Pennsylvania SB 51: An Act providing for individual and group health care insurance coverage protections and for core health benefits; imposing penalties; and providing for applicability and for regulations.

Bill Text

PRINTER'S NO. 98
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No. 51
Session of
2025
INTRODUCED BY HUGHES, KEARNEY, BOSCOLA, CAPPELLETTI, COLLETT,
COMITTA, COSTA, FLYNN, FONTANA, HAYWOOD, KANE, KIM, 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 individual and group health care insurance
coverage protections and for core health benefits; imposing
penalties; and providing for applicability and for
regulations.
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 Core Benefits Coverage 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.
"Group health insurance policy." A policy, subscriber
contract, certificate or plan issued by an insurer that provides
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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.
"Individual 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 an
individual other than in connection with a group.
"Insurer." An entity that offers, issues or renews an
individual or group health insurance policy, contract or plan
that provides medical or health care coverage by a health care
facility or licensed health care provider and that is governed
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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).
Section 3. Core health benefits.
(a) Benefits.--Except as otherwise provided in this section,
an insurer offering, issuing or renewing an individual health
insurance policy or group health insurance policy shall include
health benefits in at least the following general categories and
the items and services covered within the categories:
(1) Ambulatory patient services.
(2) Emergency services.
(3) Hospitalization.
(4) Maternity and newborn care.
(5) Mental health and substance use disorder services,
including behavioral health treatment.
(6) Prescription drugs.
(7) Rehabilitative and habilitative services and
devices.
(8) Laboratory services.
(9) Preventive and wellness services and chronic disease
management.
(10) Pediatric services, including oral and vision care.
(b) Comprehensiveness.--
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(1) An individual health insurance policy or group
health insurance policy shall cover health benefits at least
as comprehensive as the health benefits required to be
covered in an individual health insurance policy or a small
group policy first offered or issued in this Commonwealth in
2018.
(2) A large group health insurance policy also shall
cover health benefits required to be covered in a large group
policy first offered or issued in this Commonwealth in 2018.
(c) Modifications.--The department may add a health benefit
or exempt a health benefit required to be covered under this
section through a regulation promulgated under section 4. In
determining whether to add a health benefit or exempt a health
benefit required to be covered under this section, the
department shall consider all of the following:
(1) The balance of the health benefits in the categories
specified under subsection (a) and whether the health
benefits are not unduly weighted toward any category.
(2) The health care needs of the