Pennsylvania SB 52: An Act providing for health care insurance coverage protections, for duties of the Insurance Department and the Insurance Commissioner, for regulations, for enforcement and for penalties.

Bill Text

PRINTER'S NO. 96
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No. 52
Session of
2025
INTRODUCED BY HUGHES, KIM, BOSCOLA, CAPPELLETTI, COLLETT,
COMITTA, COSTA, FLYNN, FONTANA, HAYWOOD, KANE, KEARNEY,
MILLER, MUTH, PISCIOTTANO, SANTARSIERO, SAVAL, SCHWANK,
STREET, TARTAGLIONE, A. WILLIAMS AND L. WILLIAMS,
JANUARY 22, 2025
REFERRED TO BANKING AND INSURANCE, JANUARY 22, 2025
AN ACT
Providing for health care insurance coverage protections, for
duties of the Insurance Department and the Insurance
Commissioner, for regulations, for enforcement and for
penalties.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Short title.
This act shall be known and may be cited as the Health
Insurance Protection Against Limitations 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.
"Enrollee." A policyholder, subscriber, covered person or
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

other individual who is entitled to receive health care services
under a health insurance policy.
"Group health insurance policy." A policy, subscriber
contract, certificate or plan issued by an insurer that provides
medical or health care coverage on an annual basis to
individuals who obtain health insurance coverage through a
group.
"Health insurance policy." A policy, subscriber contract,
certificate or plan issued by an insurer that provides medical
or health care coverage. The term does not include any of the
following:
(1) An accident only policy.
(2) A credit only policy.
(3) A long-term care or disability income policy.
(4) A specified disease policy.
(5) A Medicare supplement policy.
(6) A fixed indemnity policy.
(7) A dental only policy.
(8) A vision only policy.
(9) A workers' compensation policy.
(10) An automobile medical payment policy.
(11) A policy under which benefits are provided by the
Federal Government to active or former military personnel and
their dependents.
(12) Any other similar policies providing for limited
benefits.
"In-network provider." A provider who contracts with an
insurer to provide health care services to an enrollee under a
health insurance policy.
"Individual health insurance policy." A policy, subscriber
20250SB0052PN0096 - 2 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

contract, certificate or plan issued by an insurer that provides
medical or health care coverage on an annual basis to an
individual other than in connection with a group.
"Insurer." An entity that offers, issues or renews an
individual or group health insurance policy that provides
medical or health care coverage by a health care facility or
licensed health care provider and that is governed under any of
the following:
(1) The act of May 17, 1921 (P.L.682, No.284), known as
The Insurance Company Law of 1921, including section 630 and
Article XXIV thereof.
(2) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
(3) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations).
(4) 40 Pa.C.S. Ch. 63 (relating to professional health
services plan corporations).
"Out-of-network provider." A provider who does not contract
with an insurer to provide health care services to an enrollee
under a health insurance policy.
Section 3. Limitation on annual and lifetime limits.
(a) Limits.--Except as otherwise provided in this section,
an insurer offering, issuing or renewing an individual or group
health insurance policy may not establish, on either an annual
or lifetime basis, a limit on the dollar value of any core
benefit for an enrollee, whether provided by an in-network
provider or out-of-network provider.
(b) Core benefit.--For purposes of this section, a core
benefit shall include:
(1) A benefit for which no annual or lifetime per
20250SB0052PN0096 - 3 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

enrollee limit was permitted to be included in an individual
or small group policy first offered or issued in this
Commonwealth in 2018.
(2) A benefit hereafter specified by the department by
regulation.
(c) Benefits not subject to limitation.--The commissioner
may promulgate regulations to exempt a benefit from the
definition of core benefit under subsection (b) for the purposes
of the limitation prohibitions under this section.
(d) No coverage requirement.--This section shall not be
construed to require coverage of any specific benefit.
Section 4. Regulations.
(a) Authority to promulgate.--The department may promulgate
regulations as may be necessary and appropriate to carry out the
provisions of this act.
(b) Temporary regulations.--
(1) In order to facilitate the prompt implementation of
this act, the department may issue temporary reg