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| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
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| HOUSE BILL |
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| 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 |
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| REFERRED TO COMMITTEE ON INSURANCE, APRIL 6, 2011 |
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| AN ACT |
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1 | Prohibiting preexisting condition exclusions for children; and |
2 | imposing penalties. |
3 | The General Assembly of the Commonwealth of Pennsylvania |
4 | hereby enacts as follows: |
5 | Section 1. Short title. |
6 | This act shall be know and may be cited as the Preexisting |
7 | Condition Prohibition Act. |
8 | Section 2. Definitions. |
9 | The following words and phrases when used in this act shall |
10 | have the meanings given to them in this section unless the |
11 | context clearly indicates otherwise: |
12 | "Commissioner." The Insurance Commissioner of the |
13 | Commonwealth. |
14 | "Department." The Insurance Department of the Commonwealth. |
15 | "Grandfathered plan coverage." Coverage provided by a health |
16 | carrier in which an individual was enrolled on March 23, 2010 |
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1 | for as long as it maintains that status in accordance with |
2 | Federal regulations. |
3 | "Group health insurance coverage." Health insurance coverage |
4 | offered in connection with a group health plan. |
5 | "Group health plan." An employee welfare benefit plan as |
6 | defined in section 3(1) of the Employee Retirement Income |
7 | Security Act of 1974 (Public Law 93-406, 88 Stat. 829) to the |
8 | extent that the plan provides medical care and includes items |
9 | and services paid for as medical care to current and former |
10 | employees, or their dependents as defined under the terms of the |
11 | plan directly or through insurance, reimbursement or otherwise. |
12 | "Health benefit plan." |
13 | (1) A policy, contract, certificate or agreement offered |
14 | by a health carrier to provide, deliver, arrange for, pay for |
15 | or reimburse any of the costs of health care services. The |
16 | term includes short-term and catastrophic health insurance |
17 | policies and a policy that pays on a cost-incurred basis, |
18 | except as otherwise exempted under this definition. |
19 | (2) The term does not include: |
20 | (i) Coverage only for accident, or disability income |
21 | insurance, or any combination thereof. |
22 | (ii) Coverage issued as a supplement to liability |
23 | insurance. |
24 | (iii) Liability insurance, including general |
25 | liability insurance and automobile liability insurance. |
26 | (iv) Workers' compensation or similar insurance. |
27 | (v) Automobile medical payment insurance. |
28 | (vi) Credit-only insurance. |
29 | (vii) Coverage for on-site medical clinics. |
30 | (viii) Other similar insurance coverage, specified |
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1 | in Federal regulations issued under the Health Insurance |
2 | Portability and Accountability Act of 1996 (Public Law |
3 | 104-191, 110 Stat. 1936) under which benefits for medical |
4 | care are secondary or incidental to other insurance |
5 | benefits. |
6 | (3) The term does not include the following benefits if |
7 | they are provided under a separate policy, certificate or |
8 | contract of insurance or are otherwise not an integral part |
9 | of the plan: |
10 | (i) Limited scope dental or vision benefits. |
11 | (ii) Benefits for long-term care, nursing home care, |
12 | home health care, community-based care, or any |
13 | combination thereof. |
14 | (iii) Other similar, limited benefits specified in |
15 | Federal regulations issued under the Health Insurance |
16 | Portability and Accountability Act of 1996. |
17 | (4) The term does not include the following benefits if |
18 | the benefits are provided under a separate policy, |
19 | certificate or contract of insurance, there is no |
20 | coordination between the provision of the benefits and any |
21 | exclusion of benefits under any group health plan maintained |
22 | by the same plan sponsor and the benefits are paid with |
23 | respect to an event without regard to whether benefits are |
24 | provided with respect to the event under any group health |
25 | plan maintained by the same plan sponsor: |
26 | (i) Coverage only for a specified disease or |
27 | illness. |
28 | (ii) Hospital indemnity or other fixed indemnity |
29 | insurance. |
30 | (5) The term does not include the following if offered |
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1 | as a separate policy, certificate or contract of insurance: |
2 | (i) Medicare supplemental health insurance as |
3 | defined under section 1882(g)(1) of the Social Security |
4 | Act (49 Stat. 620, 42 U.S.C. § 1882(g)(1)). |
5 | (ii) Coverage supplemental to the coverage provided |
6 | under the Civilian Health and Medical Program of the |
7 | Uniformed Services (CHAMPUS). |
8 | (iii) Similar supplemental coverage provided to |
9 | coverage under a group health plan. |
10 | "Health carrier." A company or health insurance entity |
11 | licensed in this Commonwealth to offer or issue any individual |
12 | or group health, sickness or accident policy or subscriber |
13 | contract or certificate or plan that provides medical or health |
14 | care coverage by a health care facility or licensed health care |
15 | provider that is governed under this act or any of the |
16 | following: |
17 | (1) Article XXIV of the act of May 17, 1921 (P.L.682, |
18 | No.284), known as The Insurance Company Law of 1921. |
19 | (2) The act of December 29, 1972 (P.L.1701, No.364), |
20 | known as the Health Maintenance Organization Act. |
21 | (3) The act of May 18, 1976 (P.L.123, No.54), known as |
22 | the Individual Accident and Sickness Insurance Minimum |
23 | Standards Act. |
24 | (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan |
25 | corporations) or Ch. 63 (relating to professional health |
26 | services plan corporations). |
27 | "Health maintenance organization." An organized system which |
28 | combines the delivery and financing of health care and which |
29 | provides basic health services to voluntarily enrolled |
30 | subscribers for a fixed prepaid fee. |
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1 | "Individual health insurance coverage." Health insurance |
2 | coverage offered to individuals in the individual market, which |
3 | includes a health benefit plan provided to individuals through a |
4 | trust arrangement, association or other discretionary group that |
5 | is not an employer plan, but does not include short-term limited |
6 | duration insurance. A health carrier offering health insurance |
7 | coverage in connection with a group health plan shall not be |
8 | deemed to be a health carrier offering individual health |
9 | insurance coverage solely because the carrier offers a |
10 | conversion policy. |
11 | "Medical care." Amounts paid for: |
12 | (1) The diagnosis, care, mitigation, treatment or |
13 | prevention of disease, or amounts paid for the purpose of |
14 | affecting any structure or function of the body. |
15 | (2) Transportation primarily for and essential to |
16 | medical care under paragraph (1). |
17 | (3) Insurance covering medical care under paragraphs (1) |
18 | and (2). |
19 | "Open enrollment." With respect to individual health |
20 | insurance coverage, the period of time during which any |
21 | individual has the opportunity to apply for coverage under a |
22 | health benefit plan offered by a health carrier and shall be |
23 | accepted for coverage under the plan without regard to a |
24 | preexisting condition. |
25 | "Preexisting condition exclusion." The term shall include |
26 | the following: |
27 | (1) A limitation or exclusion of benefits, including a |
28 | denial of coverage, based on the fact that the condition was |
29 | present before the effective date of coverage or, if the |
30 | coverage is denied, the date of denial, under a health |
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1 | benefit plan whether or not any medical advice, diagnosis, |
2 | care or treatment was recommended or received before the |
3 | effective date of coverage. |
4 | (2) Any limitation or exclusion of benefits, including a |
5 | denial of coverage, applicable to an individual as a result |
6 | of information relating to an individual's health status |
7 | before the individual's effective date of coverage or, if the |
8 | coverage is denied, the date of denial, under the health |
9 | benefit plan, such as a condition identified as a result of a |
10 | preenrollment questionnaire or physical examination given to |
11 | the individual, or review of medical records relating to the |
12 | preenrollment period. |
13 | Section 3. Prohibition on preexisting condition exclusions. |
14 | (a) General rule.--A health carrier shall not limit or |
15 | exclude coverage under an individual health insurance health |
16 | benefit plan for an individual 18 years of age or younger by |
17 | imposing a preexisting condition exclusion on that individual. |
18 | (b) Open enrollment.--Where a health carrier offers |
19 | individual health insurance coverage that only covers |
20 | individuals 18 years of age or younger, such health carrier |
21 | shall offer such coverage continuously through the year, or |
22 | during one or more open enrollment periods of 30 days. |
23 | (c) Issuance.--During an open enrollment period, a health |
24 | carrier shall not deny or unreasonably delay the issuance of a |
25 | policy, refuse to issue a policy or issue a policy with any |
26 | preexisting condition exclusion rider or endorsement to an |
27 | applicant or insured who is 18 years of age or younger on the |
28 | basis of a preexisting condition. |
29 | (d) Same coverage.--Coverage shall be effective for those |
30 | applying during an open enrollment period on the same basis as |
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1 | an applicant qualifying for coverage on an underwritten basis. |
2 | (e) Notice.--Each health carrier shall provide prior |
3 | prominent public notice on its Internet website and prior |
4 | written notice to each of its policyholders annually at least 90 |
5 | days before any open enrollment period of the open enrollment |
6 | rights for individuals 18 years of age or younger and provide |
7 | information as to how an individual eligible for this open |
8 | enrollment right may apply for coverage with the carrier during |
9 | an open enrollment period. |
10 | (f) Group plan.--A health carrier shall not limit or exclude |
11 | coverage under a group health insurance health benefit plan for |
12 | an individual 18 years of age or younger by imposing a |
13 | preexisting condition exclusion on that individual. |
14 | Section 4. Enforcement. |
15 | (a) Penalties and remedies.--Upon a determination by hearing |
16 | that this act has been violated, the commissioner may pursue one |
17 | or more of the following courses of action: |
18 | (1) Issue an order requiring the person in violation to |
19 | cease and desist from engaging in the violation. |
20 | (2) Suspend or revoke or refuse to issue or renew the |
21 | certificate or license of the person in violation. |
22 | (3) Impose a civil penalty of not more than $5,000 for |
23 | each violation. |
24 | (4) Impose any other penalty or remedy deemed |
25 | appropriate by the commissioner, including restitution. |
26 | (b) Other remedies.--The enforcement remedies imposed under |
27 | this section shall be in addition to any other remedies or |
28 | penalties that may be imposed by statute. Violations of this |
29 | article are deemed and defined by the commissioner to be an |
30 | unfair method of competition and an unfair or deceptive act or |
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1 | practice under the act of July 22, 1974 (P.L.589, No.205), known |
2 | as the Unfair Insurance Practices Act. |
3 | Section 5. Applicability. |
4 | (a) Applicability.--Except as provided under subsection (b), |
5 | this act shall apply to a health carrier providing coverage |
6 | under an individual or group health benefit plan. |
7 | (b) Exception.--This act shall not apply to grandfathered |
8 | plan coverage. |
9 | Section 6. Regulations. |
10 | The department shall promulgate regulations necessary to |
11 | implement this act. |
12 | Section 7. Effective date. |
13 | This act shall take effect in 60 days. |
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