THE GENERAL ASSEMBLY OF PENNSYLVANIA

SENATE BILL

INTRODUCED BY FARNESE, RAFFERTY, FONTANA, SOLOBAY, BOSCOLA, COSTA, STACK, WILLIAMS, TARTAGLIONE, WASHINGTON, KITCHEN, LEACH AND SCHWANK, MAY 16, 2011

REFERRED TO BANKING AND INSURANCE, MAY 16, 2011  

AN ACT

Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An

act relating to insurance; amending, revising, and

consolidating the law providing for the incorporation of

insurance companies, and the regulation, supervision, and

protection of home and foreign insurance companies, Lloyds

associations, reciprocal and inter-insurance exchanges, and

fire insurance rating bureaus, and the regulation and

supervision of insurance carried by such companies,

associations, and exchanges, including insurance carried by

the State Workmen's Insurance Fund; providing penalties; and

repealing existing laws," in health and accident insurance,

providing for pregnancy as a preexisting condition and for

coverage for maternity care; and, in health care insurance

individual accessibility, further providing for policy choice

for eligible individuals.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1.  The act of May 17, 1921 (P.L.682, No.284), known

as The Insurance Company Law of 1921, is amended by adding

sections to read:

Section 635.6.  Pregnancy as a Preexisting Condition.--(a)

All health insurance policies that are offered, issued or

renewed on or after the effective date of this section may not

impose any preexisting condition exclusion that relates to, or

includes, a current or a prior pregnancy, complications

regarding a current or prior pregnancy or the performance of a

caesarean section for a prior pregnancy as a preexisting

condition.

(b)  This section shall not apply to the following types of

policies:

(1)    Accident only.

(2)  Fixed indemnity.

(3)  Limited benefit.

(4)  Credit.

(5)  Dental.

(6)    Vision.

(7)  Specified disease.

(8)  Medicare supplement.

(9)    Civilian Health and Medical Program of the Uniformed

Services (CHAMPUS) supplement.

(10)  Long-term care or disability income.

(11)  Workers' compensation.

(12)  Automobile medical payment.

(c)    As used in this section:

(1)    "Attending physician" means the attending obstetrician,

pediatrician or other physician attending the mother of a

newborn child.

(2)    "Health care provider" means an attending physician,

nurse practitioner or certified nurse midwife.

(3)  "Health insurance policy" means any individual or group

health or accident insurance policy or subscriber contract,

certificate or plan offered to, issued to or renewed on or after

the effective date of this section by an insurer which is

offered by or subject to any of the following:

(i)    This act.

(ii)  The act of December 29, 1972 (P.L.1701, No.364), known

as the "Health Maintenance Organization Act."

(iii)  40 PaC.S. Ch. 61 (relating to hospital plan

corporations) or 63 (relating to professional health services

plan corporations).

(iv)  Subarticle (f) of Article IV of the act of June 13,

1967 (P.L.31, No.21), known as the "Public Welfare Code."

(v)    The act of May 18, 1976 (P.L.123, No.54), known as the

"Individual Accident and Sickness Insurance Minimum Standards

Act."

(4)    "Insurer" means any entity that issues a health

insurance policy, contract, certificate or plan described under

clause (2) of this subsection.

(5)  "Preexisting condition" means a condition or disease for

which medical advice or treatment was recommended by or received

from a health care provider prior to the effective date of the

coverage.

Section 635.7.  Coverage for Maternity Care.--(a)  All health

insurance policies shall provide coverage for maternity care as

follows:

(1)  Prenatal care, which shall include coverage for regular

health care visits and childbirth education in addition to

ongoing assessment of nutritional and other individual needs

consistent with nationally recognized standards and guidelines,

such as those promulgated by the Institute for Clinical Systems

Improvement (ICSI) or the American College of Obstetricians and

Gynecologists (ACOG).

(2)  Childbirth and postdelivery care as follows:

(i)  Childbirth care shall include at a minimum coverage for

delivery and postdelivery inpatient care for:

(A)  Forty-eight (48) hours of inpatient care for a mother

and her newborn child following a vaginal delivery.

(B)  Ninety-six (96) hours of inpatient care for a mother and

her newborn child following a cesarean section.

(ii)  Any decision to shorten the minimum coverage provided

shall be made by the health care provider in consultation with

the mother. A health insurance policy shall not provide any

compensation or other nonmedical remuneration to encourage a

mother and her newborn child to leave inpatient care before the

expiration of the minimum coverage specified in this section.

(iii)  When discharge occurs prior to the times stated in

this subsection, coverage shall include at least one home health

care visit within forty-eight (48) hours after discharge by a

health care provider whose scope of practice includes postpartum

care.

(iv)  Notwithstanding any other provision of this section, a

policy that provides coverage for delivery and postdelivery care

to a mother and her newborn child in the home shall not be

required to provide for a minimum of forty-eight (48) hours and

ninety-six (96) hours, respectively, of inpatient care unless

the inpatient care is determined to be medically necessary by

the health care provider consistent with nationally recognized

treatment standards and guidelines such as those promulgated by

ACOG or the American Academy of Pediatrics (AAP).

(3)  Postpartum care, which shall be provided consistent with

nationally recognized standards and guidelines, such as those

promulgated by ACOG or AAP.

(b)  Copayments, coinsurance and deductibles as follows:

(1)  The coverage required under this section may be subject

to any copayment, coinsurance or deductible amount in comparable

amounts to those imposed for similar care.

(2)  Notwithstanding clause (1), the health insurance policy

shall not include any copayment, coinsurance or deductible

amount for any postdelivery home health care visits required

under subsection (a)(2).

(c)  An insurer shall not refuse to contract with or

compensate for covered services an otherwise eligible health

care provider or nonparticipating health care provider solely

because the health care provider has in good faith communicated

with one or more of his current, former or prospective patients

regarding the provisions, terms or requirements of the insurer's

products as they relate to the needs of the health care

provider's patients.

(d)  This section shall not apply to the following types of

policies:

(1)  Accident only.

(2)  Fixed indemnity.

(3)  Limited benefit.

(4)  Credit.

(5)  Dental.

(6)  Vision.

(7)  Specified disease.

(8)  Medicare supplement.

(9)  Civilian Health and Medical Program of the Uniformed

Services (CHAMPUS) supplement.

(10)  Long-term care or disability income.

(11)  Workers' compensation.

(12)  Automobile medical payment.

(e)  As used in this section:

(1)  "Attending physician" means the attending obstetrician,

pediatrician or other physician attending to a mother or her

newborn child.

(2)  "Birth center" means a licensed facility that is not

part of a hospital that provides maternity care to mothers not

requiring hospitalization.

(3)  "Health care facility" means a hospital, birth center or

health care provider's office.

(4)  "Health care provider" means an attending physician,

nurse practitioner or certified nurse midwife.

(5)  "Health insurance policy" means any individual or group

health or accident insurance policy or subscriber contract,

certificate or plan offered to, issued to or renewed on or after

the effective date of this section by an insurer that is offered

by or is subject to any of the following:

(i)  This act.

(ii)  The act of December 29, 1972 (P.L.1701, No.364), known

as the "Health Maintenance Organization Act."

(iii)  40 Pa.C.S. Ch. 61 (relating to hospital plan

corporations) or 63 (relating to professional health services

plan corporations).

(iv)  Subarticle (f) of Article IV of the act of June 13,

1967 (P.L.31, No.21), known as the "Public Welfare Code."

(v)  The act of May 18, 1976 (P.L.123, No.54), known as the

"Individual Accident and Sickness Insurance Minimum Standards

Act."

(6)  "Hospital" means a facility having an organized medical

staff and providing equipment and services primarily for

inpatient care to persons who require definitive diagnosis or

treatment, or both, for injury, illness, pregnancy or other

disability.

(7)  "Insurer" means an entity that issues individual or

group health insurance policy, contract or plan described under

clause (5) of this subsection.

(8)  "Maternity care" means prenatal care, childbirth and

postdelivery care, and postpartum care provided at a health care

facility or at the home of a mother.

Section 2.  Section 1005-A(c) of the act, added November 4,

1997 (P.L.492, No.51), is amended and the section is amended by

adding a subsection to read:

Section 1005-A.  Policy Choice for Eligible Individuals.--

* * *

(c)  [Nothing] Except as otherwise provided in subsection

(d), nothing in this article shall prohibit an eligible

individual from purchasing a policy which includes a preexisting

condition provision or is not otherwise offered under this

section from a designated insurer or any other insurer.

(d)  (1)  Notwithstanding any other provision of law to the

contrary, a policy offered, issued or renewed on or after the

effective date of this subsection by a designated insurer or any

other insurer shall not impose any preexisting condition

exclusion that relates to, or includes, a current or a prior

pregnancy, complications regarding a current or prior pregnancy

or the performance of a caesarean section for a prior pregnancy.

(2)  For the purposes of this subsection, "preexisting

condition" shall have the meaning given in section 635.6.

Section 3.  This act shall take effect in 60 days.