HB 1445 — An Act amending Title 40 (Insurance) of the Pennsylvania Consolidated Statutes, providing for school-based services; and, in telemedicine, further providing for insurance coverage of telemedicine.

PRINTER'S NO.   1897

                     THE GENERAL ASSEMBLY OF PENNSYLVANIA



                         HOUSE BILL
                         No. 1445
                                                Session of
                                                  2025

     INTRODUCED BY WARREN, BRENNAN, MALAGARI, HILL-EVANS, SANCHEZ,
        VITALI, PIELLI, HOHENSTEIN, SCHLOSSBERG, NEILSON, MERSKI AND
        D. WILLIAMS, JUNE 10, 2025

     REFERRED TO COMMITTEE ON INSURANCE, JUNE 10, 2025


                                     AN ACT
 1   Amending Title 40 (Insurance) of the Pennsylvania Consolidated
 2      Statutes, providing for school-based services; and, in
 3      telemedicine, further providing for insurance coverage of
 4      telemedicine.
 5      The General Assembly of the Commonwealth of Pennsylvania
 6   hereby enacts as follows:
 7      Section 1.    Title 40 of the Pennsylvania Consolidated
 8   Statutes is amended by adding a chapter to read:
 9                                CHAPTER 44
10                           SCHOOL-BASED SERVICES
11   Sec.
12   4401.   Legislative findings and intent.
13   4402.   Definitions.
14   4403.   Insurance coverage for health care service in school
15               setting.
16   4404.   Permitted exclusions.
17   4405.   Coordination of benefits.
18   4406.   Construction.
 1   4407.    Regulations.
 2   4408.    Penalties.
 3   4409.    Administrative procedures.
 4   § 4401.    Legislative findings and intent.
 5      (a)    Legislative findings.--The General Assembly finds and
 6   declares as follows:
 7             (1)   Health care services, including mental health
 8      services, may be available to students in a school setting.
 9             (2)   Educational opportunities for students will be
10      maximized if students are able to access health care services
11      without leaving their school setting.
12      (b)    Intent.--The intent of this chapter is to maximize
13   educational opportunities for students by establishing
14   limitations on when health insurance coverage for health care
15   services provided in a school setting may be excluded or denied.
16   § 4402.    Definitions.
17      The following words and phrases when used in this chapter
18   shall have the meanings given to them in this section unless the
19   context clearly indicates otherwise:
20      "Administrative policy."      A written document or collection of
21   documents reflecting the terms of the contractual or operating
22   relationship between an insurer and a health care provider.
23      "Clinical review criteria."      The set of written screening
24   procedures, decision abstracts, clinical protocols and practice
25   guidelines used by an insurer to determine the necessity and
26   appropriateness of health care services.
27      "Commissioner."      The Insurance Commissioner of the
28   Commonwealth.
29      "Covered person."      A policyholder, subscriber or other
30   individual who is entitled to receive health care services under

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 1   a health insurance policy.
 2      "Habilitative speech therapy."         Speech therapy that helps an
 3   individual to keep, learn or improve skills and function for
 4   daily living.
 5      "Health care provider."       A person that is licensed,
 6   certified, registered or otherwise permitted by law or
 7   regulation to provide health care services under the laws of
 8   this Commonwealth.
 9      "Health care service."       A treatment, procedure, medical
10   supply or other service prescribed or otherwise provided or
11   proposed to be provided by a health care provider to a covered
12   person for any of the following:
13          (1)     mental health;
14          (2)     behavioral health; or
15          (3)     speech therapy.
16      "Health insurance policy."       As follows:
17          (1)     A policy, subscriber contract, certificate or plan
18      issued by an insurer that provides medical or health care
19      coverage.
20          (2)     The term does not include:
21                (i)    An accident only policy.
22                (ii)    A credit only policy.
23                (iii)    A long-term care or disability income policy.
24                (iv)    A specified disease policy.
25                (v)    A Medicare supplement policy.
26                (vi)    A policy under which benefits are provided by
27          the Federal Government to active or former military
28          personnel and their dependents, including a Tricare
29          policy or a Civilian Health And Medical Program of the
30          Uniformed Services (CHAMPUS) supplement policy.

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 1                (vii)    A fixed indemnity policy.
 2                (viii)    A hospital indemnity policy.
 3                (ix)    A dental only policy.
 4                (x)    A vision only policy.
 5                (xi)    A workers' compensation policy.
 6                (xii)    An automobile medical payment policy under 75
 7          Pa.C.S. (relating to vehicles).
 8                (xiii)    A homeowner's insurance policy.
 9                (xiv)    Any other similar policies providing for
10          limited benefits.
11      "Insurer."      An entity licensed by the department that offers,
12   issues or renews an individual or group health insurance policy
13   that is offered or governed under any of the following:
14          (1)   The act of May 17, 1921 (P.L.682, No.284), known as
15      The Insurance Company Law of 1921, including section 630 and
16      Article XXIV thereof.
17          (2)   The act of December 29, 1972 (P.L.1701, No.364),
18      known as the Health Maintenance Organization Act.
19          (3)   Chapter 61 (relating to hospital plan corporations)
20      or 63 (relating to professional health services plan
21      corporations).
22      "Medical policy."     A written document adopted, maintained and
23   applied by an insurer that combines the clinical review criteria
24   and any additional administrative policy, as applicable,
25   necessary to articulate the insurer's standards for coverage of
26   a given health care service or set of health care services under
27   the terms of a health insurance policy.
28      "Participating network provider."        A health care provider
29   that has entered into a contractual or operating relationship
30   with an insurer to participate in one or more designated

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 1   networks of the insurer and to provide health care services to
 2   covered persons under the terms of the insurer's administrative
 3   policy.
 4      "Rehabilitative speech therapy."        Speech therapy that helps
 5   an individual restore or improve skills and functioning for
 6   daily living that have been lost or impaired.
 7      "School entity."        As follows:
 8             (1)   A public school, including a charter school or cyber
 9      charter school, private school, nonpublic school,
10      intermediate unit or area career and technical school.
11             (2)   The term does not include a postsecondary
12      educational institution.
13      "School entity facility."        A school entity building, whether
14   permanent or temporary, including a mobile unit.
15      "Speech therapy."       Therapeutic care provided to an individual
16   for treatment administered by a licensed speech-language
17   pathologist. The term includes both habilitative speech therapy
18   and rehabilitative speech therapy.
19   § 4403.    Insurance coverage for health care service in school
20                   setting.
21      (a)    Prohibition.--A health insurance policy offered, issued
22   or renewed in this Commonwealth may not exclude coverage for a
23   medically necessary health care service because the health care
24   service is provided in a school setting, whether through an
25   explicit school setting exclusion or a general place of service
26   exclusion.
27      (b)    School setting.--A health care service is provided in a
28   school setting if it is provided in a school entity facility by
29   a health care provider that is:
30             (1)   an employee of the school entity;

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 1             (2)   a contractor of the school entity; or
 2             (3)   otherwise authorized by the school entity to provide
 3      the health care service in the school entity facility.
 4   § 4404.    Permitted exclusions.
 5      Notwithstanding section 4403, an insurer may exclude coverage
 6   for a health care service provided to a covered person in a
 7   school setting for any of the following reasons:
 8             (1)   The health care service is provided by an individual
 9      who:
10                   (i)    is not a health care provider; or
11                   (ii)    is practicing outside of the individual's scope
12             of practice.
13             (2)   The health care service is not medically necessary
14      under the terms of the insurer's medical policies.
15             (3)   The provision of the health care service does not
16      comply with the insurer's administrative policies.
17             (4)   A school entity or government entity, as defined in
18      2 Pa.C.S. § 101 (relating to definitions), is obligated under
19      Federal or State law to provide the health care service in
20      accordance with an individualized education program or
21      section 504 of the Rehabilitation Act of 1973 (Public Law 93-
22      122, 29 U.S.C. § 794).
23   § 4405.    Coordination of benefits.
24      (a)    Coordination.--Consistent with Federal or State law and
25   upon consent of the parent or guardian, if a covered person has
26   an individualized education program or a section 504 plan, an
27   insurer may coordinate a medically necessary health care service
28   provided in a school setting with any service included in an
29   individualized education program or section 504 plan.
30      (b)    Claim.--A health care provider may not submit a claim to

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 1   an insurer for a health care service that is provided to a
 2   covered person as part of an individualized education program or
 3   a section 504 plan.
 4      (c)    Costs and reimbursements.--A school entity may not shift
 5   costs onto or otherwise seek reimbursement from an insurer for
 6   health care services that a school entity is required to provide
 7   as part of free appropriate public education under the
 8   Individuals with Disabilities Education Act (Public Law 91-230,
 9   20 U.S.C. § 1400 et seq.).
10   § 4406.    Construction.
11      This chapter may not be construed to limit the application of
12   a health insurance policy's terms and conditions, including:
13             (1)   Prohibiting an insurer from paying or reimbursing
14      health care providers for other covered health care services
15      provided in a school setting.
16             (2)   Prohibiting an insurer from imposing cost-sharing
17      that is consistent with the terms and conditions of the
18      health insurance policy.
19             (3)   Requiring an insurer to cover a health care service
20      provided in a school setting by an out-of-network provider
21      unless otherwise required by network adequacy standards.
22             (4)   Requiring an insurer to pay or reimburse a
23      participating network provider if the provision of the health
24      care service in a school setting would be inconsistent with
25      the standard of care.
26             (5)   Requiring an insurer to pay or reimburse a health
27      care provider for a health care service for which the health
28      care provider receives or is entitled to receive compensation
29      from a school entity as part of an employment arrangement or
30      contract.

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 1   § 4407.    Regulations.
 2      The department may promulgate regulations as necessary and
 3   appropriate to carry out the provisions of this chapter.
 4   § 4408.    Penalties.
 5      (a)    Authority of commissioner.--Subject to subsection (b),
 6   upon satisfactory evidence of a violation of this chapter by an
 7   insurer, the commissioner may, in the commissioner's discretion,
 8   pursue any of the following courses of action:
 9             (1)   Suspend, revoke or refuse to renew the license of
10      the offending person.
11             (2)   Enter a cease and desist order.
12             (3)   Impose a civil penalty of not more than $5,000 for
13      each action in violation of this chapter.
14             (4)   Impose a civil penalty of not more than $10,000 for
15      each action in willful violation of this chapter.
16      (b)    Limitation.--Penalties imposed against an insurer under
17   this section may not exceed $500,000 in the aggregate during a
18   single calendar year.
19      (c)    Nonexclusive remedies.--
20             (1)   The enforcement remedies imposed under this chapter
21      are in addition to any other remedies or penalties that may
22      be imposed under any other applicable law of this
23      Commonwealth, including the act of July 22, 1974 (P.L.589,
24      No.205), known as the Unfair Insurance Practices Act.
25             (2)   A violation of this chapter by an insurer shall be
26      deemed to be an unfair method of competition and an unfair or
27      deceptive act or practice under the Unfair Insurance
28      Practices Act.
29   § 4409.    Administrative procedures.
30      (a)    Procedures generally.--The administrative provisions of

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 1   this chapter shall be subject to 2 Pa.C.S. Ch. 5 Subch. A
 2   (relating to practice and procedure of Commonwealth agencies).
 3      (b)    Appeals.--A party against whom penalties are assessed in
 4   an administrative action may appeal to Commonwealth Court as
 5   provided in 2 Pa.C.S. Ch. 7 Subch. A (relating to judicial
 6   review of Commonwealth agency action).
 7      Section 2.     Section 4803(a)(1) of Title 40, added July 3,
 8   2024 (P.L.516, No.42), is amended and subsection (c) is amended
 9   by adding a paragraph to read:
10   § 4803.    Insurance coverage of telemedicine.
11      (a)    General rule.--
12             (1)   A health insurance policy offered, issued or renewed
13      in this Commonwealth shall provide coverage for medically
14      necessary health care services provided through telemedicine
15      and delivered by a participating network provider who
16      provides a covered health care service through telemedicine
17      consistent with the insurer's medical policies. A health
18      insurance policy may not exclude a health care service from
19      coverage solely because the health care service is provided
20      through telemedicine, whether explicitly or through a place
21      of service exclusion.
22             * * *
23      (c)    Construction.--This section may not be construed to:
24             * * *
25             (4)   Require an insurer to pay or reimburse for a health
26      care service that is required by Federal or State law to be
27      provided by a school entity, including a health care service
28      provided in accordance with an individualized education
29      program or section 504 of the Rehabilitation Act of 1973
30      (Public Law 93-122, 29 U.S.C. § 794).

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 1    Section 3.    This act shall apply as follows:
 2        (1)   For health insurance policies for which either rates
 3    or forms are required to be filed with the Federal Government
 4    or the Insurance Department, this act shall apply to any
 5    policy for which a form or rate is first filed on or after
 6    the effective date of this section.
 7        (2)   For health insurance policies for which neither
 8    rates nor forms are required to be filed with the Federal
 9    Government or the Insurance Department, this act shall apply
10    to any policy issued or renewed on or after 180 days after
11    the effective date of this section.
12    Section 4.    This act shall take effect immediately.




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