF STUDY IN SCHOOL, CLINICAL OR COUNSELING PSYCHOLOGY, 27 SPECIAL EDUCATION, SOCIAL WORK, SPEECH THERAPY, OCCUPATIONAL 28 THERAPY OR ANOTHER RELATED FIELD. 29 (III) HAS AT LEAST ONE YEAR OF EXPERIENCE INVOLVING 30 FUNCTIONAL BEHAVIOR ASSESSMENTS, INCLUDING THE DEVELOPMENT AND 20070H1150B4115 - 20 -
1 IMPLEMENTATION OF BEHAVIORAL SUPPORTS OR TREATMENT PLANS. 2 (IV) HAS COMPLETED AT LEAST ONE THOUSAND (1,000) HOURS IN 3 DIRECT CLINICAL EXPERIENCE WITH INDIVIDUALS WITH BEHAVIORAL 4 CHALLENGES OR AT LEAST ONE THOUSAND (1,000) HOURS' EXPERIENCE IN 5 A RELATED FIELD WITH INDIVIDUALS WITH AUTISM SPECTRUM DISORDERS. 6 (V) HAS COMPLETED RELEVANT TRAINING PROGRAMS, INCLUDING 7 PROFESSIONAL ETHICS, AUTISM-SPECIFIC TRAINING, ASSESSMENTS 8 TRAINING, INSTRUCTIONAL STRATEGIES AND BEST PRACTICES, CRISIS 9 INTERVENTION, COMORBIDITY AND MEDICATIONS, FAMILY COLLABORATION 10 AND ADDRESSING SPECIFIC SKILL DEFICITS TRAINING. 11 (3) THE BOARD SHALL NOT ISSUE A LICENSE OR CERTIFICATE TO AN 12 APPLICANT WHO HAS BEEN CONVICTED OF A FELONY UNDER THE ACT OF 13 APRIL 14, 1972 (P.L.233, NO.64), KNOWN AS "THE CONTROLLED 14 SUBSTANCE, DRUG, DEVICE AND COSMETIC ACT," OR IF AN OFFENSE 15 UNDER THE LAWS OF ANOTHER JURISDICTION WHICH, IF COMMITTED IN 16 THIS COMMONWEALTH, WOULD BE A FELONY UNDER "THE CONTROLLED 17 SUBSTANCE, DRUG, DEVICE AND COSMETIC ACT," UNLESS: 18 (I) AT LEAST TEN (10) YEARS HAVE ELAPSED FROM THE DATE OF 19 CONVICTION. 20 (II) THE APPLICANT SATISFACTORILY DEMONSTRATES TO THE BOARD 21 THAT HE HAS MADE SIGNIFICANT PROGRESS IN PERSONAL REHABILITATION 22 SINCE THE CONVICTION SUCH THAT LICENSURE OF THE APPLICANT SHOULD 23 NOT BE EXPECTED TO CREATE A SUBSTANTIAL RISK OF HARM TO THE 24 HEALTH AND SAFETY OF HIS PATIENTS OR THE PUBLIC OR A SUBSTANTIAL 25 RISK OF FURTHER CRIMINAL VIOLATIONS. 26 (III) THE APPLICANT OTHERWISE SATISFIES THE QUALIFICATIONS 27 CONTAINED IN OR AUTHORIZED BY THIS SECTION. 28 AS USED IN THIS PARAGRAPH, THE TERM "CONVICTED" SHALL INCLUDE A 29 JUDGMENT, AN ADMISSION OF GUILT OR A PLEA OF NOLO CONTENDERE. 30 (H) AN INSURER SHALL BE REQUIRED TO CONTRACT WITH AND TO 20070H1150B4115 - 21 -
1 ACCEPT AS A PARTICIPATING PROVIDER ANY AUTISM SERVICE PROVIDER 2 WITHIN ITS SERVICE AREA AND ENROLLED IN THE COMMONWEALTH'S 3 MEDICAL ASSISTANCE PROGRAM WHO AGREES TO ACCEPT THE PAYMENT 4 LEVELS, TERMS AND CONDITIONS APPLICABLE TO THE INSURER'S OTHER 5 PARTICIPATING PROVIDERS FOR SUCH SERVICE. 6 (I) AN INSURER MAY REVIEW A TREATMENT PLAN FOR TREATMENT OF 7 AUTISM SPECTRUM DISORDERS ONCE EVERY SIX (6) MONTHS, SUBJECT TO 8 ITS UTILIZATION REVIEW REQUIREMENTS, INCLUDING CASE MANAGEMENT, 9 CONCURRENT REVIEW AND OTHER MANAGED CARE PROVISIONS. A MORE OR 10 LESS FREQUENT REVIEW CAN BE AGREED UPON BY THE INSURER AND THE 11 LICENSED PHYSICIAN OR LICENSED PSYCHOLOGIST DEVELOPING THE 12 TREATMENT PLAN. 13 (J) THE RESULTS OF A DIAGNOSTIC ASSESSMENT OF AUTISM 14 SPECTRUM DISORDER SHALL BE VALID FOR A PERIOD OF TWELVE (12) 15 MONTHS, UNLESS A LICENSED PHYSICIAN OR LICENSED PSYCHOLOGIST 16 DETERMINES AN EARLIER ASSESSMENT IS NECESSARY. 17 (K) (1) UPON DENIAL OR PARTIAL DENIAL BY AN INSURER OF A <-- 18 CLAIM FOR DIAGNOSTIC ASSESSMENT OF AUTISM SPECTRUM DISORDERS OR 19 A CLAIM FOR TREATMENT OF AUTISM SPECTRUM DISORDERS, A COVERED 20 INDIVIDUAL OR AN AUTHORIZED REPRESENTATIVE SHALL BE ENTITLED TO 21 AN EXPEDITED INTERNAL REVIEW PROCESS PURSUANT TO THE PROCEDURES 22 SET FORTH IN ARTICLE XXI, FOLLOWED BY AN EXPEDITED INDEPENDENT 23 EXTERNAL REVIEW PROCESS ESTABLISHED AND ADMINISTERED BY THE 24 INSURANCE DEPARTMENT. 25 (2) AN INSURER OR COVERED INDIVIDUAL OR AN AUTHORIZED 26 REPRESENTATIVE MAY APPEAL TO A COURT OF COMPETENT JURISDICTION 27 AN ORDER OF AN EXPEDITED INDEPENDENT EXTERNAL REVIEW 28 DISAPPROVING A DENIAL OR PARTIAL DENIAL. PENDING A RULING OF 29 SUCH COURT, THE INSURER SHALL PAY FOR THOSE SERVICES, IF ANY, 30 THAT HAVE BEEN AUTHORIZED UNTIL SUCH RULING. 20070H1150B4115 - 22 -
1 (3) THE INSURANCE COMMISSIONER MAY PROMULGATE RULES AND 2 REGULATIONS AS MAY BE NECESSARY OR APPROPRIATE TO IMPLEMENT AND 3 ADMINISTER THIS SUBSECTION. 4 (K) (L) FOR PURPOSES OF THIS SECTION, THE TERM "AUTISM <-- 5 SERVICE PROVIDER" SHALL INCLUDE ANY BEHAVIOR SPECIALIST IN THIS 6 COMMONWEALTH PROVIDING TREATMENT OF AUTISM SPECTRUM DISORDERS 7 PURSUANT TO A TREATMENT PLAN UNTIL ONE (1) YEAR FROM THE TIME 8 THAT SUCH REGULATIONS UNDER SUBSECTION (G) ARE PROMULGATED OR <-- 9 UNTIL THREE (3) YEARS FROM THE EFFECTIVE DATE OF THIS SECTION, 10 WHICHEVER IS LATER. 11 SECTION 635.3. COVERAGE FOR COLORECTAL CANCER SCREENING.-- 12 (A) EXCEPT TO THE EXTENT ALREADY COVERED UNDER ANOTHER POLICY, 13 ALL HEALTH INSURANCE POLICIES AS DEFINED IN THIS SECTION SHALL 14 ALSO PROVIDE COVERAGE FOR COLORECTAL CANCER SCREENING FOR 15 COVERED INDIVIDUALS IN ACCORDANCE WITH THE MOST RECENTLY <-- 16 PUBLISHED AMERICAN CANCER SOCIETY GUIDELINES FOR COLORECTAL 17 CANCER SCREENING PUBLISHED AS OF JANUARY 1, 2008, AND CONSISTENT <-- 18 WITH APPROVED MEDICAL STANDARDS AND PRACTICES. 19 (1) COVERAGE FOR NONSYMPTOMATIC COVERED INDIVIDUALS WHO ARE 20 FIFTY (50) YEARS OF AGE OR OLDER SHALL INCLUDE, BUT NOT BE 21 LIMITED TO: 22 (I) AN ANNUAL FECAL OCCULT BLOOD TEST. 23 (II) A SIGMOIDOSCOPY, A SCREENING BARIUM ENEMA OR A TEST 24 CONSISTENT WITH APPROVED MEDICAL STANDARDS AND PRACTICES TO 25 DETECT COLON CANCER, AT LEAST ONCE EVERY FIVE (5) YEARS. 26 (III) A COLONOSCOPY AT LEAST ONCE EVERY TEN (10) YEARS. 27 (2) COVERAGE FOR SYMPTOMATIC COVERED INDIVIDUALS SHALL 28 INCLUDE A COLONOSCOPY, SIGMOIDOSCOPY OR ANY COMBINATION OF 29 COLORECTAL CANCER SCREENING TESTS AT A FREQUENCY DETERMINED BY A 30 TREATING PHYSICIAN. 20070H1150B4115 - 23 -
1 (3) COVERAGE FOR NONSYMPTOMATIC COVERED INDIVIDUALS WHO ARE 2 AT HIGH OR INCREASED RISK FOR COLORECTAL CANCER WHO ARE UNDER 3 FIFTY (50) YEARS OF AGE SHALL INCLUDE A COLONOSCOPY OR ANY 4 COMBINATION OF COLORECTAL CANCER SCREENING TESTS IN ACCORDANCE 5 WITH THE MOST RECENTLY PUBLISHED AMERICAN CANCER SOCIETY <-- 6 GUIDELINES ON SCREENING FOR COLORECTAL CANCER PUBLISHED AS OF <-- 7 JANUARY 1, 2008. 8 (B) THE COVERAGE REQUIRED UNDER THIS SECTION SHALL BE 9 SUBJECT TO ANNUAL DEDUCTIBLES, COINSURANCE AND COPAYMENT 10 REQUIREMENTS IMPOSED BY AN ENTITY SUBJECT TO THIS SECTION FOR 11 SIMILAR COVERAGES UNDER THE SAME HEALTH INSURANCE POLICY OR 12 CONTRACT. 13 (C) FOR THE PURPOSE OF THIS SECTION: 14 (1) "HEALTH INSURANCE POLICY" MEANS ANY INDIVIDUAL OR GROUP <-- 15 HEALTH, SICKNESS OR ACCIDENT POLICY OR SUBSCRIBER CONTRACT OR 16 CERTIFICATE OFFERED TO GROUPS OF FIFTY-ONE (51) OR MORE EMPLOYES <-- 17 ISSUED BY AN ENTITY SUBJECT TO ANY ONE OF THE FOLLOWING: 18 (I) THIS ACT. 19 (II) THE ACT OF DECEMBER 29, 1972 (P.L.1701, NO.364), KNOWN 20 AS THE "HEALTH MAINTENANCE ORGANIZATION ACT." 21 (III) THE ACT OF MAY 18, 1976 (P.L.123, NO.54), KNOWN AS THE <-- 22 "INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM STANDARDS 23 ACT." 24 (IV) (III) 40 PA.C.S. CH. 61 (RELATING TO HOSPITAL PLAN <-- 25 CORPORATIONS) OR 63 (RELATING TO PROFESSIONAL HEALTH SERVICES 26 PLAN CORPORATIONS). 27 (V) MEDICAL ASSISTANCE. <-- 28 THE TERM DOES NOT INCLUDE ACCIDENT ONLY, FIXED INDEMNITY, 29 LIMITED BENEFIT, CREDIT, DENTAL, VISION, SPECIFIED DISEASE, 30 MEDICARE SUPPLEMENT, CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE 20070H1150B4115 - 24 -
1 UNIFORMED SERVICES (CHAMPUS) SUPPLEMENT, LONG-TERM CARE OR 2 DISABILITY INCOME, WORKERS' COMPENSATION OR AUTOMOBILE MEDICAL 3 PAYMENT INSURANCE. 4 (2) "COLONOSCOPY" MEANS AN EXAMINATION OF THE RECTUM AND THE 5 ENTIRE COLON USING A LIGHTED INSTRUMENT CALLED A COLONOSCOPE. 6 (3) "COLORECTAL CANCER SCREENING" MEANS ANY OF THE FOLLOWING 7 PROCEDURES THAT ARE FURNISHED TO AN INDIVIDUAL FOR THE PURPOSE 8 OF EARLY DETECTION OF COLORECTAL CANCER: 9 (I) SCREENING FECAL-OCCULT BLOOD OR FECAL IMMUNOCHEMICAL 10 TEST. 11 (II) SCREENING FLEXIBLE SIGMOIDOSCOPY. 12 (III) SCREENING COLONOSCOPY. 13 (IV) SCREENING BARIUM ENEMA. 14 (V) SCREENING TEST CONSISTENT WITH APPROVED MEDICAL 15 STANDARDS AND PRACTICES TO DETECT COLON CANCER. 16 (4) "NONSYMPTOMATIC PERSON AT HIGH OR INCREASED RISK" MEANS 17 AN INDIVIDUAL WHO POSES A HIGHER THAN AVERAGE RISK FOR 18 COLORECTAL CANCER ACCORDING TO THE MOST RECENTLY PUBLISHED <-- 19 AMERICAN CANCER SOCIETY GUIDELINES ON SCREENING FOR COLORECTAL <-- 20 CANCER AS OF JANUARY 1, 2008. 21 (5) "SYMPTOMATIC PERSON" MEANS AN INDIVIDUAL WHO EXPERIENCES 22 A CHANGE IN BOWEL HABITS, RECTAL BLEEDING OR PERSISTENT STOMACH 23 CRAMPS, WEIGHT LOSS OR ABDOMINAL PAIN. 24 SECTION 4. THE INTRODUCTORY PARAGRAPH AND THE DEFINITIONS OF 25 "INSURER" AND "PERSON" IN SECTION 1401 OF THE ACT, AMENDED 26 DECEMBER 20, 2000 (P.L.967, NO.132), ARE AMENDED AND THE SECTION 27 IS AMENDED BY ADDING A DEFINITION TO READ: 28 SECTION 1401. DEFINITIONS.--AS USED IN THIS ARTICLE, AND FOR 29 THE PURPOSES OF THIS ARTICLE ONLY, THE FOLLOWING WORDS AND 30 PHRASES SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SECTION: 20070H1150B4115 - 25 -
1 * * * 2 "INSURER." ANY HEALTH MAINTENANCE ORGANIZATION, PREFERRED 3 PROVIDER ORGANIZATION, COMPANY, ASSOCIATION [OR], EXCHANGE, 4 HOSPITAL PLAN CORPORATION AS DEFINED IN AND SUBJECT TO 40 5 PA.C.S. CH. 61 (RELATING TO HOSPITAL PLAN CORPORATIONS) OR 6 PROFESSIONAL HEALTH SERVICES PLAN CORPORATION SUBJECT TO 40 7 PA.C.S. CH. 63 (RELATING TO PROFESSIONAL HEALTH SERVICES PLAN 8 CORPORATIONS), AUTHORIZED BY THE INSURANCE COMMISSIONER TO 9 TRANSACT THE BUSINESS OF INSURANCE IN THIS COMMONWEALTH EXCEPT 10 THAT THE TERM SHALL NOT INCLUDE: 11 (1) THE COMMONWEALTH OR ANY AGENCY OR INSTRUMENTALITY 12 THEREOF; 13 (2) AGENCIES, AUTHORITIES OR INSTRUMENTALITIES OF THE UNITED 14 STATES, ITS POSSESSIONS AND TERRITORIES, THE COMMONWEALTH OF 15 PUERTO RICO, THE DISTRICT OF COLUMBIA OR A STATE OR POLITICAL 16 SUBDIVISION; OR 17 (3) FRATERNAL BENEFIT SOCIETIES[; OR 18 (4) NONPROFIT MEDICAL AND HOSPITAL SERVICE ASSOCIATIONS]. 19 * * * 20 "PERSON." AN INDIVIDUAL, AN INSURER, A CORPORATION, A 21 PARTNERSHIP, A LIMITED LIABILITY COMPANY, AN ASSOCIATION, A 22 JOINT STOCK COMPANY, A TRUST, AN UNINCORPORATED ORGANIZATION, 23 ANY SIMILAR ENTITY OR ANY COMBINATION OF THE FOREGOING ACTING IN 24 CONCERT. THE TERM SHALL NOT INCLUDE ANY JOINT VENTURE 25 PARTNERSHIP EXCLUSIVELY ENGAGED IN OWNING, MANAGING, LEASING OR 26 DEVELOPING REAL OR TANGIBLE PERSONAL PROPERTY. 27 * * * 28 "SHAREHOLDER." A RECORD HOLDER OR RECORD OWNER OF SHARES OF 29 AN INSURER. 30 (1) THE TERM SHALL INCLUDE ALL OF THE FOLLOWING: 20070H1150B4115 - 26 -
1 (I) A MEMBER OF AN INSURER THAT IS A DOMESTIC NONSTOCK 2 CORPORATION UNDER 15 PA.C.S. CH. 21 (RELATING TO NONSTOCK 3 CORPORATIONS) OR A PRIOR STATUTE. 4 (II) A MEMBER, AS DEFINED IN 15 PA.C.S. § 5103 (RELATING TO 5 DEFINITIONS), OF AN INSURER THAT IS A DOMESTIC NONPROFIT 6 CORPORATION UNDER 15 PA.C.S. CH. 51 (RELATING TO GENERAL 7 PROVISIONS) OR A PRIOR STATUTE. 8 (III) A SUBSCRIBER OF AN INSURER THAT IS A DOMESTIC 9 RECIPROCAL EXCHANGE UNDER ARTICLE X OR A PRIOR STATUTE. 10 (2) THE TERM SHALL NOT INCLUDE ANY SUBSCRIBER, INSURED OR 11 CUSTOMER OF: 12 (I) A HOSPITAL PLAN CORPORATION SUBJECT TO 40 PA.C.S. CH. 61 13 (RELATING TO HOSPITAL PLAN CORPORATIONS); OR 14 (II) A PROFESSIONAL HEALTH SERVICE PLAN CORPORATION SUBJECT 15 TO 40 PA.C.S. CH. 63 (RELATING TO PROFESSIONAL HEALTH SERVICES 16 PLAN CORPORATIONS). 17 * * * 18 SECTION 5. SECTION 1402 OF THE ACT, AMENDED OR ADDED 19 DECEMBER 18, 1992 (P.L.1519, NO.178) AND DECEMBER 21, 1998 20 (P.L.1108, NO.150), IS AMENDED TO READ: 21 SECTION 1402. ACQUISITION OF CONTROL OF OR MERGER OR 22 CONSOLIDATION WITH DOMESTIC INSURER.--(A) (1) NO PERSON OTHER 23 THAN THE ISSUER SHALL MAKE A TENDER OFFER FOR OR A REQUEST OR 24 INVITATION FOR TENDERS OF, OR ENTER INTO ANY AGREEMENT TO 25 EXCHANGE SECURITIES OR SEEK TO ACQUIRE OR ACQUIRE IN THE OPEN 26 MARKET OR OTHERWISE, ANY VOTING SECURITY OF A DOMESTIC INSURER 27 IF, AFTER THE CONSUMMATION THEREOF, SUCH PERSON WOULD DIRECTLY 28 OR INDIRECTLY OR BY CONVERSION OR BY EXERCISE OF ANY RIGHT TO 29 ACQUIRE, BE IN CONTROL OF SUCH INSURER, AND NO PERSON SHALL 30 ENTER INTO AN AGREEMENT TO MERGE OR CONSOLIDATE WITH OR 20070H1150B4115 - 27 -
1 OTHERWISE TO ACQUIRE CONTROL OF A DOMESTIC INSURER OR ANY PERSON
2 CONTROLLING A DOMESTIC INSURER UNLESS, AT THE TIME ANY SUCH
3 OFFER, REQUEST OR INVITATION IS MADE OR ANY SUCH AGREEMENT IS
4 ENTERED INTO OR PRIOR TO THE ACQUISITION OF SUCH SECURITIES IF
5 NO OFFER OR AGREEMENT IS INVOLVED, SUCH PERSON HAS FILED WITH
6 THE DEPARTMENT AND HAS SENT TO SUCH INSURER A STATEMENT
7 CONTAINING THE INFORMATION REQUIRED BY THIS SECTION AND SUCH
8 OFFER, REQUEST, INVITATION, AGREEMENT OR ACQUISITION HAS BEEN
9 APPROVED BY THE DEPARTMENT IN THE MANNER HEREINAFTER PRESCRIBED.
10 (2) FOR PURPOSES OF THIS SECTION, A "DOMESTIC INSURER" SHALL
11 INCLUDE ANY PERSON CONTROLLING A DOMESTIC INSURER UNLESS SUCH
12 PERSON AS DETERMINED BY THE DEPARTMENT IS EITHER DIRECTLY OR
13 THROUGH ITS AFFILIATES PRIMARILY ENGAGED IN BUSINESS OTHER THAN
14 THE BUSINESS OF INSURANCE. SUCH PERSON SHALL, HOWEVER, FILE A
15 PREACQUISITION NOTIFICATION WITH THE DEPARTMENT CONTAINING THE
16 INFORMATION SET FORTH IN SECTION 1403(C)(2) THIRTY (30) DAYS
17 PRIOR TO THE PROPOSED EFFECTIVE DATE OF THE ACQUISITION. FAILURE
18 TO FILE IS SUBJECT TO SECTION 1403(E)(3). FOR PURPOSES OF THIS
19 SECTION, "PERSON" SHALL NOT INCLUDE ANY SECURITIES BROKER
20 HOLDING, IN THE USUAL AND CUSTOMARY MANNER, LESS THAN TWENTY PER
21 CENTUM (20%) OF THE VOTING SECURITIES OF AN INSURANCE COMPANY OR
22 OF ANY PERSON WHICH CONTROLS AN INSURANCE COMPANY.
23 (B) THE STATEMENT TO BE FILED WITH THE DEPARTMENT UNDER THIS
24 SECTION SHALL BE MADE UNDER OATH OR AFFIRMATION AND SHALL
25 CONTAIN THE FOLLOWING INFORMATION:
26 (1) THE NAME AND ADDRESS OF EACH PERSON BY WHOM OR ON WHOSE
27 BEHALF THE MERGER, CONSOLIDATION OR OTHER ACQUISITION OF CONTROL
28 REFERRED TO IN SUBSECTION (A) IS TO BE EFFECTED, HEREINAFTER
29 CALLED "ACQUIRING PARTY," AND
30 (I) IF SUCH PERSON IS AN INDIVIDUAL, HIS PRINCIPAL
20070H1150B4115 - 28 -
1 OCCUPATION AND ALL OFFICES AND POSITIONS HELD DURING THE PAST
2 FIVE (5) YEARS, AND ANY CONVICTION OF CRIMES OTHER THAN MINOR
3 TRAFFIC VIOLATIONS DURING THE PAST TEN (10) YEARS; OR
4 (II) IF SUCH PERSON IS NOT AN INDIVIDUAL, A REPORT OF THE
5 NATURE OF ITS BUSINESS OPERATIONS DURING THE PAST FIVE (5) YEARS
6 OR FOR SUCH LESSER PERIOD AS THE PERSON AND ANY PREDECESSORS
7 THEREOF SHALL HAVE BEEN IN EXISTENCE; AN INFORMATIVE DESCRIPTION
8 OF THE BUSINESS INTENDED TO BE DONE BY THE PERSON AND THE
9 PERSON'S SUBSIDIARIES; AND A LIST OF ALL INDIVIDUALS WHO ARE OR
10 WHO HAVE BEEN SELECTED TO BECOME DIRECTORS OR EXECUTIVE OFFICERS
11 OF THE PERSON, OR WHO PERFORM OR WILL PERFORM FUNCTIONS
12 APPROPRIATE TO THOSE POSITIONS. THIS LIST SHALL INCLUDE FOR EACH
13 INDIVIDUAL THE INFORMATION REQUIRED BY SUBPARAGRAPH (I).
14 (2) THE SOURCE, NATURE AND AMOUNT OF THE CONSIDERATION USED
15 OR TO BE USED IN EFFECTING THE MERGER, CONSOLIDATION OR OTHER
16 ACQUISITION OF CONTROL, A DESCRIPTION OF ANY TRANSACTION WHEREIN
17 FUNDS WERE OR ARE TO BE OBTAINED FOR ANY SUCH PURPOSE, INCLUDING
18 ANY PLEDGE OF THE INSURER'S STOCK OR THE STOCK OF ANY OF ITS
19 SUBSIDIARIES OR CONTROLLING AFFILIATES, AND THE IDENTITY OF
20 PERSONS FURNISHING SUCH CONSIDERATION, PROVIDED, HOWEVER, THAT
21 WHERE A SOURCE OF SUCH CONSIDERATION IS A LOAN MADE IN THE
22 LENDER'S ORDINARY COURSE OF BUSINESS, THE IDENTITY OF THE LENDER
23 SHALL REMAIN CONFIDENTIAL IF THE PERSON FILING SUCH STATEMENT SO
24 REQUESTS.
25 (3) FULLY AUDITED FINANCIAL INFORMATION AS TO THE EARNINGS
26 AND FINANCIAL CONDITION OF EACH ACQUIRING PARTY FOR THE
27 PRECEDING FIVE (5) FISCAL YEARS OF EACH SUCH ACQUIRING PARTY, OR
28 FOR SUCH LESSER PERIOD AS SUCH ACQUIRING PARTY AND ANY
29 PREDECESSORS THEREOF SHALL HAVE BEEN IN EXISTENCE, AND SIMILAR
30 UNAUDITED INFORMATION AS OF A DATE NOT EARLIER THAN NINETY (90)
20070H1150B4115 - 29 -
1 DAYS PRIOR TO THE FILING OF THE STATEMENT. 2 (4) ANY PLANS OR PROPOSALS WHICH EACH ACQUIRING PARTY MAY 3 HAVE TO LIQUIDATE SUCH INSURER, TO SELL ITS ASSETS OR MERGE OR 4 CONSOLIDATE IT WITH ANY PERSON OR TO MAKE ANY OTHER MATERIAL 5 CHANGE IN ITS BUSINESS OR CORPORATE STRUCTURE OR MANAGEMENT. 6 (5) THE NUMBER OF SHARES OF ANY SECURITY REFERRED TO IN 7 SUBSECTION (A) WHICH EACH ACQUIRING PARTY PROPOSES TO ACQUIRE, 8 AND THE TERMS OF THE OFFER, REQUEST, INVITATION, AGREEMENT OR 9 ACQUISITION REFERRED TO IN SUBSECTION (A), AND A STATEMENT AS TO 10 THE METHOD BY WHICH THE FAIRNESS OF THE PROPOSAL WAS ARRIVED. 11 (6) THE AMOUNT OF EACH CLASS OF ANY SECURITY REFERRED TO IN 12 SUBSECTION (A) WHICH IS BENEFICIALLY OWNED OR CONCERNING WHICH 13 THERE IS A RIGHT TO ACQUIRE BENEFICIAL OWNERSHIP BY EACH 14 ACQUIRING PARTY. 15 (7) A FULL DESCRIPTION OF ANY CONTRACTS, ARRANGEMENTS OR 16 UNDERSTANDINGS WITH RESPECT TO ANY SECURITY REFERRED TO IN 17 SUBSECTION (A) IN WHICH ANY ACQUIRING PARTY IS INVOLVED, 18 INCLUDING, BUT NOT LIMITED TO, TRANSFER OF ANY OF THE 19 SECURITIES, JOINT VENTURES, LOAN OR OPTION ARRANGEMENTS, PUTS OR 20 CALLS, GUARANTEES OF LOANS, GUARANTEES AGAINST LOSS OR 21 GUARANTEES OF PROFITS, DIVISION OF LOSSES OR PROFITS, OR THE 22 GIVING OR WITHHOLDING OF PROXIES. SUCH DESCRIPTION SHALL 23 IDENTIFY THE PERSONS WITH WHOM SUCH CONTRACTS, ARRANGEMENTS OR 24 UNDERSTANDINGS HAVE BEEN ENTERED INTO. 25 (8) A DESCRIPTION OF THE PURCHASE OF ANY SECURITY REFERRED 26 TO IN SUBSECTION (A) DURING THE TWELVE CALENDAR MONTHS PRECEDING 27 THE FILING OF THE STATEMENT, BY ANY ACQUIRING PARTY, INCLUDING 28 THE DATES OF PURCHASE, NAMES OF THE PURCHASERS AND CONSIDERATION 29 PAID OR AGREED TO BE PAID THEREFOR. 30 (9) A DESCRIPTION OF ANY RECOMMENDATIONS TO PURCHASE ANY 20070H1150B4115 - 30 -
1 SECURITY REFERRED TO IN SUBSECTION (A) MADE DURING THE TWELVE 2 CALENDAR MONTHS PRECEDING THE FILING OF THE STATEMENT, BY ANY 3 ACQUIRING PARTY, OR BY ANYONE BASED UPON INTERVIEWS OR AT THE 4 SUGGESTION OF SUCH ACQUIRING PARTY. 5 (10) COPIES OF ALL TENDER OFFERS FOR, REQUESTS OR 6 INVITATIONS FOR TENDERS OF, EXCHANGE OFFERS FOR AND AGREEMENTS 7 TO ACQUIRE OR EXCHANGE ANY SECURITIES REFERRED TO IN SUBSECTION 8 (A) AND, IF DISTRIBUTED, OF ADDITIONAL SOLICITING MATERIAL 9 RELATING THERETO. 10 (11) THE TERM OF ANY AGREEMENT, CONTRACT OR UNDERSTANDING 11 MADE WITH OR PROPOSED TO BE MADE WITH ANY BROKER-DEALER AS TO 12 SOLICITATION OF SECURITIES REFERRED TO IN SUBSECTION (A) FOR 13 TENDER AND THE AMOUNT OF ANY FEES, COMMISSIONS OR OTHER 14 COMPENSATION TO BE PAID TO BROKER-DEALERS WITH REGARD THERETO. 15 (12) SUCH ADDITIONAL INFORMATION AS THE DEPARTMENT MAY BY 16 RULE OR REGULATION PRESCRIBE AS NECESSARY OR APPROPRIATE FOR THE 17 PROTECTION OF POLICYHOLDERS OF THE INSURER OR IN THE PUBLIC 18 INTEREST. 19 (C) IF THE PERSON REQUIRED TO FILE THE STATEMENT REFERRED TO 20 IN SUBSECTION (A) IS A PARTNERSHIP, LIMITED PARTNERSHIP, 21 SYNDICATE OR OTHER GROUP, THE DEPARTMENT MAY REQUIRE THAT THE 22 INFORMATION CALLED FOR BY SUBSECTION (B)(1) THROUGH (12) SHALL 23 BE GIVEN WITH RESPECT TO EACH PARTNER OF SUCH PARTNERSHIP OR 24 LIMITED PARTNERSHIP, EACH MEMBER OF SUCH SYNDICATE OR GROUP AND 25 EACH PERSON WHO CONTROLS SUCH PARTNER OR MEMBER. IF ANY SUCH 26 PARTNER, MEMBER OR PERSON IS A CORPORATION OR THE PERSON 27 REQUIRED TO FILE THE STATEMENT REFERRED TO IN SUBSECTION (A) IS 28 A CORPORATION, THE DEPARTMENT MAY REQUIRE THAT THE INFORMATION 29 CALLED FOR BY SUBSECTION (B)(1) THROUGH (12) SHALL BE GIVEN WITH 30 RESPECT TO SUCH CORPORATION, EACH OFFICER AND DIRECTOR OF SUCH 20070H1150B4115 - 31 -
1 CORPORATION AND EACH PERSON WHO IS DIRECTLY OR INDIRECTLY THE 2 BENEFICIAL OWNER OF MORE THAN TEN PER CENTUM (10%) OF THE 3 OUTSTANDING VOTING SECURITIES OF SUCH CORPORATION. 4 (D) IF ANY MATERIAL CHANGE OCCURS IN THE FACTS SET FORTH IN 5 THE STATEMENT FILED WITH THE DEPARTMENT AND SENT TO SUCH INSURER 6 PURSUANT TO THIS SECTION, AN AMENDMENT SETTING FORTH SUCH 7 CHANGE, TOGETHER WITH COPIES OF ALL DOCUMENTS AND OTHER MATERIAL 8 RELEVANT TO SUCH CHANGE, SHALL BE FILED WITH THE DEPARTMENT AND 9 SENT TO SUCH INSURER WITHIN TWO (2) BUSINESS DAYS AFTER THE 10 PERSON LEARNS OF SUCH CHANGE. 11 (E) IF ANY OFFER, REQUEST, INVITATION, AGREEMENT OR 12 ACQUISITION REFERRED TO IN SUBSECTION (A) IS PROPOSED TO BE MADE 13 BY MEANS OF A REGISTRATION STATEMENT UNDER THE SECURITIES ACT OF 14 1933 (48 STAT. 74, 15 U.S.C. § 77A ET SEQ.), OR IN CIRCUMSTANCES 15 REQUIRING THE DISCLOSURE OF SIMILAR INFORMATION UNDER THE 16 SECURITIES EXCHANGE ACT OF 1934 (48 STAT. 881, 15 U.S.C. § 78A 17 ET SEQ.), OR UNDER A STATE LAW REQUIRING SIMILAR REGISTRATION OR 18 DISCLOSURE, THE PERSON REQUIRED TO FILE THE STATEMENT REFERRED 19 TO IN SUBSECTION (A) MAY UTILIZE SUCH DOCUMENTS IN FURNISHING 20 THE INFORMATION CALLED FOR BY THAT STATEMENT. 21 (F) (1) THE DEPARTMENT SHALL APPROVE ANY MERGER, 22 CONSOLIDATION OR OTHER ACQUISITION OF CONTROL REFERRED TO IN 23 SUBSECTION (A) UNLESS IT FINDS ANY OF THE FOLLOWING: 24 (I) AFTER THE [CHANGE] MERGER, CONSOLIDATION OR OTHER 25 ACQUISITION OF CONTROL, THE DOMESTIC INSURER REFERRED TO IN 26 SUBSECTION (A) WOULD NOT BE ABLE TO SATISFY THE REQUIREMENTS FOR 27 THE ISSUANCE OF A LICENSE TO WRITE THE LINE OR LINES OF 28 INSURANCE FOR WHICH IT IS PRESENTLY LICENSED. 29 (II) THE EFFECT OF THE MERGER, CONSOLIDATION OR OTHER 30 ACQUISITION OF CONTROL WOULD BE TO SUBSTANTIALLY LESSEN 20070H1150B4115 - 32 -
1 COMPETITION IN INSURANCE IN THIS COMMONWEALTH OR TEND TO CREATE 2 A MONOPOLY THEREIN. IN APPLYING THE COMPETITIVE STANDARD IN THIS 3 SUBPARAGRAPH: 4 (A) THE INFORMATIONAL REQUIREMENTS OF SECTION 1403(C)(2) AND 5 THE STANDARDS OF SECTION 1403(D)(2) SHALL APPLY; 6 (B) THE MERGER, CONSOLIDATION OR OTHER ACQUISITION OF 7 CONTROL SHALL NOT BE DISAPPROVED IF THE DEPARTMENT FINDS THAT 8 ANY OF THE SITUATIONS MEETING THE CRITERIA PROVIDED BY SECTION 9 1403(D)(3) EXIST; AND 10 (C) THE DEPARTMENT MAY CONDITION THE APPROVAL OF THE MERGER, 11 CONSOLIDATION OR OTHER ACQUISITION OF CONTROL ON THE REMOVAL OF 12 THE BASIS OF DISAPPROVAL WITHIN A SPECIFIED PERIOD OF TIME. 13 (III) THE FINANCIAL CONDITION OF ANY ACQUIRING PARTY IS SUCH 14 AS MIGHT JEOPARDIZE THE FINANCIAL STABILITY OF THE INSURER OR 15 PREJUDICE THE INTEREST OF ITS POLICYHOLDERS. 16 (IV) THE PLANS OR PROPOSALS WHICH THE ACQUIRING PARTY HAS TO 17 LIQUIDATE THE INSURER, SELL ITS ASSETS OR CONSOLIDATE OR MERGE 18 IT WITH ANY PERSON, OR TO MAKE ANY OTHER MATERIAL CHANGE IN ITS 19 BUSINESS OR CORPORATE STRUCTURE OR MANAGEMENT, ARE UNFAIR AND 20 UNREASONABLE [TO POLICYHOLDERS OF THE INSURER AND NOT IN THE <-- 21 PUBLIC INTEREST.] AND FAIL TO CONFER BENEFIT ON POLICYHOLDERS OF <-- 22 THE INSURER AND ARE NOT IN THE PUBLIC INTEREST. 23 (V) THE COMPETENCE, EXPERIENCE AND INTEGRITY OF THOSE 24 PERSONS WHO WOULD CONTROL THE OPERATION OF THE INSURER ARE SUCH 25 THAT IT WOULD NOT BE IN THE INTEREST OF POLICYHOLDERS OF THE 26 INSURER AND OF THE PUBLIC TO PERMIT THE MERGER, CONSOLIDATION OR 27 OTHER ACQUISITION OF CONTROL. 28 (VI) THE [ACQUISITION] MERGER, CONSOLIDATION OR OTHER 29 ACQUISITION OF CONTROL IS LIKELY TO BE HAZARDOUS OR PREJUDICIAL 30 TO THE INSURANCE BUYING PUBLIC. 20070H1150B4115 - 33 -
1 (VII) THE MERGER, CONSOLIDATION OR OTHER ACQUISITION OF 2 CONTROL IS NOT IN COMPLIANCE WITH THE LAWS OF THIS COMMONWEALTH, 3 INCLUDING ARTICLE VIII-A. 4 (2) IF THE MERGER, CONSOLIDATION OR OTHER ACQUISITION OF 5 CONTROL IS APPROVED, THE DEPARTMENT SHALL SO NOTIFY THE PERSON 6 FILING THE STATEMENT AND THE INSURER [WHOSE STOCK] THAT IS 7 PROPOSED TO BE ACQUIRED, AND SUCH A DETERMINATION IS HEREAFTER 8 REFERRED TO AS AN APPROVING DETERMINATION. NOTICE SHALL ALSO BE 9 GIVEN BY THE DEPARTMENT OF ANY DETERMINATION WHICH IS NOT AN 10 APPROVING DETERMINATION. IF AN APPROVING DETERMINATION IS MADE 11 BY THE DEPARTMENT AND NOT OTHERWISE, THE PROPOSED OFFER AND 12 ACQUISITION MAY THEREAFTER BE MADE AND CONSUMMATED ON THE TERMS 13 AND CONDITIONS AND IN THE MANNER DESCRIBED IN THE STATEMENT AND 14 SUBJECT TO SUCH CONDITIONS AS MAY BE PRESCRIBED BY THE 15 DEPARTMENT AS HEREINAFTER PROVIDED. AN APPROVING DETERMINATION 16 BY THE DEPARTMENT SHALL BE DEEMED TO EXTEND TO OFFERS OR 17 ACQUISITIONS MADE PURSUANT THERETO WITHIN ONE YEAR FOLLOWING THE 18 DATE OF DETERMINATION. THE DEPARTMENT MAY, AS A CONDITION OF ITS 19 APPROVING DETERMINATION, REQUIRE THE INCLUSION IN ANY OFFER OF 20 PROVISIONS REQUIRING THE OFFER TO REMAIN OPEN A SPECIFIED 21 MINIMUM LENGTH OF TIME, PERMITTING WITHDRAWAL OF SHARES 22 DEPOSITED PRIOR TO THE TIME THE OFFEROR BECOMES BOUND TO 23 CONSUMMATE THE ACQUISITION AND REQUIRING PRO RATA ACCEPTANCE OF 24 ANY SHARES DEPOSITED PURSUANT TO THE OFFER. THE DEPARTMENT SHALL 25 HOLD A HEARING BEFORE MAKING THE DETERMINATION REQUIRED BY THIS 26 SUBSECTION IF, WITHIN TEN (10) DAYS FOLLOWING THE FILING WITH 27 THE DEPARTMENT OF THE STATEMENT, WRITTEN REQUEST FOR THE HOLDING 28 OF SUCH HEARING IS MADE EITHER BY THE PERSON PROPOSING TO MAKE 29 THE ACQUISITION, BY THE INSURER [WHOSE STOCK] THAT IS PROPOSED 30 TO BE ACQUIRED OR, IF [SUCH] THE ISSUER OF STOCK PROPOSED TO BE 20070H1150B4115 - 34 -
1 ACQUIRED IS NOT AN INSURER, BY THE [INSURANCE COMPANY] INSURER 2 CONTROLLED BY SUCH ISSUER. OTHERWISE, THE DEPARTMENT SHALL 3 DETERMINE IN ITS DISCRETION WHETHER SUCH A HEARING SHALL BE 4 HELD. THIRTY (30) DAYS' NOTICE OF ANY SUCH HEARING SHALL BE 5 GIVEN TO THE PERSON PROPOSING TO MAKE THE ACQUISITION, TO THE 6 ISSUER WHOSE STOCK IS PROPOSED TO BE ACQUIRED AND, IF SUCH 7 ISSUER IS NOT AN INSURER, TO THE INSURANCE COMPANY CONTROLLED BY 8 SUCH ISSUER. NOTICE OF ANY SUCH HEARING SHALL ALSO BE GIVEN TO 9 SUCH OTHER PERSONS, IF ANY, AS THE DEPARTMENT MAY DETERMINE. 10 (3) THE DEPARTMENT MAY RETAIN AT THE ACQUIRING PERSON'S 11 EXPENSE ANY ATTORNEYS, ACTUARIES, ACCOUNTANTS AND OTHER EXPERTS 12 NOT OTHERWISE A PART OF THE DEPARTMENT'S STAFF AS MAY BE 13 REASONABLY NECESSARY TO ASSIST THE DEPARTMENT IN REVIEWING THE 14 PROPOSED ACQUISITION OF CONTROL. 15 (G) THE PROVISIONS OF THIS SECTION SHALL NOT APPLY TO ANY 16 OFFER, REQUEST, INVITATION, AGREEMENT OR ACQUISITION WHICH THE 17 DEPARTMENT BY ORDER SHALL EXEMPT THEREFROM AS: 18 (1) NOT HAVING BEEN MADE OR ENTERED INTO FOR THE PURPOSE AND 19 NOT HAVING THE EFFECT OF CHANGING OR INFLUENCING THE CONTROL OF 20 A DOMESTIC INSURER; OR 21 (2) AS OTHERWISE NOT COMPREHENDED WITHIN THE PURPOSES OF 22 THIS SECTION. 23 (H) THE FOLLOWING SHALL CONSTITUTE A VIOLATION OF THIS 24 SECTION: 25 (1) THE FAILURE TO FILE ANY STATEMENT, AMENDMENT OR OTHER 26 MATERIAL REQUIRED TO BE FILED PURSUANT TO SUBSECTION (A) OR (B); 27 (2) THE EFFECTUATION OR ANY ATTEMPT TO EFFECTUATE AN 28 ACQUISITION OF CONTROL OF OR MERGER OR CONSOLIDATION WITH A 29 DOMESTIC INSURER UNLESS THE DEPARTMENT HAS GIVEN ITS APPROVAL 30 THERETO; OR 20070H1150B4115 - 35 -
1 (3) A VIOLATION OF SECTION 819-A. 2 (I) THE DEPARTMENT SHALL, WITHIN SEVENTY-TWO HOURS OF 3 RECEIVING A STATEMENT FILED UNDER THIS SECTION, PROVIDE 4 NOTIFICATION TO THE OFFICE OF ATTORNEY GENERAL THAT THE FILING 5 WAS RECEIVED. 6 (J) AS USED IN THIS SECTION, THE TERM "ANNUAL STATEMENT" 7 SHALL MEAN THE ANNUAL REPORT OF THE FINANCIAL CONDITION REQUIRED 8 TO BE FILED UNDER 40 PA.C.S. § 6331 (RELATING TO REPORTS AND 9 EXAMINATIONS). 10 SECTION 6. SECTION 1403(A), (B) AND (D), ADDED DECEMBER 18, 11 1992 (P.L.1519, NO.178), ARE AMENDED TO READ: 12 SECTION 1403. ACQUISITIONS INVOLVING INSURERS NOT OTHERWISE 13 COVERED.--(A) AS USED IN THIS SECTION THE FOLLOWING WORDS AND 14 PHRASES SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS 15 SUBSECTION: 16 "ACQUISITION." ANY AGREEMENT, ARRANGEMENT OR ACTIVITY THE 17 CONSUMMATION OF WHICH RESULTS IN A PERSON ACQUIRING, DIRECTLY OR 18 INDIRECTLY, THE CONTROL OF ANOTHER PERSON AND INCLUDES, BUT IS 19 NOT LIMITED TO, THE ACQUISITION OF VOTING SECURITIES, THE 20 ACQUISITION OF ASSETS, BULK REINSURANCE [AND], MERGERS AND 21 CONSOLIDATIONS. 22 "INVOLVED INSURER." INCLUDES AN INSURER WHICH EITHER 23 ACQUIRES OR IS ACQUIRED, IS AFFILIATED WITH AN ACQUIRER OR 24 ACQUIRED OR IS THE RESULT OF A MERGER OR CONSOLIDATION. 25 (B) (1) EXCEPT AS EXEMPTED IN PARAGRAPH (2), THIS SECTION 26 APPLIES TO ANY ACQUISITION IN WHICH THERE IS A CHANGE IN CONTROL 27 OF AN INSURER AUTHORIZED TO DO BUSINESS IN THIS COMMONWEALTH. 28 (2) THIS SECTION SHALL NOT APPLY TO ANY OF THE FOLLOWING: 29 (I) AN ACQUISITION SUBJECT TO APPROVAL OR DISAPPROVAL BY THE 30 DEPARTMENT PURSUANT TO SECTION 1402. 20070H1150B4115 - 36 -
1 (II) A PURCHASE OF SECURITIES SOLELY FOR INVESTMENT PURPOSES
2 SO LONG AS SUCH SECURITIES ARE NOT USED BY VOTING OR OTHERWISE
3 TO CAUSE OR ATTEMPT TO CAUSE THE SUBSTANTIAL LESSENING OF
4 COMPETITION IN ANY INSURANCE MARKET IN THIS COMMONWEALTH. IF A
5 PURCHASE OF SECURITIES RESULTS IN A PRESUMPTION OF CONTROL AS
6 DESCRIBED IN THE DEFINITION OF "CONTROL" IN SECTION [1301] 1401,
7 IT IS NOT SOLELY FOR INVESTMENT PURPOSES UNLESS THE INSURANCE
8 DEPARTMENT OF THE INSURER'S STATE OF DOMICILE ACCEPTS A
9 DISCLAIMER OF CONTROL OR AFFIRMATIVELY FINDS THAT CONTROL DOES
10 NOT EXIST AND SUCH DISCLAIMER ACTION OR AFFIRMATIVE FINDING IS
11 COMMUNICATED BY THE DOMICILIARY INSURANCE DEPARTMENT TO THE
12 INSURANCE DEPARTMENT OF THE COMMONWEALTH.
13 (III) THE ACQUISITION OF A PERSON BY ANOTHER PERSON WHEN
14 BOTH PERSONS ARE NEITHER DIRECTLY NOR THROUGH AFFILIATES
15 PRIMARILY ENGAGED IN THE BUSINESS OF INSURANCE, IF
16 PREACQUISITION NOTIFICATION IS FILED WITH THE DEPARTMENT IN
17 ACCORDANCE WITH SUBSECTION (C)(2) THIRTY (30) DAYS PRIOR TO THE
18 PROPOSED EFFECTIVE DATE OF THE ACQUISITION. HOWEVER, SUCH
19 PREACQUISITION NOTIFICATION IS NOT REQUIRED FOR EXCLUSION FROM
20 THIS SECTION IF THE ACQUISITION WOULD OTHERWISE BE EXCLUDED FROM
21 THIS SECTION BY THIS PARAGRAPH.
22 (IV) THE ACQUISITION OF ALREADY AFFILIATED PERSONS.
23 (V) AN ACQUISITION IF, AS AN IMMEDIATE RESULT OF THE
24 ACQUISITION:
25 (A) IN NO MARKET WOULD THE COMBINED MARKET SHARE OF THE
26 INVOLVED INSURERS EXCEED FIVE PER CENTUM (5%) OF THE TOTAL
27 MARKET;
28 (B) THERE WOULD BE NO INCREASE IN ANY MARKET SHARE; OR
29 (C) IN NO MARKET WOULD:
30 (I) THE COMBINED MARKET SHARE OF THE INVOLVED INSURERS
20070H1150B4115 - 37 -
1 EXCEEDS TWELVE PER CENTUM (12%) OF THE TOTAL MARKET; AND 2 (II) THE MARKET SHARE INCREASES BY MORE THAN TWO PER CENTUM 3 (2%) OF THE TOTAL MARKET. 4 FOR THE PURPOSE OF THIS SUBPARAGRAPH, A MARKET MEANS DIRECT 5 WRITTEN INSURANCE PREMIUM IN THIS COMMONWEALTH FOR A LINE OF 6 BUSINESS AS CONTAINED IN THE ANNUAL STATEMENT REQUIRED TO BE 7 FILED BY INSURERS LICENSED TO DO BUSINESS IN THIS COMMONWEALTH. 8 (VI) AN ACQUISITION FOR WHICH A PREACQUISITION NOTIFICATION 9 WOULD BE REQUIRED PURSUANT TO THIS SECTION DUE SOLELY TO THE 10 RESULTING EFFECT ON THE OCEAN MARINE INSURANCE LINE OF BUSINESS. 11 (VII) AN ACQUISITION OF AN INSURER WHOSE DOMICILIARY 12 INSURANCE DEPARTMENT AFFIRMATIVELY FINDS THAT SUCH INSURER IS IN 13 FAILING CONDITION; THERE IS A LACK OF FEASIBLE ALTERNATIVE TO 14 IMPROVING SUCH CONDITION; THE PUBLIC BENEFITS OF IMPROVING SUCH 15 INSURER'S CONDITION THROUGH THE ACQUISITION EXCEED THE PUBLIC 16 BENEFITS THAT WOULD ARISE FROM NOT LESSENING COMPETITION; AND 17 SUCH FINDINGS ARE COMMUNICATED BY THE DOMICILIARY INSURANCE 18 DEPARTMENT TO THE INSURANCE DEPARTMENT OF THE COMMONWEALTH. 19 (3) SECTIONS 1409(B) AND (C) AND 1411 SHALL NOT APPLY TO 20 ACQUISITIONS PROVIDED FOR IN THIS SUBSECTION. 21 * * * 22 (D) (1) THE DEPARTMENT MAY ENTER AN ORDER UNDER SUBSECTION 23 (E)(1) WITH RESPECT TO AN ACQUISITION IF THERE IS SUBSTANTIAL 24 EVIDENCE THAT THE EFFECT OF THE ACQUISITION MAY BE SUBSTANTIALLY 25 TO LESSEN COMPETITION IN ANY LINE OF INSURANCE IN THIS 26 COMMONWEALTH OR TEND TO CREATE A MONOPOLY THEREIN OR IF THE 27 INSURER FAILS TO FILE ADEQUATE INFORMATION IN COMPLIANCE WITH 28 SUBSECTION (C). 29 (2) IN DETERMINING WHETHER A PROPOSED ACQUISITION WOULD 30 VIOLATE THE COMPETITIVE STANDARD OF PARAGRAPH (1), THE 20070H1150B4115 - 38 -
1 DEPARTMENT SHALL CONSIDER THE FOLLOWING: 2 (I) ANY ACQUISITION COVERED UNDER SUBSECTION (B) INVOLVING 3 TWO OR MORE INSURERS COMPETING IN THE SAME MARKET IS PRIMA FACIE 4 EVIDENCE OF VIOLATION OF THE COMPETITIVE STANDARDS AS FOLLOWS: 5 (A) IF THE MARKET IS HIGHLY CONCENTRATED AND THE INVOLVED 6 INSURERS POSSESS THE FOLLOWING SHARES OF THE MARKET: 7 INSURER A INSURER B 8 4% 4% OR MORE 9 10% 2% OR MORE 10 15% 1% OR MORE; OR 11 (B) IF THE MARKET IS NOT HIGHLY CONCENTRATED AND THE 12 INVOLVED INSURERS POSSESS THE FOLLOWING SHARES OF THE MARKET: 13 INSURER A INSURER B 14 5% 5% OR MORE 15 10% 4% OR MORE 16 15% 3% OR MORE 17 19% 1% OR MORE. 18 A HIGHLY CONCENTRATED MARKET IS ONE IN WHICH THE SHARE OF THE 19 FOUR LARGEST INSURERS IS SEVENTY-FIVE PER CENTUM (75%) OR MORE 20 OF THE MARKET. PERCENTAGES NOT SHOWN IN THE TABLES ARE 21 INTERPOLATED PROPORTIONATELY TO THE PERCENTAGES THAT ARE SHOWN. 22 IF MORE THAN TWO INSURERS ARE INVOLVED, EXCEEDING THE TOTAL OF 23 THE TWO COLUMNS IN THE TABLE IS PRIMA FACIE EVIDENCE OF 24 VIOLATION OF THE COMPETITIVE STANDARD IN PARAGRAPH (1). FOR THE 25 PURPOSE OF THIS SUBPARAGRAPH, THE INSURER WITH THE LARGEST SHARE 26 OF THE MARKET SHALL BE DEEMED TO BE INSURER A. 27 (II) THERE IS A SIGNIFICANT TREND TOWARD INCREASED 28 CONCENTRATION WHEN THE AGGREGATE MARKET SHARE OF ANY GROUPING OF 29 THE LARGEST INSURERS IN THE MARKET, FROM THE TWO LARGEST TO THE 30 EIGHT LARGEST, HAS INCREASED BY SEVEN PER CENTUM (7%) OR MORE OF 20070H1150B4115 - 39 -
1 THE MARKET OVER A PERIOD OF TIME EXTENDING FROM ANY BASE YEAR 2 FIVE (5) TO TEN (10) YEARS PRIOR TO THE ACQUISITION UP TO THE 3 TIME OF THE ACQUISITION. ANY ACQUISITION [OR MERGER], MERGER OR 4 CONSOLIDATION COVERED UNDER SUBSECTION (B) INVOLVING TWO OR MORE 5 INSURERS COMPETING IN THE SAME MARKET IS PRIMA FACIE EVIDENCE OF 6 VIOLATION OF THE COMPETITIVE STANDARD IN PARAGRAPH (1) IF: 7 (A) THERE IS A SIGNIFICANT TREND TOWARD INCREASED 8 CONCENTRATION IN THE MARKET; 9 (B) ONE OF THE INSURERS INVOLVED IS ONE OF THE INSURERS IN A 10 GROUPING OF SUCH LARGE INSURERS SHOWING THE REQUISITE INCREASE 11 IN THE MARKET SHARE; AND 12 (C) ANOTHER INVOLVED INSURER'S MARKET IS TWO PER CENTUM (2%) 13 OR MORE. 14 (III) FOR THE PURPOSES OF THIS PARAGRAPH: 15 (A) THE TERM "INSURER" INCLUDES ANY COMPANY OR GROUP OF 16 COMPANIES UNDER COMMON MANAGEMENT, OWNERSHIP OR CONTROL. 17 (B) THE TERM "MARKET" MEANS THE RELEVANT PRODUCT AND 18 GEOGRAPHICAL MARKETS. IN DETERMINING THE RELEVANT PRODUCT AND 19 GEOGRAPHICAL MARKETS, THE DEPARTMENT SHALL GIVE DUE 20 CONSIDERATION TO, AMONG OTHER THINGS, THE DEFINITIONS OR 21 GUIDELINES, IF ANY, PROMULGATED BY THE NAIC AND TO INFORMATION, 22 IF ANY, SUBMITTED BY PARTIES TO THE ACQUISITION. IN THE ABSENCE 23 OF SUFFICIENT INFORMATION TO THE CONTRARY, THE RELEVANT PRODUCT 24 MARKET IS ASSUMED TO BE THE DIRECT WRITTEN INSURANCE PREMIUM FOR 25 A LINE OF BUSINESS, SUCH LINE BEING THAT USED IN THE ANNUAL 26 STATEMENT REQUIRED TO BE FILED BY INSURERS DOING BUSINESS IN 27 THIS COMMONWEALTH AND THE RELEVANT GEOGRAPHICAL MARKET IS 28 ASSUMED TO BE THIS COMMONWEALTH. 29 (C) THE BURDEN OF SHOWING PRIMA FACIE EVIDENCE OF VIOLATION 30 OF THE COMPETITIVE STANDARD RESTS UPON THE COMMISSIONER. 20070H1150B4115 - 40 -
1 (IV) EVEN THOUGH AN ACQUISITION IS NOT PRIMA FACIE VIOLATIVE 2 OF THE COMPETITIVE STANDARD UNDER SUBPARAGRAPHS (I) AND (II), 3 THE DEPARTMENT MAY ESTABLISH THE REQUISITE ANTICOMPETITIVE 4 EFFECT BASED UPON OTHER SUBSTANTIAL EVIDENCE. EVEN THOUGH AN 5 ACQUISITION IS PRIMA FACIE VIOLATIVE OF THE COMPETITIVE STANDARD 6 UNDER SUBPARAGRAPHS (I) AND (II), A PARTY MAY ESTABLISH THE 7 ABSENCE OF THE REQUISITE ANTICOMPETITIVE EFFECT BASED UPON OTHER 8 SUBSTANTIAL EVIDENCE. RELEVANT FACTORS IN MAKING A DETERMINATION 9 UNDER THIS PARAGRAPH INCLUDE, BUT ARE NOT LIMITED TO, THE 10 FOLLOWING: MARKET SHARES, VOLATILITY OF RANKING OF MARKET 11 LEADERS, NUMBER OF COMPETITORS, CONCENTRATION, TREND OF 12 CONCENTRATION IN THE INDUSTRY AND EASE OF ENTRY AND EXIT INTO 13 THE MARKET. 14 (3) AN ORDER MAY NOT BE ENTERED UNDER SUBSECTION (E)(1) IF: 15 (I) THE ACQUISITION WILL YIELD SUBSTANTIAL ECONOMIES OF 16 SCALE OR ECONOMIES IN RESOURCE UTILIZATION THAT CANNOT BE 17 FEASIBLY ACHIEVED IN ANY OTHER WAY, AND THE PUBLIC BENEFITS 18 WHICH WOULD ARISE FROM SUCH ECONOMIES EXCEED THE PUBLIC BENEFITS 19 WHICH WOULD ARISE FROM NOT LESSENING COMPETITION; OR 20 (II) THE ACQUISITION WILL SUBSTANTIALLY INCREASE THE 21 AVAILABILITY OF INSURANCE, AND THE PUBLIC BENEFITS OF SUCH 22 INCREASE EXCEED THE PUBLIC BENEFITS WHICH WOULD ARISE FROM NOT 23 LESSENING COMPETITION. 24 * * * 25 SECTION 7. THE ACT IS AMENDED BY ADDING SECTIONS TO READ: 26 SECTION 1403.1. COMMITTEE REVIEW.--(A) THE BANKING AND 27 INSURANCE COMMITTEE OF THE SENATE AND THE INSURANCE COMMITTEE OF 28 THE HOUSE OF REPRESENTATIVES MAY REVIEW AN APPLICATION OR 29 STATEMENT SUBMITTED BY A HOSPITAL PLAN CORPORATION OR 30 PROFESSIONAL HEALTH SERVICES PLAN CORPORATION SEEKING THE 20070H1150B4115 - 41 -
1 APPROVAL OF A MERGER, CONSOLIDATION OR OTHER ACQUISITION OF 2 CONTROL OF A HOSPITAL PLAN CORPORATION OR PROFESSIONAL HEALTH 3 SERVICES PLAN CORPORATION UNDER THIS ACT. 4 (B) THE BANKING AND INSURANCE COMMITTEE OF THE SENATE AND 5 THE INSURANCE COMMITTEE OF THE HOUSE OF REPRESENTATIVES SHALL 6 HAVE THE FOLLOWING POWERS AND DUTIES: 7 (1) TO CONVENE THE COMMITTEE FOR PURPOSES OF REVIEWING AN 8 APPLICATION FOR APPROVAL OF A MERGER, CONSOLIDATION OR OTHER 9 ACQUISITION OF CONTROL UNDER THIS SECTION. 10 (2) TO RECEIVE AND REVIEW ALL FILINGS SUBMITTED TO THE 11 DEPARTMENT RELATING TO THE MERGER, CONSOLIDATION OR OTHER 12 ACQUISITION OF CONTROL AND ALL ACCOMPANYING DATA AND OTHER 13 INFORMATION. THIS PARAGRAPH SHALL NOT APPLY TO INFORMATION 14 DEEMED CONFIDENTIAL OR PROPRIETARY BY THE DEPARTMENT. 15 (3) TO CONSULT EXPERTS, HOLD HEARINGS AND OBTAIN ADDITIONAL 16 INFORMATION RELATING TO THE MERGER, CONSOLIDATION OR OTHER 17 ACQUISITION OF CONTROL. 18 (4) TO DEVELOP WRITTEN COMMENTS AND RECOMMENDATIONS ON THE 19 MERGER, CONSOLIDATION OR ACQUISITION OF CONTROL AND SUBMIT THEM 20 TO THE DEPARTMENT WITHIN FORTY-FIVE (45) DAYS OF THE CLOSE OF 21 THE PUBLIC COMMENT PERIOD ESTABLISHED UNDER THIS PARAGRAPH, 22 DEVELOPED BY THE DEPARTMENT ON THE MERGER, CONSOLIDATION OR 23 OTHER ACQUISITION OF CONTROL. THE DEPARTMENT SHALL PUBLISH THE 24 DATE OF THE CLOSE OF THE PUBLIC COMMENT PERIOD IN THE 25 PENNSYLVANIA BULLETIN PRIOR TO FINAL CLOSURE OF THE RECORD <-- 26 PUBLIC COMMENT PERIOD. THE DEPARTMENT MAY ISSUE A FINAL ORDER <-- 27 AND DETERMINATION ON OR AFTER ONE HUNDRED FIVE (105) DAYS 28 FOLLOWING THE PUBLIC COMMENT PERIOD. 29 (C) THE COMMISSIONER, THE DEPARTMENT AND ITS ATTORNEYS AND 30 EXPERTS, INCLUDING EXPERTS EMPLOYED OR RETAINED BY THE 20070H1150B4115 - 42 -
1 DEPARTMENT, SHALL BE AVAILABLE TO PROVIDE TESTIMONY TO EACH 2 COMMITTEE RELATING TO THE MERGER, CONSOLIDATION OR OTHER 3 ACQUISITION OF CONTROL. NOTHING IN THIS ACT SHALL AFFECT ANY 4 PRIVILEGES OR IMMUNITIES OF THE DEPARTMENT OR ITS ATTORNEYS, 5 EXPERTS OR CONSULTANTS. THE DEPARTMENT OR ITS ATTORNEYS, EXPERTS 6 OR CONSULTANTS SHALL NOT BE REQUIRED TO APPEAR BEFORE EITHER 7 COMMITTEE WITHIN THIRTY (30) DAYS FOLLOWING THE DEPARTMENT'S 8 ISSUANCE OF A FINAL ORDER AND DETERMINATION. 9 (D) THE DEPARTMENT SHALL PROVIDE A DETAILED WRITTEN RESPONSE 10 TO EACH COMMENT AND RECOMMENDATION SUBMITTED BY THE BANKING AND 11 INSURANCE COMMITTEE OF THE SENATE OR THE INSURANCE COMMITTEE OF 12 THE HOUSE OF REPRESENTATIVES IN ITS FINAL ORDER. THE ORDER AND 13 DETERMINATION SHALL NOT BE ISSUED BEFORE SIXTY (60) DAYS HAVE 14 ELAPSED FOLLOWING RECEIPT OF THE COMMENTS AND RECOMMENDATIONS 15 UNDER SUBSECTION (B)(4). 16 (E) IN ORDER TO APPROVE A MERGER, CONSOLIDATION OR OTHER <-- 17 ACQUISITION OF CONTROL OF A HOSPITAL PLAN CORPORATION OR 18 PROFESSIONAL HEALTH SERVICE PLAN CORPORATION, THE ORDER AND 19 DETERMINATION OF THE DEPARTMENT MUST FIND THAT POLICYHOLDERS AND 20 CERTIFICATE HOLDERS AND SUBSCRIBERS SHALL RECEIVE A SUSTAINED 21 BENEFIT FROM THE MERGER, CONSOLIDATION OR OTHER ACQUISITION OF 22 CONTROL. IF NO COMMENTS AND RECOMMENDATIONS ARE RECEIVED UNDER 23 SUBSECTION (B)(4), THE DEPARTMENT MAY ISSUE A FINAL ORDER AND 24 DETERMINATION ON OR AFTER ONE HUNDRED FIVE (105) DAYS FOLLOWING 25 THE CLOSE OF THE PUBLIC COMMENT PERIOD. 26 SECTION 1403.2. INSURANCE RESTRUCTURING RESTRICTED RECEIPT 27 ACCOUNT.--(A) THERE IS ESTABLISHED IN THE STATE TREASURY A 28 RESTRICTED RECEIPT ACCOUNT TO BE KNOWN AS THE INSURANCE 29 RESTRUCTURING RESTRICTED RECEIPT ACCOUNT. INTEREST EARNED ON 30 MONEY IN THE ACCOUNT SHALL BE DEPOSITED INTO THE ACCOUNT. 20070H1150B4115 - 43 -
1 (B) ALL NET ECONOMIC BENEFITS, INCLUDING PROCEEDS, SAVINGS, 2 FUNDS OR MONEYS DIRECTLY DERIVED FROM AND PAID TO THE <-- 3 COMMONWEALTH OR A COMMONWEALTH PROGRAM AND ANY AGREEMENT RELATED <-- 4 TO OR FROM THE MERGER, CONSOLIDATION OR OTHER ACQUISITION OF 5 CONTROL OF A HOSPITAL PLAN CORPORATION OR PROFESSIONAL HEALTH 6 SERVICES PLAN CORPORATION SHALL BE DEPOSITED INTO THE ACCOUNT <-- 7 FOR PURPOSES AS DETERMINED BY THE GENERAL ASSEMBLY. WHICH ARE TO <-- 8 BE PAID TO THE COMMONWEALTH OR A COMMONWEALTH PROGRAM SHALL BE <-- 9 DEPOSITED INTO THE ACCOUNT FOR PURPOSES AS DETERMINED BY THE 10 GENERAL ASSEMBLY. 11 (C) NO CONTRACT OR WRITTEN AGREEMENT BETWEEN A HOSPITAL PLAN 12 CORPORATION OR PROFESSIONAL HEALTH SERVICES PLAN CORPORATION AND 13 THE COMMONWEALTH OR ANY OTHER ENTITY RELATING TO THE 14 DISBURSEMENT OR SPENDING OF MONEY IN THE ACCOUNT MAY BE ENTERED 15 INTO UNTIL MONEYS IN THAT MAY EXIST OR ARE TO BE DERIVED FROM <-- 16 ANY CONTRACT OR WRITTEN AGREEMENT FOR DEPOSIT INTO THE ACCOUNT 17 ARE APPROPRIATED BY THE GENERAL ASSEMBLY. 18 (D) NO MONEYS OR FUNDS MAY BE TRANSFERRED OR PAID FROM THE 19 ACCOUNT UNLESS APPROPRIATED BY THE GENERAL ASSEMBLY. 20 SECTION 8. SECTION 1405(C) OF THE ACT, AMENDED FEBRUARY 17, 21 1994 (P.L.92, NO.9), IS AMENDED TO READ: 22 SECTION 1405. STANDARDS AND MANAGEMENT OF AN INSURER WITHIN 23 A HOLDING COMPANY SYSTEM.--* * * 24 (C) (1) NOTWITHSTANDING THE CONTROL OF A DOMESTIC INSURER 25 BY ANY PERSON, THE OFFICERS AND DIRECTORS OF THE INSURER SHALL 26 NOT THEREBY BE RELIEVED OF ANY OBLIGATION OR LIABILITY TO WHICH 27 THEY WOULD OTHERWISE BE SUBJECT BY LAW, AND THE INSURER SHALL BE 28 MANAGED SO AS TO ASSURE ITS SEPARATE OPERATING IDENTITY 29 CONSISTENT WITH THIS ARTICLE. 30 (2) NOTHING HEREIN SHALL PRECLUDE A DOMESTIC INSURER FROM 20070H1150B4115 - 44 -
1 HAVING OR SHARING A COMMON MANAGEMENT OR COOPERATIVE OR JOINT 2 USE OF PERSONNEL, PROPERTY OR SERVICES WITH ONE OR MORE OTHER 3 PERSONS UNDER ARRANGEMENTS MEETING THE STANDARDS OF SUBSECTION 4 (A)(1). 5 (3) (I) NOT LESS THAN ONE-THIRD OF THE DIRECTORS OF A 6 DOMESTIC INSURER [AND NOT LESS THAN ONE-THIRD OF THE MEMBERS OF 7 EACH COMMITTEE OF THE BOARD OF DIRECTORS OF ANY DOMESTIC 8 INSURER] SHALL BE PERSONS WHO ARE NOT OFFICERS OR EMPLOYES OF 9 SUCH INSURER OR OF ANY ENTITY CONTROLLING, CONTROLLED BY OR 10 UNDER COMMON CONTROL WITH SUCH INSURER AND WHO ARE NOT 11 BENEFICIAL OWNERS OF A CONTROLLING INTEREST IN THE VOTING STOCK 12 OF SUCH INSURER OR ANY SUCH ENTITY. AT LEAST ONE SUCH PERSON 13 MUST BE INCLUDED IN ANY QUORUM FOR THE TRANSACTION OF BUSINESS 14 AT ANY MEETING OF THE BOARD OF DIRECTORS [OR ANY COMMITTEE 15 THEREOF]. 16 (II) NOT LESS THAN ONE-THIRD OF THE MEMBERS OF EACH 17 COMMITTEE OF THE BOARD OF DIRECTORS OF ANY DOMESTIC INSURER 18 SHALL BE PERSONS WHO ARE NOT OFFICERS OR EMPLOYES OF SUCH 19 INSURER OR OF ANY ENTITY CONTROLLING, CONTROLLED BY OR UNDER 20 COMMON CONTROL WITH SUCH INSURER. AT LEAST ONE SUCH PERSON MUST 21 BE INCLUDED IN ANY QUORUM FOR THE TRANSACTION OF BUSINESS AT ANY 22 MEETING OF EACH COMMITTEE. 23 (4) THE BOARD OF DIRECTORS OF A DOMESTIC INSURER SHALL 24 ESTABLISH [ONE OR MORE COMMITTEES] A COMMITTEE COMPRISED SOLELY 25 OF DIRECTORS WHO ARE NOT OFFICERS OR EMPLOYES OF THE INSURER OR 26 OF ANY ENTITY CONTROLLING, CONTROLLED BY OR UNDER COMMON CONTROL 27 WITH THE INSURER AND WHO ARE NOT BENEFICIAL OWNERS OF A 28 CONTROLLING INTEREST IN THE VOTING STOCK OF THE INSURER OR ANY 29 SUCH ENTITY. THE COMMITTEE [OR COMMITTEES] SHALL HAVE 30 RESPONSIBILITY FOR RECOMMENDING THE SELECTION OF INDEPENDENT 20070H1150B4115 - 45 -
1 CERTIFIED PUBLIC ACCOUNTANTS[,] AND REVIEWING THE INSURER'S 2 FINANCIAL CONDITION, THE SCOPE AND RESULTS OF THE INDEPENDENT 3 AUDIT AND ANY INTERNAL AUDIT[, NOMINATING CANDIDATES FOR 4 DIRECTOR FOR ELECTION BY SHAREHOLDERS OR POLICYHOLDERS, 5 EVALUATING THE PERFORMANCE OF OFFICERS DEEMED TO BE PRINCIPAL 6 OFFICERS OF THE INSURER AND RECOMMENDING TO THE BOARD OF 7 DIRECTORS THE SELECTION AND COMPENSATION OF THE PRINCIPAL 8 OFFICERS]. THE COMMITTEE MAY ALSO HAVE THE RESPONSIBILITIES 9 DESCRIBED IN PARAGRAPH (4.1) IF ONE OR MORE COMMITTEES DESCRIBED 10 IN PARAGRAPH (4.1) ARE NOT SEPARATELY ESTABLISHED. 11 (4.1) THE BOARD OF DIRECTORS OF A DOMESTIC INSURER SHALL 12 ESTABLISH ONE OR MORE COMMITTEES COMPRISED SOLELY OF DIRECTORS 13 WHO ARE NOT OFFICERS OR EMPLOYES OF THE INSURER OR OF ANY ENTITY 14 CONTROLLING, CONTROLLED BY OR UNDER COMMON CONTROL WITH THE 15 INSURER. THE COMMITTEE OR COMMITTEES SHALL HAVE RESPONSIBILITY 16 FOR RECOMMENDING CANDIDATES TO BE NOMINATED BY THE BOARD OF 17 DIRECTORS, IN ADDITION TO ANY OTHER NOMINATIONS BY VOTING 18 SHAREHOLDERS OR POLICYHOLDERS, FOR ELECTION AS DIRECTORS BY 19 VOTING SHAREHOLDERS OR POLICYHOLDERS, EVALUATING THE PERFORMANCE 20 OF OFFICERS DEEMED TO BE PRINCIPAL OFFICERS OF THE INSURER AND 21 RECOMMENDING TO THE BOARD OF DIRECTORS THE SELECTION AND 22 COMPENSATION OF THE PRINCIPAL OFFICERS. 23 (5) THE PROVISIONS OF PARAGRAPHS (3) [AND], (4) AND (4.1) 24 SHALL NOT APPLY TO A DOMESTIC INSURER IF THE PERSON CONTROLLING 25 SUCH INSURER IS AN INSURER OR [A PUBLICLY HELD CORPORATION] 26 ANOTHER BUSINESS ENTITY HAVING A BOARD OF DIRECTORS AND 27 COMMITTEES THEREOF WHICH ALREADY MEET THE REQUIREMENTS OF 28 PARAGRAPHS (3) [AND (4)], (4) AND (4.1). 29 * * * 30 SECTION 9. THE ACT IS AMENDED BY ADDING AN ARTICLE TO READ: 20070H1150B4115 - 46 -
1 ARTICLE XXV 2 COMMUNITY HEALTH REINVESTMENT 3 SECTION 2501. DEFINITIONS. 4 THE FOLLOWING WORDS AND PHRASES WHEN USED IN THIS ARTICLE 5 SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SECTION UNLESS THE 6 CONTEXT CLEARLY INDICATES OTHERWISE: 7 "COMMUNITY HEALTH REINVESTMENT ACTIVITY." COMMUNITY HEALTH 8 SERVICES AND PROJECTS THAT IMPROVE HEALTH CARE OR MAKE HEALTH 9 CARE MORE ACCESSIBLE. THE TERM INCLUDES FUNDING, SUBSIDIZATION 10 OR PROVISION OF THE FOLLOWING: 11 (1) HEALTH CARE COVERAGE FOR PERSONS WHO ARE DETERMINED 12 BY RECOGNIZED STANDARDS AS DETERMINED BY THE INSURANCE 13 DEPARTMENT TO BE UNABLE TO PAY FOR COVERAGE. 14 (2) HEALTH CARE SERVICES FOR PERSONS WHO ARE DETERMINED 15 BY RECOGNIZED STANDARDS TO BE UNINSURED AND UNABLE TO PAY FOR 16 SERVICES. 17 (3) PROGRAMS FOR THE PREVENTION AND TREATMENT OF DISEASE 18 OR INJURY, INCLUDING MENTAL RETARDATION, MENTAL DISORDERS, 19 MENTAL HEALTH COUNSELING OR THE PROMOTION OF HEALTH OR 20 WELLNESS. 21 THE TERM SHALL NOT INCLUDE EXPENDITURES FOR ADVERTISING, PUBLIC 22 RELATIONS, SPONSORSHIPS, BAD DEBT, THE COST OF ADMINISTERING <-- 23 ADMINISTRATIVE COSTS ASSOCIATED WITH STATE HEALTH CARE PROGRAMS, <-- 24 PROGRAMS PROVIDED AS AN EMPLOYEE BENEFIT, USE OF FACILITIES FOR 25 MEETINGS HELD BY COMMUNITY GROUPS OR EXPENSES FOR IN-SERVICE 26 TRAINING, CONTINUING EDUCATION, ORIENTATION OR MENTORING OF 27 EMPLOYEES. 28 "DEPARTMENT." THE INSURANCE DEPARTMENT OF THE COMMONWEALTH. 29 "PLAN." A HOSPITAL PLAN CORPORATION AS DEFINED IN 40 PA.C.S. 30 CH. 61 (RELATING TO HOSPITAL PLAN CORPORATIONS) OR PROFESSIONAL 20070H1150B4115 - 47 -
1 HEALTH SERVICES PLAN CORPORATION AS DEFINED IN 40 PA.C.S. CH. 63 2 (RELATING TO PROFESSIONAL HEALTH SERVICES PLAN CORPORATIONS). 3 SECTION 2502. DUTIES OF PLAN AND DEPARTMENT. 4 (A) PLAN DUTIES.--A PLAN SHALL HAVE THE FOLLOWING DUTIES: 5 (1) TO SUBMIT A PROPOSAL TO THE DEPARTMENT ON OR BEFORE 6 MARCH 30 OF EACH YEAR SETTING FORTH THE MANNER IN WHICH THE 7 PLAN WILL PROVIDE PROPOSED COMMUNITY HEALTH REINVESTMENT 8 ACTIVITIES CONDUCTED OR PROVIDED BY THE PLAN DURING THE NEXT 9 FISCAL YEAR. 10 (2) TO ANNUALLY PROVIDE TO THE DEPARTMENT, THE BANKING 11 AND INSURANCE COMMITTEE OF THE SENATE AND THE INSURANCE 12 COMMITTEE OF THE HOUSE OF REPRESENTATIVES THE NAME AND 13 ADDRESS OF EACH OFFICER, DIRECTOR OR EMPLOYEE WHO SERVES ON 14 THE BOARD OF DIRECTORS OF A HOSPITAL OR OTHER HEALTH CARE 15 FACILITY AS DEFINED IN SECTION 802.1 OF THE ACT OF JULY 19, 16 1979 (P.L.130, NO.48), KNOWN AS THE HEALTH CARE FACILITIES 17 ACT, OR ON THE BOARD OF AN ENTITY THAT OWNS, OPERATES OR 18 MANAGES A HOSPITAL OR OTHER HEALTH CARE FACILITY. THIS 19 PARAGRAPH SHALL APPLY TO A NONPROFIT OR FOR-PROFIT SUBSIDIARY 20 OR AFFILIATE OF A HOSPITAL PLAN CORPORATION OR PROFESSIONAL 21 HEALTH SERVICES PLAN CORPORATION. THE INFORMATION SHALL BE 22 SUBMITTED BY JANUARY 31 FOR THE IMMEDIATELY PRECEDING YEAR. 23 (B) DEPARTMENT DUTIES.--THE DEPARTMENT SHALL HAVE THE 24 FOLLOWING DUTIES: 25 (1) TO DEVELOP A FORM WHICH SHALL BE USED BY EACH PLAN 26 FOR THE SUBMISSION OF THE PROPOSAL UNDER SUBSECTION (A)(1). 27 THE FORM SHALL REQUIRE THE ITEMIZATION OF INDIVIDUAL 28 COMMUNITY HEALTH REINVESTMENT ACTIVITIES AND THE COST OF EACH 29 ACTIVITY UNDER THE AGREEMENT ON COMMUNITY HEALTH REINVESTMENT <-- 30 ENTERED INTO FEBRUARY 2, 2005, BY THE INSURANCE DEPARTMENT 20070H1150B4115 - 48 -
1 AND CAPITAL BLUE CROSS, HIGHMARK, INC., THE HOSPITAL SERVICE 2 ASSOCIATION OF NORTHEASTERN PENNSYLVANIA AND INDEPENDENCE 3 BLUE CROSS AND PUBLISHED AT 35 PA.B. 4155 OR ANY SUCCESSOR OR 4 OTHER AGREEMENTS. THE PROPOSAL SHALL BE ON A FORM PUBLISHED 5 BY THE DEPARTMENT IN THE PENNSYLVANIA BULLETIN. 6 (2) TO APPROVE OR DISAPPROVE THE EXPENDITURES IN THE 7 PROPOSAL SUBMITTED UNDER SUBSECTION (A)(1). 8 SECTION 2503. PUBLIC RECORD. 9 ALL PROPOSALS SUBMITTED UNDER SECTION 2502 SHALL BE PUBLIC 10 RECORDS. 11 SECTION 2504. REGULATIONS. 12 THE DEPARTMENT MAY PROMULGATE REGULATIONS AS NECESSARY FOR 13 THE ADMINISTRATION OF THIS ARTICLE. 14 SECTION 10. REPEALS ARE AS FOLLOWS: 15 (1) THE GENERAL ASSEMBLY DECLARES THE REPEAL UNDER 16 PARAGRAPH (2) IS NECESSARY TO EFFECTUATE THE ADDITION OF 17 SECTION 1403.2 OF THE ACT. 18 (2) SECTION 1716.1-E OF THE ACT OF APRIL 9, 1929 19 (P.L.343, NO.176), KNOWN AS THE FISCAL CODE, IS REPEALED. 20 (3) THE ACT OF DECEMBER 19, 1990 (P.L.834, NO.198), 21 KNOWN AS THE GAA AMENDMENTS ACT OF 1990, IS REPEALED INSOFAR 22 AS IT IS INCONSISTENT WITH THIS ACT. 23 SECTION 11. THIS ACT SHALL NOT APPLY TO ANY MERGER, 24 CONSOLIDATION OR OTHER ACQUISITION OF CONTROL COMPLETED OR 25 CONSUMMATED PRIOR TO THE EFFECTIVE DATE OF THIS SECTION AND, IF 26 REQUIRED, FOLLOWING THE ISSUANCE OF AN APPROVING DETERMINATION. 27 SECTION 12. THIS ACT SHALL APPLY TO ANY APPLICATION, 28 STATEMENT OR OTHER PLAN OR PROPOSAL RELATING TO A MERGER, 29 CONSOLIDATION OR OTHER ACQUISITION OF CONTROL FILED WITH THE 30 INSURANCE DEPARTMENT ON OR AFTER JANUARY 1, 2007. 20070H1150B4115 - 49 -
1 SECTION 13. THIS ACT SHALL TAKE EFFECT AS FOLLOWS: 2 (1) THE AMENDMENT OR ADDITION OF SECTIONS 405.2(C), 3 635.3 AND 1405(C) OF THE ACT SHALL TAKE EFFECT IN 60 DAYS. 4 (2) THE REMAINDER OF THIS ACT SHALL TAKE EFFECT 5 IMMEDIATELY. D25L40MSP/20070H1150B4115 - 50 -