SB 50 — 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.

PRINTER'S NO.    97

                   THE GENERAL ASSEMBLY OF PENNSYLVANIA



                       SENATE BILL
                       No. 50
                                              Session of
                                                2025

     INTRODUCED BY HUGHES, COLLETT, BOSCOLA, CAPPELLETTI, COMITTA,
        COSTA, FLYNN, FONTANA, HAYWOOD, KANE, KEARNEY, 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
 1   Providing for health care insurance coverage protections, for
 2      duties of the Insurance Department and the Insurance
 3      Commissioner, for regulations, for enforcement and for
 4      penalties.
 5      The General Assembly of the Commonwealth of Pennsylvania
 6   hereby enacts as follows:
 7   Section 1.   Short title.
 8      This act shall be known and may be cited as the Health
 9   Insurance Access Protection Act.
10   Section 2.   Definitions.
11      The following words and phrases when used in this act shall
12   have the meanings given to them in this section unless the
13   context clearly indicates otherwise:
14      "Affordable Care Act."   Collectively, the Patient Protection
15   and Affordable Care Act (Public Law 111-148, 124 Stat. 119) and
16   the Health Care and Education Reconciliation Act of 2010 (Public
17   Law 111-152, 124 Stat. 1029).
18      "Commissioner."   The Insurance Commissioner of the
 1   Commonwealth.
 2      "Department."    The Insurance Department of the Commonwealth.
 3      "Enrollee."    A policyholder, subscriber, covered person or
 4   other individual who is entitled to receive health care services
 5   under a health insurance policy.
 6      "Grandfathered health plan."       Individual or group health
 7   insurance coverage in which an individual was enrolled prior to
 8   the date of enactment of the Affordable Care Act or as otherwise
 9   specified in 42 U.S.C. § 18011 (relating to preservation of
10   right to maintain existing coverage).
11      "Group health insurance policy."       A policy, subscriber
12   contract, certificate or plan issued by an insurer that provides
13   medical or health care coverage on an annual basis to
14   individuals who obtain health insurance coverage through a
15   group.
16      "Health factor."    An element related to an individual's
17   physical or mental makeup, including:
18            (1)   Health status.
19            (2)   Medical condition.
20            (3)   Claims experience.
21            (4)   Receipt of health care.
22            (5)   Medical history.
23            (6)   Genetic information.
24            (7)   Evidence of insurability, including conditions
25      arising out of acts of domestic violence.
26            (8)   Disability.
27      "Health insurance policy."       A policy, subscriber contract,
28   certificate or plan issued by an insurer that provides medical
29   or health care coverage. The term does not include any of the
30   following:

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 1            (1)    An accident only policy.
 2            (2)    A credit only policy.
 3            (3)    A long-term care or disability income policy.
 4            (4)    A specified disease policy.
 5            (5)    A Medicare supplement policy.
 6            (6)    A fixed indemnity policy.
 7            (7)    A dental only policy.
 8            (8)    A vision only policy.
 9            (9)    A workers' compensation policy.
10            (10)    An automobile medical payment policy.
11            (11)    A policy under which benefits are provided by the
12      Federal Government to active or former military personnel and
13      their dependents.
14            (12)    Any other similar policies providing for limited
15      benefits.
16      "Individual health insurance policy."        A policy, subscriber
17   contract, certificate or plan issued by an insurer that provides
18   medical or health care coverage on an annual basis to an
19   individual other than in connection with a group.
20      "Individual market."     The market for health insurance
21   coverage offered to individuals other than in connection with a
22   group.
23      "Insurer."     An entity that offers, issues or renews an
24   individual health insurance policy or group health insurance
25   policy that provides medical or health care coverage by a health
26   care facility or licensed health care provider and that is
27   governed under any of the following:
28            (1)    The act of May 17, 1921 (P.L.682, No.284), known as
29      The Insurance Company Law of 1921, including section 630 and
30      Article XXIV of that act.

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 1            (2)   The act of December 29, 1972 (P.L.1701, No.364),
 2      known as the Health Maintenance Organization Act.
 3            (3)   40 Pa.C.S. Ch. 61 (relating to hospital plan
 4      corporations).
 5            (4)   40 Pa.C.S. Ch. 63 (relating to professional health
 6      services plan corporations).
 7      "Pre-existing condition."     A health condition present before
 8   the date of enrollment for coverage, or, if coverage is denied,
 9   the date of the denial, whether or not any medical advice,
10   diagnosis, care or treatment was recommended or received before
11   that date.
12      "Small group market."     The market for health insurance for
13   coverage offered through a group health insurance policy for a
14   group of 2 to 50 individuals, exclusive of their dependents.
15      "Wellness program."     A program offered by an employer that is
16   designed to promote health or prevent disease.
17   Section 3.     Prohibitions concerning discrimination based on pre-
18                  existing conditions or health factors.
19      (a)   Prohibition concerning eligibility for and enrollment in
20   health insurance.--An insurer offering, issuing or renewing an
21   individual health insurance policy or group health insurance
22   policy may not impose any rule for initial or continued
23   eligibility of any individual to enroll in or renew a health
24   insurance policy based on any pre-existing condition or health
25   factor in relation to an individual or a dependent of the
26   individual.
27      (b)   Prohibition concerning premium rates.--
28            (1)   An insurer offering, issuing or renewing an
29      individual health insurance policy or group health insurance
30      policy may not require an individual to pay a premium rate

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 1      that is greater than the premium rate for a similarly
 2      situated individual enrolled in the policy on the basis of
 3      any pre-existing condition or health factor in relation to an
 4      individual or a dependent of the individual.
 5             (2)   Nothing in paragraph (1) shall be construed to
 6      prevent an insurer offering a group health insurance policy
 7      from establishing premium discounts or rebates or modifying
 8      otherwise applicable copayments or deductibles in return for
 9      adherence to a wellness program. Pending the promulgation of
10      regulations by the department, a wellness program shall be
11      subject to limitations as may be established in Federal law
12      or regulation.
13      (c)    Prohibition concerning benefit coverage.--An insurer
14   offering, issuing or renewing an individual health insurance
15   policy or group health insurance policy may not exclude or deny
16   coverage for any benefit provided for in a policy based on any
17   pre-existing condition or health factor in relation to an
18   individual or a dependent of the individual.
19   Section 4.      Limitations on premium rating factors.
20      (a)    Rate variation.--With respect to the premium rate
21   charged by an insurer for health insurance coverage offered in
22   the individual market or small group market, the premium rate
23   may only vary for a particular plan or coverage based on the
24   following:
25             (1)   Family size.
26             (2)   Geographic rating area.
27             (3)   Age, except that the rate shall not vary by more
28      than 3 to 1 for adults except as provided under subsection
29      (d).
30             (4)   Tobacco use, except that the rate shall not vary by

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 1      more than 1.5 to 1 except as provided under subsection (d).
 2      (b)   Geographic rating areas.--The department may specify the
 3   geographic rating areas by publication on the department's
 4   publicly accessible Internet website and transmission of a
 5   notice to the Legislative Reference Bureau for publication in
 6   the next available issue of the Pennsylvania Bulletin. Prior to
 7   publication, the department shall provide a 30-day comment
 8   period and shall consult with insurers offering health insurance
 9   policies in this Commonwealth.
10      (c)   Age bands.--The department may define the permissible
11   age bands for rating purposes by publication on the department's
12   publicly accessible Internet website and transmission of a
13   notice to the Legislative Reference Bureau for publication in
14   the next available issue of the Pennsylvania Bulletin. Prior to
15   publication, the department shall provide a 30-day comment
16   period and shall consult with insurers offering health insurance
17   policies in this Commonwealth.
18      (d)   Adjustment of age and tobacco rating variations.--The
19   department may, by regulation, adjust the rating bands for age
20   and tobacco use.
21   Section 5.   Single risk pools.
22      (a)   Individual market.--An insurer shall consider all
23   enrollees in all health insurance policies offered by the
24   insurer in the individual market, other than grandfathered
25   health plans, to be members of a single risk pool.
26      (b)   Small group market.--An insurer shall consider all
27   enrollees in all health insurance policies offered by the
28   insurer in the small group market, other than grandfathered
29   health plans, to be members of a single risk pool.
30   Section 6.   Regulations.

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 1      (a)   Authority to promulgate.--The department may promulgate
 2   regulations as may be necessary and appropriate to carry out the
 3   provisions of this act.
 4      (b)   Temporary regulations.--
 5            (1)    In order to facilitate the prompt implementation of
 6      this act, the department may issue temporary regulations,
 7      which shall expire not later than two years following
 8      publication of the temporary regulations in the Pennsylvania
 9      Bulletin. The temporary regulations shall be exempt from the
10      following:
11                   (i)    Section 612 of the act of April 9, 1929
12            (P.L.177, No.175), known as The Administrative Code of
13            1929.
14                   (ii)    Sections 201, 202, 203, 204 and 205 of the act
15            of July 31, 1968 (P.L.769, No.240), referred to as the
16            Commonwealth Documents Law.
17                   (iii)    Section 204(b) of the act of October 15, 1980
18            (P.L.950, No.164), known as the Commonwealth Attorneys
19            Act.
20                   (iv)    The act of June 25, 1982 (P.L.633, No.181),
21            known as the Regulatory Review Act.
22            (2)    The authority of the department to issue temporary
23      regulations under this subsection shall expire two years from
24      the effective date of this paragraph. Regulations adopted
25      after the two-year period shall be promulgated as provided by
26      statute.
27   Section 7.      Enforcement.
28      (a)   Penalties.--Upon satisfactory evidence of a violation of
29   this act by an insurer or any other person, one or more of the
30   following penalties may be imposed at the commissioner's

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 1   discretion:
 2            (1)   Suspension or revocation of the license of the
 3      offending insurer or other person.
 4            (2)   Refusal, for a period not to exceed one year, to
 5      issue a new license to the offending insurer or other person.
 6            (3)   A fine of not more than $5,000 for each violation of
 7      this act.
 8            (4)   A fine of not more than $10,000 for each willful
 9      violation of this act.
10      (b)   Limitations.--
11            (1)   Fines imposed against an individual insurer under
12      this act may not exceed $500,000 in the aggregate during a
13      single calendar year.
14            (2)   Fines imposed against any other person under this
15      act may not exceed $100,000 in the aggregate during a single
16      calendar year.
17      (c)   Additional remedies.--The enforcement remedies imposed
18   under this section are in addition to any other remedies or
19   penalties that may be imposed under any other applicable law of
20   this Commonwealth, including:
21            (1)   The act of July 22, 1974 (P.L.589, No.205), known as
22      the Unfair Insurance Practices Act. Violations of this act
23      shall be deemed to be an unfair method of competition and an
24      unfair or deceptive act or practice under the Unfair
25      Insurance Practices Act.
26            (2)   The act of December 18, 1996 (P.L.1066, No.159),
27      known as the Accident and Health Filing Reform Act.
28            (3)   The act of June 25, 1997 (P.L.295, No.29), known as
29      the Pennsylvania Health Care Insurance Portability Act.
30      (d)   Administrative procedure.--The administrative provisions

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 1   of this section shall be subject to 2 Pa.C.S. Ch. 5 Subch. A
 2   (relating to practice and procedure of Commonwealth agencies).
 3   A party against whom penalties are assessed in an administrative
 4   action may appeal to Commonwealth Court as provided in 2 Pa.C.S.
 5   Ch. 7 Subch. A (relating to judicial review of Commonwealth
 6   agency action).
 7   Section 8.   Repeals.
 8      All acts and parts of acts are repealed insofar as they are
 9   inconsistent with this act.
10   Section 9.   Effective date.
11      This act shall take effect immediately.




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