Bill Text: PA HB481 | 2011-2012 | Regular Session | Introduced

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Bill Title: Prohibiting preexisting condition exclusions for children; and imposing penalties.

Spectrum: Strong Partisan Bill (Democrat 32-2)

Status: (Introduced - Dead) 2011-04-06 - Referred to INSURANCE [HB481 Detail]

Download: Pennsylvania-2011-HB481-Introduced.html

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PRINTER'S NO. 1454
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No. 481 Session of2011
INTRODUCED BY M. SMITH, DeLUCA, BRADFORD, CALTAGIRONE, COHEN, D. COSTA, DAVIS, DONATUCCI, FABRIZIO, GEORGE, GIBBONS, GOODMAN, HARKINS, HORNAMAN, JOSEPHS, KORTZ, KOTIK, LONGIETTI, MAHONEY, MANN, MATZIE, McGEEHAN, MUNDY, MURT, M. O'BRIEN, PASHINSKI, PAYTON, SANTARSIERO, STURLA, J. TAYLOR, WAGNER, WHEATLEY, WHITE AND YOUNGBLOOD, APRIL 6, 2011
REFERRED TO COMMITTEE ON INSURANCE, APRIL 6, 2011
AN ACT
Prohibiting preexisting condition exclusions for children; and
imposing penalties.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Short title.
This act shall be know and may be cited as the Preexisting
Condition Prohibition 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.
"Grandfathered plan coverage." Coverage provided by a health
carrier in which an individual was enrolled on March 23, 2010
for as long as it maintains that status in accordance with
Federal regulations.
"Group health insurance coverage." Health insurance coverage
offered in connection with a group health plan.
"Group health plan." An employee welfare benefit plan as
defined in section 3(1) of the Employee Retirement Income
Security Act of 1974 (Public Law 93-406, 88 Stat. 829) to the
extent that the plan provides medical care and includes items
and services paid for as medical care to current and former
employees, or their dependents as defined under the terms of the
plan directly or through insurance, reimbursement or otherwise.
"Health benefit plan."
(1) A policy, contract, certificate or agreement offered
by a health carrier to provide, deliver, arrange for, pay for
or reimburse any of the costs of health care services. The
term includes short-term and catastrophic health insurance
policies and a policy that pays on a cost-incurred basis,
except as otherwise exempted under this definition.
(2) The term does not include:
(i) Coverage only for accident, or disability income
insurance, or any combination thereof.
(ii) Coverage issued as a supplement to liability
insurance.
(iii) Liability insurance, including general
liability insurance and automobile liability insurance.
(iv) Workers' compensation or similar insurance.
(v) Automobile medical payment insurance.
(vi) Credit-only insurance.
(vii) Coverage for on-site medical clinics.
(viii) Other similar insurance coverage, specified
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in Federal regulations issued under the Health Insurance
Portability and Accountability Act of 1996 (Public Law
104-191, 110 Stat. 1936) under which benefits for medical
care are secondary or incidental to other insurance
benefits.
(3) The term does not include the following benefits if
they are provided under a separate policy, certificate or
contract of insurance or are otherwise not an integral part
of the plan:
(i) Limited scope dental or vision benefits.
(ii) Benefits for long-term care, nursing home care,
home health care, community-based care, or any
combination thereof.
(iii) Other similar, limited benefits specified in
Federal regulations issued under the Health Insurance
Portability and Accountability Act of 1996.
(4) The term does not include the following benefits if
the benefits are provided under a separate policy,
certificate or contract of insurance, there is no
coordination between the provision of the benefits and any
exclusion of benefits under any group health plan maintained
by the same plan sponsor and the benefits are paid with
respect to an event without regard to whether benefits are
provided with respect to the event under any group health
plan maintained by the same plan sponsor:
(i) Coverage only for a specified disease or
illness.
(ii) Hospital indemnity or other fixed indemnity
insurance.
(5) The term does not include the following if offered
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as a separate policy, certificate or contract of insurance:
(i) Medicare supplemental health insurance as
defined under section 1882(g)(1) of the Social Security
Act (49 Stat. 620, 42 U.S.C. § 1882(g)(1)).
(ii) Coverage supplemental to the coverage provided
under the Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS).
(iii) Similar supplemental coverage provided to
coverage under a group health plan.
"Health carrier." A company or health insurance entity
licensed in this Commonwealth to offer or issue any individual
or group health, sickness or accident policy or subscriber
contract or certificate or plan that provides medical or health
care coverage by a health care facility or licensed health care
provider that is governed under this act or any of the
following:
(1) Article XXIV of the act of May 17, 1921 (P.L.682,
No.284), known as The Insurance Company Law of 1921.
(2) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
(3) The act of May 18, 1976 (P.L.123, No.54), known as
the Individual Accident and Sickness Insurance Minimum
Standards Act.
(4) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations) or Ch. 63 (relating to professional health
services plan corporations).
"Health maintenance organization." An organized system which
combines the delivery and financing of health care and which
provides basic health services to voluntarily enrolled
subscribers for a fixed prepaid fee.
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"Individual health insurance coverage." Health insurance
coverage offered to individuals in the individual market, which
includes a health benefit plan provided to individuals through a
trust arrangement, association or other discretionary group that
is not an employer plan, but does not include short-term limited
duration insurance. A health carrier offering health insurance
coverage in connection with a group health plan shall not be
deemed to be a health carrier offering individual health
insurance coverage solely because the carrier offers a
conversion policy.
"Medical care." Amounts paid for:
(1) The diagnosis, care, mitigation, treatment or
prevention of disease, or amounts paid for the purpose of
affecting any structure or function of the body.
(2) Transportation primarily for and essential to
medical care under paragraph (1).
(3) Insurance covering medical care under paragraphs (1)
and (2).
"Open enrollment." With respect to individual health
insurance coverage, the period of time during which any
individual has the opportunity to apply for coverage under a
health benefit plan offered by a health carrier and shall be
accepted for coverage under the plan without regard to a
preexisting condition.
"Preexisting condition exclusion." The term shall include
the following:
(1) A limitation or exclusion of benefits, including a
denial of coverage, based on the fact that the condition was
present before the effective date of coverage or, if the
coverage is denied, the date of denial, under a health
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benefit plan whether or not any medical advice, diagnosis,
care or treatment was recommended or received before the
effective date of coverage.
(2) Any limitation or exclusion of benefits, including a
denial of coverage, applicable to an individual as a result
of information relating to an individual's health status
before the individual's effective date of coverage or, if the
coverage is denied, the date of denial, under the health
benefit plan, such as a condition identified as a result of a
preenrollment questionnaire or physical examination given to
the individual, or review of medical records relating to the
preenrollment period.
Section 3. Prohibition on preexisting condition exclusions.
(a) General rule.--A health carrier shall not limit or
exclude coverage under an individual health insurance health
benefit plan for an individual 18 years of age or younger by
imposing a preexisting condition exclusion on that individual.
(b) Open enrollment.--Where a health carrier offers
individual health insurance coverage that only covers
individuals 18 years of age or younger, such health carrier
shall offer such coverage continuously through the year, or
during one or more open enrollment periods of 30 days.
(c) Issuance.--During an open enrollment period, a health
carrier shall not deny or unreasonably delay the issuance of a
policy, refuse to issue a policy or issue a policy with any
preexisting condition exclusion rider or endorsement to an
applicant or insured who is 18 years of age or younger on the
basis of a preexisting condition.
(d) Same coverage.--Coverage shall be effective for those
applying during an open enrollment period on the same basis as
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an applicant qualifying for coverage on an underwritten basis.
(e) Notice.--Each health carrier shall provide prior
prominent public notice on its Internet website and prior
written notice to each of its policyholders annually at least 90
days before any open enrollment period of the open enrollment
rights for individuals 18 years of age or younger and provide
information as to how an individual eligible for this open
enrollment right may apply for coverage with the carrier during
an open enrollment period.
(f) Group plan.--A health carrier shall not limit or exclude
coverage under a group health insurance health benefit plan for
an individual 18 years of age or younger by imposing a
preexisting condition exclusion on that individual.
Section 4. Enforcement.
(a) Penalties and remedies.--Upon a determination by hearing
that this act has been violated, the commissioner may pursue one
or more of the following courses of action:
(1) Issue an order requiring the person in violation to
cease and desist from engaging in the violation.
(2) Suspend or revoke or refuse to issue or renew the
certificate or license of the person in violation.
(3) Impose a civil penalty of not more than $5,000 for
each violation.
(4) Impose any other penalty or remedy deemed
appropriate by the commissioner, including restitution.
(b) Other remedies.--The enforcement remedies imposed under
this section shall be in addition to any other remedies or
penalties that may be imposed by statute. Violations of this
article are deemed and defined by the commissioner to be an
unfair method of competition and an unfair or deceptive act or
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practice under the act of July 22, 1974 (P.L.589, No.205), known
as the Unfair Insurance Practices Act.
Section 5. Applicability.
(a) Applicability.--Except as provided under subsection (b),
this act shall apply to a health carrier providing coverage
under an individual or group health benefit plan.
(b) Exception.--This act shall not apply to grandfathered
plan coverage.
Section 6. Regulations.
The department shall promulgate regulations necessary to
implement this act.
Section 7. Effective date.
This act shall take effect in 60 days.
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